Extravasation of hyperalimentation into the liver parenchyma from a peripherally inserted central catheter

Indications, Measurements, and Complications of Ten Essential Neonatal Procedures

About 10% of newborns require some degree of assistance to begin their breathing, and 1% necessitates extensive resuscitation. Sick neonates are exposed to a number of invasive life-saving procedures as part of their management, either for investigation or for treatment. In order to support the neonates with the maximum possible benefits and reduce iatrogenic morbidity, health-care providers performing these procedures must be familiar with their indications, measurements, and potential complications. Hence, the aim of this review is to summarise ten of the main neonatal intensive care procedures with highlighting of their indications, measurements, and complications. They include the umbilical venous and arterial catheterizations and the intraosseous line which represent the principal postnatal emergency vascular accesses; the peripherally inserted central catheter for long-term venous access; the endotracheal tube and laryngeal mask airway for airway control and ventilation; chest tube for drainage of air and fluid from the thorax; and the nasogastric/orogastric tube for enteral feeding. Furthermore, lumber puncture and heel stick were included in this review as very important and frequently performed diagnostic procedures in the neonatal intensive care unit.

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.

Extravasation of total parenteral nutrition into the liver from an upper extremity peripherally inserted central venous catheter

Peripherally inserted central catheters (PICC) are the mainstay of central venous access in preterm infants, and one of the common procedures performed in neonatal intensive care unit (NICU). Complications of PICC include infection, mechanical dysfunction, thrombosis, migration, and extravasation of the infusate. In this report, we describe a case of PICC inserted from an upper extremity with migration into the inferior vena cava (IVC) and the hepatic vein associated with extravasation of the total parenteral nutrition (TPN) into the peritoneum and the liver. This case highlights the vigilance required not only to insert but for the maintenance of PICC to prevent complications associated with migration of PICC.

Peripherally Inserted Central Catheters Complicated by Vascular Erosion in Neonates

Peripherally inserted central catheters (PICCs) are widely used in the pediatric population, and their use continues to grow in popularity. These catheters provide a reliable source of venous access to neonatal patients but can also be the cause of life-threatening complications. There are several well-documented complications such as infections, catheter thrombosis, vascular extravasations, and fractured catheters. However, the complication of vascular erosion into the pleural space using both small and silicone-based catheters is rarely described. After obtaining institutional review board approval, we identified 4 cases to review of PICCs complicated by vascular erosions in the past 2 years. Herein, we also review the current literature of PICC complications. Getting the catheter tip as close to the atrial-caval junction as possible and confirmation of this placement are of the utmost importance. The thick wall of the vena cava near the atrium seems to be less likely to perforate; in addition, this position provides increased volume and turbulence to help dilute the hyperosmolar fluid, which seems to also be a factor in this complication. A daily screening chest x-ray in patients with upper extremity PICCs and ongoing parenteral nutrition (PN) are not necessary at this time given the overall low rate of vascular erosion and concerns regarding excessive radiation exposure in pediatric populations. However, a low threshold for chest x-ray imaging in patients with even mild respiratory symptoms in the setting of upper extremity PN is recommended.

Neonatal peripherally inserted central catheter practices and their association with demographics, training, and radiographic monitoring: results from a national survey

The goal of this secondary analysis of results from a national survey of peripherally inserted central catheters (PICCs) practices in neonates was to determine whether demographics and types of training were associated with differing radiographic confirmation practices of these catheters. Correlational analyses were performed on the 2010 national database of neonatal PICC practices. The sample consisted of 187 respondents, representing 25% of the level III neonatal intensive care units (NICUs) of more than 20 beds in the United States. The key factors examined were geographic location, size of NICU, academic affiliation, and type of training related to radiographic confirmation of the catheter tip position, routine monitoring and reconfirmation of the catheter tip position following adjustments, and associated patient positioning practices for consistent evaluation of the catheter tip position. Formal training and annual retraining were statistically significantly associated with consistent patient positioning practices for more accurate monitoring of the catheter tip position and acceptable tip location. Size of NICU and academic affiliation were not associated with differences in practices. Adherence to specific national guidelines and recommendations for care of infants with PICCs is significantly impacted by formal training and annual retraining. This underscores the importance of education and annual retraining in preventing PICC-related complications beyond the crucial prevention of central line-associated bloodstream infections.

A national survey of neonatal peripherally inserted central catheter (PICC) practices

PURPOSE

The purpose of this study was to assess and describe the practices involved in the insertion and maintenance of peripherally inserted central catheters (PICCs) in neonates in level III neonatal intensive care units (NICUs) in the United States and to compare the findings with current recommendations and evidence.

SUBJECTS

The study included responses from 187 nurses, nurse practitioners, and neonatologists who place PICCs in NICUs representing 43 states.

METHODS

A 90-question, multiple-choice survey of a variety of PICC practices was sent to NICU directors and nursing staff responsible for PICC insertion. The explorative survey was sent by electronic and standard mail services. A descriptive analysis of the responses was performed.

MAIN OUTCOME MEASURES

Main outcome measures included the response rate to the survey and the summarized responses of multiple categories of PICC practices.

PRINCIPAL RESULTS

Of the 460 level III NICUs contacted, 187 returned surveys meeting criteria for analysis, yielding a 42% response rate. Responses showed wide variation of PICC practices in multiple aspects of PICC insertion and maintenance. The greatest level of conformity was seen with the following practices: use of 2 nurses to perform a dressing change, trimming the PICC, using a kit or cart containing insertion supplies, use of maximal sterile barrier precautions during insertion, catheter tip residing in the superior vena cava for upper body insertions, and not heparin locking, infusing blood products, performing catheter repair, or inserting using Modified Seldinger Technique. Some identified practices, such as infusion tubing change and catheter entry techniques, were contrary to current evidence and demonstrated a lack of correct information, and some represented safety concerns for the neonates having PICCs.

CONCLUSION

This extensive national survey of NICU PICC practices showed wide variation in multiple aspects of PICC insertion and maintenance. A gap between the evidence and current practice was evident in many facets of training, insertion techniques, and maintenance processes. The data suggest a need for an increase in awareness of clinicians of current practice guidelines and standards and the need for further research to develop an evidence basis for many aspects of PICC care where lacking.

Iatrogenic chylothorax due to pleural cavity extravasation of total parenteral nutrition in two adults receiving nutrition through a peripherally inserted central catheter

Extravasation of total parenteral nutrition (TPN) delivered via central lines is a known potential complication, but significant extravasations of infusate into the pleural space when using peripherally inserted central catheters (PICCs) have not been reported in adults. We report 2 cases ofpleural cavity extravasation ofTPN delivered via a PICC. Measurement of the glucose level of the effusate is a quick way to determine the presence of TPN and should be considered in any patient receiving TPN via any type of central line with a rapidly developing effusion.

Are supine chest and abdominal radiographs the best way to confirm PICC placement in neonates?

BACKGROUND

Peripherally inserted central catheters (PICCs) are commonly used in NICUs. Although they have many benefits, they also have many potential complications. Confirming catheter tip position is essential to decreasing complications, but the best method to achieve confirmation is unclear.

OBJECTIVES

Literature review for studies that address line position confirmation to assist health care providers in evaluating the available research and to identify gaps in the literature.

METHOD

A literature search of four major databases followed by an ancestry approach was performed. Articles reviewed specifically discuss PICC lines and PICC line placement confirmation.

RESULTS

Data on confirming PICC placement were lacking. Fluoroscopic placement is ideal, but cannot be done at the bedside and is costly. Supine chest radiograph is the most widely used method and is convenient, but when line tip position is unclear, contrast or ultrasound confirmation can be used. When PICC lines are placed in the saphenous vein, infants may benefit from supine and lateral abdominal radiographs to ensure placement in the inferior vena cava.

DISCUSSION

More studies are needed to generalize findings. PICC line tips should be located in the superior vena cava or inferior vena cava close to the junction with the right atrium (0.5-1 cm outside of the cardiac chambers in premature infants and 1-2 cm outside of the cardiac chambers in larger infants). Arm position is very important when performing radiographs for placement because movement of the arm can cause migration of the catheter. There is also significant inter-observer variability when identifying line tip position.

Parenteral nutrition

PURPOSE OF REVIEW

Although there have been no fundamental changes in the nature and practice of parenteral nutrition during the review period, there have been important observations with respect to adjunctive hormonal manipulation and the recognition of new hazards that warrant review.

RECENT FINDINGS

Papers summarized include those demonstrating benefit from addition of growth hormone, and of medium-chain triglycerides, and those indicating that there is no apparent aggravation to osteoporosis, even with long-term intravenous nutrition. General advice is given on the place for new interventions and avoidance of complications.

SUMMARY

The relative safety of long-term parenteral nutrition is reconfirmed. Interesting new manipulations of the hormonal and lipid milieu may prove to be important developments.

Globalization of infectious diseases: the impact of migration

With up to 2% of the world's population living outside of their country of birth, the potential impact of population mobility on health and on use of health services of migrant host nations is increasing in its importance. The drivers of mobility, the process of the international movement, and the back-and-forth transitioning between differential risk environments has significance for the management of infectious diseases in migrant receiving areas. The management issues are broad, high-level, and cross-cutting, including policy decisions on managing the migration process for skilled-labor requirements, population demographic and biometric characteristics, and family reunification; to program issues encompassing health care professional education, training, and maintenance of competence; communication of global events of public health significance; development of management guidelines, particularly for nonendemic diseases; access to diagnostic and therapeutic interventions for exotic or rare clinical presentations; and monitoring of health service use and health outcomes in both the migrant and local populations.