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Revista da Escola de Enfermagem da USP

Print version ISSN 0080-6234

Rev. esc. enferm. USP vol.46 no.6 São Paulo Dec. 2012 



Peripherally inserted central catheter care in neonates: an integrative literature review


Cuidados con catéter central de inserción periférica en el neonato: revisión integrativa de la literatura



Derdried Athanasio JohannI; Luciana Souza Marques De LazzariII; Edivane PedroloIII; Priscila MingoranceIV; Tatiana Queiroz Ribeiro de AlmeidaV; Mitzy Tannia Reichembach DanskiVI

IRN. Master student of the Nursing Graduate Program at Federal University of Paraná. RN at the Paraná Federal Institute. Member of the Research Group Health Technology and Innovation: Foundations for Professional Practice. Curitiba, PR, Brazil.
IINursing undergraduate at Federal University of Paraná. Volunteer of the research apprenticeship program. Member of the Research Group Health Technology and Innovation: Foundations for Professional Practice. Curitiba, PR, Brazil.
IIIRN. Master student of the Nursing Graduate Program at Federal University of Paraná. Professor of the Paraná Federal Institute. Member of the Research Group Health Technology and Innovation: Foundations for Professional Practice. Curitiba, PR, Brazil.
IVNursing undergraduate at Federal University of Paraná. Fellow of the PIBIC/CNPq research apprenticeship program. Member of the Research Group Health Technology and Innovation: Foundations for Professional Practice. Curitiba, PR, Brazil.
VNursing undergraduate at Federal University of Paraná. Volunteer of the research apprenticeship program. Member of the Research Group Health Technology and Innovation: Foundations for Professional Practice. Curitiba, PR, Brazil.
VIRN. Ph.D. Professor of the Undergraduate Program of the Nursing Department and the Nursing Graduate Program at Federal University of Paraná. Vice-leader of the Research Group Health Technology and Innovation: Foundations for Professional Practice. Curitiba, PR, Brazil.





The peripherally inserted central catheter (PICC) is a common technology employed in the intravenous therapy of neonates. This integrative review was performed with the objective to investigate and analyze the evidence available in the literature regarding this technology. The databases searched included the Latin American and Caribbean Health Sciences Literature (LILACS) and the United States National Library of Medicine (PubMed). Results point at gaps in relation to their use in the neonatal population (n=1); various themes regarding the use of anticoagulants (n=6), comparison with other catheters (n=4), diagnostic imaging (n=2), pain (n=2), and catheter-relation infection and its prevention (n=7), among others. There is a need for staff education regarding their use; scientific evidence with easy access; and national publications regarding their use.

Descriptors: Catheterization, central venous; Infant, newborn; Nursing care; Technology.


El catéter central de inserción periférica (PICC) es una tecnología común empleada en terapia endovenosa de neonatos. Se trata de una revisión integrativa, cuyo objetivo fue investigar y analizar las evidencias disponibles en la literatura acerca de la temática. Se investigaron las bases de datos Literatura Latinoamericana y del Caribe en Ciencias de la Salud (LILACS) y la Biblioteca Nacional de Medicina de los Estados Unidos (PubMed). Los resultados expresan omisiones en lo referente a la población neonatal; conocimiento insuficiente de los profesionales al respecto de las indicaciones (n=1), diagnóstico por imagen (n=2), dolor (n=2), infección relacionada al catéter y su prevención (n=7), entre otras. Se necesita de actualización profesional; evidencias científicas de fácil acceso y publicaciones nacionales.

Descriptores: Cateterismo venoso central; Recién nacido; Atención de enfermaría; Tecnología




Nursing is dedicated to the care for the individual in all life stages. The importance of these professionals in providing care for neonatal patients in Intensive Care Units (ICU) stands in the limelight due to its high complexity and specific needs.

Vascular access ports are indispensable devices for intensive care due to the need for medication therapy, hemodynamics monitoring, parenteral nutrition, among other recommendations(1). The most used vascular access ports in neonatal care are: Peripheral Venous Access (PVA), Peripherally Inserted Central Catheter (PICC) or Umbilical catheter(2).

PICC is an intravascular device inserted through a superficial vein from the extremity of the body which, with the help of an introducing needle, advances through the superior or inferior cava, with the characteristics of a central catheter(3).

PICC is highly used in neonatal ICU units due to its easy insertion, prolonged use, less traumatic insertion and reduced risk for complications(4-5). However, PICC requires a trained professional for its insertion and daily care and maintenance, with a view to avoid complications(4-5).

The suitable referential for developing this present study was the Evidence Based Practice (EBP). EBP employs instruments to consolidate scientific knowledge about a specific subject, searches for ideal and efficient professional conduct towards a specific problem, by organizing coherent and relevant evidence, listed according to quality(6). The main evidence corresponds to the results of the research(7).

Implementing EBP in nursing is consonant to scientific evidence incorporation in clinical practice, allowing for knowledge acquisition and validation. Hence, there is a need for returning studies results into practice and research themes are a result to the need for it in an objective and applicable way in its routine(8).

The objective of this review is to investigate and analyze the available evidence in literature regarding the care for the insertion and maintenance of peripherally inserted central catheter in neonates.



An integrative literature review was conducted, which allows for a synthesis of multiple published studies thus providing a general conclusion regarding this particular area of study. A simultaneous inclusion of experimental and semi-experimental studies is enabled, thus providing a more comprehensive understanding of the theme of interest(9).

The integrative review was developed following six stages: formulation of the research question, literature search, study categorization, evaluation of the included studies, results discussion and interpretation and an evidenced knowledge synthesis(9-10).

The research question used was: what are the clinical practice publications regarding peripherally inserted central venous catheter in neonates?

The article search was performed on the Latin American and Caribbean Health Sciences Literature Database (LILACS) and United States National Medical Library (PubMed) databases. The articles were selected according to descriptors from DeCS - Health Sciences Descriptors for the BVS portal, and from MeSH - Medical Subject Heading from PubMed.

LILACS database was electronically accessed through the Virtual Health Library and the PubMed through the National Center for Biotechnology Information – NCBI. Searches were performed in May of 2010.

In LILACS, three fields were crossed, the first and the second were 'subject descriptors' and the third 'type of publication', following the Boolean logic, according to the description on Chart 1.

In PubMed, ten descriptors were crossed to eight types of publications, following the Boolean logic, as shown by Chart 2.

The articles included in the review met the following criteria: published between January of 2000 and May of 2010; in national and international journals; available in Portuguese, English or Spanish; presented a clinical research design; addressed the PICC theme.

To select publications, first the title and the abstract were analyzed, in order to confirm if they contemplated the research question and if they met the inclusion criteria. Pre-selected articles were fully read with a view to avoid selection bias. LILACS database search resulted in 19 references; however, none met the inclusion criteria. In PubMed, 221 articles were selected and 28 were included in this present study.

For data extraction, a validated instrument was adjusted to compose the article identification, methodological precision, evidence level, intervention, results and conclusions(11). Studies evaluations were performed by analyzing the research lineation according to the researchers' area concepts(12-13).

A synthesis of the extracted data is presented in a descriptive format, contemplating the fifth and sixth stages of the integrative review. The evidence level was determined according to Chart 3



Regarding the methodological design, from the 28 analyzed studies, the following was extracted: eleven randomized clinical trials (RCT), four cohort studies, four descriptive, three observational, three systematic reviews (two with two RCT each and one with five), two before and after, and one clinical guideline. The frequency of publications throughout the analyzed years was of three publications/year with a variation of one to four per year.

Regarding the study objects, the following was found: seventeen were on children, thirteen were specifically on neonatal subjects; six on catheters; one on diagnoses exams; one on neonatal ICU; and one on nurses. The evidence level in the studies covered the following: three studies on evidence 1, ten on evidence 2, twelve on evidence 3 and three on evidence 5.

Regarding population/sample, interventions, results and conclusion designs, in each study they are succinctly, orderly presented according to the emerging categories in data collection. The general Complication and Infection categories were composed of four studies each and the Infection prevention category of three studies; they are detailed in Chart 4.

Six sub-categories (Chart 5) were inserted in the general aspects related to PICC: Comparison between PICC and other catheters (n=4 studies); Image diagnosis (n=2); Pain (n=2); Perception from nurses (n=1); Filter (n=2); and Use of anticoagulant (n=6).



Promoting the education for professionals who insert and handle intravenous catheters is internationally recommended, since the proper level of knowledge is fundamental for working in the ICU(21). Within this context the nurse plays the role of team educator. Moreover, knowledge regarding guidelines and competences to insert and handle catheters must be periodically evaluated, and this function can only be performed by competent professionals(43).

Regarding PICC punctures, it is indicated for patients who will stay in the hospital for periods longer than 4 days(27). When compared to PVA in extremely low weight neonatal subjects, the PICC reduces painful procedures and extends intravenous therapy time, without the incidence of asepsis (Evidence 2)(26).

Results in studies comparing Total Parenteral Nutrition (TPN) administration through central venous and peripheral catheter, demonstrate the infusion through PICC as favorable to nutritional intake. Moreover, there is evidence relating the use of PICC to a lower number of catheters used to fulfill the therapy (Evidence 1)(29).

During the insertion, the professional must use maximum barrier precautions: mask, cap, sterilized gown, gloves and surgical drapes. For cutaneous anti-sepsis, chlorhexidin is indicated as first choice antiseptic, however, there is no evidence regarding the comparison between chlorhexidine, iodine tincture and 70% alcohol solution. The antiseptic must be thoroughly dry before the puncture. Hands hygiene must be strictly performed each time the catheter must be manipulated(43).

In neonatal subjects younger than two weeks there is no consensus regarding the first choice antiseptic, since chlorhexidine is not indicated for this population due to the cutaneous reactions it triggers (Evidence 2)(21,43).

Regarding the total catheter insertions, there is no consensus in the best site for the pediatric population (Evidence 2)(21,43). There is evidence pointing the use of PICC on lower limbs, whenever technically viable, must be considered for the prolonged administration of TPN (Evidence 5)(17). However, there is also evidence that central lines installed on the femoral or subclavian veins demonstrated higher incidence for thromboembolic venous events, therefore the jugular or brachial veins should be chosen (Evidence 3)(16).

When analgesia during the PICC insertion is mentioned, evidence point the topical use of 4% tetracaine within 30 minutes before the puncture demonstrated no reduction in the pain related to the procedure (Evidence 2)(32). The associated use of morphine and tetracaine demonstrated higher performance in pain relief related to catheter progression; however, both medications were associated to complications (Evidence 2)(33).

Verifying the tip of the catheter after the insertion is recommended. Evidence that ultrasonography provides precise information about the position of the tip of the catheter regarding vascular structures and dislocation after postural changes was demonstrated, contributing for the safe positioning of the catheter (Evidence 3)(30). The recommended positioning of the catheter tip, in order to be considered central, must be near the cardiac shape, prioritizing the cava vein(44). The digital image files technology and communication system (PACS) present no advantages in the view of the PICC tip when compared to the standard x-ray with contrast (Evidence 3)(31).

Ostial catheter coverage requires both gauze and tape dressings and transparent polyurethane dressing; gauze is preferred in cases of exudates or excessive transpiration (Evidence 5)(21,43). Transparent dressings change must occur every seven days, unless in pediatric patients where dislocation risks of the catheter are higher than the benefit of the dressing change (Evidence 2)(21,43). For gauze and tape dressings, the change must be performed every two days(43).

This present study related the 70% alcohol disinfection associated to chlorhexidine impregnated dressings of weekly changes for the protection against central catheters colonization. The use of impregnated chlorhexidine dressings is recommended, however, it is recommended for adolescents and adults with CVC who will stay for longer than seven days (Evidence 2)(19). As demonstrated by this present study the use of this technology is restricted to subjects older than two weeks, and other studies support these findings as they affirm there is no recommendation for the use in neonatal subjects younger than seven days or gestational age inferior to 26 weeks (Evidence 5)(21).

It is recommended that the device should be removed from the subjects as soon as it is no longer needed, and also the daily evaluation of the insertion site, in order to monitor phlogiston signals (Evidence 5)(21,43). There is no recommendation of prophylactic systemic antibiotics before the insertion or even while the catheter stay(43). Moreover, topical administration of antibiotic ointments is not indicated due to their micro biotic and fungi infection resistance potential (Evidence 5)(21,43). A study recommends the use of vancomycin solution associated to heparin (25µ/mL) twice a day in order to fill the catheter (Evidence 3)(39).

Regarding the use of antiseptic impregnated catheters or covered by antibiotics, it is recommended only for adults in institutions where the infection rates have been reduced due to broadly employed preventive measures. In addition, its use is recommended for patients who are expected to stay with the catheter longer than five days. There is no recommendation for the pediatric population (Evidence 5)(21,43).

Regarding connections, they are not to be submersed; therefore, during the bath both the catheter and all its connections must be protected. The non-needle system must be substituted within the same frequency as the equipment and occlusion agents must be substituted every 72 hours or according to the manufacturer's guidelines (Evidence 5)(21,43).

Equipment used for lipid emulsions, blood or blood components infusions must be substituted every 24 hours; in case of propofol administration, the equipment must be changed between 6 to 12 hours of use. Parenteral solutions must be prepared in pharmacies under a laminar flow. In parenteral solutions cases of continuous infusion, the equipment may be changed after 72 to 96 hours, when associated to anti-microbial catheters, after seven days of use. There is no recommendation for the change of equipment used for intermittent infusions(43).

A study related the use of an intravenous filter with the higher durability of equipment and the reduction of nursing time and costs, however, it presented no reduction in the infection rates (Evidence 2)(36).

Regarding CVC and PICC, on the opposite of peripheral catheters, the routine change is not advised in order to prevent infections. The catheter is advised to be changed when there is purulent exsudate in the ostial catheter exit, as well as hyperthermia in cases of suspecting infections related to the catheter (Evidence 5)(21,43).

In case of infections related to the catheter caused by enterobacteria, there is evidence of success (45%) when the catheter was kept, however there was no success in maintaining the catheter in patients with infections lasting more than two days. Infections caused by enterobacteria associated to severe thrombocytopenia are rarely solved, unless the catheter is removed (Evidence 3)(22).

Monitoring these infections is stated as crucial and must be constant, both by regular evaluations of the insertion sites and by the institutional control of infection rates related to catheters, which must be expressed as infection rates related to central venous catheter by one thousand days with the catheter (Evidence 5)(21). A Study pointed out the team's motivation as being connected to the reduction in infection rates related to catheters (Evidence 3)(23).

Heparin infusion demonstrated to linger PICC permeability time, with no additional adverse events (Evidence 2)(40). Adding this anticoagulant to the total parenteral nutrition, however, showed no reduction in PICC obstruction incidence (Evidence 2)(37). A systematic review was not able to determine the effectiveness of the heparin impregnated catheter regarding durability, thrombosis, occlusion, sepsis and other adverse effects, due to the lack of studies (Evidence 1)(42). The prophylactic use of heparin allowed for most neonatal subjects with PICC to complete their treatment, due to a reduction in occlusion rates. Evidence supports the use of heparin in PICC for neonatal subjects within a 0.5UI/Kg/hr dose (Evidence 1)(42).

Although the use of anticoagulants was verified as a reducing agent in thrombosis risks related to central venous catheters (CVC), the use of prophylactic anticoagulants represented no significant reduction in infection rates of the blood stream related to catheters, therefore it is not recommended for routine use in order to prevent infections(43).



The care to neonatal subjects must be supported on reliable evidence in order to reestablish their health condition in the shortest period possible. Hospital complications as blood stream infections related to catheters and many others related to intravenous devices must be minimized in a way to offer neonatal patients and their families a less traumatic hospital stay, free of malpractices.

In face of this evidence-based practice, professional updating is considered mandatory; however, ways to facilitate information to nurses and their teams must be created. Evidence must be available in clear and concise language in a way to optimize research time.

The evidence presented in this review is, mostly, from international sources, a fact that points out the need for developing national nursing clinical studies with a view to evaluate and create technologies related to the working process.



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Correspondence addressed to:
Derdried Athanasio Johann
Av. Lothário Meissner, 632 – Jardim Botânico
CEP 80210-170 – Curitiba, PR, Brazil

Received: 03/28/2012
Approved: 05/03/2012

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