IV Holding Techniques-Neonates and Infants Remember to gather all necessary equipment as well as a second person to hold Equipment includes: 24 gauge insyte IV catheter, NS for flush, extension tubing, 4X4’s, extension tubing, padded armboards, protective cups for older infants, tape (microbore &/or paper), tourniquet, tegaderm (small or medium), and gloves, cotton (from the 4X4’s)

Appropriate IV Sites Extremities (Hicks & Gilles, 1999) Hands/arms-when choosing hand IV, take into account which hand is used for finger/thumb sucking Feet/legs- make sure that there is adequate access for heelsticks if applicable Scalp-for infants 18 months and younger only; contraindicated with infants with hydrocephalus Important to tell to parents that scalp IV’s are just under the skin and do not go into the brain or skull, that hair may be shaved; also the advantage of scalp IV’s is that they allow their infant to have full mobility of their hands and feet (Zaichkin, 2002)

Appropriate IV Sites Scalp IV’s all attempts should be made to minimize the amount of hair to be shaved for IV’s-look before shaving Save shaved hair for parents-show RCNIC card Best places-scalp line along the forehead, especially in the middle, on the temporal sides, and behind the ears: try to avoid areas near the eyes can part hair with alcohol wipes/swabs, water, or surgilube

Armboards Can be placed before or after IV insertion, usually easier after insertion There are small and regular size padded armboards used for neonates and preemies Use as little tape as possible, in some instances you should use double back tape to secure extremity Tape should not cover tips of fingers or toes and nailbeds should remain exposed IMPORTANT: Have an experienced assistant help you hold site/extremity/infant securely and keep infant as calm as possible

Other Helpful Tips (Hicks & Gilles, 1999) Warm area by using heel warmer or warm wet cloth for 10-15 minutes OR turn on radiant warmer if readily available Calm infant by swaddling, snuggling, offering pacifier, playing music, placing toys in view; Also ask parents what their infant likes Apply tourniquet-can use rubber band-but be aware of latex precautions when applicable Hold extremity in dependent position-extremity should be lower than heart to allow venous distention Rub site vigorously with alcohol, but be cautious with preemies and infants with impaired/compromised skin integrity

Developmentally Supportive Care It is important to watch infants for maladaptive behaviors. You should allow a rest period whenever possible between caregiving activities, including IV starts. Use the infant’s clinical status to determine what and how much you do. This helps to prevent overstimulation. (NANN, 2000)

Developmentally Supportive Care Touch and Pain (Zaichkin, 2002) The sense of touch is the first to develop The nerves carrying feeling to and from the extremities develop during the 5th week of gestation. Sensory endings in the skin develop during early gestation. As early as 25 weeks, infants have an acute sense of touch. Therefore, interventions that provide a positive sense of touch is extremely important, even in the most premature of infants.

Developmentally Supportive Care Touch and Pain- Consider the use of Sweet-Ease before beginning painful procedures such as IV starts and heelsticks See RCNIC protocol for use of Sweet-Ease Must be ordered by physician or NNP

Developmentally Supportive Care Swaddling and/or snuggling for containment swaddling in blankets or snuggling in a “snuggle-up” provides containment containment helps to (NANN, 2000): maintain flexed position for infant, bringing arms and legs midline, which is similar to the fetal positions; this is an example of self-consoling behavior facilitate tucking, which has been shown to positively help a preterm infant’s response to pain decrease stress during routine procedures stabilize infant’s motor and physiologic subsystems during stressful manipulations

Developmentally Supportive Care Containment (continued) helps to: promote self-regulatory/self-consoling behaviors such as finger and fist sucking, hand to mouth maneuvers, leg-bracing (pressing up against a stable object) and hand clasping (NANN, 2000) provide boundaries which gives infants a sense of security because of the “womb feeling” (Zaichkin, 2002) Infants prefer boundaries or a “nest” made of soft surfaces that yield to their movements (Zaichkin, 2002)

Developmentally Supportive Care Other Interventions/Considerations Grasping can provide comfort for the infant-provide objects such as blanket, diaper, piece of tubing (NANN, 2000) Light-Dim lighting by shading face during IV starts-helps to reduce environmental stress and provide them with “womb-déjà vu” (dark and muted environment). (Zaichkin, 2002) Visual-Provide toys for distraction. Infants prefer objects high in contrast like black & white bull’s eye shape; infants also like faces, like your face or photos (Zaichkin, 2002)

Developmentally Supportive Care Sound-(Zaichkin, 2002) Ears are functionally developed at 27 weeks, but auditory canal continues to mature after birth making infants susceptible to noise damage; continuous loud noises can harm infant’s hearing and produce physical stress you can protect hearing during IV starts by playing only soft, soothing music conversing softly when near infant; minimizing conversations

Peripherally Inserted Central Catheters (PICCs) Long, soft, flexible catheters inserted through a peripheral vein (extremities or scalp) designed to reach one of the larger veins near the heart They are placed sterilely by specially-trained RCNIC RN’s or CVC RN’s May be done at the bedside or under fluroscopy Follow central line protocol See Nursing Policy and Procedure III-3.03 Central Venous Catheters for care and maintenance of PICC’s

PICC’s Generally use 1.9 French Neo-PICC’s in the RCNIC

Central Venous Catheters (CVC) A special intravenous catheter placed for long-term use Allows a child with chronic conditions who have need of long term intravenous access to receive needed fluids, medications, blood products, or blood draws

Central Venous Catheters (CVC) Placement of Central Venous Catheters (CVC)

Central Venous Catheters (CVC) Types of CVC’s Tunneled- Usually tunneled under the skin on the chest into a vein near the neck; tip of the catheter is in a large blood vessel near the heart (superior vena cava)

Central Venous Catheters (CVC) Types of CVC’s Non-Tunneled- (‘Cutdown”)-Placed percutaneously in a major vein such as the subclavian or femoral veins; usually double-lumen “Cook” catheter used in the RCNIC

Central Venous Catheters (CVC) Refer to the following policies and procedures for care and maintenance and care of CVC’s- Nursing Policy and Procedure III-3.03 for care and maintenance of CVC’s RCNIC Policy III-2.06-Care of venous and arterial cutdown in neonates RCNIC Policy-2.15-Drawing blood from a CVC in the RCNIC

Umbilical Arterial (UAC) and Venous (UVC) Catheters Venous and arterial access that is placed in the umbilical artery and umbilical vein by the physician or practitioner Ideally, catheters must be placed within 24 hours of delivery In general, use a 3.5 FR or 5 FR catheter for the umbilical artery and a 5 FR or 8 FR catheter for the umbilical vein May place a double lumen catheter in the umbilical vein See RCNIC Policy III 2.05 and III 2.11 for care and maintenance of UAC’s and UVC’s

Umbilical Arterial (UAC) and Venous (UVC) Catheters Proper placement- UAC-recommended low placement-tip at L3-L4 UVC-tip of the catheter should be visible just above the diaphragm on x-ray Ideal placement is at the junction of the inferior vena cava and the right atrium Uses- UAC-continuous blood pressure monitoring, blood sampling, volume exchanges; must be transduced UVC-provide IV fluids, administer meds, volume exchanges

Umbilical Arterial (UAC) and Venous (UVC) Catheters Available in 3.5, 5, and 8 french catheters

Peripheral Arterial Lines May be placed in the same manner as a PIV or placed surgically Provides blood sampling and continuous blood pressure monitoring May also be used in volume exchanges Must be transduced See RCNIC Policy III-2.06-Care of venous and arterial cutdown in neonates

Resources Hicks, K., RN & Gilles, A., RN (Revised, 1999). CHMC orientation module: Phlebotomy Skills and IV insertion. Cincinnati, OH: Children’s Hospital Medical Center. National Association for Neonatal Nurses (NANN). (2000). Infant and family-centered developmental care: Guidelines for practice (Document 1201). Des Plaines, IL: Author. Zaichkin, J., RNC, MN (2002). Newborn intensive care: What every parent needs to know . Santa Rosa, CA: NICU Link.