Percutaneous and surgical placement of fine silicone elastomer central catheters in high-risk newborns

Cardiac tamponade by peripherally inserted central catheter in preterm infants: role of bedside ultrasonography and therapeutic approach

OBJECTIVE

to determine the incidence of pericardial effusion with cardiac tamponade in preterm infants in a pediatric intensive care unit, with emphasis on the relationship between pericardial effusion and peripherally inserted central catheter, and to evaluate the role of bedside ultrasound in approaching these cases.

METHODS

we conducted a retrospective analysis of patients admitted to a pediatric intensive care unit between July 2014 and December 2016, who presented pericardial effusion with hemodynamic repercussion, evaluated by ultrasonography.

RESULTS

we studied 426 patients admitted to the five beds of the neonatal unit. In the period, there were 285 bedside ultrasound exams. We found six cases of pericardial effusion, four of which with obstructive shock and need for pericardial drainage. There was no procedure-related mortality, and all patients evolved with hemodynamic improvement after the procedure. The incidence of pericardial effusion was 2.4 cases per year.

CONCLUSION

the incidence of pericardial effusion is low in neonates, but early diagnosis is fundamental due to high morbidity and mortality, especially in cases of abrupt onset. All cases were diagnosed by bedside ultrasonography, demonstrating its importance in the screening of these cases, especially in shocks of uncertain etiology and neonates with sudden onset hemodynamic instability who are using central venous access.

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.

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.

Assessment of infants with peripherally inserted central catheters: Part 2. Detecting less frequently occurring complications

Peripherally inserted central catheters (PICCs) are frequently placed in neonates to optimize nutrition and provide stable infusions of critical medications into the central vascular system. PICCs have been associated with a number of device-specific complications that can manifest during insertion, while the line is indwelling, and/or after the removal of the line. The first article of this series in Focus on the Physical, titled "Assessment of Infants With Peripherally Inserted Central Catheters: Part I. Detecting the Most Frequently Occurring Complications," presented assessment strategies to detect common complications such as catheter occlusions and catheter-related bloodstream infections. Part 2 of this series emphasizes the importance of ongoing systematic assessment of PICCs for device-specific complications such as catheter migration, dislodgement, breakage, phlebitis, and thrombosis, as well as the life-threatening complications of pleural and pericardial effusion and tamponade. Each complication is described, along with a review of the etiology, a description of presenting signs and symptoms, and key clinical interventions.

Assessment of infants with peripherally inserted central catheters: Part 1. Detecting the most frequently occurring complications

Inserting, maintaining, and monitoring vascular access are integral components of neonatal care. Advances in vascular access technology have led to the insertion of peripherally inserted central catheters (PICC) to provide stable venous access for early and aggressive parenteral nutrition. Medications that are irritating or damaging, or those with a high osmolality or a nonphysiologic pH, can also be safely administered into the central venous system. The need for repeated peripheral intravenous attempts, as well as the associated pain and physiologic instability, are virtually eliminated once a PICC line is placed. Complications related to PICCs may occur at any phase of therapy: during insertion, while indwelling, or after discontinuing the line. The risk factors associated with PICCs are distinctly different from peripheral intravenous lines because of their long dwell time, central placement, and potential to migrate. Part 1 of Focus on the Physical offers a review of the relevant anatomy of the vascular system and a discussion of the appropriate sites for catheter tip placement. Guidelines for a systematic physical assessment, along with recommendations for standardized PICC documentation, are provided. A review of the signs and symptoms of more frequently occurring complications, such as catheter occlusion and bloodstream infections, is presented to enhance awareness of PICC-specific complications in the neonate and to expedite early detection and treatment. Part 2 of this series will focus on systematic assessment for less common complications such as catheter migration, dislodgement, breakage, and thrombosis, as well as the life-threatening complications of pleural and pericardial effusion.

The use of alteplase to restore patency of central venous lines in pediatric patients: a cohort study

We evaluated the efficacy and safety of alteplase to restore central venous line (CVL) patency in a consecutive cohort study. A uniform, weight-dependent protocol for alteplase administration was established prospectively. For children < or =10 kg, a dose of 0.5 mg was used; for children >10 kg, doses of 1 to 2 mg were used. The alteplase remained instilled for 1 to 4 hours or overnight. Retrospective data accrual found that 25 children received alteplase for a total of 34 courses; 29 (85%) of the 34 courses of alteplase completely restored CVL patency. Alteplase appears to be a safe and effective thrombolytic agent for CVL patency restoration in children.

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.

Central venous catheter-related bacteraemia in critically ill neonates: risk factors and impact of a prevention programme

Risk factors for central venous catheter (CVC)-related bacteraemia among infants admitted to a neonatal intensive care unit (NICU) were analysed and the impact of surveillance and continuing education on the incidence of this complication investigated. Among patients admitted to a NICU, CVC-related bacteraemia increased from 1/15 (7%) in 1987 to 11/26 (42%) in 1988 (P = 0.01). Coagulase-negative staphylococci isolated from bacteraemia patients showed clonal diversity by plasmid and chromosomal fingerprinting. A review of CVC care procedures suggested breaches in aseptic techniques. Catheter-care technique was revised to ensure maximal aseptic precautions, including the use of sterile gloves, gown and drapes. The new policy was promoted by a continuing education programme and regular feed-back of CVC-related bacteraemia incidence to NICU staff. In the four-year follow-up period, the attack-rate of CVC-related bacteraemia decreased to 18/156 (12%) patients [relative risk (RR): 0.27, 95% confidence interval (CI); 0.15-0.51; P < 0.001 vs the previous period]. By using the Cox's model proportional hazards, very low birthweight and the period before use of strict aseptic CVC care were found to be predictors of increased risk of catheter-related bacteraemia after adjustment for duration of catheterization. These data provide further evidence that strict aseptic precautions during the maintenance and utilization of CVC can contribute to lower the risk of catheter infection in critically ill neonates. Regular feedback of surveillance data was associated with a progressive decrease in incidence of infection, suggesting that it improved staff compliance with aseptic precautions.

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.

Peripheral versus central intravenous nutrition: comparison of two delivery systems

Forty-six surgical patients who required intravenous nutrition (IVN) were randomly allocated to receive complete IVN by a peripheral (n = 23) or central (n = 23) venous delivery system. The peripheral IVN system combined a fine-bore silicone catheter with lipid-based nutrient solutions whereas the central system used a conventional glucose-based nutrient regimen and a single-lumen central venous catheter. The incidence of catheter complications and the complication-free system function over time were compared. Problems of venous access were not observed with peripheral IVN but occurred with one central catheterization. Three patients with central venous catheters developed bacteraemia but only one incident was thought to be catheter related (bacterial translocation). There were no such episodes with peripheral IVN. Peripheral catheterization was not associated with infective phlebitis, although late-onset chemical phlebitis occurred on four occasions after a mean(s.e.m.) time of 22.8(6.1) days, representing a daily risk of phlebitis of 0.009. There was no significant difference in the probability of complication-free system function with time between peripheral and central IVN (P = 0.14). The fine-bore silicone catheter peripheral IVN delivery system resulted in long-term phlebitis-free infusion for periods that were similar to those of single-lumen central catheterization by life-table analysis.

Sonographic detection of internal jugular vein thrombosis after central venous catheterization in the newborn period

We sonographically investigated the internal jugular veins of 40 children who had undergone catheterization of the vein (group A: silastic catheter, n = 24; group B: polyurethane catheter, n = 16) in the neonatal period. The average age at catheter implantation was 43 +/- 73 days, the average birthweight 2414 +/- 1145 g, and the average gestational age 34.8 +/- 5.0 weeks. We performed follow-up longitudinal and transverse high resolution sonographic scans including routine examination of the contralateral jugular vein at a mean age of 3.7 +/- 1.5 years. In group A thrombotic alterations were detected in 8 aut of 24 patients. In three of these patients we found mild clinical symptoms. In group B thrombotic alterations were detected in 1 aut of 16 patients without clinical symptoms. Mean birthweight (1815 versus 3313 g) and mean gestational age (32.3 versus 38 weeks) were significantly lower and indwelling time of the catheters (18 versus 11 days) was significantly longer in group A. Our results indicate that jugular vein thrombosis is a frequent long-term complication in neonates after jugular vein catheterization. High resolution ultrasonography is an adequate method for detecting jugular vein thrombosis and should therefore routinely be performed for long-term follow-up.

Difficulty in removing a percutaneous central venous catheter inserted from a peripheral vein

Two girls with acute lymphocytic leukemia (ALL) are reported. There were difficulties in removing their central venous catheters inserted from a peripheral vein. One girl required surgery under general anesthesia for the removal. The other patient received continuous infusion of low dose urokinase from a distal peripheral vein. The residual catheter was then removed successfully.

Central venous catheter-related complications in newborns and infants: a 587-case survey

In an attempt to identify factors determining central venous catheter-related complications in newborns and infants, 587 cases have been retrospectively analyzed. Attention has been paid to the influence of the incidence of babies' body weight, site of insertion, and technique of placement of the catheter and the material used, ie, silicone (SI) or polyurethane (PU). Overall complications occurred in 28% of the catheters with 2 deaths due to cardiac tamponade. Mechanical complications happened in 22% of the catheters, including dislodgement (11.6%), extracorporeal perforation (5.3%), and obstruction (5%). Septic complications occurred in 4% catheters, including proven bacteriemia (2.5%), abscess at the entry site (1%), and isolated fever (0.8%). Clinically evident caval thrombosis occurred in 1% of the catheters. Overall complications were significantly higher when the body weight was lower than 2,500 g (P less than .01) due to a significantly higher incidence of septic complications (P less than .05). When a proximal site of placement of the catheter was used, both septic and mechanical complications were more frequent than in the distal approach (P less than .01). The incidence of complications was similar in surgically and in percutaneously placed catheters as in SI and PU catheters. Nevertheless, fatal complications occurred only in PU catheters, leading us to avoid the choice of such material in newborns and small infants.

Evaluation of a percutaneously placed 27-gauge central venous catheter in neonates weighing less than 1200 grams

A percutaneous 27-gauge OD central venous catheter was inserted at 4 +/- 3 (SD) days of age and left in place for up to 2 weeks in 20 neonates with birth weights less than 1200 g and greater than 24 h of age. Parenteral nutritional solutions and medications were administered through these catheters. Twenty neonates matched for birth weight and gestational age served as paired controls. In vitro studies demonstrate that the maximum infusion rate for parenteral nutrition solutions is about 20 ml/hr. Packed red blood cells could not be infused through these catheters. In vivo results demonstrate a significant (p less than 0.05) reduction in number of peripheral iv catheters inserted during study (2 +/- 1 vs 7 +/- 4, SD) with no difference in cost per day of iv access ($79.42 +/- 113.51 vs $43.91 +/- 15.99, SD). Two-dimensional ultrasound assessment of catheter thrombosis was unsuccessful. Moreover, there was no correlation between angiographic and electron microscopic evaluation of catheter tip thrombosis. Electron microscopy of catheter tips revealed 33% with complete, partial and no occlusion, respectively, and 39% with sheath thrombosis. In summary, percutaneous insertion of a 27-gauge OD Vialon central venous catheter is a feasible alternative in providing venous access in very low birth weight infants.

Multiple purpose central venous access in infants less than 1,000 grams

The use of central venous catheters in low birthweight infants has been associated with a high rate of infectious and mechanical-related complications. We reviewed our experience with multipurpose central venous catheters in infants less than 1,000 g to determine the rate of catheter-related sepsis and mechanical catheter malfunction. From October 1981 to August 1984, 20 infants (average weight 778 g) underwent placement of 22 central venous Broviac catheters. In addition to parenteral nutrition, antibiotics, aminophylline, and replacement fluids were infused. Total catheter days were 961, with an average of 44 days per catheter. Primary catheter sepsis occurred with two catheters (9%). Mechanical complications occurred with six catheters (exposed cuff, 1; catheter break, 2; catheter reposition, 1; catheter thrombosis, 1; dehiscence of cutdown site, 1). The incidence of catheter-related sepsis was acceptably low. The high incidence of mechanical catheter malfunction (6/22, 27%) resulted in minimal morbidity to the infant and could have been avoided by better operative technique, proper positioning intraoperatively, and meticulous care of the catheter post-operatively. We conclude that multipurpose long-term central venous access can be safely utilized with the Broviac catheter in infants less than 1,000 g.

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

A comparison of randomized placement of percutaneous and surgical central venous catheters was made in 53 low birthweight infants. Twenty-eight infants received percutaneous central venous lines, and 21 infants underwent surgical placement of catheters. The incidence of complications did not differ between the groups. The mean length of time the catheter was in place also was similar. Percutaneous placement of central venous catheters appears to compare favorably with the traditional surgical approach.