Pediatric Nursing and Healthcare

Biography

Biography: Priscila Costa

Abstract

Advances in neonatal intensive care have improved the survival rates of severely ill preterm newborns. This population usually requires a safe vascular access in order to infuse parenteral nutrition, intravenous fluids, and medications such as antibiotics. Nurses are constantly challenged to improve methods of safe and consistent vascular access for this vulnerable population. The frequent use of percutaneously inserted central catheters (PICC) requires evidence to inform best practices for nurses. What are some of the nursing challenges? Before PICC insertion: Can PICC-related complications be predicted? Some studies1,2,3 identified predictors of unplanned removal of PICC lines in infants. The early recognition of these predictors provides evidence for nurses to implement preventative measures in order to decrease catheter-related complications, medical costs, mortality and suffering of the infant and his family. A risk score with an accuracy of 0.76 was developed combing some predictors of unplanned removal. The risk score was made up of the following risk factors: transient metabolic disorders, previous insertion of catheter, use of a polyurethane double-lumen catheter, infusion of multiple intravenous solutions through a single-lumen catheter, and tip in a noncentral position. Newborns were classified into three categories of risk of unplanned removal: low (0 to 3 points), moderate (4 to 8 points), and high (≥ 9 points)3. During PICC insertion: what are the strategies for pain management? PICC insertion results in a pain response of moderate to severe intensity4. However, measures for the relief of pain caused by the procedure are uncommon in neonatal care. A study showed that analgesic or sedative strategies occurred in only 34.6% of catheter placements. Non-pharmacological strategies such as oral sucrose or non-nutritive sucking were adopted in only 2.4% of the procedures5. After PICC insertion: should nurses verify tip position? It is known that the best location for the tip of a PICC is the lower third of the superior vena cava (SVC), close to the SVC-RA junction. However catheter tip can be located at noncentral positions, such as axillary, subclavian, brachiocephalic, or iliac veins. Considering that identifying catheter´s tip, and a frequent monitoring of noncentral PICCs are necessary to detect and prevent catheter-related complications such as extravasation and thrombosis, it is crucial enable nurses to verify tip position at radiography. Nurses can use the thoracic vertebral bodies (T) and the carina as anatomical landmarks to determine the location of the catheter tip on radiographs. The catheter tip is considered to be located at the subclavian vein if it was located at the T1 level, brachiocephalic vein at the T2 level, superior vena cava at the T3-T5 level, superior vena cava-right atrium junction at the T6 level, or at two vertebral bodies under the carina and at the right atrium if it was located at the T7 to T8 level. It can be considered to be at the inferior vena cava if it is located at the T9 to T10 level and at the iliac vein if it is below the T9 to T10 level. Another aspect of interest is the prevalence of noncentral PICCs. A study showed that 12.6% of the catheters were placed in noncentral veins, such as subclavian vein (10.1%), iliac vein (1.7%), and the axillary vein (0.9%) PICCs6. Conclusion The use of standardized evidence based care practice checklists, bundled care practices, and a dedicated PICC team should be encouraged to improve nursing quality of care worldwide.