**5. Conclusion**

which leads to more advancement of PICC line. This can be avoided by using rope method of measurements (can use a nasogastric tube or any flexible tubes) along the course of

**3.** Before insertion, make sure the catheter tip is not bent or curved, which is proposed to cause more damage to the vessel wall and vascular erosion. If the catheter is inappropriately placed in the intracardiac position, it can cause pericardial tamponade and pleural

**4.** Central venous catheter insertion should be done under strict cardiac monitoring with properly placed ECG leads. Performing physician should monitor the ECG wave patterns carefully especially while introducing the catheter beyond brachiocephalic vein. If any mild changes are observed in the ECG, the catheter should be withdrawn immediately. **5.** If the introducer feels the cardiac pulsations in the catheter or the slightest resistance dur-

**6.** Fix the catheter with the exact measurement. One should avoid increasing 1 or 2 cm more,

**7.** Confirmation of catheter positioning with radiography should be done immediately after the insertion of catheters. Optimizing a good position of the neonate is mandatory (**Table 5**). The interaction between the neonatal posture, and radiological catheter position is well

**8.** Always aim to place the catheter in an optimal position. The ideal position is 0.5–1 cm away from the cardiac outline in preterm and 1–2 cm away from the cardiac outline in term neonates. Confirmation by ultrasound is upcoming and it is welcoming advancement in neonatal care [15]. Real-time ultrasound has been shown to have good diagnostic utility in comparison with X-ray with sensitivity of 95–96.5% and specificity of 100% in neonates [18–20].

**9.** Know the catheter tip position. Identify it in each X-ray and if it needs adjustments, per-

**10.** Prevention of catheter migration is at most important by application of the secure transparent dressing. Secure it with proper measurement and document the external catheter length. External length needs to be verified in each shift. Proper hand over by the concerned staff nurse is mandatory to notify the migration early. Repeated pump occlusion

**11.** Arrhythmic complications can occur anytime from the time of insertion to the time of removal of catheters. Any neonate with the catheter in situ developed arrhythmia could

Upper extremity X-ray Keep both arms and forearms straight Over the sides of the neonate

assuming that can later withdraw it after confirming the position with X-ray.

veins applicable to lower and upper extremity veins.

ing the pathway, the catheter should be withdrawn immediately.

form the amendments. Do not ever forget to document it.

**Table 5.** Ideal positions for X-rays pertaining to different sites of PICC line [10].

effusion secondary to the curved catheter.

172 Cardiac Arrhythmias

explained in advances in neonatal care.

alarms could be a sign of migration [13].

Lower extremity X-ray Keep both legs straight

Central line insertion is a very common bedside procedure in NICU setup, it is not uncommon to encounter complications. Although there are various complications related to PICC line insertion, arrhythmic complications are preventable by exact measurements along the venous course, avoidance of willful over advancement of the catheter, prevention of migration and early detection of migration and adjusting the catheter tip properly. Ultrasoundguided insertion of catheter and placement of catheter tip using real-time ultrasonography is a welcoming advancement to minimize arrhythmic complications. Worldwide, the reported incidence of arrhythmic complications published in the literatures are few.
