Neonatal PICC and Midline Insertion: A Practical Guide to First-Time Success

Part 3 of the series: Neonatal Vascular Access: A Practical Guide to PICCs and Midlines

Introduction

Every vascular access attempt matters.

Failed insertion attempts may contribute to procedural delays, vessel trauma, increased workload and reduced future access opportunities. For neonatal patients with limited venous access, achieving first-time success has become a key objective of contemporary vascular access practice.

This practical guide outlines the steps clinicians can take to maximise the likelihood of successful PICC and Midline placement.

Step 1: Confirm Device Selection

Before preparing for insertion, confirm that the selected device aligns with:

• Therapy requirements
• Expected treatment duration
• Vessel preservation goals
• Future treatment plans

Insertion success begins with selecting the correct device.

Step 2: Perform a Structured Vessel Assessment

Evaluate:

Vessel Size

Can the selected vessel safely accommodate the catheter?

Vessel Quality

Has the vessel previously been cannulated?

Is there evidence of irritation or damage?

Vessel Location

Will securement be achievable?

Will routine care interfere with catheter stability?

Future Access Needs

Should this vessel be reserved for future treatment requirements?

Step 3: Plan the Procedure

Successful insertion relies on preparation.

Before starting, confirm:

• Appropriate catheter selection
• Availability of insertion equipment
• Suitable patient positioning
• Adequate lighting
• Availability of assistance if required
• Maintenance of aseptic technique

Preparation can reduce procedural delays and improve efficiency.

Step 4: Consider Technologies That Support Access

Small neonatal vessels can be challenging to access consistently.

Adjunct technologies may help improve procedural success, including:

• Ultrasound guidance
• Vein visualisation systems
• Introducer kits

Modified Seldinger Technique and Specialised Access Systems

For PICC and Midline placement, some clinicians may utilise Modified Seldinger Technique (MST) to support access to small or difficult-to-cannulate vessels. Using a guidewire-assisted approach, MST can facilitate catheter placement while helping to minimise vessel trauma. Specific insertion kits have been designed to support this technique and may provide greater procedural control when accessing fragile neonatal veins. When used alongside vessel assessment and appropriate vein selection, these approaches may contribute to first-attempt success and support vessel preservation goals.

Step 5: Focus on Vessel Preservation During Insertion

Throughout the procedure, ask:

• Is the selected vessel still appropriate?
• Are repeated attempts becoming harmful?
• Should an alternative strategy be considered?

Maintaining a vessel preservation mindset can help prevent avoidable vessel injury.

Step 6: Secure the Device Correctly

Insertion success does not end once the catheter enters the vein.

Following placement:

• Confirm catheter position
• Record baseline measurements
• Secure the device appropriately
• Apply dressings according to local policy
• Establish an ongoing monitoring plan

First-Time Success Checklist

Before insertion:

✅ Right patient

✅ Right therapy

✅ Right device

✅ Right vein

✅ Right equipment

✅ Right inserter

✅ Right securement plan

Clinical Takeaways

• First-time success starts before the procedure begins.
• Structured vessel assessment improves decision-making.
• Appropriate technology may help reduce repeated puncture attempts.
• Vessel preservation should guide every insertion decision.
• Successful insertion extends beyond catheter placement to include securement and ongoing care.

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