Hepatic laceration because of malpositioning of the umbilical vein catheter: case report and literature review

Accuracy of chest radiography compared to ultrasound for positioning the umbilical venous catheter in neonates: A meta-analysis and systematic review

This study was aimed to investigate the accuracy of anteroposterior chest radiography for tip position verification for the umbilical venous catheters in neonates compared to ultrasound. A search in the PubMed, Embase, the Cochrane Library, and EBSCO was conducted to evaluate all the related articles on umbilical venous catheter (UVC), ultrasound AND neonates updated to August, 2020. Study selection, data extraction, and quality assessment were performed independently by two investigators. Random effects model was used to estimate the pooled sensitivity, specificity, and diagnostic odds ratio (DOR). The summary receiver operator characteristic (SROC) curve was constructed, and the area under the SROC curve (AUC) was calculated. Fourteen related studies were finally included for meta-analysis. The overall diagnostic sensitivity and specificity of X-ray on tip verification of UVC were 0.90 (95% CI 0.71-0.97) and 0.82 (95% CI 0.53-0.95), respectively. The pooled DOR was 3.69 (95% CI 1.64-5.71). The AUC was 0.93 (95% CI 0.90-0.95). The meta-regression analysis suggested that study sample size, study design, different US confirming method, and different gold standard in original design might be potential sources of heterogeneity. Our conclusion is that the commonly used anteroposterior X-ray is not reliable in identifying the exact anatomical location of UVC tip in neonates. Studies suggested ultrasound or echocardiography with saline contrast injection could be the gold standard for verification of catheter location and should be considered whenever possible, especially in premature patients. More studies are needed to expand the use of ultrasound or echocardiography in tip position confirming of UVCs.

Complications Associated with Low Position versus Good Position Umbilical Venous Catheters in Neonates of ≤32 Weeks' Gestation

OBJECTIVE

This study aimed to determine the incidence of umbilical venous catheter associated infection (UVCAI) in very preterm infants based on UVC tip position.

STUDY DESIGN

In this retrospective cohort study, infants born at ≤32 weeks were divided into groups with a UVC tip in either a low-lying or good position. The primary outcome was UVCAI. Survival analysis represented time to infection between groups. Subgroup analyses were based on duration of UVC indwelling time.

RESULTS

Of 1,983 infants, 1,638 infants were eligible; 33% had low-lying UVC and 67% had good position UVC. Survival analyses suggested a significantly higher probability of infection was associated with low UVC (adjusted hazard ratio [HR]: 1.9, 95% confidence interval [CI]: 1.1-3.2; p = 0.001). The risk of infection was higher for UVC of >7 days duration (adjusted HR: 2.2, 95% CI: 1.1-4.2). Extravasation as a complication was significantly higher in the low UVC versus good position UVC (1.3 vs. 0.1%; odds ratio: 14.4, 95% CI: 1.8-119).

CONCLUSION

Low-lying UVC was associated with higher risk of infection and extravasation.

KEY POINTS

· Low-lying UVC are at higher risk of UVCAI.. · Presence of UVC in situ for > 7 days carries higher risk of UVCAI.. · There was a higher risk of UVC extravasation with low UVCs..

Incidence of umbilical vein catheter-associated thrombosis of the portal system: A systematic review and meta-analysis

BACKGROUND

The use of umbilical venous catheters (UVCs) in the perinatal period may be associated with severe complications, including the occurrence of portal vein thrombosis (PVT).

AIM

To assess the incidence of UVC-related PVT in infants with postnatal age up to three months.

METHODS

A systematic and comprehensive database searching (PubMed, Cochrane Library, Scopus, Web of Science) was performed for studies from 1980 to 2020 (the search was last updated on November 28, 2020). We included in the final analyses all peer-reviewed prospective cohort studies, retrospective cohort studies and case-control studies. The reference lists of included articles were hand-searched to identify additional studies of interest. Studies were considered eligible when they included infants with postnatal age up to three months with UVC-associated PVT. Incidence estimates were pooled by using random effects meta-analyses. The quality of included studies was assessed using the Newcastle-Ottawa scale. The systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines.

RESULTS

Overall, 16 studies were considered eligible and included in the final analyses. The data confirmed the relevant risk of UVC-related thrombosis. The mean pooled incidence of such condition was 12%, although it varied across studies (0%-49%). In 15/16 studies (94%), diagnosis of thrombosis was made accidentally during routine screening controls, whilst in 1/16 study (6%) targeted imaging assessments were carried out in neonates with clinical concerns for a thrombus. Tip position was investigated by abdominal ultrasound (US) alone in 1/16 (6%) studies, by a combination of radiography and abdominal US in 14/16 (88%) studies and by a combination of radiography, abdominal US and echocardiography in 1/16 (6%) studies.

CONCLUSION

To the best of our knowledge, this is the first systematic review specifically investigating the incidence of UVC-related PVT. The use of UVCs requires a high index of suspicion, because its use is significantly associated with PVT. Well-designed prospective studies are required to assess the optimal approach to prevent UVC-related thrombosis of the portal system.

Sonographic features of umbilical catheter-related complications

Umbilical catheters are commonly used in the neonatal period for blood sampling or for administering medication or parenteral nutrition. The position of the catheter is usually confirmed with radiography. However, many complications associated with the use of umbilical catheters, such as liver collections from extravasation or vascular thrombosis, are not apparent on radiographs but can be easily diagnosed with ultrasound. This pictorial review illustrates the sonographic findings of complications that should be excluded in the sick neonate with an indwelling catheter.

Hepatic Complications of Umbilical Venous Catheters in the Neonatal Period: The Ultrasound Spectrum

OBJECTIVES

Umbilical venous catheterization is commonly used in the neonatal period; however, it has some complications. In this study, we evaluated neonates who underwent umbilical venous catheterization and developed hepatic complications. Furthermore, we aimed to define all of the possible lesions and to clarify the imaging findings of umbilical venous catheter-induced hepatic injury.

METHODS

Two hundred forty-four neonates who underwent umbilical venous catheterization between March 2013 and September 2015 in a single tertiary care referral center were included in this study. To determine whether they had any hepatic complications, all patients underwent abdominal grayscale and Doppler ultrasound examinations, and their clinical data were recorded.

RESULTS

The frequency of liver-related complications from umbilical venous catheterization was 33.6% (82 of 244). Air in the portal venous system was the most frequent complication (20.1% [49 of 244]). Left portal venous thrombosis was noted in 6.1% (15 of 244). Parenchymal lesions in the liver related to umbilical venous catheterization were seen in 7.4% of patients (18 of 244) as follows: single nodular echogenic lesions (4.1% [10 of 244]), branching small nodular echogenic lesions (2.1% [5 of 244]), and large irregular heterogeneous lesions with laceration and perihepatic fluid (1.2% [3 of 244]). There was no statistical significance for any type of complication according to the gestational age (P > .05).

CONCLUSIONS

Hepatic complications due to umbilical venous catheters are not uncommon in the neonatal period. Ultrasound is the best imaging modality for confirming the diagnosis and for follow-up.

Review of Routes to Administer Medication During Prolonged Neonatal Resuscitation

OBJECTIVE

During neonatal cardiopulmonary resuscitation, early establishment of vascular access is crucial. We aimed to review current evidence regarding different routes for the administration of medications during neonatal resuscitation.

DATA SOURCES

We reviewed PubMed, EMBASE, and Google Scholar using MeSH terms "catheterization," "umbilical cord," "delivery room," "catecholamine," "resuscitation," "simulation," "newborn," "infant," "intraosseous," "umbilical vein catheter," "access," "intubation," and "endotracheal."

STUDY SELECTION

Articles in all languages were included. Initially, we aimed to identify only neonatal studies and limited the search to randomized controlled trials.

DATA EXTRACTION

Due to a lack of available studies, studies in children and adults, as well as animal studies and also nonrandomized studies were included.

DATA SYNTHESIS

No randomized controlled trials comparing intraosseous access versus peripheral intravascular access versus umbilical venous catheter versus endotracheal tube versus laryngeal mask airway or any combination of these during neonatal resuscitation in the delivery room were identified. Endotracheal tube: endotracheal tube epinephrine administration should be limited to situations were no vascular access can be established. Laryngeal mask airway: animal studies suggest that a higher dose of epinephrine for endotracheal tube and laryngeal mask airway is required compared with IV administration, potentially increasing side effects. Umbilical venous catheter: European resuscitation guidelines propose the placement of a centrally positioned umbilical venous catheter during neonatal cardiopulmonary resuscitation; intraosseous access: case series reported successful and quick intraosseous access placement in newborn infants. Peripheral intravascular access: median time for peripheral intravascular access insertion was 4-5 minutes in previous studies.

CONCLUSIONS

Based on animal studies, endotracheal tube administration of medications requires a higher dose than that by peripheral intravascular access or umbilical venous catheter. Epinephrine via laryngeal mask airway is feasible as a noninvasive alternative approach for drug delivery. Intraosseous access should be considered in situations with difficulty in establishing other access. Randomized controlled clinical trials in neonates are required to compare all access possibilities described above.

Positioning newborns on their back or right side for umbilical venous catheter insertion

AIM

Newborns are placed supine for umbilical venous catheter insertion, and catheter tip position is confirmed with X-ray. Umbilical venous catheters are considered correctly positioned when the tip is in the inferior vena cava; however, frequently, the catheter tip enters the portal venous circulation. We wished to determine whether placing infants on their right side, rather than on the back, for umbilical venous catheter insertion results in more correctly placed catheters.

METHODS

Newborns were randomised to be placed on their back, or turned onto their right side for catheter insertion. Primary outcome was correct catheter tip position on X-ray (visible in the midline at diaphragm level).

RESULTS

Umbilical venous catheter insertion was successful in all infants enrolled. There was no difference in the proportion of correctly positioned catheters between the groups [back 23/44 (52%) versus right side 27/44 (61%), p = 0.389]. More infants randomised to back had the catheter tip in the portal circulation [back 13/44 (30%) versus right side 5/44 (11%), p = 0.034].

CONCLUSION

Positioning newborn infants on their right side did not result in more correctly placed umbilical venous catheters. The procedure was well tolerated and reduced the rate of tip insertion into the portal venous circulation.

Hepatic Abscesses in Preterm Infants: Report of Three Cases and Review of the Literature

PURPOSE

Hepatic abscess is a rare but potentially fatal entity in neonates. The aim of this study was to provide valuable data for diagnosis, management and prevention of hepatic abscess in preterm infants.

METHODS

A retrospective chart review was made for patients diagnosed with hepatic abscesses between 2012 and 2015. Methods included clinical and radiological review of records and evaluation of potential risk factors.

RESULTS

A total of three infants with hepatic abscesses were identified. All of them had low birth weight and low gestational age. Predisposing factors included prematurity, late sepsis, umbilical catheterization, necrotizing enterocolitis and previous antibiotic therapy. Isolated organisms from blood included Staphylococcus spp. in two cases and Pseudomonas spp. in one case. To the best of our knowledge, this is the first preterm case of hepatic abscess caused by Pseudomonas aeruginosa in the literature. All patients responded well to antibiotic therapy alone, and no interventional drainage was required.

CONCLUSION

We suggest evaluating all preterm neonates who have severe sepsis and/or necrotizing enterocolitis signs and who do not respond to prolonged antibiotic therapy with detailed abdominal ultrasound for possible hepatic abscesses as early diagnosis, and treatment favors prognosis.

Umbilical venous catheterization gone wrong: Hepatic complications

Hepatic complications of malposition of umbilical venous catheter (UVC) are uncommon and occur due to extravasation of hypertonic fluids and the blood products in the liver tissue. Various hepatic complications include thrombosis of hepatic vessels, hepatic necrosis, hepatic fluid collections, and hematoma, with the intraparenchymal liver lesions seen along the course of ductus venosus. Radiologists must be aware of these complications and their imaging findings, as the timely recognition and immediate management can prevent the fatal outcome. Here, we present a rare case of intraparenchymal liver lesions associated with malposition of UVC in a preterm baby.

Umbilical venous catheter complications in newborns: a 6-year single-center experience

OBJECTIVE

Umbilical venous catheter (UVC) insertion is frequently performed in critically ill neonates. Various mild or serious complications of umbilical venous catheterization can be observed associated with this procedure. In this study, newborns that have undergone UVC and developed complications were evaluated.

METHODS

This retrospective observational study was carried out in newborns that have undergone UVC and developed complications were evaluated between June 2008 and November 2014.

RESULTS

Umbilical venous catheter were inserted to 974 (22.4%) newborn and followed for 7402/catheter days. UVC-related complications developed at 198 patients (20.3%). The most common UVC-related complications were malposition (n = 189), catheter-related bloodstream infection (n = 6) and remnant of catheter in the umbilicus (n = 3), respectively. Remnant of catheter in the umbilicus was removed by pediatric surgeon. Except one patient, all patients were discharged.

CONCLUSION

Although UVC is a common and easy vascular access, this process is not without complications. UVC may be inappropriate position because the catheter is inserted by the pediatrician without imaging guidance and may occasionally be associated with complications. Inappropriate positioning of the catheter may observe during the follow-up and maintained care. Therefore, newborns particularly in premature and very low birth-weight newborn should be followed in terms of catheter complications during insertion, following and just after removing of the catheter.

Umbilical venous catheter malposition and errors in interpretation in newborns with Bochdalek hernia

BACKGROUND

Neonates with congenital diaphragmatic hernia (CDH) often require placement of lines and tubes for supportive therapy. The resulting altered anatomy can result in diagnostic errors when interpreting the location of support lines and tubes such as UVCs (umbilical venous catheters).

OBJECTIVE

The purpose of this study was to evaluate the effect of CDH on UVC position and to evaluate the accuracy at which radiologists describe the position on chest radiographs.

MATERIALS AND METHODS

During a 5-year period, 406 chest radiographs performed within 7 days of birth in infants with congenital diaphragmatic hernia were identified and reviewed for the following data: presence of UVC, location of catheter tip (cavoatrial junction, intracardiac, intrahepatic or umbilical vein), and location of CDH (right or left). The radiologic report of the UVC tip location for each case was then reviewed individually to determine the adequacy of interpretation. Inadequate reports were classified as incorrect (the wrong location of the catheter tip was reported), no mention (the location of the catheter tip was in a suboptimal location but not mentioned), and not specified (the precise location of the catheter tip was not clearly stated in the report when the tip was in a suboptimal location).

RESULTS

A total of 60 infants were identified as having CDH (56 on the left, 4 on the right). The most common location for an incorrectly placed UVC was the contralateral chest, accounting for 26.7% (16/60) of the infants, followed by an abdominal intrahepatic location (16.7%) and the umbilical vein (8.3%). Thirty percent (120/406) of the chest radiograph reports were found to be inadequate regarding the interpretation of the location of the catheter tip. The majority of the inadequate reports (48/406, 11.8%) did not specify when the catheter tip was in a suboptimal location. In 37 reports (9.1%), the location of the catheter tip was reported incorrectly, and no mention of the catheter location was made in 35 reports (8.6%).

CONCLUSION

The location of an UVC in an infant with Bochdalek hernia can pose a diagnostic challenge because of the altered anatomy and change in the expected course of the catheter. Familiarity with the altered anatomy and vigilance of the various abnormal locations in which UVCs can be placed can help optimize management for the child and reduce morbidity and mortality.

Venobiliary fistula related to umbilical venous catheter in a newborn

We present a case of venobiliary fistula due to umbilical venous catheter (UVC). UVC was inserted the day before surgery in a newborn who was scheduled for type IIIB jejunal atresia surgery. The UVC was superimposed on the liver. It was noted that the gastric drainage became chylous and increased to 790 and then 1977 mL daily. I.v. contrast tomography with 650 mL contrast showed that the opaque substance was dispersed around the catheter and a venobiliary fistula formed, with the administered fluid accumulating in the duodenum. Rapid improvement was seen in the clinical picture after the UVC was removed. Venobiliary fistula may develop in patients with UVC that is not placed appropriately, and can direct the fluid administered from the UVC to the gastrointestinal system through the choledochal duct. The importance of contrast computed tomography in the diagnosis of venobiliary fistula in the newborn is also emphasized.

Iatrogenic injury and unexpected hospital death in the newborn

Neonates are unusually vulnerable to iatrogenic injury due to small body size, delicate tissues, and immature immune systems. Investigation of an unexpected neonatal death in the hospital should begin with a review of the medical record and discussion with medical staff involved in the patient׳s care. Postmortem investigation should include a complete and well-documented autopsy. Additional investigations, such as microbiological studies and chemical and toxicological studies of postmortem and antemortem fluid samples, may be crucial in arriving at a diagnosis. Causes of iatrogenic injury include birth trauma, medication errors and adverse drug effects, hospital-acquired infection, and medical device malfunction, incorrect placement, and misuse. Autopsy is an important tool for understanding the cause of an unexpected death, improving the quality of care, and providing closure to parents and family.

Clinical-radiologic features and treatment of hepatic lesions caused by inadvertent infusion of parenteral nutrition in liver parenchyma due to malposition of umbilical vein catheters

BACKGROUND

Umbilical venous catheterization is a common procedure performed in neonatal intensive care units. Hepatic collections due to inadvertent extravasation of parenteral nutrition into the liver have been described previously in literature.

OBJECTIVE

To recognize the clinicoradiologic features and treatment options of hepatic collections due to inadvertent extravasation of parenteral nutrition fluids caused by malpositioning of umbilical venous catheter (UVC) in the portal venous system.

MATERIALS AND METHODS

This is a case series describing five neonates during a 6-year period at a single tertiary care referral center, with extravasation of parenteral nutrition into the liver parenchyma causing hepatic collections.

RESULTS

All five neonates receiving parenteral nutrition presented with abdominal distension in the second week of life. Two out of five (40%) had anemia requiring blood transfusion and 3/5 (60%) had hemodynamic instability at presentation. Ultrasound of the liver confirmed the diagnosis in all the cases. Three of the five (60%) cases underwent US-guided aspiration of the collections, one case underwent conservative management and one case required emergent laparotomy due to abdominal compartment syndrome. US used in follow-up of these cases revealed decrease in size of the lesions and/or development of calcifications.

CONCLUSION

Early recognition of this complication, prompt diagnosis with US of liver and timely treatment can lead to better outcome in newborns with hepatic collections secondary to inadvertent parenteral nutrition infusion via malposition of UVC.

Central vascular catheter insertion in the NICU: a Lean approach

PURPOSE

To apply Lean principles to the process of inserting central lines into neonates in the NICU.

DESIGN

The authors used standard interviews and live observations to obtain concrete data on the current process of central line insertions. Recommendations for improvement were then suggested based on Lean principles.

SAMPLE

NICU care providers.

MAIN OUTCOME VARIABLE

Non-value-added time (waste), provider confidence, and variation in placing central lines.

RESULTS

There was large variation in how providers inserted central lines, and providers were least confident with placing peripherally inserted central catheter lines (55 percent confident). Live observations showed that 53 percent of the current process consisted of waste, with the line insertion and radiography phases of the process as the most wasteful. Lean principles can be applied to a neonatal clinical setting and can be an effective methodology for NICU care providers to improve the way that we care for our patients.

Phenotypes of Liver Diseases in Infants, Children, and Adolescents

Liver disease in childhood is rare and is frequently the cause of dismay as the medical care provider attempts to recall the myriad of diagnoses that they read about during their training but may never have encountered. The aim of this chapter is to describe hepatic disease phenotypes based on age and primary manifestation of liver disease such as cholestasis, hepatomegaly, or acute liver failure and to provide a reasonably comprehensive list of hepatic diseases that may present with the clinical phenotypes. The hope is to help primary medical providers determine the differential diagnosis and thus guide early studies and appropriate referral and pediatric gastroenterologists and trainees to determine a comprehensive differential diagnosis for their patients on which to base a rational work-up and management plan. Our patients range from day-old premature infants to 18-year-old postpubescent teens and from seemingly healthy children in the outpatient clinic to profoundly sick infants in ICU on life support. The best way to determine a diagnosis safely and efficiently is to develop a deep understanding of the pathophysiology of liver disease, but even for the most experienced, a checklist of diagnostic possibilities may be helpful to ensure no oversights.

Neonatal liver abscesses associated with candidemia: three cases and review of literature

BACKGROUND

Our aim was to identify risk factors for the development of neonatal Candida liver abscess and to find useful information to better manage this potentially fatal complication.

METHODS

A computerized search was conducted using PubMed. Overall, three articles describing the history of seven infants were finally considered. The characteristics of these seven cases were analyzed together with those of three new cases that we treated in the recent past.

RESULTS

All the neonates were premature. Previous antibiotic use was reported in all the cases, umbilical venous catheterization in 9/10 and total parenteral nutrition in 8/10. Candida albicans was isolated in 9/10. All the patients presented with aspecific signs of sepsis. Liver abscesses were described as "microabscesses" or "miliary abscesses" in three cases, as solitary lesion in two cases. In one case two lesions and in one four lesions were reported. Three infants died.

CONCLUSIONS

Liver ultrasonography should be performed in all the neonates with signs of sepsis, especially in the presence of candidemia and/or hepatomegaly and/or significant change in liver enzymes. Umbilical venous catheter should be removed, and peripheral IV access should be used until there is documented clearance from the blood with three or more negative blood cultures.

Liver fluid collection in neonates and its association with the use of a specific umbilical vein catheter: Report of five cases

In newborns, the presence of liver fluid collection is a rare event. The reported cases are isolated or described over long periods. Within four months, five neonates were diagnosed with liver fluid collection from safety occurrence reports. Clinical, laboratory and radiological data were extracted from medical records. The definite diagnosis was made by ultrasound. Four of the patients were preterm, male and had very low birth weights. The osmolality of the infused solution was within the acceptable range. Investigations revealed that the use of a new brand of umbilical vein catheter introduced in the neonatal intensive care unit, one month before the first case, was associated with this cluster. Low positioning of the umbilical vein catheter tip appeared to be a second contributory factor. Neonatal practitioners may benefit from the present report when facing the occurrence of similar lesions.

Umbilical vein catheterization--appropriate and inappropriate placement

Because of the dangers of inappropriate placement of an umbilical vein catheter (UVC), knowledge of the proper pathway and tip localization is important. The acceptable ductus venosus/hepatic vein/inferior vena cava confluence location is compared to inappropriate localizations below and above the diaphragm, with emphasis on confusion about the position when the UVC tip is in the umbilical vein itself, including the umbilical vein recess. Small amounts of gas can inadvertently accompany initial UVC placement and provide landmarks for position evaluation.

Umbilical venous catheter complication in an infant with left-sided congenital diaphragmatic hernia: extravasation owing to hepatic vein catheterization

Infants with left-sided congenital diaphragmatic hernia (CDH) are subject to possible intrahepatic placement of the umbilical venous catheter (UVC) during catheterization. A left-sided CDH containing the left lobe of the liver is subject to repositioned anatomy of the umbilical vein, ductus venosus, and hepatic vasculature. This substantially increases the risk of incidentally cannulating the shifted intrahepatic vessels of the liver when placing a UVC. We present a case of hepatic extravasation with line erosion through the liver capsule secondary to UVC placement in an infant with left-sided CDH containing the left lobe of the liver. The patient underwent successful repair of the diaphragmatic defect and is a healthy youngster without complication from CDH or extravasation of the liver capsule. Cannulation of the hepatic vasculature cannot be ruled out with radiograph in infants with left-sided CDH.