Assessment of an umbilical venous catheter dwell-time of 8-14 days versus 1-7 days in very low birth weight infacts (UVC - You Will See): a pilot single-center, randomized controlled trial

Adverse events associated with umbilical vascular catheters in neonatal intensive care: Development of a risk prediction model

BACKGROUND

Adverse events associated with umbilical vascular catheters occur frequently in the neonatal intensive care unit. International guidelines recommend limiting catheter dwell time to reduce the risk of adverse events, and this drives clinical decision-making regarding catheter removal, yet other risk factors may also influence the risk of adverse events.

OBJECTIVES

The aim of this study was to develop a clinically useful risk prediction model that could be utilised in the neonatal intensive care unit to identify infants at a greater risk of developing an adverse event associated with umbilical vascular catheters.

METHODS

A risk prediction model was developed for the umbilical venous catheter and umbilical arterial catheter based on the dataset of a published retrospective cohort study in a South Australian neonatal intensive care unit. Least absolute shrinkage and selection operator regression was used to develop the model. Deviance was used to evaluate the model's goodness of fit, and the Hosmer-Lemeshow test and calibration plot were used to assess calibration. The area under the receiver operating characteristic curve evaluated the model's discrimination.

RESULTS

For adverse events associated with umbilical venous catheters, the least absolute shrinkage and selection operator model selected none of the potential predictor variables. Five predictors of adverse events were identified for umbilical arterial catheters: thrombocytopaenia, intrauterine growth restriction/small for gestational age, congenital heart disease/defects including patent ductus arteriosus, maternal diabetes, and a dwell time of >7 days. The area under the receiver operating characteristic curve was 0.68 (95% confidence interval: 0.61-0.74). A link test found that the model was properly specified, and a Hosmer-Lemeshow test demonstrated that the model was well calibrated (p = 0.104).

CONCLUSIONS

A risk prediction model has been developed to identify infants at a greater risk of an adverse event associated with umbilical arterial catheters. The model needs to be externally validated before it can be implemented into clinical practice.

Neonatal Liver Imaging: Techniques, Role of Imaging, and Indications

The neonatal liver may be affected by a variety of congenital and acquired diseases. Imaging has an important role in the workup and management of many neonatal hepatic abnormalities. Some aspects of imaging the liver and imaging findings are specific to neonatal patients when compared with those in older children. Therefore, selecting and tailoring the imaging technique for each indication in the neonate is important for optimal care, with minimal invasiveness. Common indications for imaging include incidental focal lesions, neonatal liver failure, cholestasis, and sepsis. US is the primary imaging modality, and for most conditions it is the only imaging modality required. MRI is the next modality after US for neonatal liver assessment and is especially required for complete assessment and staging of neoplasms, vascular abnormalities, and diagnosis of neonatal hemochromatosis. CT can be used when MRI is not available and should be used sparingly and in patients with acute conditions such as intra-abdominal bleeding. The authors emphasize imaging modalities that can be used for assessment of neonatal liver abnormalities, the imaging appearances of normal and changing structures in the neonatal liver, and indications for imaging. Abnormalities that are described include neonatal liver failure, infections, hepatic calcifications, umbilical venous catheter-related complications, and vascular abnormalities. ©RSNA, 2024 Supplemental material is available for this article.

Identification of Neonatal Factors Predicting Pre-Discharge Mortality in Extremely Preterm or Extremely Low Birth Weight Infants: A Historical Cohort Study

BACKGROUND/OBJECTIVES

This study identified early neonatal factors predicting pre-discharge mortality among extremely preterm infants (EPIs) or extremely low birth weight infants (ELBWIs) in China, where data are scarce.

METHODS

We conducted a retrospective analysis of 211 (92 deaths) neonates born <28 weeks of gestation or with a birth weight <1000 g, admitted to University Affiliated Hospitals from 2013 to 2024 in Guangzhou, China. Data on 26 neonatal factors before the first 24 h of life and pre-discharge mortality were collected. LASSO-Cox regression was employed to screen predictive factors, followed by stepwise Cox regression to develop the final mortality prediction model. The model's performance was evaluated using the area under the curve (AUC) of the receiver operating characteristic, calibration curves, and decision curve analysis.

RESULTS

The LASSO-Cox model identified 13 predictors that showed strong predictive accuracy (AUC: 0.806/0.864 in the training/validation sets), with sensitivity and specificity rates above 70%. Among them, six predictors remained significant in the final stepwise Cox model and generated similar predictive accuracy (AUC: 0.830; 95% CI: 0.775-0.885). Besides the well-established predictors (e.g., gestational age, 5 min Apgar scores, and multiplicity), this study highlights the predictive value of the maximum FiO2. It emphasizes the significance of the early use of additional doses of surfactant and umbilical vein catheterization (UVC) in reducing mortality.

CONCLUSIONS

We identified six significant predictors for pre-discharge mortality. The findings highlighted the modifiable factors (FiO2, surfactant, and UVC) as crucial neonatal factors for predicting mortality risk in EPIs or ELBWIs, and offer valuable guidance for early clinical management.

Can a Shorter Dwell Time Reduce Infective Complications Associated with the Use of Umbilical Catheters?

BACKGROUND

Umbilical venous catheters (UVCs) are the standard of care in neonatal intensive care units (NICUs) to administer fluids, parenteral nutrition and medications, although complications may occur, including central line-associated blood stream infections (CLABSIs). However, the dwell time to reduce CLABSI risk remains an open issue.

METHODS

We performed a single-center retrospective study of newborns hospitalized in the Modena NICU with at least one UVC inserted over a 6-year period (period 1: January 2011-December 2013; period 2: January 2019-December 2021). We selected a non-consecutive 6-year period to emphasize the differences in UVC management practices that have occurred over time in our NICU. The UVC dwell time and catheter-related complications during the first 4 weeks of life were examined.

RESULTS

The UVC dwell time was shorter in period 2 (median 4 days vs. 5 days, p < 0.00001). Between the two periods, the incidence of CLABSIs remained unchanged (p = 0.5425). However, in period 2, there was an increased need for peripherally inserted central catheters (PICCs) after UVC removal, with a rise in PICC infections after UVC removal (p = 0.0239).

CONCLUSIONS

In our NICU, shortening UVC dwell time from 5 to 4 days did not decrease the UVC-related complications. Instead, the earlier removal of UVCs led to a higher number of PICCs inserted, possibly increasing the overall infectious risk.

Study draft: "UVC-You Will See" study: longer vs. shorter umbilical venous catheter (UVC) dwell time (6-10 vs. 1-5 days) in very premature infants with birth weight < 1250 g and/or gestational age < 30 weeks

BACKGROUND

Umbilical venous catheters (UVCs) are often used in preterm infants. Their use is associated with complications (infections, clot formation, organ injury). Very preterm infants with acquired bloodstream infection are at a higher risk for death and important morbidities (e.g., adverse neurodevelopmental outcomes). It is standard clinical practice to remove UVCs in the first days of life. Replacement of intravenous access is often performed using percutaneously inserted central catheters (PICCs). It is unclear whether serial central line use affects the rates of catheter-related complications.

METHODS

A multicenter randomized controlled trial (random group assignment) was performed in 562 very premature (gestational age < 30 weeks) and/or very low birth weight infants (< 1250 g) requiring an UVC for administration of parenteral nutrition and/or drugs. Group allocation was random.

HYPOTHESIS

A UVC dwell time of 6-10 days (281 infants) is not associated with an increased rate of central venous catheter (UVC, PICC)-related complications compared to 1-5 days (281 infants), and a longer UVC dwell time will significantly reduce the number of painful, invasive procedures associated with the need for vascular access as well as radiation exposure, use of antibiotics, and medical costs.

PRIMARY OUTCOME PARAMETER

The number of catheter-related bloodstream infections and/or catheter-related thromboses and/or catheter-associated organ injuries related to the use of UVC/PICC was the primary outcome.

CONCLUSION

Extending the UVC dwell time may significantly reduce the number of painful invasive procedures, with the potential to positively impact not only long-term pain perception but also important social competencies (attention, learning, and behavior). Thus, the "UVC-You Will See" study has the potential to substantially change current neonatal intensive care practice.

Adverse events associated with umbilical vascular catheters in the neonatal intensive care unit: A retrospective cohort study

BACKGROUND

Umbilical catheters are commonly inserted in newborns in the neonatal intensive care unit (NICU) yet are associated with serious adverse events (AEs) such as malposition, migration, infection, thrombosis, hepatic complications, cardiac effusion, and cardiac tamponade. There is a need to determine the incidence and risk factors for AEs to inform safe practice.

OBJECTIVES

The objective of this study was to determine the incidence and risk factors for AEs (all-cause and individual types) associated with umbilical venous catheters (UVCs) and umbilical arterial catheters (UACs) in the NICU.

METHODS

A retrospective cohort study was conducted in an Australian level-VI NICU over a 3-year period. Any newborn who had both a UVC and UAC insertion attempt was included.

RESULTS

There were 236 neonates who had 494 catheters (245 UVCs and 249 UACs). Of these, 71% of UVCs (95% confidence interval [CI]: 65.6-76.9%; incidence rate: 181.1-237.3 per 1000 catheter days) and 43.8% of UACs (95% CI: 38-50.5%; incidence rate: 102.0-146.3 per 1000 catheter days) were associated with an AE. The most common AE was malposition on first X-ray for UVCs (60.1%, 95% CI: 55.1-67.3) and UACs (32.6%, 95% CI: 26.8-39.6). A dwell time of ≥7 days was a significant predictor of UAC failure (incidence risk ratio: 1.5, 95% CI: 1.1-2.1, p = 0.006) and migration of the UVC (incidence risk ratio: 3.5, 95% CI: 1.0-11.5, p = 0.043).

CONCLUSION

Adverse events related to insertion occurred in a relatively high percentage of umbilical catheters placed. Increased dwell time remains a significant risk factor for catheter migration and overall failure. Practice change and consideration of risk factors for both individual and overall AE risk are necessary to reduce complications.

Safety of Skin-to-Skin Contact with Umbilical Venous Catheter in Preterm Infants: A Prospective Study

OBJECTIVE

 For many health care providers, an umbilical venous catheter (UVC) may be a contraindication for skin-to-skin contact (SSC). Our aim was to compare the frequency of adverse events between preterm infants who were on SSC with UVC and those who remained in an incubator.

STUDY DESIGN

 Prospective observational study in newborns less than 35 weeks gestation. UVC-related adverse events were compared between neonates who performed SSC and those who did not. The incidence of catheter-related displacement, leak, loss, hemorrhage, malfunction, and bloodstream infection was studied.

RESULTS

 From 226 patients, 171 performed SSC with UVC. Their first contact was earlier than in those who remained in an incubator (SSC-UVC, 29 hours [interquartile range (IQR): 21-53] vs. no SSC-UVC, 132 hours [IQR: 96-188]; p < 0.001). Both groups were similar in gestational age (SSC-UVC, 30 weeks vs. no SSC-UVC, 30.3 weeks; p = 0.331) and birth weight (SSC-UVC, 1,285 g vs. no SSC-UVC, 1,355 g; p = 0.2). Studied complications were not more frequent in patients who performed SSC. In fact, although it was not statistically significant, a lower overall incidence of adverse events (SSC-UVC, 13.5% vs. no SSC-UVC, 20%; p = 0.237) and catheter-related bloodstream infection (SSC-UVC, 4.7% vs. no SSC-UVC, 10.9%; p = 0.111) was observed in this group.

CONCLUSION

 SSC with a UVC is a safe procedure and there are no more complications in newborns who perform SSC compared to those who remain in the incubator. Due to its demonstrated benefits, SSC should be promoted in premature newborns regardless of the presence of a UVC.

KEY POINTS

· SSC in preterm infants with UVCs is safe.. · Early SSC does not increase UVC-related bloodstream infection.. · Early SSC should be promoted in stable patients regardless of the presence of a UVC..

Central Lines and Their Complications in Neonates: A Case Report and Literature Review

Central lines are essential devices in NICUs, used primarily in preterm neonates and critically ill term neonates. They are typically divided into non-tunnelled, tunnelled and totally implanted. In light of the increasing use of central lines in the NICU setting, monitoring of the risk factors associated with complications has to be an important part of neonatal care quality management. Presented here is a case of a preterm neonate with cardiac tamponade caused by UVC tip migration. Among complications of central lines are CLABSI, with an incidence of 3 to 21 per 1000 catheter days, and portal vein thrombosis, which is common but probably under-recognised, whereas other mechanical complications such as pericardial and pleural effusions are rare, with an incidence of less than 1%. Complications can cause injury to the neonates, as well as increase the costs of health services because of increases in the length of stay in the NICU. It is recommended that the catheter tip location is confirmed either by X-ray or ultrasonography. In order to minimise the risk of CLABSI, the use of bundles is recommended. Certain recommendations need to be followed when using different types of catheters. Future research is aimed at novel ways of central line securement to minimise mechanical complications and the use of antimicrobial catheters to reduce the rate of CLABSI.