PICC Line Placement Procedure Note (Neonate)

Date/Time: [Start time — End time]

Location: [NICU / Radiology suite / Operating room / Bedside]

Primary Operator: [Name, credentials/role]

Assistant(s): [Name(s), role(s) / None]

Urgency: [Elective / Urgent / Emergent]

Procedure Status: [Completed / Aborted / Unsuccessful]

Patient Context

Gestational Age at Birth: [weeks + days] | Corrected GA: [weeks + days / N/A]

Day of Life: [number] | Current Weight: [kg]

Clinical Rationale for Central Access: [Brief reason for central access, e.g., anticipated prolonged IV therapy, TPN requirement, escalating dextrose needs, difficult peripheral access]

Procedure Summary

[Brief synopsis: vein and side accessed, catheter size and type (French, single vs multi-lumen), tip confirmation result with imaging modality, and immediate complications or "none"] (Limit to 1–3 sentences.)

Indication

[Primary indication for PICC placement] — [Brief rationale why peripheral access is insufficient]

Consent

Consent Obtained From: [Parent/Guardian relationship to patient / Not obtained] (If not obtained, document reason such as emergent necessity or guardian unavailable.)

Discussion: [Indication, risks, benefits, alternatives discussed; questions answered]

Interpreter: [Used / Not used] — [Language, interpreter ID or modality / N/A]

Pre-Procedure Assessment

• Risk Assessment: [Contraindications/relative risks assessed: skin integrity, signs of infection, thrombosis history, prior line complications]
• Labs: [Platelet count, coagulation status / Not obtained — rationale]
• Planned Tip Target: [SVC outside cardiac silhouette (upper extremity/scalp) / IVC outside cardiac silhouette (lower extremity)]

Time-Out

[Time-out performed immediately prior to insertion: correct patient, procedure, site/side, allergies reviewed, equipment confirmed] (If emergent and abbreviated, document which elements were verified and why.)

Analgesia and Comfort

• Nonpharmacologic: [Sucrose / Non-nutritive sucking / Swaddling / Facilitated tuck / Other]
• Pharmacologic: [Agent, dose, route / None]
• Monitoring: [Continuous HR and SpO2 monitoring during procedure]

Aseptic Technique

• [Hand hygiene performed prior to donning PPE]
• [Maximal sterile barrier precautions: cap, mask, sterile gown, sterile gloves, full-body sterile drape]
• Skin Antiseptic: [Chlorhexidine / Povidone-iodine / Alcohol-based / Other] — allowed to dry completely (If chlorhexidine not used due to gestational age or policy, document alternative and rationale.)
• [Sterile field maintained throughout] (Note any breaks in sterility and corrective actions.)
• Dressing: [Transparent semipermeable / Sterile gauze] — Securement: [Securement device / Sterile tape / Sutureless device]

Site Selection

Selected Site: [Right / Left] — [Basilic / Cephalic / Brachial / Long saphenous / Popliteal / Scalp vein (specify) / Other]

Rationale: [Vessel quality, prior access attempts, skin/infection considerations]

Limb/Head Position During Measurement: [Adducted / Abducted / Neutral / Other]

Ultrasound Guidance

[Ultrasound guidance used / Ultrasound guidance not used] (If not used, optionally include brief reason.)

• Indication: [Vessel identification / Cannulation assistance / Difficult access]
• Vessel Assessment: [Patency, compressibility, absence of thrombosis]
• Needle Passes: [Number]

Equipment

• Catheter: [Brand/Model or "not recorded"], [Size in French], [Single / Double lumen]
• Lot/Batch Number: [Lot number / Not recorded]
• Trimmed: [Yes — method / No]
• Introducer Technique: [Standard cannulation / Modified Seldinger / Other]
• Priming/Flush Solution: [Solution used]

Technique

[Narrative of patient positioning, cannulation approach (e.g., transillumination, tourniquet use), venous entry, catheter advancement. Note whether advancement was smooth or if resistance was encountered and how addressed, including any withdrawal and re-advancement.]

• Skin Punctures: [Number]
• Venous Cannulation Attempts: [Number]
• Second Operator: [Name, role / No]

Measurements

• Measured Optimal Insertion Distance: [cm] — Method: [Entry site to anatomic landmark]
• Actual Catheter Length Inserted: [cm]
• External Length at Skin: [cm]
• (If not advanced to measured optimum, document reason: resistance, anatomic limitation, malposition concern.)

Line Function and Securement

• Aspirate Blood: [Yes / No / Not attempted — reason]
• Flush: [Flows without resistance / Resistance encountered — action taken]
• Site Assessment: [No swelling or infiltration / Swelling/infiltration present — description and action]
• Dressing Confirmed: [Clean, dry, intact]

Tip Confirmation

• Imaging Modality: [CXR / Abdominal radiograph / Contrast study / Ultrasound / Other]
• Tip Location: [SVC / IVC / Other vessel] — [Outside cardiac silhouette / Not outside cardiac silhouette] — [Vertebral level if used locally]
• Limb/Head Position During Imaging: [Position] (Include if relevant to interpretation.)
• Repositioning: [Not required / Adjusted by cm in/out — repeat imaging result]
• Approving Clinician: [Name, role]
• Line Cleared for Use: [Yes / No] (If interpretation pending, state line will not be used for TPN or hyperosmolar infusions until tip confirmed.)

Complications

[Immediate complications: bleeding, hematoma, arterial puncture, arrhythmia, catheter malposition or damage, infiltration, suspected thrombosis — actions taken / None] (If procedure aborted or unsuccessful, document reason and post-attempt patient condition.)

Post-Procedure Condition

• Tolerance: [Stable vital signs / Changes noted — describe]
• Respiratory Support: [Returned to baseline / Changed — describe]
• Site Appearance: [Clean, dry, intact] — Hemostasis: [Achieved / Not achieved — action]
• Disposition: [Remained in NICU / Transferred] — [Returned to baseline support]

Line Maintenance Plan

• Permitted Uses: [List permitted infusates] — Restrictions: [Until tip confirmed / If tip non-central: concentration limits and infusate restrictions]
• TPN Start: [Now / After tip confirmation / Deferred — reason]
• Dressing Management: [Change if loose, soiled, or bleeding; routine schedule per protocol]
• Hub Access: [Scrub and disinfect per protocol; minimize entries]
• Daily Review: [Assess necessity; plan for earliest removal]
• Tip Surveillance: [Re-image per institutional schedule or if clinically indicated]
• Escalation: [If concern for migration, inability to flush, site swelling, or unexplained deterioration: stop infusions, secure line, notify provider, obtain imaging]