Major thrombotic complications with lower limb PICCs in surgical neonates

Incidence and risk factors of neonatal peripherally inserted central catheter-related thrombosis: A systematic review and meta-analysis

BACKGROUND

Catheter-related thrombosis is a common complication of the peripherally inserted central catheter (PICC) in neonates, leading to unintended tube removal and significantly affecting neonatal health and safety. Despite widespread reporting on the estimated occurrence and factors contributing to neonatal PICC-related thrombosis, these findings have not been synthesized.

OBJECTIVES

The purpose of this study was to determine the incidence and risk factors of neonatal PICC-related thrombosis.

DESIGN

Systematic literature review and meta-analysis.

METHODS

Two independent researchers systematically explored multiple databases-such as PubMed, Medline, Embase and the Cochrane Library-from their inception until October 2023. Our study aggregates and scrutinizes studies specifically addressing the incidence and risk factors of neonatal PICC-related thrombosis. Employing the RevMan 5.3 software, a meta-analysis was executed to determine the incidence of both thrombosis and odds ratios (OR), accompanied by their respective 95% confidence intervals (CI) for the risk factors.

RESULTS

A total of 327 articles were screened, and data from 24 studies were used in synthesis. Neonatal PICC-related thrombosis incidence varied from 0.23% to 17.91%. The pooled incidence was 2% (95% CI: 1%-2%; I2 = 94%; p < .0001). The study identified 12 risk factors, including insertion sites in the lower extremities (OR = 0.22; 95% CI: 0.09-0.56; p = .001), gestational age <28 weeks, abdominal pathology, fresh frozen plasma by day 5 > 50 mL/kg, PICC tip location (proximal placement), two lumens, three lumens, prolonged hospital stay, infection, mothers' use of anticoagulants, patients with cardiac insufficiency and being twin-to-twin transfusion syndrome donor.

CONCLUSIONS

The analysis indicates an overall pooled incidence of neonatal PICC-related thrombosis of 2%. Twelve factors were identified as risks associated with neonatal PICC-related thrombosis. Understanding the risk factors can provide evidence-based recommendations for improving awareness, control and treatment and better nursing management.

RELEVANCE TO CLINICAL PRACTICE

This systematic review and meta-analysis illuminates the incidence and risk factors linked to neonatal PICC-related thrombosis, delivering essential insights pivotal for clinical decision-making and enhancing patient care within neonatal health care settings.

Lower extremity peripherally inserted central catheter placement ectopic to the ascending lumbar vein: A case report

BACKGROUND

Peripherally inserted central catheters (PICCs) are an essential infusion route for oncology patients receiving intravenous treatments, but lower extremity venipuncture is the preferred technique for patients with superior vena cava syndrome (SVCS). We report the case of a patient with a lower extremity PICC ectopic to the ascending lumbar vein, to indicate and verify PICC catheterisation in the lower extremity is safe and feasible. And hope to provide different perspectives for clinical PICC venipuncture to get the attention of peers.

CASE SUMMARY

On 24 August 2022, a 58-year-old male was admitted to our department due to an intermittent cough persisting for over a month, which worsened 10 d prior. Imaging and laboratory investigations suggested the patient with pulmonary malignancy and SVCS. Chemotherapy was not an absolute contraindication in this patient. Lower extremity venipuncture is the preferred technique because administering upper extremity venous transfusion to patients with SVCS can exacerbate oedema in the head, neck, and upper extremities. The patient and his family were informed about the procedure, and informed consent was obtained. After successful puncture and prompt treatment, the patient was discharged, experiencing some relief from symptoms.

CONCLUSION

Inferior vena cava catheterisation is rare and important for cancer patients with SVCS, particularly in complex situations involving ectopic placement.

Placement of peripherally inserted central catheters in neonates: A retrospective study

BACKGROUND

Peripherally inserted central catheters (PICCs) are commonly used in neonatal intensive care units for extended intravenous nutrition and therapy. The selection of PICCs insertion sites can significantly influence insertion outcomes and neonatal safety.

AIM

This study aimed to determine the most suitable insertion site in the lower extremities for neonatal PICCs.

STUDY DESIGN

A retrospective case note review was conducted on PICCs inserted through lower extremity (LE) sites in a 40-bed tertiary-level neonatal intensive care unit at a university teaching hospital. The dates when data were accessed for research purposes were from June 2019 to June 2022. In total, 223 neonates were identified as having had PICCs, with 254 catheters inserted in the lower extremities. The STROBE checklist guided the reporting of this study.

RESULTS

Neonates underwent PICC insertion via the LE vein, with an overall complication rate of 13.4% and a one-attempt success rate of puncture of 86.2%. The rates of complications, catheter occlusion, and catheter-related infection in the PICC group with insertion through the great saphenous vein were significantly lower than those in the femoral vein group (p < .05). The success rate was significantly higher than that in the femoral vein group (p < .05). Additionally, the incidence of total complications and catheter occlusion complications with PICC insertion via the right LE was significantly lower than that with insertion via the left LE (p < .05).

CONCLUSION

Our study suggested that, when feasible, the saphenous vein in the right LE could be the most suitable insertion site for neonatal PICCs.

RELEVANCE TO CLINICAL PRACTICE

These findings provide insights into the complications, indwelling time, and safety of neonatal PICCs in different LE sites, serving as a valuable reference for clinical practice. This study was retrospective in nature, and all staff involved obtained approved access to patient clinical data. Ethical approval was granted by the Ethics Committee of Xiangya Hospital, Central South University (registry number 2022010001).

No Critical Ultrasound, No Life: The Value of Point-of Care Critical Ultrasound in the Rescue of Critically Ill Infants

Point-of-care critical ultrasound (POC-CUS) screening plays an increasingly important role in the treatment of critically ill infants. Without POC-CUS, the lives of many infants would not be saved in time and correctly. A premature infant with systemic multiple organ system dysfunction caused by fungal sepsis was treated and nursed under the guidance of POC-CUS monitoring, and the infant was ultimately cured. This premature infant had systemic multiple organ system dysfunction and disseminated intravascular coagulation (DIC) caused by fungal sepsis. In the hypercoagulable state of early-stage DIC, cardiac thrombosis could be found using ultrasound screening. For this case, right renal artery thrombosis was found via renal artery Doppler ultrasound examination. Due to the severity of this disease, ultrasound-guided peripherally inserted central catheter (PICC) insertion and ultrasound checks of the PICC tip's position were performed, which ensured the success of this one-time catheterization and shortened the catheterization time. Lung ultrasound is used for the diagnosis and differential diagnosis of pulmonary diseases, and to guide the application of mechanical ventilation. Because the abdominal circumference of the patient's markedly enlarged abdominal circumference, bloody stool, and absence of bowel sounds, abdominal ultrasonography was performed, which revealed a markedly enlarged liver, significant peritoneal effusion, and necrotizing enterocolitis. Guided by POC-CUS monitoring, we had the opportunity to implement timely and effective treatment that ultimately saved this critically ill patient's life. The successful treatment of this newborn infant fully reflects the importance of carrying out POC-CUS screening.

Charakteristika und klinische Manifestation katheterassoziierter Thrombosen bei Frühgeborenen

Hintergrund

In der Neonatologie sind peripher eingeführte zentrale Katheter ein häufiger Zugangsweg zur parenteralen Ernährung und Verabreichung von Medikamenten und Flüssigkeit. Die Vorteile stehen den Risiken wie Infektion, Thrombose und Fehllage gegenüber.

Fragestellung

Welche Charakteristika und klinischen Zeichen weisen auf das Vorliegen einer katheterassoziierten Thrombose hin?

Material und Methoden

In einer retrospektiven Betrachung aus dem Zeitraum 2010–2016 wurden alle Fälle von katheterassoziierten Thrombosen untersucht. Identifiziert wurden 10 Frühgeborene, deren Indikation zur Katheteranlage, Zugangsweg, Lage der Katheterspitze, Liegedauer, klinische Symptome und Krankheitsverlauf analysiert wurden.

Ergebnisse

Bei 10 Frühgeborenen mit einem Gestationsalter von 23 + 4 bis 34 + 5 SSW wurden 11 Thromboseereignisse beobachtet. Zehn der 11 Thromboseereignisse betrafen die V. cava inferior nach Katheteranlage an der unteren Extremität. Die Indikation zur Katheteranlage waren parenterale Ernährung und chirurgische Eingriffe. Bei 9 Patienten traten perinatale Komplikationen auf. Bei allen Patienten bestand während der Liegedauer der Katheter der Verdacht auf eine Infektion. Das Auftreten der Thrombose wurde nach 3 bis 27 Tagen sonographisch dokumentiert. In 8 Thromboseereignissen war eine Thrombozytopenie, in 4 Fällen eine Beinschwellung auffällig.

Diskussion

Das Patientenkollektiv zeigt Gemeinsamkeiten im klinischen Verlauf und bei den Symptomen, welche auf das Vorliegen einer Thrombose deuten. Auffällig ist außerdem, dass die meisten Thromboseereignisse das Stromgebiet der V. cava inferior betrafen.

Use of an Electronic Reporting Tool and Clinical Surveillance Process in the Neonatal Intensive Care Unit to Decrease Risk for Central Venous Catheter Complications Associated With Tip Migration

This quality improvement project formalized central venous catheter tip surveillance augmented by the use of electronic patient reporting tool. The project setting was a large level IV academic neonatal intensive care unit with a representative convenience sample of patients with central venous catheters and quality improvement reports of complications from tip migration. Providers received education before implementation of a central venous catheter tip surveillance program using a revised electronic reporting tool was initiated. Provider evaluations of the electronic reporting tool included compliance with the guidelines and use of the tool in multidisciplinary patient rounds, and were entered into a database for analysis. Nine evaluations of the electronic reporting tool were completed, with an average of 97% compliance with guidelines. Seven evaluations during multidisciplinary patient rounds using the reporting tool data demonstrated use by both resident physicians and advanced practice nurses. Central venous catheter patient data were reviewed after process implementation. Overall, infant central venous catheter complications related to tip migration decreased following implementation. Therefore, the use of an electronic reporting tool improved compliance with evidence-based clinical practice guidelines and resulted in a decrease in the risk for central venous line complications related to tip migration in this setting.

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.

Outcomes of upper extremity versus lower extremity placed peripherally inserted central catheters in a medical-surgical neonatal intensive care unit1

OBJECTIVE

To compare outcomes of peripherally inserted central catheters (PICCs) placed in the upper extremity (UE) versus the lower extremity (LE) in a quaternary medical-surgical neonatal intensive care unit (NICU).

RESULTS

We analyzed a total of 365 PICCs of which 250 (68%) were removed for end of therapy and 115 (32%) were removed due to complications. Patients who had UE insertions compared to LE insertions were of lower gestational age (median (IQR)), 30 (26, 35) vs. 32 (27, 37) weeks respectively (p = 0.014). UE PICCs were more likely to be removed due to complications compared to LE PICCs (39.9% vs. 26.4%, RR 1.51, 95% CI 1.12 -2.03, p = 0.007). UE PICCs were more likely than LE PICCs to be removed for the complications of malposition, dislodgement, and pleural or pericardial effusions; while LE PICCs were more likely to be removed for phlebitis. There were no differences in the rates of sepsis at 13.0% vs. 12.8% for UE vs. LE respectively, or causal organisms for sepsis. Survival analysis demonstrated that LE PICCs had a longer time to removal for a complication (p = 0.031).

CONCLUSIONS

LE compared with UE PICCs were not associated with worse outcomes in a medical-surgical neonatal population that included a significant proportion of full-term neonates, and provide a valuable alternate site for central venous access. Increased awareness of the types of complications for UE compared with LE PICCs may help focus preventive and surveillance efforts based on PICC location, to improve safety and minimize the complications of NICU PICCs.

Complications of upper extremity versus lower extremity placed peripherally inserted central catheters in neonatal intensive care units: A meta-analysis

OBJECTIVE

To compare the risks of catheter-related complications between peripherally inserted central catheters placed via the upper and lower extremities in neonatal intensive care units.

RESEARCH METHODOLOGY

PUBMED, EMBASE, SCOPUS, and the Cochrane Library databases were searched from inception to 3 January 2019. All studies were of patients in neonatal intensive care units who underwent insertion of peripherally inserted central catheters and were published in English.

RESULTS

Eight studies covering 4405 peripherally inserted central catheters were included. The upper extremity group was associated with a higher risk of non-elective removal (OR = 1.41; 95% 1.16-1.72; p = 0.0007) and malposition (OR = 4.52, 95% CI 2.16-9.47; p < 0.0001) and a lower risk of thrombosis (OR = 0.23, 95% CI 0.07-0.77; p = 0.02) compared with the lower extremity group. There was no significant difference in mechanical complications, catheter-related infection, or phlebitis.

CONCLUSION

This meta-analysis showed that the lower extremity group was not associated with worse outcomes compared with the upper extremity group in the neonatal intensive care unit, with the exception of thrombosis. However, further prospective randomised controlled studies are needed to ensure the quality of the results.

Improved visualization of peripherally inserted central catheters on chest radiographs of neonates using fractional multiscale image processing

BACKGROUND

Peripherally inserted central catheters (PICCs) provide secure intravenous access for the delivery of life-sustaining medications and nutrition. They are commonly used in pediatrics. Confirmation of correct central catheter tip position is crucial. Verification is usually done by a radiograph. The aim of this study is to evaluate the ability of Fractional Multiscale image Processing (FMP) to detect PICC tips on the digital chest radiographs of neonates.

METHODS

A total of 94 radiographs of 47 patients were included in the study. 29 patients were male, 18 were female. The mean age of all examined children was 9.2 days (range 0-99 days). In total, six readers (two radiologists, two residents in radiology, one last year medical student, one neonatologist) evaluated 94 unprocessed and catheter-enhanced radiographs using a 5-point Likert scale (1 = poor catheter tip visualization, 5 = excellent catheter tip visualization). Additionally, the two radiologists evaluated the diagnostic confidence for chest pathologies using a 5-point Likert scale (1 = poor diagnostic confidence, 5 = excellent diagnostic confidence). Radiographs were evaluated on a dedicated workstation.

RESULTS

In all cases, the catheter-enhanced radiograph rated higher than (n = 471), or equal (n = 93) to, the unprocessed radiograph when visualizing catheter tips. 87% of the catheter-enhanced radiographs obtained a rating of 4 or higher, while only 42% of unprocessed radiographs received 4 or more points. Regarding diagnostic confidence for chest pathologies one radiologist rated two catheter-enhanced radiographs higher than the unprocessed radiographs, while all other 186 evaluations rated the catheter-enhanced radiographs equal to (n = 78) or lower than (n = 108) the unprocessed radiographs. Only 60% of the catheter-enhanced radiographs yielded a diagnostic confidence of 4 or higher, while 90% of the unprocessed images received 4 or more points.

CONCLUSION

Catheter-enhanced digital chest radiographs demonstrate improved visualization of low contrast PICC tips in neonates compared to unprocessed radiographs. Furthermore, they enable detection of accompanying chest pathologies. However, definitive diagnosis of chest pathologies should be made on unprocessed radiographs.

Risk factors for venous thromboembolic events in pediatric surgical patients: Defining indications for prophylaxis

BACKGROUND

Venous thromboembolism (VTE) in pediatric surgical patients is a rare event. The risk factors for VTE in pediatric general surgery patients undergoing abdominopelvic procedures are unknown.

STUDY DESIGN

The American College of Surgeon's National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database (2012-2015) was queried for patients with VTE after abdominopelvic general surgery procedures. Patient and operative variables were assessed to identify risk factors associated with VTE and develop a pediatric risk score.

RESULTS

From 2012-2015, 68 of 34,813 (0.20%) patients who underwent abdominopelvic general surgery procedures were diagnosed with VTE. On multivariate analysis, there was no increased risk of VTE based on concomitant malignancy, chemotherapy, inflammatory bowel disease, or laparoscopic surgical approach, while a higher rate of VTE was identified among female patients. The odds of experiencing VTE were increased on stepwise regression for patients older than 15 years and those with preexisting renal failure or a diagnosis of septic shock, patients with American Society of Anesthesia (ASA) classification ≥ 2, and for anesthesia time longer than 2 h. The combination of age > 15 years, ASA classification ≥ 2, anesthesia time > 2 h, renal failure, and septic shock was included in a model for predicting risk of VTE (AUC = 0.907, sensitivity 84.4%, specificity 88.2%).

CONCLUSION

VTE is rare in pediatric patients, but prediction modeling may help identify those patients at heightened risk. Additional studies are needed to validate the factors identified in this study in a risk assessment model as well as to assess the efficacy and cost-effectiveness of prophylaxis methods.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Risk Factors Related to Peripherally Inserted Central Venous Catheter Nonselective Removal in Neonates

We aimed to investigate the incidence and risk factors associated with nonselective removal of peripherally inserted central venous catheter (PICC) in neonates. In this prospective cohort study, neonates who underwent PICC placement at neonatal intensive care units (NICUs) in China from October 2012 to November 2015 were included. The patient demographics, catheter characteristics, catheter duration, PICC insertion site, indication for PICC insertion, infuscate composition, PICC tip location, and catheter complications were recorded in a computerized database. Risk factors for nonselective removal were analyzed. A total of 497 PICCs were placed in 496 neonates. Nonselective removal occurred in 9.3% of PICCs during 10,540 catheter-days (4.6 nonselective removals per 1,000 catheter-days). These included occlusion (3%), infection (1.4%), leakage (2.0%), phlebitis (0.6%), displacement (1%), pleural effusion(0.6%), and breaks (0.6%). Noncentral tip position was independently associated with an increased risk of nonselective removal (odds ratio 2.621; 95% confidence interval, 1.258-5.461) after adjusting for gestational age, sex, birth weight, and PICC dwell time. No significant differences in the rate of complications occurred between silastic and polyurethane PICC or different insertion sites. Noncentral PICC tip position was the only independent risk factor for nonselective removal of PICC.