Radiographic inguinal curl may indicate paraspinal misplacement of percutaneously inserted central venous catheters: report of three cases

The appropriate frequency of dressing for percutaneous central venous catheters in preventing catheter-related blood stream infection in NICU - A randomized controlled trial

BACKGROUND

Complications of percutaneous central venous catheters (PCVCs) include catheter-related blood stream infection (CRBSI), occlusion, leakage, and phlebitis, which may lead to sepsis or prolonged hospitalization. The primary objective of this randomized controlled trial was to determine the appropriate frequency of dressing for percutaneous central venous catheters in preventing CRBSI, every week regularly vs. non-regularly, in premature neonates in NICU.

METHODS

Patients in NICU requiring PCVCs from March 2019-May 2020 were enrolled. Enrolled patients were randomly assigned into 2 groups: regular dressing group (RD), for which dressings were changed every week regularly, or additionally when oozing was noticed; and non-regular dressing group (ND), for which dressings were changed only when oozing was visible. The incidence of CRBSI, occlusion, leakage, and phlebitis were compared between the two groups using the Chi-squared test. The incidence of catheter-related complications was defined as numbers of episodes per 1000 catheter-days.

RESULTS

A total of 197 PCVCs were enrolled. The ND and RD groups had 99 and 98 PCVCs, respectively. The average CD interval was 9.3 days in ND group and 5.8 days in RD group. The incidence of CRBSI in RD group was 0‰, which was significantly lower than that of ND group, which was 2.0‰ (p = 0.048), but no significant differences were found between groups in the incidence of occlusion, leakage, and phlebitis of PCVCs.

CONCLUSION

Regular dressing changes every week and when oozing occurs while maintaining the protocol of maximum sterile barrier precautions is the best method and frequency of dressings of PCVCs.

Central venous catheters misplaced in paraspinal veins: A systematic literature review based on case reports

BACKGROUND

Paraspinal vein misplacement is an uncommon complication of central venous catheterization via lower extremities, most of which have been reported in case reports.

AIM

To determine the clinical characteristics of paraspinal vein misplacement.

DESIGN

This was a systematic review.

METHODS

A systematic literature search in the PubMed, EMBASE, Scopus, and Web of Science databases was performed from their inception to 18 June 2019. Case reports and small case series describing central venous catheter misplacement in the paraspinal vein were included. Data on the catheterization procedure, catheter tip position, complications, and radiographic features of misplacement were extracted.

RESULTS

Thirty studies with a total of 36 patients were included. The ascending lumbar vein accounted for the majority of misplacements (n = 30), followed by the lumbar vein (n = 4), iliolumbar vein (n = 1), and vertebral venous plexus (n = 1). Six patients had eventful catheterization procedures. Twenty-six patients experienced misplacement-induced complications, of whom seven died. The most common complications included cerebrospinal fluid abnormalities, neurological symptoms, and deteriorated respiration. Among the entire case cohort, the onset of complications was the primary sign that alerted medical staff to misplacement (n = 23). The typical radiographic characteristics were posterior deviation of the catheter course overlapping with the spine on lateral X-rays and a bend, kink, or hump in the catheter course on anteroposterior X-rays at the L4 to L5 levels.

CONCLUSIONS

Nurses should be aware of this particular complication if a patient who has undergone catheterization via a lower extremity presents deterioration of neurological function and respiration.

RELEVANCE TO CLINICAL PRACTICE

Lateral X-ray radiography is an effective method to verify misplacement and is recommended as routine practice during catheterization via lower extremities.

The equations of the inserted length of percutaneous central venous catheters on neonates in NICU

BACKGROUND

In neonatal intensive care units, a percutaneous central venous catheter (PCVC) is inserted peripherally and threaded into a central venous location, when intravenous access is anticipated for an extended period of time. The tip location of PCVCs should be checked by an X-ray after the procedure. The present study aimed to determine an equation to estimate the optimal insertion length of PCVCs in neonates prior to the procedure.

METHODS

The data of all neonates who had PCVC insertion between May 1st 2015 and April 30^th 2016 was reviewed. Their gender, body weight and body length at the insertion date, any complications and the tip culture of their PCVCs were recorded. The tip location of the PCVC, which was confirmed by X-ray, was either in the inferior vena cava near to the diaphragm or in the superior vena cava before the right atrial junction, depending on the insertion site. We analyzed the correlation among inserted length of PCVCs, body weight and body length by linear regression to determine an equation for estimating the optimal insertion length of PCVCs. The accuracy of the equations was evaluated prospectively by Pearson's correlation analysis, and the adjusting rate of PCVCs after the initial insertion was compared between the traditional method and using the equation.

RESULTS

The equation of PCVCs inserted in the foot was "insertion length (cm) = 16 + 4.27 × body weight (kg)", in the femoral vein was "inserted length (cm) = 9.8 + 1.7 × body weight (kg)", in the popliteal vein was "inserted length (cm) = -0.3 + 0.45 × body length (cm)", in the hand was "inserted length (cm) = 4.46 + 0.32 × body length (cm)", and in the axillary vein was inserted length (cm) = 1 + 0.18 × body length (cm). The adjusting rate of PCVCs after initial insertion was decreased from 73.5% to 53% following use of the equation.

CONCLUSIONS

Equations provided a convenient and accurate method to estimate the optimal insertion length of PCVCs before their placement.

Parenteral Nutrition Solution in Cerebrospinal Fluid in Preterm Newborn – a Case Report and Review of the Literature

Introduction

Percutaneously inserted central venous catheters (epicutaneo-cava-catheter - ECC) are widely used in neonatal intensive care, facilitating the parenteral nutrition and the treatment of critically ill newborns. This invasive procedure is regarded as safe and associated with low complication rate. Possible life-threatening complications may result from malpositioning of ECC. Paraspinal misplacement of ECC is one of the most serious complications.

Case Presentation

The authors report a case of misplacement of ECC inserted via left saphenous vein for intravenous feeding. A plane radiograph performed after the procedure showed the line tip at L3-L4 level, supposed to indicate location of the catheter in the vena cava inferior. Three days later, the infant developed neurologic symptoms (lethargy, hypotonia, seizures). Lumbar puncture revealed milky fluid containing parenteral nutrition solution. The infusion was stopped. X-ray with contrast showed the catheterization of the left ascending lumbar vein draining the vertebral venous plexuses. The contrast was highlighting the epidural space. The line was immediately removed resulting in improvement in patient's condition and resolution of all neurological symptoms. There was no sequela of this infiltration and the baby had an uneventful recovery. Follow-up at the age of 12 months showed normal development.

Conclusions

A percutaneous catheter inserted via a lower limb may inadvertently enter the ascending lumbar vein. As previously reported, a catheter inserted via the left lower limb is a risk factor of this malposition. The life-threatening complications may be avoided by careful verification of ECC position (lateral x-ray, contrast examination). Plain radiography alone may not be sufficient for tip localization.

Neonatal peripherally inserted central catheter practices and their association with demographics, training, and radiographic monitoring: results from a national survey

The goal of this secondary analysis of results from a national survey of peripherally inserted central catheters (PICCs) practices in neonates was to determine whether demographics and types of training were associated with differing radiographic confirmation practices of these catheters. Correlational analyses were performed on the 2010 national database of neonatal PICC practices. The sample consisted of 187 respondents, representing 25% of the level III neonatal intensive care units (NICUs) of more than 20 beds in the United States. The key factors examined were geographic location, size of NICU, academic affiliation, and type of training related to radiographic confirmation of the catheter tip position, routine monitoring and reconfirmation of the catheter tip position following adjustments, and associated patient positioning practices for consistent evaluation of the catheter tip position. Formal training and annual retraining were statistically significantly associated with consistent patient positioning practices for more accurate monitoring of the catheter tip position and acceptable tip location. Size of NICU and academic affiliation were not associated with differences in practices. Adherence to specific national guidelines and recommendations for care of infants with PICCs is significantly impacted by formal training and annual retraining. This underscores the importance of education and annual retraining in preventing PICC-related complications beyond the crucial prevention of central line-associated bloodstream infections.

Anatomical and radiological evidence for the iliolumbar vein as an inferior lumbar venous system

The purpose of this work was to study an inferior lumbar venous system, which turned out to be the vertical component of the iliolumbar vein as defined in early works by Bourgery and Jacob, though there is a terminological ambiguity between the iliolumbar vein and the ascending lumbar vein in the literature. However, the iliolumbar vein is most commonly defined as a vein draining the fourth and fifth lumbar vertebral segments. Cadaver studies, including one injection-corrosion, and in vivo venograms were analyzed by visual inspection and measurements. Whether the injection was made via the axillary or the saphenous veins, the inferior lumbar vein was always filled, demonstrating that it is part of the vertebral venous system. An interruption or a plexiform shape of the venous system at the level of the third lumbar vertebra, and an increase in caliber as this vein runs downwards, allowed differentiating the inferior lumbar vein from the ascending lumbar vein. The inferior lumbar vein and the superior iliac vein drained into the iliac veins, either external or internal iliac vein, but typically into the common iliac vein, separately or with a single common trunk. This common trunk was observed in 92% of the dissected cases on the right side and in 46% on the left, whereas it was seen in 50% of the radiological studies on the right side and 52% on the left. Consequently, the inferior lumbar vein was the main component of the iliolumbar vein, and as such should be differentiated from the ascending lumbar vein.