Comparison of percutaneous and surgical placement of central venous catheters in neonates

Outcomes of peripherally inserted double lumen central catheter in very low birth weight infants

OBJECTIVE

In order to evaluate safety and usefulness of peripherally inserted double lumen central catheter (PIDLCC) in very low birth weight (VLBW) infants, outcomes of VLBW infants who had PIDLCC was studied.

SUBJECTIVE

Thirty-nine VLBW infants who were admitted to our NICU in 2013 were retrospectively analyzed.

RESULTS

Mean birth weight and gestational age was 1042.7 gram and 28.5 weeks, respectively. Total duration of indwelling PIDLCC was 1121 days (mean 28.5+18.2 days) with 85 PIDLCCs used. Dressing at the insertion site was done twice weekly with 10% povidone iodine. Four (10.3% with mean of 48 days) infants had catheter-related blood stream infection (CRBSI), with a 3.57 infection per 1000 catheter-day. The mean for days of PIDLCC in 35 infants without CRBSI was 26.5 days. Organisms isolated were Staphylococcus epidermidis, Staphylococcus aureus and Staphylococcus capitis ureolytic. Our study showed significant difference in the duration of indwelling catheter (p = 0.023) and intraventricular hemorrhage (p = 0.043) between the CRBSI group and non-CRBSI group. Five (12.8%) infants had abnormal thyroid function test, in which two infants required thyroxine supplementation upon discharge. However, duration of PIDLCC and abnormal thyroid function test was not statistically significant (p = 0.218). One (2.5%) infant died (death was not related to CRBSI). There was no serious adverse effects secondary to PIDLCC.

CONCLUSION

It is concluded that the use and maintenance of PIDLCC is safe for VLBW infants, but close monitoring should be observed to detect early signs of infection.

Effect of Catheter Dwell Time on Risk of Central Line-Associated Bloodstream Infection in Infants

BACKGROUND AND OBJECTIVE

Central venous catheters in the NICU are associated with significant morbidity and mortality because of the risk of central line-associated bloodstream infections (CLABSIs). The purpose of this study was to determine the effect of catheter dwell time on risk of CLABSI.

METHODS

Retrospective cohort study of 13,327 infants with 15,567 catheters (93% peripherally inserted central catheters [PICCs], 7% tunneled catheters) and 256,088 catheter days cared for in 141 NICUs. CLABSI was defined using National Health Surveillance Network criteria. We defined dwell time as the number of days from line insertion until either line removal or day of CLABSI. We generated survival curves for each week of dwell time and estimated hazard ratios for CLABSI at each week by using a Cox proportional hazards frailty model. We controlled for postmenstrual age and year, included facility as a random effect, and generated separate models by line type.

RESULTS

Median postmenstrual age was 29 weeks (interquartile range 26-33). The overall incidence of CLABSI was 0.93 per 1000 catheter days. Increased dwell time was not associated with increased risk of CLABSI for PICCs. For tunneled catheters, infection incidence was significantly higher in weeks 7 and 9 compared with week 1.

CONCLUSIONS

Clinicians should not routinely replace uninfected PICCs for fear of infection but should consider removing tunneled catheters before week 7 if no longer needed. Additional studies are needed to determine what daily maintenance practices may be associated with decreased risk of infection, especially for tunneled catheters.

Is an increased dwell time of a peripherally inserted catheter associated with an increased risk of bloodstream infection in infants?

OBJECTIVE

To estimate the risk of bloodstream infection associated with catheter dwell time in infants.

DESIGN

Retrospective study.

SETTING

Duke University Medical Center neonatal intensive care unit, an academic, level 3 nursery in Durham, North Carolina.

METHODS

A case of catheter-associated bloodstream infection was defined as one that occurred in an infant whose culture-positive blood sample was collected more than 24 hours after catheter insertion or within 72 hours after catheter removal. We used multivariable logistic regression to control for the catheter's position and dwell time as well as the infant's sex, gestational age, age at time of catheter insertion, birth weight, and weight at time of catheter insertion.

RESULTS

We identified 135 cases of catheter-associated bloodstream infection. The mean catheter dwell time was 12.2 days (range, 0-113 days), and the mean time to bloodstream infection was 10.8 days (range, 1-57 days). An increase in catheter dwell time was associated with a lower risk of bloodstream infection (odds ratio, 0.975 [95% confidence interval, 0.954-0.996]; P = .02).

CONCLUSION

No increased risk of catheter-associated bloodstream infection was observed with increased catheter dwell time. This may have been due to the infant's improved nutrition, decreased need for other invasive devices, and maturing skin and immune system as catheter dwell time increased.

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%).

Risk of Catheter-Related Bloodstream Infection With Peripherally Inserted Central Venous Catheters Used in Hospitalized Patients

BACKGROUND

Peripherally inserted central venous catheters (PICCs) are now widely used for intermediate and long-term access in current-day health care, especially in the inpatient setting, where they are increasingly supplanting conventional central venous catheters (CVCs) placed percutaneously into the internal jugular, subclavian, or femoral veins. Data on the risk of PICC-related bloodstream infection (BSI) with PICCs used in hospitalized patients are limited.

STUDY OBJECTIVES

To determine the risk of PICC-related BSI in hospitalized patients.

STUDY DESIGN

Prospective cohort study using data from two randomized trials assessing the efficacy of chlorhexidine-impregnated sponge dressing and chlorhexidine for cutaneous antisepsis.

METHODS

PICCs inserted into the antecubital vein in two randomized trials during from 1998 to 2000 were prospectively studied; most patients were in an ICU. PICC-related BSI was confirmed in each case by demonstrating concordance between isolates colonizing the PICC at the time of removal and from blood cultures by restriction-fragment DNA subtyping.

RESULTS

Overall, 115 patients had 251 PICCs placed. Mean duration of catheterization was 11.3 days (total, 2,832 PICC-days); 42% of the patients were in an ICU at some time, 62% had urinary catheters, and 49% had received mechanical ventilation. Six PICC-related BSIs were identified (2.4%), four with coagulase-negative staphylococcus, one with Staphylococcus aureus, and one with Klebsiella pneumoniae, a rate of 2.1 per 1,000 catheter-days.

CONCLUSION

This prospective study shows that PICCs used in high-risk hospitalized patients are associated with a rate of catheter-related BSI similar to conventional CVCs placed in the internal jugular or subclavian veins (2 to 5 per 1,000 catheter-days), much higher than with PICCs used exclusively in the outpatient setting (approximately 0.4 per 1,000 catheter-days), and higher than with cuffed and tunneled Hickman-like CVCs (approximately 1 per 1,000 catheter-days). A randomized trial of PICCs and conventional CVCs in hospitalized patients requiring central access is needed. Our data raise the question of whether the growing trend in many hospital hematology and oncology services to switch from use of cuffed and tunneled CVCs to PICCs is justified, particularly since PICCs are more vulnerable to thrombosis and dislodgment, and are less useful for drawing blood specimens. Moreover, PICCs are not advisable in patients with renal failure and impending need for dialysis, in whom preservation of upper-extremity veins is needed for fistula or graft implantation.

Extravascular collection of fluid around the vertebra resulting from malpositioning of a peripherally inserted central venous catheter in extremely low birth weight infants

Peripherally inserted central venous catheters (PICCs) have allowed central venous access via peripheral veins for a long period. PICCs have become an indispensable tool in neonatal medicine. Despite their benefits, PICCs involve some risks, which include infection, thrombosis, malpositioning, and extravascular collection of fluid. We presented two patients with extravascular collection of fluid around the vertebra resulting from malpositioning of PICCs. The PICCs were placed via the saphenous veins in both patients. The PICCs were judged to be centrally placed in the inferior vena cava by means of supine abdominal roentgenograms. The next day one patient exhibited frequent apneic attacks and the other exhibited twitching movements. A lumbar puncture revealed extravascular collection of fluid around the vertebra. In lateral view chest-abdominal roentgenograms, the PICC tips were observed to be in the vertebral lumen. The PICCs were removed immediately and the condition of the patients improved. We stressed the usefulness of the lateral view abdominal roentgenograms for revealing the malpositioning of PICCs in the inferior vena cava.

Variations in central venous catheter-related infection risks among Canadian neonatal intensive care units

BACKGROUND

The objective of this study was to examine central venous catheter (CVC)-related nosocomial blood stream infection risks of umbilical venous, percutaneous and Broviac catheters, as well as variations in CVC use and CVC-related risk for nosocomial blood stream infection in the neonatal intensive care unit (NICU).

METHODS

A cohort study was performed based on 19,507 infants admitted to 17 NICUs in the Canadian Neonatal Network from January, 1996, through October, 1997. Information on these subjects was prospectively collected by trained abstractors. Incidence of infection was measured as infection episodes per 1000 patient days. The risk ratio (RR) of CVC use for nosocomial blood stream infection was calculated as the infection rate during catheter days divided by the infection rate during noncatheter days. Using a Poisson regression model we examined the adjusted RR of CVC use for nosocomial blood stream infection, controlling for patient characteristics and illness severity at admission. Interinstitutional variations in CVC-related infection risks were examined by stratified analyses.

RESULTS

CVC were used in 22.5% of patients. The incidence of nosocomial blood stream infection was 2.9 per 1000 noncatheter days, 7.2 per 1000 umbilical venous catheter days, 13.1 per 1000 percutaneous catheter days and 12.1 per 1000 Broviac catheter days. The RR for nosocomial blood stream infection, adjusted for differences in patient characteristics and admission illness severity, was 2.5 for umbilical venous catheter, 4.6 for percutaneous catheter and 4.3 for Broviac catheter (P < 0.05). There were significant (P < 0.05) risk-adjusted variations in CVC-related infection risks among NICUs.

CONCLUSIONS

CVC use increased the risk of nosocomial blood stream infection. The risk of nosocomial blood stream infection in percutaneous and Broviac catheters was 70 to 80% higher than in umbilical venous catheters. There was significant variation in CVC-related infection risks among Canadian NICUs.

Survival after an acute pericardial tamponade as a result of percutaneously inserted central venous catheter in a preterm neonate

Percutaneously inserted central venous catheters (PICC) are used in premature infants to deliver intravenous fluids, total parenteral nutrition (TPN) and medications. This article reports a case in which the baby developed pericardial tamponade within 3 hours of starting TPN through a PICC. This was successfully treated with percutaneous subxiphoid pericardiocentesis. Pericardial tamponade should be suspected in any infant with a PICC line in place, and who suddenly develops shock like symptoms, non-attributable to usual causes.

Pulmonary sequestration

THE CLINICIAN FREQUENTLY DEALS WITH INFANTS WHO present with respiratory distress and/or abnormal chest x-ray findings of undetermined etiology. One of the essential components in the process of patient evaluation is consideration of differential diagnosis with correlation to radiologic findings and clinical presentation. Sequestrations are estimated to account for 0.15–1.7 percent of all congenital pulmonary malformations.1Although rare, often asymptomatic, and frequently not presenting in the neonatal period, pulmonary sequestrations or bronchovascular foregut malformation anomalies (with or without respiratory distress) can result in abnormal radiographic findings and should be considered in the differential diagnosis.

A randomized trial comparing peripherally inserted central venous catheters and peripheral intravenous catheters in infants with very low birth weight

BACKGROUND/PURPOSE

To determine whether percutaneously inserted central venous catheters (PICC) and peripheral intravenous catheters (PIV) in infants with very low birth weight (VLBW) differ with respect to (1) incidence of sepsis, (2) number of insertion attempts and catheters required for total intravenous therapy, (3) courses of antibiotics, and (4) total duration of intravenous (IV) use.

METHODS

A randomized comparative trial was conducted involving 63 VLBW infants (<1,251 g) who required IV therapy. Infants were assigned randomly at 1 week of age to either a PIV or a PICC catheter and followed up prospectively until an IV was no longer required or the infant was transferred out of the neonatal intensive care unit.

RESULTS

Data were analyzed on an intention-to-treat basis. There was no difference in the incidence of sepsis (P = .64), number of courses of antibiotics (P = .16), or total duration of IV use (P= .34) between the 2 groups. The number of insertion attempts required for total IV therapy was significantly lower in the PICC group than in the PIV group (P = .008). There also was a significantly lower number of total catheters utilized in the PICC group (P = .002). When data were controlled for birth weight strata the results were similar.

CONCLUSION

PICC lines reduced the number of painful IV procedures in VLBW infants without additional morbidity.

Percutaneously inserted polyurethane central catheters in the NICU: one unit's experience

This article describes the authors' experiences with using polyurethane percutaneously inserted central catheters from June 1993, when these catheters were introduced in the NICU at Children's Hospital, Omaha, Nebraska, through September 1997. Indications for line placement and anatomy are reviewed. Patient demographics, success rates, and complications are analyzed. Line cares, including dressing changes, management of infusions, and troubleshooting, are also discussed.

Sepsis outcomes in infants and children with central venous catheters: percutaneous versus surgical insertion

OBJECTIVE

To review the literature on central venous catheters (CVCs) in infants and children.

DATA SOURCES

Published surgical, medical, nursing, and nutritional studies from 1968 to the present.

STUDY SELECTION

More than 250 studies were reviewed; selection criteria for the 64 studies chosen included age, percutaneous CVC (PCVC) or surgical CVC (SCVC) use, and defined rate of sepsis.

DATA EXTRACTION

Included study purpose, sample size and age, indications for total parenteral nutrition, insertion method and sites, number of CVCs, and sepsis outcomes.

DATA SYNTHESIS

Yielded weighted mean sepsis rates that were 3.5 times higher for SCVC use in neonatal and/or pediatric populations; subanalyses of homogeneous groups of studies yielded rates that were 2.5 to 3.8 times higher.

CONCLUSIONS

Percutaneous CVC insertion should be given primary consideration for neonatal and pediatric intensive-care patients.

Parenteral nutrition for hospitalized infants: 20th-century advances in venous access

OBJECTIVE

To review the literature related to venous access for parenteral infant feeding.

DATA SOURCES

Sources included medical, nursing, and nutrition literature from 1900 to 1994.

STUDY SELECTION

One hundred ten studies were reviewed. Studies were selected based on historical significance and contribution to current practice.

DATA EXTRACTION

Data relating to the development of parenteral nutrients or evolution of parenteral techniques were extracted.

DATA SYNTHESIS

The central venous catheter was a significant development in meeting the nutritional needs of hospitalized infants.

CONCLUSION

Delivery of parenteral nutrition through percutaneous, peripherally inserted central venous catheters provides the least trauma and greatest benefit.

Catheter related sepsis during long-term parenteral nutrition in paediatric gastroenterology patients: a study of 185 consecutive central venous catheters

We report the results of a prospective study of catheter-related sepsis (CRS) in 154 gastroenterology paediatric patients treated for medical (n = 102) or surgical (n = 52) disorders. Over 2 years, 185 central venous catheters (CVC) were placed, including 155 Broviac and 30 Jonathan Shaw CVC. CVC remained in place 13,331 days (6,539 days of cyclic parenteral nutrition), with a mean catheter life of 72 days. Forty-eight episodes of CRS occurred, most of them due to coagulase-negative staphylococci (n = 29) and Staphylococcus aureus (n = 17). CRS rate was 0.26, with an overall incidence of 1 infection per 278 days of parenteral nutrition (PN). Factors significantly associated with CRS were: age 1-5 years (p < 0.01), a medical indication for treatment (p < 0.001) and summer months of PN (p < 0.01). Interestingly, CRS occurred predominantly (65%) within the first 2 months following CVC placement and the risk of infection correlated with local haemorrhage at the time of insertion (p < 0.01). Appropriate systemic therapy, without removing the catheter, permitted resolution of 90.9% (40/44) of all CRS and 100% (28/28) of CRS due to coagulase-negative staphylococci.

Subdural intravenous fat collection: an unusual complication of central intravenous feeding in the neonate

We report on a very low birth weight preterm infant who developed a subdural collection of infusion lipid while receiving total parenteral nutrition. A possible mechanism is outlined.

Complications of intravenous feeding catheters

Complications of intravenous nutrition are uncommon but may prove problematic in patients requiring long-term nutritional support. This article reviews the complications associated with intravenous catheters with particular emphasis on problems associated with insertion, catheter-related sepsis, venous thrombosis, catheter occlusion, endocarditis and intracardiac thrombus formation.