Ultrasound-guided central venous access in the NICU: indications, insertion and management

Ultrasound-guided cannulation of deep veins has advanced in little more than a decade from the operating room to the neonatal bedside and from a rescue maneuver to a planned procedure. Centrally inserted central catheters (CICCs) and femorally inserted central catheters (FICCs) are quite different from epicutaneo-cava catheters: they are 3-4 Fr power-injectable polyurethane catheters that are easy to tunnel, secured by subcutaneous anchorage, and suitable for blood transfusion, high-flow infusions, repeated blood sampling, and hemodynamic monitoring. This narrative review examines the indications, materials, insertion bundles for CICCs and FICCs in newborns, as well as their management, complications, and the training gap that now limits their diffusion more than any technical obstacle. In published studies, procedural success is 97-100%, immediate complications are absent or rare (when an insertion bundle is used), and the bloodstream infection rate is severalfold lower in infants below 1,500 g and below 1,000 g compared with the epicutaneo-cava catheter. Since the evidence comes mainly from a few high-volume centers with high procedural expertise, the priority for future research is to define strategies - structured programs, simulation, proctoring - to build and maintain the same level of competence in lower-volume units.

Though the supporting evidence is observational, Ultrasound-guided CICCs (or FICCs, if in selected cases) appear to be the most appropriate central venous access for the critically ill newborn.

• Ultrasound-guided CICCs and FICCs can be placed at the bedside in neonates, including extremely low birth weight infants, and outperform epicutaneo-cava catheters in safety, flow, dwell time, and range of use. • The adoption of insertion bundles reduces immediate and late complications of central venous catheterization in neonates and children.

• Multicenter and comparative neonatal data show reproducible procedural success across centers and several-fold lower bloodstream infection rates in the smallest infants, compared with epicutaneo-cava catheters. • The limiting factor is no longer technical feasibility but structured training; tunneling remains the most frequently omitted step in the insertion bundle and the least easily replaced.