Implementation of modified Seldinger technology for percutaneous catheterization in critically ill newborns

Pereira, Higor Pacheco; Secco, Izabela Linha; Arrué, Andrea Moreira; Pontes, Letícia; Danski, Mitzy Tannia Reichembach

doi:10.1590/1980-220X-REEUSP-2022-0347en

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Original Article • Rev. esc. enferm. USP 57 • 2023 • https://doi.org/10.1590/1980-220X-REEUSP-2022-0347en copy

Implementation of modified Seldinger technology for percutaneous catheterization in critically ill newborns

Implantación de tecnología Seldinger modificada para cateterismo percutáneo en recién nacidos en estado crítico

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To describe the implementation of Modified Seldinger Technology for percutaneous catheterization in critically ill newborns.

Method:

A quasi-experimental before- and-after study, carried out with neonatologist nurses in a Neonatal Intensive Care Unit.

Results:

Seven nurses participated in the research. Catheter pre-insertion, insertion and maintenance were assessed using the conventional and modified Seldinger technique. Reliability was satisfactory in pre-test, 5.40 (Md = 6.00), and post-test, 5.94 (Md = 7.00), and perfect in the items about device insertion and maintenance. There was low assertiveness in the items on indication, microintroduction procedure via ultrasound, limb repositioning and disinfection of connections/connectors.

Conclusion:

Despite the Modified Seldinger Technique expanding some stages of execution over the traditional method of percutaneous catheterization, nurses were more assertive after theoretical-practical training. The technology was implemented and is in the process of being implemented in the health service.

DESCRIPTORS
Newborn; Catheterization, Peripheral; Intensive Care Units, Neonatal; Technology; Evidence-Based Nursing

Pre-insertion questions	Pre-test hit	Post-test hit	p
1. Once formally qualified through a course and regulated by the Class Council, nurses can insert the PICC, regardless of the technique to be used.	3 (43%)	5 (71%)	0.500* 0.462^†
2. Nurses must perform a physical examination of patients’ venous network using the inspection and palpation technique, tourniqueting the limb to visualize the vein and using a tape measure to measure the length of the catheter to be introduced.	7 (100%)	7 (100%)	1^†
3. The catheter gauge must be previously chosen, taking into account NB’s weight and size as well as aspects of the condition of patients’ venous network. The PICC diameter should not exceed one third of the internal diameter of the chosen vein.	7 (100%)	7 (100%)	1^†
4. It is recommended to indicate PICC after six days of intravenous therapy. Thus, NB who underwent unsuccessful peripheral venipuncture and have a difficult venous network do not meet the PICC insertion criteria and should receive another type of central catheter.	4 (57%)	5 (71%)	1* 0.552^†
5. In NB with a history of difficult peripheral venous access, PICC insertion should be considered early, in order to have a greater chance of success with the insertion procedure.	7 (100%)	7 (100%)	1^†
6. In neonatology, the main indications for PICC insertion are intravenous therapy after 6 days and administration of fluids or irritating and/or vesicant medications.	6 (86%)	6 (86%)	1* 0.167^†
7. There are some contraindications for PICC insertion, such as impaired venous network visualization/identification, thrombocytopenia and coagulation disorders, presence of skin lesions, infection, phlebitis and infiltration close to the planned puncture site.	7 (100%)	7 (100%)	1^†
8. Guardians’ legal consent of NB for PICC insertion is not required in an emergency.	3 (43%)	3 (43%)	1* 0.417^†
9. For insertion in lower limbs, position the measuring tape at the site chosen for puncture, run the tape to the inguinal region of the same member, from this point to the umbilicus and then to the xiphoid process.	7 (100%)	7 (100%)	1^†
10. For insertion in the upper regions (arms, jugular veins and head), position the measuring tape at the site chosen for the puncture and run it towards the right wishbone and then to the second intercostal space.	6 (86%)	7 (100%)
11. The microintroduction can only be performed with the aid of ultrasound (guided or assisted puncture) so that, without this imaging equipment, it is not possible to perform the technique in its entirety.	3 (43%)	5 (71%)	0.625* 0.077^†
12. Provide measures for pain control before and during the procedure. Use non-pharmacological measures such as non-nutritive sucking with sucrose or breast milk, restraint and swaddling. Also consider administering opioids 30 minutes before the procedure, such as fentanyl. In addition to mitigating pain, measures are necessary to reduce NB’s psychomotor agitation, ensuring safety and access to the target vessel.	7 (100%)	7 (100%)	1^†
13. The basilic vein is the first vein of choice for PICC insertion, as it is smaller in length and has fewer valves, ensuring better catheter progression.	7 (100%)	7 (100%)	1^†
14. The cephalic vein is the second vein of choice. It is more superficial than the basilica, more extensive and presents a slight curve in its most distal portion, which may be a factor that hinders catheter progression.	7 (100%)	7 (100%)	1^†
15. The brachial vein is the third vein of choice. In this case, we have to select it, ensuring that the brachial artery will not be inadvertently punctured.	7 (100%)	7 (100%)	1^†
16. Other puncture alternatives in neonatology are the scalp (temporal and auricular), cervical (internal jugular) and lower limbs (great saphenous, popliteal).	2 (28%)	3 (43%)	1.000* 0.696^†
Total	7 (100%)	7 (100%)

Insertion questions	Hit pre-test	Hit post-test	p
17. Microintroduction or MST is defined by the insertion of a larger gauge catheter than the introducer used for its insertion, which makes venous catheterization less traumatic and painful, increasing assertiveness in the first puncture attempt.	5 (71%)	7 (100%)
18. NB should be preferably positioned in dorsal decubitus and restrained to facilitate catheter progression, without the need for adequate positioning for each insertion site.	5 (71%)	5 (71%)	1* 0.400^†
19. It is necessary to perform antisepsis of the puncture site with 0.5% alcoholic chlorhexidine for term NB and 0.1% for premature NB, for 30 seconds, and allow the antiseptic to completely dry. The direction of the cleaning movement can be in the “back and forth” direction or with circular movements.	4 (57%)	4 (57%)	1* 0.417^†
20. After insertion site antisepsis and protection with the sterile field, microintroduction is performed in this sequence: A– Establish access to the venous network through a fine-gauge needle as per the manufacturer; B– After blood reflux, insert the guide wire approximately 5 cm into the needle; C– If necessary, perform the anesthetic button with lidocaine without vasoconstrictor 2 minutes before placing the dilator (peel-away); D– The access needle is subsequently removed over the guide wire, followed by peel-away total placement; E– Insert the PICC catheter until the desired measurement through this dilator. If the catheter progresses successfully, break the peel-away and stabilize the PICC, awaiting confirmation of the distal tip by imaging exam.	1 (14%)	3 (43%)	0.500* 0.364^†
21. Regarding the performance of local anesthesia by nurses in PICC insertion, the Opinion 15/2014 of the Federal Council of Nursing (COFEN) advises that nurses with training/qualification course for PICC insertion, in an institution that has a protocol that regulates the application of local anesthetic by nurses and professional training for this activity, perform the local anesthesia procedure with 1% or 2% lidocaine without vasoconstrictor in the subcutaneous tissue.	7 (100%)	7 (100%)	1^†
22. Microscopically, cutting the PICC changes its tip morphology. Therefore, evidence points to fewer complications related to thrombosis when the catheter is trimmed with a guillotine.	7 (100%)	7 (100%)	1^†
23. The use of adhesive devices for PICC fixation has not been shown to reduce the risk of infection and catheter displacement; therefore, stabilization can be performed using sutures or other materials available at the institution.	5 (71%)	7 (100%)
24. Any external length of catheter should be stabilized with a slight curve as it exits the skin. This minimizes the risk of accidental device detachment.	7 (100%)	7 (100%)	1^†
25. When positioned in the subclavian vein, the PICC cannot be considered central. In this vessel, there is an increased risk of thrombosis, infiltration, occlusion and extravasation, complications that can be avoided if the tip of the device is in the cavoatrial junction.	6 (86%)	7 (100%)
26. If the PICC is inserted in the head, jugular or upper limbs, it is recommended to position the tip between the 3–5 thoracic vertebrae. For punctures performed in lower limbs, it is recommended between 8–10 thoracic vertebrae.	6 (86%)	6 (86%)	1.000* 1.000^†
27. After the imaging exam, if there is a need to introduce or pull the PICC, there are no contraindications.	4 (57%)	5 (71%)	1.000* 0.087^†
28. Simultaneous flushing with 0.9% saline, using no resistance for insertion, gently massaging along the vein length, and applying warm compresses to promote vasodilation are considered measures to aid catheter progression.	7 (100%)	7 (100%)	1^†
29. Slow catheter insertion after blood return impairs PICC progression, due to the risk of clotting inside the introducer, preventing the procedure’s success.	5 (71%)	6 (86%)	1.000* 0.235^†
30. In case of difficulty in centrally positioning the PICC, it is allowed to perform a more vigorous washing of the catheter with 0.9% saline solution to reposition it in the vena cava.	1 (14%)	2 (28%)	1* 0.588^†
Total	7 (100%)	7 (100%)

Maintenance	Hit pre-test	Hit pre-test	p
31. It is necessary to assess PICC’s functionality using a 10 ml syringe or a syringe designed specifically to generate low injection pressure, performing an initial flush, slowly aspirating the catheter until blood returns, which is an important component in catheter function assessment, before the administration of drugs and solutions.	7 (100%)	7 (100%)	1^†
32. The appropriate volume of saline solution for washing the catheter does not need to be followed in care practice, which consists of at least twice the catheter’s total internal volume.	5 (71%)	6 (86%)	1* 0.235^†
33. The positive pressure technique for PICC flushing allows the reduction of blood backflow into the catheter. Measurement of the circumference of the limb where the PICC is inserted should be done frequently to assess signs of deep vein thrombosis, such as edema.	7 (100%)	7 (100%)	1^†
34. Disinfect the PICC connections and connectors once every 12 hours with alcohol-based antiseptic solution, with mechanical friction for 5 to 15 seconds.	3 (43%)	5 (71%)	0.625* 0.077^†
35. In neonatology, changing the dressing that is made of a transparent semipermeable membrane for the PICC should be performed every seven days or in case of detachment/dirt.	4 (57%)	4 (57%)	1* 0.167^†
36. Healthcare professionals have a duty to document the care provided to patients in relation to infusion therapy (monitoring, patient response, side effects and measures taken).	7 (100%)	7 (100%)	1^†
37. The need for permanence of central venous access must be reassessed daily by the care team.	7 (100%)	7 (100%)	1^†
Total	7 (100%)	7 (100%))

Professional category	Moment	N	Mean	Median	Standard deviation	P-value*
Nurses	Pre-test	7	5.40	6.00	1.87	0.000
Nurses	Post-test	7	5.94	7.00	1.47	0.000

Universidade de São Paulo, Escola de Enfermagem Av. Dr. Enéas de Carvalho Aguiar, 419 , 05403-000 São Paulo - SP/ Brasil, Tel./Fax: (55 11) 3061-7553, - São Paulo - SP - Brazil
E-mail: reeusp@usp.br

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[1] Corresponding author: Higor Pacheco Pereira Rua XV de Novembro, 3701, Bom Jesus 83601-030 – Campo Largo, PR, Brazil Higor.pachecopereira@hotmail.com