Less Pain in Neonates During Central Lines Insertion
Less Pain in Neonates During Central Lines Insertion
Central venous access is an imperative measure used in neonates whether being a
 peri-operative measure for children undergoing cardiac procedures for congenital heart
 diseases or as a mean of nutrition in neonatal enteral malnutrition and drug administration
 in oncology patients. Central catheters fall into two categories, a peripherally inserted
 central catheter (PICC) line or centrally inserted central catheters (CICC). Although these
 two modalities practically have the same aim, identifying the more effective technique is
 imperative for deciding which procedure should be applied to ameliorate patient outcomes.
 Many studies have been previously done that delineate the indications for central venous
 access with practically no absolute contraindications. These indications include central
 venous pressure (CVP) monitoring, poor venous access, volume resuscitation, and prolonged
 venous access in critically ill patients, total parenteral nutrition (TPN), cardio-pulmonary
 resuscitation and medication administration. Centrally inserted catheters have evolved from
 being blindly inserted catheters using landmarks techniques, is the usual standard of care,
 to being placed under direct visualization using ultrasound guidance. Since its first use
 back in the 90's, ultrasound guided insertion of central venous catheters has gained
 attention and successful attempts have been made to improve this technique. US-guidance
 initially used acoustic Doppler techniques but is now largely replaced by two-dimensional
 (2D) imaging and internal jugular vein (IJV) being the preferred site of insertion by US over
 femoral and subclavian vein. Several studies have compared these two techniques.
 Small-caliber vessels remain a great challenge in the pediatric population which backup the
 use of imaging modalities for a successful and safer insertion of CVCs.

 This study aims to develop a better understanding of pain during central line insertions,
 compare pain scores between the two techniques in order to adopt the less painful technique
 and ultimately provide insight about the use of analgesics during these procedures for a
 better outcome.
A single-center prospective randomized controlled study of neonates (preterm and term babies)
 who underwent an elective or emergent central line insertion between November 2016 and May
 2017 was conducted at SGHUMC Neonatal Intensive Care Unit. Hospital's Institutional Review
 Board approved the study and an informed parental consent was signed for study entry.
 Inclusion criteria included neonates requiring TPN, antibiotic therapy for at least 7 days,
 and babies with poor or difficult venous access. Exclusion criteria included refusal to sign
 consent, patients with previously attempted or placed central lines, and patients who were
 converted from one technique to the other. Patients were randomized into the control and
 intervention group through a flip of coin each time a patient enrolled in the study The
 catheter used for all the patients was an epicutaneo-cava-catheter (ECC), silicone tube
 material kit, 24G, VYGON® (Aachen, Germany). All procedures were performed under sterile
 precautions such as hand washing, use of sterile gloves and gowns, facemask, hair cover, and
 protective eyewear.

 The control group consisted of neonates who underwent a PICC line placement. The method of
 insertion performed followed the procedure previously described by Pettit. Patients in the
 intervention group underwent US-IJV. This procedure was carried out as follows: The patient's
 skin was sterilized with chlorhexidine gluconate and the area was infiltrated with local
 anesthetic agent (lidocaine). Vascular cannulation was performed using the ECC's winged
 needle. The target vessel was located via the US dynamic (real-time) method. At the point of
 needle insertion, the ECC was placed through the needle without guide wire placement. Once
 the catheter was inserted, a gentle aspiration was performed to show blood flow through the 3
 ml syringe that was connected to the ECC. The catheter was then secured and fixed with simple
 steri-strips and covered by the transparent dressing. Both techniques were performed by two
 institutional neonatologists who according to their expertise, one performed all PICC line
 placements while the other performed all US-IJV.

 Transducer selection and the axis of visualization are important to consider in the use of US
 for ECC, as such a linear 6-13 MHz transducer Sonosite M-turbo was used (manufacturer's
 recommendations). The transverse view shows the vessel under the transducer and the adjacent
 structures. The tip of the needle is visualized and inserted at a 45° angle. The longitudinal
 view helps to track the needle progression toward the IJV. Post procedural chest radiography
 was done for both groups to confirm placement and evaluate for complications.

 The primary outcome measured was the pain score difference between Ultrasound inserted
 central line and peripherally inserted central line. The pain score was measures using the
 Neonatal Pain, Agitation and Sedation Scale (N -PASS). The N-PASS is based on several
 criteria: crying / irritability, behavior / state, facial expression, extremities / tone and
 vital signs. Patient characteristics such as gestational age, age, gender, admission
 diagnosis, weight have been taken into account and the scores was recorded by the nurse in
 charge of the baby before and during the procedure. Pain score difference was calculated by
 subtracting the score during the procedure from the pain score before the procedure.

 The secondary outcome measures included the number of first successful attempts, number of
 total attempts and procedure duration. Additional patient information collected included
 gender, TPN administration, gestational age, birth weight and diagnosis.
Inclusion Criteria:

 -  neonates requiring TPN

 -  antibiotic therapy for at least 7 days

 -  babies with poor or difficult venous access

 Exclusion Criteria:

 -  refusal to sign consent

 -  patients with previously attempted or placed central lines

 -  patients who were converted from one technique to the other