Minimally Invasive Technique of Direct Central Venous Access in Micro Preemies—a Case Series

Abstract

Central venous line insertion and its maintenance in micro preemies carry significant risk for serious complications considering their small size and the skill involved in insertion. Hence, for uninterrupted and safe administration of essential medications and nutrition in these extreme preemies, we have come up with a minimally invasive technique of central venous access (MICVA technique) using peripherally inserted central catheter (PICC) of smaller caliber. We report a case series of 7 micro preemies who had difficult peripheral venous access because of their long stay in the neonatal intensive care unit (NICU) due to their extreme prematurity. We used a minimally invasive technique wherein under ultrasound guidance, the femoral vein was directly punctured with the splitting introducer needle (24G) available in a PICC set (28G/1Fr catheter with a stylet and splitting needle, Premicath, Vygon) (a size appropriate for micro preemies). Once the blood return was seen, the catheter was advanced up to the premeasured length, and then, the introducer needle was slowly withdrawn out and split. The catheter tip position was then checked with X-ray before starting any infusions. Throughout the procedure, non-pharmacological developmentally supportive care measures were followed. We did not encounter any serious complications except for a small hematoma which was encountered in 2 (28.6%) cases. The Premature Infant Pain Scale (PIPS) score measured for this minimally invasive technique was < 8 for all neonates. In our case series, using this technique (MICVA), we did not concur any serious complications. Local application of 2.5% Prilox cream with 25% oral dextrose and other non-pharmacological measures such as facilitated tuck, swaddling, nesting, and positioning significantly reduced pain and stress during the procedure. We recommend that this technique would be a safe approach in hemodynamically unstable neonates or in difficult venous access scenarios in extreme preterms. Invasive ventilatory support and use of benzodiazepines or opioids can be safely avoided with this technique.