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- Proper positioning of the baby with a roll placed under the shoulder and the head turned to the contralateral side
- Deep sedation increases the cannulation success
- Prescanning of veins i.e., RaCeVA: Rapid Central Vein Assessment
- Size measurement of the targeted vein sonographically because the caliber of the catheter must not exceed ⅓ of the vessel lumen in order to avoid thrombosis
- Maximal barrier precautions including skin antisepsis with 2% chlorhexidine in 70% isopropilic alcohol
- USG venipuncture by using a high-quality ultrasound machine with a small broadband linear array transducer providing a resolution between 13-22MHz
- Seldinger technique by inserting a soft tipped, straight 0.018-inch (0.46mm) Nitinol guidewire
- Ultrasound assessment of the direction of the guidewire into the vasculature i.e., tip navigation
- Insertion of preferably power injectable 2-4 Fr catheters made from silicone or polyurethane
- Tip location by intracavitary ECG and/or transthoracic echocardiography
- Consider subcutaneous tunneling of the catheter to the infraclavicular area if the catheter is to remain in place for a longer period of time
- Securement by sutureless devices such as Securcath®, Grip-Lok®, or StatLock®
- Cyanoacrylate glue for the closure of the puncture site and for the sealing of the exit site
- Coverage of the exit site with semipermeable transparent membrane
FEMORAL VEIN CANNULATION (FICC, FEMORALLY INSERTED CENTRAL CATHETER)
A towel is folded and placed under the pelvic region to eliminate any inward flexion of the hips or concavity to the area. The US probe is placed so as to obtain a good short-axis view of the femoral vein. By using usually an OOP technique which can also include a DNTP technique the needle is inserted into the vein. After successful puncture of the vein Seldinger technique is applied. Femoral venous cannulations can be difficult in neonates because of the small size of the vein, its collapse, and the narrow angle making sometimes the insertion of the guide-wire difficult. High catheter related obstruction, infection, and thrombosis rates have been described, however, recently Ostroff  has reported the successful long-term use of tunneled femoral venous catheters in neonates [15,25].
Due to the meticulous use of real-time USG cannulation techniques including a proper training in this field fatal puncture complications should not occur any more. Inadvertent arterial injuries are now reported to be below 1% [1-3]. Likewise, by applying the previously mentioned insertion bundles, long term complications in particular catheter related infections, and thrombosis should also be avoided nearly completely. However, it has to be said that catheter dwell time, small size of the veins, and overall extreme fragility of these babies will remain constant risk factors for complications. Apart from this ultrasound has also become the first choice to diagnose/exclude pneumothorax, pericardial effusion, and thrombotic events . The latter one must not be confounded with the harmless fibroelastic sheaths frequently detected in vessels after catheter removal.
The most appropriate access in neonates seems to be the supraclavicular, USG in-plane cannulation of the BCV. By using the insertion bundles meticulously fatal catheter complications should not occur any more.
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