Central venous catheter-related complications in newborns and infants: a 587-case survey

A quality improvement initiative standardizing the antibiotic treatment and feeding practices in patients with medical necrotizing enterocolitis

OBJECTIVE

Evaluate the impact of a multidisciplinary guideline standardizing antibiotic duration and enteral feeding practices following medical necrotizing enterocolitis (mNEC).

STUDY DESIGN

For preterm infants with Bell Stage 2 A mNEC and negative blood culture, antibiotic treatment was standardized to 7 days. Trophic feeds of unfortified human milk began 72 h after resolution of pneumatosis. Feeds were advanced by 20 cc/kg/day starting on the last day of antibiotics. Primary outcomes were antibiotic days and days to full feeds, defined as 120 cc/kg/day of enteral nutrition. Secondary outcomes included central line days and length of stay (LOS).

RESULTS

Antibiotic duration decreased 23%. Time to start trophic feeds and time to full feeds decreased 33 and 16% respectively. Central line use dropped (98 to 72% of infants) and central line days were reduced by 59%.

CONCLUSION

Implementation of a mNEC QI package reduced antibiotic duration, time to full feeds, central line use and CL days.

The incidence and mortality rate of catheter-related neonatal pericardial effusion: A meta-analysis

BACKGROUD

Neonatal pericardial effusion (PCE) is one of the most severe complications of central catheters in neonates with its rapid progression and high mortality. We aim to estimate the overall incidence and mortality of catheter-related neonatal PCE, more importantly, to identify possible predictors for clinical reference.

METHODS

We searched MEDLINE, Embase, Cochrane Library, Web of Science, china national knowledge infrastructure, Wanfang Data, and Sinomed databases for subject words "central catheter," "neonate," "pericardial effusion" and their random words till June 8, 2020. This meta-analysis is based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Possible predictors of occurrences and deaths were extracted and assessed cooperatively. The pooled incidence rate of catheter-related neonatal PCE was calculated using a random effects model.

RESULTS

Twenty-one cohort studies and 99 cases were eligible. Pooled incidence is 3·8‰[2.2‰, 6.7‰]. Polyurethane catheters generate significantly more neonatal PCE than silicone counterparts (P < .01). 27% of the patients die. The mortality of patients with bradycardia is higher than others (P < .05). Catheters with a guidewire result in more deaths than umbilical venous catheter (UVC) and peripherally inserted central catheters (PICC) (P < .05). Without pericardiocentesis, mortality increases (P < .01). The difference of deaths between reposition and removing the catheter is insignificant (P > .05).

CONCLUSION

Central catheters in Seldinger Technique (with a guidewire) put neonates at greater risk of PCE and consequent death. Silicone catheters excel at avoiding deadly catheter-related PCE, which could be a better choice in neonatal intensive care units (NICU). When catheter-related PCE occurs, timely diagnosis and pericardiocentesis save lives.

Simplify long-term venous access via external jugular vein in children

Background

Bone marrow transfer has begun to be widely used in complicated conditions, such as chemotherapy or hemodialysis, following the description of indwelling central venous catheters and demonstrating their suitability in pediatric patients. The widespread use of it has increased the incidence of complications as well. The use of external jugular vein catheterization, which is a safer route compared to the blind route of administration, has topographical difficulties. The findings obtained in this study showed that these difficulties could be overcome. Our study revealed that the catheterization was possible and described a facilitating technique. Of the pediatric patients involved in the bone marrow transfer programs, patients who were deemed eligible candidates for the use of external jugular vein, based on the preoperative assessment, were included in the present study.

Results

No early complication was observed in this study. The central catheter was placed on all patients in the same session. Catheters were inserted using the external jugular vein in 98 patients and percutaneous internal jugular vein in 2 patients. A central catheter was inserted through 105 interventions and 103 incisions in 100 patients. External jugular vein use, which was planned before the procedure, was achieved in 98 patients. The internal jugular vein was selected as the second option in 2 patients. The success rate of external jugular vein use was 95.1%.

Conclusions

The findings obtained in this study suggest that placement of a central catheter using an external jugular vein is an appropriate option. Application difficulties can be overcome. Mechanical and early complications are negligible compared to percutaneous blind techniques. The use of the external jugular vein route is easy, requires less equipment, has few complications, and the success of the procedure is a preoperatively predictable technique. External jugular vein catheterization is a better alternative compared to the Seldinger technique, in the absence of ultrasonography, which enhances the success of the percutaneous technique, and in cases where blind techniques, such as bleeding diathesis, may be unfavorable.

Bin Mahmoud L, AlHemiad M, Almuhaini M, Huseynov O. Early pericardial effusion as complication of umbilical venous catheter insertion in extreme preterm baby: A case report

Reminder essential clinical practice: Pericardial effusion is a rare fatal condition, however potentially reversible when grasped in time. It should always be thought out in neonate with a central line who develops unexplained cardiorespiratory failure.

Long-term IV access in paediatrics - why, what, where, who and how

Establishment of long-term central venous access imposes the risk of procedural adverse events (air embolism, pneumothorax, accidental arterial cannulation of the great vessels, tricuspid valve damage and cardiac tamponade) as well as the risk of increased morbidity and mortality due to catheter related blood stream infections, vessel stenosis, deep vein thrombosis and the often high risk anaesthetic management of syndromic children. This narrative review aims to provide a historical and clinical background for the development and use of CVADs (central venous access devices), origin and management of the most common complications (catheter related thrombosis, infections and persistent withdrawal occlusion) and present the reader with an update on the "why, what, where, who and how" in paediatric long-term central venous access. Finally, we will present the reader with a clinical method for applying a retrograde inserted tunnelled and cuffed catheter using the left brachiocephalic vein access.

Ultrasound-guided double central venous access for azygos vein via the ninth and tenth intercostal veins

Some patients with intestinal failure, who are dependent on total parenteral nutrition for long periods, suffer from a lack of suitable conventional venous access points, including axillary, external jugular, internal jugular, subclavian, saphenous, and the brachio-cephalic and femoral veins, due to their occlusion. Furthermore, extensive central venous stenosis and/or thrombosis of the superior and inferior vena cava may preclude further catheterization, so uncommon routes must be used, which can be challenging. In such patients, the azygos vein via the intercostal vein is a viable candidate. Thoracotomy-assisted, thoracoscopy-assisted, and cut-down procedures are currently suggested such access. We found that ultrasound-guided percutaneous puncture method was a safe and minimally invasive approach and successfully placed two central venous lines in preparation for small bowel transplantation via two different intercostal veins (ninth and tenth). Although the lung was actually located just below the target veins, an ultrasound provided augmented and clear vision, which contributed to the safe performance of the procedure without the need for invasive surgical intervention, such as thoracotomy, thoracoscopy, or rib resection using the cut-down technique. Furthermore, constant positive-pressure ventilation during vein puncture under general anesthesia also helps avoid venous collapse. Despite carrying a slight risk of light injury to the lung, artery, and nerve along with the vein compared to other procedures, we believe that ultrasound-guided puncture under general anesthesia is feasible as a minimally invasive method.

Risk factors for peripherally inserted central catheter complications in neonates

OBJECTIVE

To determine factors associated with nonelective PICC removal and complications.

STUDY DESIGN

Overall, 1234 PICCs were placed in 918 hospitalized infants <45 weeks postmenstrual age. Outcomes studied include nonelective PICC removal (removal prior to completion of therapy) and line complications. Univariate and multivariate mixed-effects logistic regression analyses were conducted to evaluate the associations between potential predictor variables and clinical outcomes RESULTS: Nonelective PICC removal occurred in 28.4% and complications in 34.4% of infants. Nonelective removal (p < 0.001) and complications (p = 0.006) occurred more often with upper than lower extremity PICCs. Malposition in the first 72 h (p = 0.0009) and over time (p = 0.0003) were more common in upper extremity PICCS; however, upper extremity PICCs were associated with a decreased incidence of phlebitis, edema, and perfusion changes (p = 0.03).

CONCLUSIONS

Approximately one-third of PICCs were associated with complications. When feasible, lower extremity PICCs should be placed as they may be associated with fewer complications.

Open tunneled central line insertion in children - External or internal jugular vein?

BACKGROUND/PURPOSE

Tunneled central venous catheters (TCVCs) are commonly used to manage pediatric patients with chronic disease. The aim of this study is to compare the outcomes of external jugular vein (EJV) and internal jugular vein (IJV) tunneled catheters inserted using the open technique.

METHODS

This is a single institution retrospective analysis of patients requiring an IJV or EJV TCVC in the period between 2009 and 2014. Data collected included the following: patient demographics, site/side of insertion, catheter size, number of lumens, duration of catheter in situ, and complications.

RESULTS

A total of 942 TCVCs (690 IJV; 252 EJV) were inserted in 761 patients. No statistical difference was seen between the two groups for procedure indications, age, gender, duration of line in situ, side of insertion, catheter size, number of lumens, and rate of premature catheter removals owing to complications. Rates of infection, blockage, and breakage were similar, but dislodgement was higher in the IJV group. EJV access was successful in 91% of attempts.

CONCLUSIONS

Open EJV TCVC insertion is a safe, quick, and feasible alternative to IJV insertion. EJV access offers comparable outcomes, reduced surgical morbidity, and improved hemostasis especially in children with coagulopathy and/or reduced platelet counts.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

Level 3.

Rare Complications during Surgical Vein Cannulation in Extremely Low Birthweight Neonates

Extremely low birthweight neonates often require total parenteral nutrition by central venous catheterization. The technique of choice is the percutaneous cannulation via the basilica or cephalic vein; in particular cases, these peculiar patients need a cut down catheterization. This paper describes some unusual complications of this surgical approach.

Central Venous Access in Pediatric Patients

Occlusion of traditional sites for central venous cannulation is a challenging problem in patients that require a permanent central venous line for chronic administration of nutrients or drugs.

In rare cases, extensive central venous thrombosis of the superior and inferior vena cava may preclude catheterization, and uncommon routes should be used.

We describe our approach for placement of chronic central venous lines in two pediatric patients with short bowel syndrome and extensive caval occlusion.

Replaceable Jejunal Feeding Tubes in Severely Ill Children

Long-term enteral nutrition in chronically ill, malnourished children represents a clinical challenge if adequate feeding via nasogastric or gastrostomy tubes fails. We evaluated the usefulness and complications of a new type of surgical jejunostomy that allows for easier positioning and replacement of the jejunal feeding tube in children. We surgically inserted replaceable jejunal feeding tubes (RJFT) connected to a guide thread which exited through a separate tiny opening of the abdominal wall. In a retrospective case series, we assessed the effectiveness and complications of this technique in severely ill children suffering from malnutrition and complex disorders. Three surgical complications occurred, and these were addressed by reoperation. Four children died from their severe chronic disorders within the study period. The RJFT permitted continuous enteral feeding and facilitated easy replacement of the tube. After the postoperative period, jejunal feeding by RJFT resulted in adequate weight gain. This feeding access represents an option for children in whom sufficient enteral nutrition by nasogastric tubes or gastrostomy proved impossible. Further studies are required to investigate the safety and effectiveness of this surgical technique in a larger case series.

Vascular Access in the Pediatric Population

Vascular access procedures are an important and frequent component of the day-to-day practice of the pediatric surgeon. Most access procedures can be performed percutaneously via Seldinger or modified Seldinger technique and are aided by technology, such as ultrasound and fluoroscopy. Complications, such as infection, do occur, and the pediatric surgeon should be able to diagnose and treat these when they arise. The indications, techniques, and complications of vascular access are covered in this article.

Evaluation of neonatal peripherally inserted central catheter tip movement in a consistent upper extremity position

OBJECTIVE

To compare the effect of standardized upper extremity position versus varied upper extremity positions on neonatal peripherally inserted central catheter (PICC) tip placement and movement. Secondary outcomes assessed were compliance with education, implementation, and complication rates.

STUDY DESIGN

Tip movement was analyzed between 136 post-PICC insertion x-ray pairs from 72 infants in the 6 months before and after standardization of upper extremity position. Tip movement was regressed over days between x-ray pairs, respiratory support, absolute weight change, and insertion vein.

RESULTS

There was no difference in PICC tip movement among varied analysis pairs or when standard position pairs were compared with pairs that were in a same nonstandard position. Days between x-rays, respiratory support, absolute weight change, and insertion vein did not predict tip movement. Attendance at education sessions was 100%. Compliance with the new standard was 73%. Complication rates were not significantly different.

CONCLUSION

Standardization of upper extremity position during neonatal PICC confirmation x-rays did not alter PICC tip movement.

Echocardiography allows more accurate placement of peripherally inserted central catheters in low birthweight infants

AIM

The use of plain radiographs provides limited information on the placement of peripherally inserted central catheters (PICCs). Moreover, changes in upper extremity positioning cause migration of the catheters in neonates. This study aimed to investigate the use of echocardiography for determining catheter tip position, compared with plain radiographs, in low birthweight (LBW) infants in a tertiary neonatal intensive care unit.

METHODS

The study examined the placement of 109 catheters in 89 infants born between September 2010 and December 2012. The placement of these catheters was controlled by echocardiography, with the patient's shoulder in adduction and the elbow in flexion. The number of catheter tips, echocardiographically identified within the heart, was expressed as a percentage of the total catheters deemed to be well positioned on plain radiographs.

RESULTS

The number of catheter tips that were echocardiographically identified within the heart was significant (25%, p < 0.001). Twenty-three catheters were repositioned to be outside of the heart, without any complications.

CONCLUSION

This study demonstrated the value of echocardiography for identifying the positioning of catheter tips in LBW infants. Echocardiography, coupled with initial plain radiographs, should be the gold standard for assessing PICC tip positions in those infants.

Peripherally inserted central catheters for long-term parenteral nutrition in infants with intestinal failure

BACKGROUND AND AIM

Infants with intestinal failure often require long-term central access for delivery of parenteral nutrition (PN). Traditionally, surgically placed central venous catheters (CVCs) have been used; however, the complications associated with these catheters can lead to significant morbidity. Peripherally inserted central catheters (PICCs) are potentially superior to CVCs because they tend to be smaller, and can be placed without general anesthesia. The purpose of the study is to report the use of PICCs for long-term administration of PN in infants with intestinal failure and compare with previously published catheter infection and venous thrombosis rates.

METHODS

A 4-year review of infants younger than 12 months with intestinal failure and a PICC for PN delivery was performed to determine the incidence of catheter-related bloodstream infections (CRBSIs) and PICC-associated venous thrombosis. The complication rates were compared with those reported for CVCs and PICCs in the pediatric literature.

RESULTS

A total of 45 infants with intestinal failure, receiving PN through a PICC were included in the study. Data from 95 PICCs accounting for 10,189 catheter days were collected. The overall incidence of CRBSI was 5.3/1000 catheter days and the incidence of venous thrombosis was 2.0/1000 catheter days.

CONCLUSIONS

PICCs offer an advantage over CVCs in that they can often be inserted without a general anesthesia and do not require manipulation of the vein. Given the low rate of CRBSI and venous thrombosis, we recommend PICCs for infants with intestinal failure requiring PN.

Management of peripherally inserted central catheter associated deep vein thrombosis in children

INTRODUCTION

No protocol exists for prophylaxis or therapeutic management of peripherally inserted central catheter (PICC) related deep venous thrombosis (DVT) in children. Currently, very few patients are provided prophylaxis for DVT. In this study, we analyzed our current practice of PICC placement to identify the frequency of DVT, analyze risk factors and determine current treatment patterns in order to determine the need for protocols.

METHODS

The dataset was retrospectively collected from January 1, 2000 to December 31, 2011. Patients with an upper extremity PICC were assessed for subsequent DVT formation. Variables included: demographics, co-morbidities, method of DVT diagnosis, treatment course, and recurrence.

RESULTS

There were 1,289 PICC placements, with 24 (1.9 %) per line events of DVT in 23 patients, of which 3 had recent surgery, 2 had sepsis, 1 had a family history of clots, and 2 had a malignancy. All but one was symptomatic. Diagnosis was made in 92 % by ultrasound, the remaining with CT. No patients had prophylaxis. Of the seven patients who underwent hypercoagulable work-up, three were positive. 15 patients were treated with enoxaparin, 5 patients were treated with heparin, 2 treated with tissue plasminogen activator and 2 were observed. 84 % were treated with long-term enoxaparin for a mean of 3.3 months with 54 % proven clot resolution and 1 patient had recurrence of UE DVT.

CONCLUSIONS

The risk of DVT with PICC placement is small in children and prophylaxis can probably be reserved for those with previous DVT or known hypercoagulable state.

[Cardiac tamponade with anterior interventricular vein thrombosis complicating central venous catheter insertion in a neonate]

Tamponade is a rare but particularly serious complication of central venous catheters in the newborn. Tamponade can be due to the endocardic aggression caused by the continuous flow of a hyperosmotic solution or by a mechanical injury that can result in perforation of the atrial wall. The risk of tamponade is present whatever is the position of the tip of the catheter, although it has been shown that this risk is increased when this tip is in the right auricle. The originality of our observation is the discovery at the post-mortem examination of an anterior interventricular vein thrombosis, without any lesion of the atrial wall. In the event of the diagnosis of tamponade in living newborn, this etiology must be required because of its therapeutic implications.

The effect of low-dose heparin on maintaining peripherally inserted percutaneous central venous catheters in neonates

OBJECTIVE

To evaluate the effect of low-dose heparin on duration of peripherally inserted percutaneous central venous catheter (PCVC) patency and catheter occlusion.

STUDY DESIGN

Our research was a prospective, randomized, controlled, double-blind clinical study including 246 eligible neonates with PCVCs. It was conducted at the neonatal intensive care unit (NICU) of Diyarbakir Children's Hospital between 1 February 2007 and 31 October 2008. In the heparin group (n=118), the total parenteral nutrition (TPN) solutions contained heparin, which was infused at a rate of 0.5 IU kg⁻¹ h⁻¹ . The no-heparin group (n=121) received TPN fluids without heparin.

RESULT

In the heparin group, the duration of catheter patency was longer than that of the no-heparin group reaching a statistically significant difference (12.4 ± 4.5 vs 9.7 ± 4.0, P<0.0001). In the heparin group, the proportion of patients completing the TPN therapy successfully was higher than in the no-heparin group (P=0.0001; relative risk (RR): 3.32 (95% confidence interval (CI): 1.92 to 5.73)) also demonstrating a statistically significant difference. The rate of catheter occlusion among infants in the heparin group was smaller (P=0.0001; RR: 3.44 (95% CI: 1.92 to 6.44)). There were no statistically significant differences between the two groups in the incidence of other catheter-related problems. The length of the occluded catheter outside the skin, TPN infusion rate and catheter duration time were found to be the factors associated with catheter occlusion. Heparin prevented catheter occlusion with a mechanism unrelated to these factors.

CONCLUSION

In neonates with PCVCs, low-dose continuous infusion of heparin (0.5 IU kg ⁻¹h⁻¹ within TPN fluids is an effective measure in terms of reducing catheter occlusion, allowing successful completion of the therapy, without increasing adverse effects. Furthermore, this effect of heparin may occur independently via occlusion-related factors that we evaluated in the study.

Ultrasound-guided percutaneous insertion of Hickman lines in children. Prospective study of 500 consecutive procedures

AIM

The ultrasound-guided percutaneous technique of Hickman line insertion has not been widely adopted in pediatric surgical practice. We wished to review our own experience of using this technique for insertion into the internal jugular vein.

METHODS

Our vascular access team consists of a consultant surgeon and 2 consultant anesthetists. All procedures were prospectively recorded on a database and were either performed or directly supervised by our team.

RESULTS

Five hundred consecutive Hickman lines were inserted between June 2004 and October 2006. Patients' ages ranged from 14 days to 19 years (median, 44 months). Patients weighed between 600 g to more than 100 kg. Lines inserted were all tunneled silicone Hickman lines with a Dacron cuff (size 2.7F-10F, with 1-3 lumens), of which 60% were 7F double-lumen lines. Successful cannulation occurred in 99.8%. Perioperative complications (within 30 days) occurred in 12 patients (2.4%) and were all treated conservatively with no need for either blood transfusion or chest drain. Catheter-related sepsis rate was 3.16 per 1000 line days.

DISCUSSION

1. The technique of ultrasound-guided percutaneous insertion of Hickman line to the internal jugular vein is safe and is applicable to all children regardless of size, age, or diagnosis. 2. Pediatric surgeons and anesthetists can learn this technique without specific training in interventional radiology. 3. A learning curve does exist, and we recommend concentrating pediatric vascular access procedures to a specialist team.

Rare but serious complications of central line insertion

Discussions on the complications of central venous catheterization in children typically focus on infectious and the more common mechanical complications of pneumothorax, hemothorax, or thrombosis. Rare complications are often more life-threatening, and inexperience may compound the problem. Central venous catheter complications can be broken down into early or late, depending on when they occur. The more serious complications are typically mechanical and occur early, but delayed presentations of pericardial effusions, cardiac tamponade, and pleural effusions may be of equal severity, and delay in diagnosis can be catastrophic. Careful insertion techniques, as well as continued vigilance in the correct position and function of central venous catheters, are imperative to help prevent serious complications.

Percutaneously inserted central catheter for total parenteral nutrition in neonates: complications rates related to upper versus lower extremity insertion

OBJECTIVE

The objective of this study was to compare the complication rates of upper versus lower extremity percutaneously inserted central catheters used for total parenteral nutrition in neonates.

METHODS

During a 48-month study period, 396 neonates were identified as having had percutaneously inserted central venous catheters. A total of 370 catheters were inserted from the upper and 107 from the lower extremity. Data retrieved and analyzed were birth weight, gestational age, age at placement, duration in place, duration of total parenteral nutrition, type of infusates, catheter-related bloodstream infection, phlebitis, leakage, occlusion, necrotizing enterocolitis, intraventricular hemorrhage, serum creatinine, liver function tests, and length of hospitalization.

RESULTS

The median birth weight and gestational age were 940 g and 28 weeks. The rate of catheter-related bloodstream infection was 11.6% for the upper and 9.3% in the lower extremity catheters. The most common organism was coagulase-negative Staphylococcus for both upper and lower extremity catheters and significantly higher with catheters from the upper extremity. Lower extremity catheters were in place longer, and the time from insertion to complication was also longer. The rate of cholestasis was higher for the upper extremity catheters. Multiple regression analysis showed that the most significant contributor to cholestasis was duration of time the catheters were in place and the duration of total parenteral nutrition administration. Receiver operating characteristics curve demonstrated higher sensitivity for duration of catheters in predicting cholestasis with duration of total parenteral nutrition being more specific.

CONCLUSION

Lower extremity percutaneously inserted central venous catheters had lower rates of catheter-related bloodstream infection, longer time to first complication, and lower cholestasis despite longer duration of total parenteral nutrition. When possible, lower extremity inserted catheters should be used for the administration of total parenteral nutrition.

Incidence of deep vein thrombosis related to peripherally inserted central catheters in children and adolescents

BACKGROUND

Peripherally inserted central catheters (PICC) in children and adolescents are being used with increasing frequency. We sought to determine the incidence and characterize risk factors of deep vein thrombosis associated with peripherally inserted central catheters in a pediatric population.

METHODS

We conducted a prospective study involving consecutive patients referred to the radiology department of a tertiary care university-affiliated hospital for insertion of a peripherally inserted central catheter. We included patients aged 18 years or less who weighed more than 2.5 kg and had a peripherally inserted central catheter successfully inserted in his or her arm between June 2004 and November 2005. The primary outcome was the occurrence of partial or complete deep vein thrombosis evaluated by clinical examination, ultrasonography and venous angiography.

RESULTS

A total of 214 patients (101 girls, 113 boys) were included in the study. Partial or complete deep vein thrombosis occurred in 20 patients, for an incidence of 93.5 per 1000 patients and 3.85 per 1000 catheter-days. Only 1 of the cases was symptomatic. In the univariable analyses, the only variable significantly associated with deep vein thrombosis was the presence of factor II mutation G20210A (odds ratio 7.08, 95% confidence interval 1.11-45.15, p = 0.04), a genetic mutation that increases the risk of a blood clot and that was present in 5 (2.3%) of the 214 patients.

INTERPRETATION

The incidence of deep vein thrombosis related to peripherally inserted central catheters in our study was lower than the incidence related to centrally inserted venous catheters described in the pediatric literature (11%-50%).

Dose and image quality optimization in neonatal radiography

In a special care baby unit, neonates, mainly premature, encounter serious to life-threatening diseases, the timely diagnosis and treatment of which may require a large number of radiographs. Increased neonatal radiosensitivity and longer life expectancy increase the risk of radiation-induced cancer, which emphasizes the importance of minimizing dose while maintaining clinically satisfactory image quality. An optimization study on radiation dose and image quality in neonatal radiography is presented. Neonates were categorized into four groups depending on birthweight. For a total of 378 chest and chest-abdomen radiographs, exposure parameters were recorded. Entrance surface dose (ESD) was estimated and dose-area product (DAP) was measured. Image quality evaluation was performed by two observers and was based on the visibility of certain anatomical features and catheters placed during treatment using a five-grade scale. ESD values increased with neonatal weight and demonstrated wide variation (16.4-76.9 microGy, mean 38.2 microGy). A wide variation was also observed in DAP values (1.2-15.0 mGycm2, mean 7.2 mGycm2). Image quality evaluation revealed the feasibility of achieving a diagnostically satisfactory image (score >70%) using both low and high tube voltage techniques, with the latter resulting in reduced ESDs. The majority of estimated ESDs are in accordance with the reference level of 50 microGy recommended by the National Radiological Protection Board for neonatal radiography. The results suggest that the use of high tube voltage techniques could result in further reductions in neonatal dose, without image quality degradation, underlying the requirement for establishing standard examination protocols for neonatal radiography with respect to neonatal weight.

Retained central venous lines in the newborn: report of one case and systematic review of the literature

The use of percutaneously inserted central catheters (PICCs) is an established practice in most NICUs. With the widespread use of these catheters, an increasing number of PICC complications has been reported in neonates. We present one case of a PICC retained and tethered in the vein in a very low birth weight infant, as well as a systematic review of PICC retention cases. Ten previous cases of PICC retention in neonates were found. Among those cases, the most common associated factors were coagulase-negative staphylococcus catheter colonization/bactcremia and long duration of catheterization. Occlusion was not a usefiul sign for predicting catheter retention. Once retention was established, heparin or urokinase instillations were ineffective. Although surgical exploration was sometimes required, firm, continuous traction applied to the catheter over several hours or intermittent, moderately strong pulling maneuvers were successful in 44.4 percent of the cases in which they were performed. Traction did not show major side effects. Our case provides additional support for use of traction as the initial approach in the management of this rare complication.

A randomized, controlled trial of heparin versus placebo infusion to prolong the usability of peripherally placed percutaneous central venous catheters (PCVCs) in neonates: the HIP (Heparin Infusion for PCVC) study

BACKGROUND

Mechanical and infectious complications shorten the effective duration of peripherally inserted central venous catheters. Heparin use to prevent such complications and prolong the usability of peripherally inserted central venous catheters is inconclusive.

OBJECTIVE

Our goal was to evaluate the effectiveness of heparin in prolonging the usability of peripherally inserted central venous catheters in neonates.

DESIGN/METHODS

We performed a multicenter, randomized, controlled trial of heparin infusion (0.5 U/kg per hour) versus placebo for peripherally inserted central venous catheters in neonates. The primary outcome was duration of catheter use. Secondary outcomes were occlusion, catheter-related sepsis, thrombosis, and adverse effects of heparin. To detect a 168-hour (1-week) difference in the duration of catheter use, 192 patients were needed. Kaplan-Meier and Cox regression analyses were performed.

RESULTS

A total of 201 neonates were enrolled (heparin group: n = 100; control group: n = 101). Baseline demographics were similar between the groups. Duration of catheter use was longer in the infants in the heparin versus the placebo group. Study center, gender, birth weight, and type and position of the catheter were not predictors of duration of catheter use. For those in the heparin versus the placebo group, the incidence of elective catheter removal (therapy completed) was 63% vs 42%, of occlusion was 6% vs 31%, of thrombosis was 20% vs 21%, and of catheter-related sepsis was 10% vs 6%, respectively. No adverse events were noted.

CONCLUSIONS

Heparin infusion prolonged the duration of peripherally inserted central venous catheter usability, which permitted a higher percentage of neonates to complete therapy without increasing adverse effects.

Mechanical and Infectious Complications of Central Venous Cannulation in Children: Lessons Learned From a 10-Year Experience Placing More Than 1000 Catheters

We sought to better describe the expected incidence of mechanical and infectious complications associated with central venous cannulation of critically ill children. We undertook a retrospective analysis of a prospective data collection of 1056 consecutive percutaneous central venous catheters inserted under the supervision of an experienced surgeon. There were 245 (23%) subclavian (SC), 118 (11%) internal jugular (IJ), and 693 (66%) femoral (F) catheters placed in 289 children with an average age of 6.4 +/- 5.1 years (range, 4 weeks to 18 years) admitted to a burn intensive care unit. Catheter sepsis occurred in 7.4% of SC, 7.6% of IJ, and 4.9% of F catheters (NS, P = .25), for an overall sepsis rate of 5.8%. The number of catheter lumens did not impact infection rate. Infection rates increased in catheters left in situ more than 10 days, increasing to 37.5% at 14 days. Acute mechanical complications occurred in three insertions (0.3%), including two (0.8%) SC, zero (0%) IJ, and one (0.1%) F catheters (NS, P = .20). All three were arterial cannulations that were recognized and treated successfully without surgery. There were no pneumothoraces, vascular lacerations, acute thromboses, or catheter emboli. There were six (0.6%) cases of deep venous thrombosis that occurred in cannulated sites: one (0.4%) SC, two (1.6.%) IJ, and three (0.4%) F sites (NS, P = .23). Patient age did not influence complication rates. A total of 239 (23%) of the CVCs were placed in infants less than 24 months; 273 (26%) 2 to 5 years, 259 (25%) 6 to 10 years, and 285 (27%) >10 to 18 years. Catheter sepsis occurred in 6.7%, 5.9%, 6.2%, and 4.6%, respectively (NS, P = .75). There was no difference in rates of infection or mechanical complication between younger and older children. When closely supervised by an experienced surgeon, a low rate of infection (5.8%), acute mechanical complication (0.3%), and deep venous thrombosis (0.6%) accompanies central venous cannulation of critically ill children.

Central venous catheter thrombosis as a cause of SVC obstruction and cardiac tamponade in a patient with Diamond-Blackfan anemia and iron overload

Cardiac tamponade is an infrequent but potentially lethal complication related to use of central venous catheters (CVC). We present the case of a 16-year-old female with Diamond-Blackfan anemia (DBA) who developed pericardial tamponade secondary to superior venous caval obstruction caused by CVC thrombosis. The patient presented 3 months after line placement with vomiting, abdominal pain, and cardiomegaly on chest X-ray (CXR). Her condition quickly decompensated with cardiac arrest and subsequent death despite immediate pericardiocentesis. As a result of this case, our center has developed a protocol for the management of CVC problems as a means of facilitating rapid recognition of central line clots.

Neonatal hydrothorax following migration of a central venous catheter

The use of a central venous catheter may occasionally be associated with complications like sepsis, effusions and thrombosis. Migration of the central catheter is an unusual complication that often goes unrecognized. This case report is of a neonate who developed hydrothorax resulting from a migrating central line and highlights the need for a high level of clinical suspicion in diagnosing catheter related problems.

Catheter-malposition-induced cardiac tamponade via contrast media leakage during computed tomography study

We present a rare case of a central venous catheter-malposition-induced life-threatening cardiac tamponade as a result of computed tomography (CT) with contrast enhancement in an infant with a ventricular septal defect and pulmonary atresia after a modified Blalock-Taussig shunt. The diagnosis was confirmed by chest radiographs and CT study with catheter perforation through the right atrial wall and extravasation of the contrast medium into the pericardium, leading to cardiac tamponade and subsequent circulatory collapse. Two hours after successful cardiopulmonary resuscitation, the patient gradually resumed normal hemodynamic status.

Differences in the outcome of surgically placed long-term central venous catheters in neonates: neck vs groin placement

BACKGROUND/PURPOSE

Long-term tunneled central venous catheters (CVC) are frequently used in the neonatal intensive care unit (NICU) babies. They are placed either in the neck or groin based primarily upon the surgeon's preference. There is meager published information available about the relative risks of these lines.

METHODS

This is a retrospective analysis of all the tunneled central venous catheters placed in NICU babies at a children's hospital over a nearly 5-year period. Single lumen Broviac catheters were used in all cases.

RESULTS

A total of 137 catheters were placed in 126 patients. There were 88 neck lines and 49 groin lines. Age, gestational maturity, and body weight were significantly lower for babies who underwent groin line placement. There was no significant difference in the number of days the catheters were live between the 2 groups. Total complication rates and catheter infection rates were significantly higher with neck lines. The accidental removal rate was higher with neck lines but did not reach statistical significance.

CONCLUSIONS

Broviac catheters placed in the groin of NICU babies are associated with significantly fewer complications compared with those placed in the neck.

Central venous catheters and cardiac tamponade in preterm infants

OBJECTIVE

To determine the incidence of cardiac tamponade related to peripherally inserted central catheters in newborns weighing less than 1,500 g during the past 8 years and to provide guidelines in order to avoid death due to this complication.

DESIGN

Retrospective case review.

SETTING

Tertiary level neonatal intensive care unit.

PATIENTS AND PARTICIPANTS

Retrospective study of a total of 280 peripherally inserted central catheters positioned in 258 preterm newborns.

MEASUREMENTS AND RESULTS

Five cardiac tamponades were observed, giving an incidence of 1.8%. Data from our cases included clinical presentation and outcome, biochemical evaluation of pericardial fluid, days until diagnosis, central catheters characteristics, insertion site and tip placement site.

INTERVENTION

Two of the infants did not respond to resuscitation measures including cardiac massage and the administration of epinephrine. Post-mortem examination revealed the intrapericardial accumulation of protein and lipid alimentation solution. The other three patients were successfully resuscitated by timely pericardiocentesis. All five infants had routinely performed serial radiographs and cardiac color Doppler ultrasonography that showed correct catheter tip placement.

CONCLUSIONS

The incidence of cardiac tamponade could be reduced by following specific guidelines. The possibility of tamponade must be kept in mind during the resuscitation of any preterm infant with a peripherally inserted central catheter in place who develops symptoms of shock or sudden bradycardia. Our experience shows that even preterm infants with cardiac tamponade can be successfully resuscitated by timely pericardiocentesis in most cases.

Life-Threatening Mediastinal Hematoma Caused by Extravascular Infusion Through a Triple-Lumen Central Venous Catheter

We report a case of life-threatening mediastinal hematoma in a 6-mo-old girl during surgical correction of scaphocephaly. The hematoma was caused by extravascular infusion via the proximal lumen of a dislocated triple-lumen central venous catheter (CVC). Worsening symptoms of hypovolemia and ventilation problems prompted performance of transesophageal echocardiography, which reliably and quickly allowed us to exclude pericardial tamponade and detect a mediastinal hematoma. The anesthesiologist should be alert when a patient with a CVC develops acute cardiopulmonary or respiratory symptoms. Repeated aspirations of blood, especially after major positional changes and before giving large quantities of fluid or blood, should be performed to detect secondary malposition of the CVC.

Long line positioning in neonates: does computed radiography improve visibility?

OBJECTIVES

To assess the use of soft copy reporting of computed radiography (CR) images in determining intravenous long line tip position in neonates and compare visibility rates with hard copy printed images.

METHOD

A retrospective study of all long lines inserted on the neonatal unit over a period of one year was performed. Forty five lines were inserted in 30 neonates over this time. Assessment of the CR images was made by three independent observers by reviewing the films on the viewing console and as hard copy printed films.

RESULTS

Accurate identification of the line tip could be made in 66.7% of cases (kappa = 0.9) using hard copy images and 95.6% cases (kappa = 1.0) using soft copy reporting (significant difference: p = 0.002). The difference in percentage visibility using the two techniques was 28.9% (95% confidence interval 10.2% to 36.7%).

CONCLUSION

The use of soft copy review of CR image improves the visibility of the line tip position compared with hard copy films and reduces the need for repeat radiographs with/without intravenous contrast.

Pericardial effusion and cardiac tamponade as complications of neonatal long lines: are they really a problem?

AIM

To estimate the frequency of pericardial effusion/cardiac tamponade associated with the use of neonatal percutaneous long lines (PLLs) over the past five years.

METHOD

A retrospective nationwide postal survey, of all neonatal and special care units in the United Kingdom.

RESULTS

Eighty two cases of pericardial effusion/cardiac tamponade were reported from the five year period, during which we estimate that 46 000 PLLs were inserted. The calculated frequency of pericardial effusion/cardiac tamponade occurring with PLLs was 1.8/1000 lines. There were 30 deaths, giving a fatality rate after pericardial effusion of 0.7/1000 lines.

CONCLUSIONS

Pericardial effusion/cardiac tamponade is a serious but infrequent complication of PLL use.

Assessment of infants with peripherally inserted central catheters: Part 2. Detecting less frequently occurring complications

Peripherally inserted central catheters (PICCs) are frequently placed in neonates to optimize nutrition and provide stable infusions of critical medications into the central vascular system. PICCs have been associated with a number of device-specific complications that can manifest during insertion, while the line is indwelling, and/or after the removal of the line. The first article of this series in Focus on the Physical, titled "Assessment of Infants With Peripherally Inserted Central Catheters: Part I. Detecting the Most Frequently Occurring Complications," presented assessment strategies to detect common complications such as catheter occlusions and catheter-related bloodstream infections. Part 2 of this series emphasizes the importance of ongoing systematic assessment of PICCs for device-specific complications such as catheter migration, dislodgement, breakage, phlebitis, and thrombosis, as well as the life-threatening complications of pleural and pericardial effusion and tamponade. Each complication is described, along with a review of the etiology, a description of presenting signs and symptoms, and key clinical interventions.

Unexpected resistance to external cardiac compression may signal pericardial tamponade

Pericardial tamponade associated with central catheters is often lethal, unless promptly identified. We report our experience with two infants who suffered this complication but were successfully resuscitated. In each case, associated radiographs showed the tip of the central catheter beyond the superior vena cava-right atrium (SVC-RA) junction. Identifying the clinical triad of (1) sudden cardiovascular collapse unresponsive to usual resuscitative measures, (2) thoracic transillumination not suggestive of air leak, and (3) unexpected resistance to external cardiac compression led to the working diagnosis of pericardial tamponade and therapeutic pericardiocentesis. Prompt recovery followed. Central catheters within the RA seem prone to cause pericardial tamponade.

Assessment of infants with peripherally inserted central catheters: Part 1. Detecting the most frequently occurring complications

Inserting, maintaining, and monitoring vascular access are integral components of neonatal care. Advances in vascular access technology have led to the insertion of peripherally inserted central catheters (PICC) to provide stable venous access for early and aggressive parenteral nutrition. Medications that are irritating or damaging, or those with a high osmolality or a nonphysiologic pH, can also be safely administered into the central venous system. The need for repeated peripheral intravenous attempts, as well as the associated pain and physiologic instability, are virtually eliminated once a PICC line is placed. Complications related to PICCs may occur at any phase of therapy: during insertion, while indwelling, or after discontinuing the line. The risk factors associated with PICCs are distinctly different from peripheral intravenous lines because of their long dwell time, central placement, and potential to migrate. Part 1 of Focus on the Physical offers a review of the relevant anatomy of the vascular system and a discussion of the appropriate sites for catheter tip placement. Guidelines for a systematic physical assessment, along with recommendations for standardized PICC documentation, are provided. A review of the signs and symptoms of more frequently occurring complications, such as catheter occlusion and bloodstream infections, is presented to enhance awareness of PICC-specific complications in the neonate and to expedite early detection and treatment. Part 2 of this series will focus on systematic assessment for less common complications such as catheter migration, dislodgement, breakage, and thrombosis, as well as the life-threatening complications of pleural and pericardial effusion.

Brachiocephalic veins: an overlooked approach for central venous catheterization

Central venous access is important in both assessment and treatment of the patient. In modern clinical practice, a percutaneous approach is preferred. The well-established subclavian and internal jugular vein catheterization techniques, however, still carry the risk of major acute complications. In this article we describe a trial study of a percutaneous brachiocephalic vein catheterization technique conducted on a total of 74 cadavers undergoing autopsy. Relying on constant and easily recognizable anatomical landmarks, we performed a total of 128 catheterizations of the right and left brachiocephalic veins. The success of catheterization was ascertained by regional dissection. Our results show very high reproducibility with a success rate of about 97% on the first attempt of catheterization on both right and left sides. Equally important, collateral injury of neighboring structures was consistently absent. We propose the introduction of this rather overlooked approach into clinical practice.

Changes in upper extremity position cause migration of peripherally inserted central catheters in neonates

OBJECTIVE

The migration of peripherally inserted central catheters (PICCs) from the superior or inferior vena cava into the right atrium can pose a significant risk of lethal pericardial effusion and tamponade secondary to myocardial perforation. Arm movement has been reported to cause displacement of the catheter tip toward the heart and lead to ventricular tachycardia in adults. The objective of this study was to investigate whether adduction or abduction at the shoulder and flexion or extension at the elbow affect the position of PICCs placed via upper limb veins. We also hypothesized that arm movements can be used to reposition malpositioned catheters.

METHODS

A total of 280 radiographs of 60 neonates with PICCs inserted via upper limb veins from July 2000 through June 2001 were reviewed. Differences in catheter tip position as a result of abduction versus adduction at the shoulder, flexion versus extension at the elbow, and combination changes in arm posture were determined by measurements in paired radiographs. Correction of malpositioned catheters was attempted in 10 patients by using arm movements without any alterations at the site of insertion.

RESULTS

Arm movements were associated with significant displacement of catheters. Catheters that were placed via the basilic or axillary vein migrated toward the heart with adduction of the arm, whereas those that were placed via the cephalic vein moved away from the heart with adduction. Flexion of the elbow displaced catheters that were placed in the basilic or cephalic vein below the elbow toward the heart but did not have any effect on catheters that were placed via the axillary vein. For catheters that were placed in the basilic vein, simultaneous shoulder adduction and elbow flexion caused the greatest movement toward the heart (15.11 +/- 1.22 mm). We were able to reposition correctly inappropriately placed catheters in 9 of 10 patients by using arm movements.

CONCLUSIONS

Arm movements significantly affect the position of the tip of the PICCs. Prevention of catheter migration into the right atrium requires radiographic determination of vein of insertion and monitoring of catheter tip position with upper extremity in position of maximum inward movement of catheter for that vein. Arm movements can be used to correct the malpositioned catheters.

Are femoral Broviac catheters effective and safe? A prospective comparison of femoral and jugular venous broviac catheters in newborn infants

STUDY OBJECTIVES

Patients with femoral venous catheters are commonly believed to be at higher risk of infectious complications as compared to patients with jugular catheters. Although reports have suggested that femoral venous Broviac catheters (Davol; Cranston, RI) are safe, no comparisons with jugular catheters were presented. Thus, we compared our efficacy and complications of femoral and jugular venous Broviac catheters in newborns.

METHODS

We prospectively recorded demographic data, cannulation requirements, duration of catheter use, and complications.

SETTING

Special-care nursery.

PATIENTS

Newborns.

INTERVENTIONS

Insertion of tunneled single-lumen Broviac catheters into vessels of the femoral triangle or the internal jugular, external jugular, or facial veins by surgical cutdown.

MEASUREMENTS AND RESULTS

Sixty infants had 2,503 catheter-days with 111 catheters. Twenty-six infants had 47 femoral catheters, and 34 infants had 64 jugular catheters. All insertion attempts were successful. The median durations of catheter use were 24.0 days and 17.0 days for femoral and jugular catheters, respectively (p = 0.021). Group characteristics, insertion variables, incidences of complications, and deaths were not significantly different between groups.

CONCLUSIONS

We conclude that compared to jugular catheters, femoral venous Broviac catheters are an effective means to vascular access, with similar incidences of complications in newborn infants.

"Proactive" management of percutaneously inserted central catheters results in decreased incidence of infection in the ELBW population

OBJECTIVE

Extremely low birth weight (ELBW) infants often acquire catheter-related infections (CRIs) when a percutaneously inserted central catheter (PICC) is used for parenteral nutrition or drug administration. Our objective was to compare the incidence of CRIs after we established a "PICC Maintenance Team" for the proactive management--compared to expectant management--of these lines.

STUDY DESIGN

We did a prospective collection and analysis of catheter-related sepsis data over a 15-month period from February 1, 1998 through May 1, 1999. Eligible patients included all neonates weighing <1000 g at birth.

RESULTS

There was a significantly decreased incidence of CRIs, to a rate of 7.1%, or 5.1/1000 catheter days (p<0.05).

CONCLUSION

"Proactive" management of PICC, significantly reduced the incidence of CRIs. The reduction in infection rate is estimated to save 180 hospitalized patient days/100 very low birth weight neonates, with a concomitant savings in morbidity and medical expense.

Complications in tunneled CVL versus PICC lines in very low birth weight infants

OBJECTIVE

Comparison of complications associated with tunneled central venous lines (TCVLs) versus peripherally inserted central catheters (PICCs) in infants <1500 g.

STUDY DESIGN

A retrospective cohort study at a university medical center. A total of 96 catheters were placed in 60 infants between 4/94 and 3/99. A retrospective review of these infants' medical record was done to review associated complications of catheter placement.

RESULTS

Both groups had similar weights and gestational ages. The duration of catheterization was 28 days in TCVLs and 11 days in PICCs (p<0.05). Total, infectious, and mechanical complications between the two groups were similar. Survival function estimates showed no difference between the two groups up to the 15th day of catheterization.

CONCLUSION

There is no difference in efficacy or associated complications between the two groups. If one could anticipate needing a catheter longer than 15 days, then a TCVL might be the better choice.

Recombinant tissue plasminogen activator in the treatment of central venous catheter occlusion in children

Tissue plasminogen activator was used to treat 228 children with 320 central venous catheter (CVC) occlusion events. Patency was restored in 91% of CVCs after 1 to 3 treatments, with no adverse events. Tissue plasminogen activator is effective in restoring patency to occluded CVCs and is a viable alternative to CVC removal or urokinase treatment.