Neonatal Anthropometric Measures and Peripherally Inserted Central Catheter Depth

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.

Midline Catheter Use in the Neonatal Intensive Care Unit

Neonates admitted to the neonatal intensive care unit (NICU) are a unique population who most often begin life acutely or critically ill. Venous access is required by most acutely/critically ill neonates, especially those born preterm. Access is required for implementing management strategies such as stabilization, medications, fluids, nutrition, and transfusion of blood products. However, achieving and maintaining venous access in these neonates can be difficult, especially in preterm infants due to a myriad of contributing factors. Peripheral intravenous (PIV) catheters and peripherally inserted central catheters (PICC) are 2 common vascular access approaches used in the NICU and have traditionally been the most studied in the neonatal literature. Both options offer advantages and disadvantages. An alternative to PIVs and PICCs is the midline peripheral catheter (MPC), which in the literature may also be referred to as extended dwell peripheral intravenous catheters. Depending on the intended use, the MPC offers a venous access approach between a PIV and PICC. Usage of MPCs in the NICU is slowly increasing with the limited published evidence suggesting they are viable option when considering the need for vascular access. The purpose of this article is to present the advantages and disadvantages of MPCs as an alternative approach for venous access in neonates when appropriate.

Placement of peripherally inserted central catheter through upper versus lower limb vein in neonates: A meta-analysis of randomized controlled trials

AIM

Peripherally inserted central catheter (PICC) is an important treatment for the drug and nutrition administration in neonates. We aimed to evaluate the effects and safety of PICC placement through upper versus lower limb vein in neonates, to provide insights into the clinical PICC nursing care.

DESIGN

A meta-analysis.

METHODS

We searched the Cochrane Library, Web of Science, PubMed, Science Direct, China national knowledge infrastructure, Wanfang Data Knowledge Service Platform, China Weipu Database, China Biomedical Literature Database for published randomized controlled trials (RCTs) on the placement of PICC via upper limb and lower limb venipuncture. Two reviewers independently evaluated and cross-checked the quality of the included studies in accordance with the quality standards of the Cochrane Manual. We used RevMan 5.3 software for statistical processing.

RESULTS

A total of 12 RCTs were included in this meta-analysis. Meta-analysis indicated that compared with upper limb veins, PICC insertion through lower limb veins is beneficial to increase the one-time puncture success rate (relative risk [RR]  =  0.73, 95% confidence interval [CI]: 0.68-0.79) and the indwelling time (mean difference [MD] =  -3.60, 95% CI: -5.35 to -1.86), reduce the operation time (MD =  10.37, 95% CI: 7.48-13.26), estimated bleeding volume (MD =  0.55, 95% CI: 0.34-0.75), incidence of catheter ectopia (RR  =  2.46, 95% CI: 1.81-3.35), PICC-associated infection (RR  =  2.82, 95% CI: 1.65-4.83), exosmosis (RR  =  2.45, 95% CI: 1.49-4.04, p < .001) and phlebitis (RR  =  1.40, 95% CI: 1.03-1.90). No significant difference in the Incidence of catheter obstruction between the upper and lower limb veins (RR  =  1.20, 95% CI: 0.73-1.97, p = .48) was found.

PUBLIC CONTRIBUTION

There are certain advantages in neonatal PICC puncture through the lower limb vein. The lower limb vein may be the preferred choice for neonatal PICC puncture.

Effectiveness and safety of intracardiac electrocardiogram guidance for epicutaneo-cava catheters via the lower extremity in preterm infants: a retrospective study

INTRODUCTION

In recent years, intracardiac electrocardiogram (IC-ECG) technology has been widely used for epicutaneo-cava catheter (ECC) placement and has shown many potential advantages. However, evidence about the quantitative changes, effectiveness, and safety of IC-ECG for lower extremity ECC is sparse. This study aimed to explore the quantitative changes in IC-ECG for lower extremity ECC and determine its effectiveness and safety.

METHODS

A retrospective study was conducted on 303 premature infants who underwent successful IC-ECG-guided lower extremity ECC placement between January 2019 and December 2021. All patients underwent chest X-ray postoperatively to verify the position of the catheter tip. The amplitudes of the surface electrocardiogram and IC-ECG QRS waves and the difference between the two amplitudes were measured. The effectiveness (matching rate between IC-ECG and chest X-ray) and safety (incidence of catheter-related complications) of IC-ECG for lower extremity ECC were evaluated.

RESULTS

The matching rate between IC-ECG and chest X-ray was 95.0%. When the catheter tip was optimally positioned, the QRS amplitude of the IC-ECG was 0.85 ± 0.56 mv higher than that of the surface electrocardiogram. The overall incidence of catheter-related complications was 10.6%. The actual ECC insertion length was associated with a noticeably increased risk of catheter-related complications.

CONCLUSIONS

This study suggests that IC-ECG is an effective and safe method by observing the dynamic changes in both QRS complexes and P wave to locate the tip of lower extremity ECC in preterm infants. Our findings would facilitate the application of IC-ECG for ECC localization.

Role of a radiopaque agent and surveillance radiographs for peripherally inserted central catheters in newborn infants

BACKGROUND

Controversy exists regarding the use of a radiopaque agent to identify peripherally inserted central catheter (PICC) tip positions in newborn infants and of serial radiography to monitor PICC tip migration.

OBJECTIVE

To investigate the roles of (1) the injection of a radiopaque agent to identify PICC tip position and (2) the performance of weekly radiography to monitor PICC migration.

MATERIALS AND METHODS

This retrospective single-centre cohort study included newborn infants who received a PICC between 1 January 2016 and 31 December 2020. A radiopaque agent was injected to identify PICC tip position and radiographs were performed weekly to detect PICC migration.

RESULTS

We identified 676 PICC episodes in 601 infants. A radiopaque agent was used for 590 of these episodes. There was no difference in the proportion of central PICC tip positions based on radiopaque agent use status (490/590, 83% for the radiopaque agent used group versus 73/85, 85.8% for the radiopaque agent not used group, P=0.51). Irrespective of the site of PICC insertion, outward migration was observed for most centrally placed PICCs over their entire in situ duration. Inward migration was identified in 23 out of 643 PICC episodes (3.6%) only on radiographs obtained on or before day 7. Based on serial radiographs, the odds for PICC tips remaining in a central position were lower the longer the PICC remained in situ (adjusted odds ratio-OR 0.93; 95% confidence interval 0.92-0.95). There was no difference in PICC migration between side and limb of insertion.

CONCLUSION

PICC tips can be identified without injection of a radiopaque agent. Serial radiographs identified PICC migration over the in situ duration. This study has implications for reducing exposure to a radiopaque agent and ongoing migration surveillance practices.

Recommendations for Peripherally Inserted Central Catheter Insertion Depths in Neonates

OBJECTIVE

Malposition of peripherally inserted central catheters (PICCs) is common. Recommendations for PICC insertion depths are scarce and comprise complex equations. This study aimed to develop diagrams and tables for the recommendation of PICC insertion depths in neonates based on anthropometric parameters.

STUDY DESIGN

In this retrospective single-center study, the individual optimal PICC insertion depths were correlated with body weight, length, and head circumference. Using linear regression analysis, line charts and tables for the recommendation of PICC insertion depth were generated and compared with previously published recommendations.

RESULT

PICC insertion depths of 204 infants (gestational age at PICC installation: 24.0-44.9 weeks) with 131 (64%) PICC in the upper extremities and 73 (36%) in the lower extremities were analyzed. Linear logistic regression models revealed R2 values between 0.387 and 0.884.

CONCLUSION

The charts and table developed in this study enable a fast and accurate determination of recommended PICC insertion depths in neonates.