1. 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)

2. 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)

3. 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

4. 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

5. Other Helpful Tips (Hicks & Gilles, 1999)
Warm area by using heel warmer or warm wet cloth for 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

6. 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)

7. 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.

8. 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

9. 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

10. 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)

11. 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)

12. 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

13. 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 Central Venous Catheters for care and maintenance of PICC’s

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

15. 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

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

17. 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)

18. 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

19. 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

20. 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

21. 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

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

23. 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

24. 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.