Epicutaneo-caval catheters in neonates: New insights and new suggestions from the recent literature

A narrative review on tip navigation and tip location of central venous access devices in the neonate: Intracavitary ECG or real time ultrasound?

The proper location of the tip of a central venous access device plays a crucial role in minimizing the risks potentially associated with its use. Recent guidelines strongly recommend preferring real-time, intra-procedural methods of tip location since they are more accurate, more reliable and more cost-effective than post-procedural methods. Intracavitary electrocardiography and real time ultrasound can both be applied in the neonatal setting, but they offer different advantages or disadvantages depending on the type of central venous access device. Reviewing the evidence currently available about the use of these two methods in neonates, in terms of applicability, feasibility and accuracy, it can be concluded that (a) real time ultrasound is the only acceptable methodology for tip navigation for any central venous access device in neonates, (b) intracavitary electrocardiography is the preferred method of tip location for central catheters inserted by ultrasound-guided cannulation of the internal jugular vein or the brachiocephalic vein, and (c) real time ultrasound is the preferred method of tip location for umbilical venous catheters, epicutaneo-cava catheters, and central catheters inserted by ultrasound-guided cannulation of the common femoral vein.

Prevention of complications related to peripherally inserted central catheter insertion techniques in newborns: systematic review and network meta-analysis

OBJECTIVE

to analyze the effectiveness of peripherally inserted central catheter insertion techniques in preventing the occurrence of complications related to this device in newborns.

METHOD

a paired and network systematic literature review and meta-analysis, with its search carried out in seven databases and in the Grey Literature, including randomized and non-randomized clinical trials. The risk of bias was assessed using the Cochrane Risk of Bias 2 and Risk of Bias In Non-randomized Studies of Interventions tools. Certainty of the evidence was assessed by means of the Grading of Recommendations Assessment, Development and Evaluation. A meta-analysis was carried out with the aid of the R statistical program.

RESULTS

eight studies with 1,126 newborns were included and six insertion techniques were identified: intracavitary electrocardiogram; intracavitary electrocardiogram associated with ultrasound; ultrasound; formula; anatomical landmark; and modified anatomical landmark. Five techniques significantly decreased primary tip malpositioning when compared to the control ( p <0.05). Intracavitary electrocardiogram significantly and more effectively reduced arrhythmias, general complications and phlebitis; the technique that used a formula also reduced general complications. Infection, infiltration, secondary tip malpositioning, catheter rupture, thrombosis, occlusion and catheter-associated skin lesion were not significantly preventable events.

CONCLUSION

intracavitary electrocardiogram and use of the formula were the most effective techniques in reducing complications.

Prospective case series study on the use of a novel analgosedation protocol for ultrasound-guided catheterization in Neonatal Intensive Care Unit

Critically ill newborns admitted to Neonatal Intensive Care Unit often require a centrally inserted central catheters (CICCs) inserted by ultrasound-guided puncture of the internal jugular or brachio-cephalic vein. Achieving an appropriate level of sedation and analgesia is paramount for procedure success and patient safety, avoiding the potential risks associated with excessive deep sedation. The aim of this study is to evaluate the feasibility of a novel protocol of sedation. Data from 46 patients were prospectively collected. The feasibility was assessed throughout the monitoring of adverse events and the incidence of spontaneous movements. The procedure was completed in 100% of cases. There were no cases of escalation of the baseline ventilatory support despite the procedure and no case of hypotension, and all spontaneous movements were controlled with additional boluses when required.

CONCLUSION

Our study represents the very first step towards the design of a validated protocol for analgosedation during ultrasound-guided CICC insertion in NICU.

WHAT IS KNOWN

• Critically ill newborns admitted to Neonatal Intensive Care Unit often require a centrally inserted central catheter. • Achieving an appropriate level of sedation and analgesia is paramount for procedure success and patient safety, avoiding the potential risks associated with excessive deep sedation.

WHAT IS NEW

• The use of this new protocol for analgosedation is able to achieve a good level of sedation and pain control without significant adverse event. • Ultrasound-guided CICC insertion can be performed even in non-ventilated newborns.

Real-Time Ultrasound Tip Location Reduces Malposition and Radiation Exposure during Epicutaneo-Caval Catheter Placement in Neonates

OBJECTIVE

Epicutaneo-caval catheters (ECCs) are essential for the care of sick infants who require long-term medical and nutritional management. The aim of this study was to investigate the use of real-time ultrasound as an alternative to X-rays to reduce the incidence of primary malpositions during catheter insertion.

STUDY DESIGN

Data on ECCs were retrospectively collected in a tertiary neonatal intensive care unit. Catheter were analyzed considering the tip location technique (standard chest-abdominal radiograph vs real-time ultrasound) RESULTS:  A total of 248 ECCs were analyzed. Of these, 118 catheters had primary malposition (47.6%). The tip of 165 catheters was assessed using standard chest-abdominal X-rays and 107 (64.8%) were found to be in an inappropriate location. In the group of 83 catheters that were placed using real-time ultrasound for tip location, only 11 catheters (13.2%) had primary malposition. The rate of malposition among the two groups showed a statistically significant difference (p < 0.001). Hypothetically, 300 chest X-rays could have been saved if real-time ultrasound had been used to locate the tip, reducing radiation exposure to infants.

CONCLUSION

The use of a real-time ultrasound may be beneficial in reducing primary catheter malpositions compared with conventional radiography. In addition, secondary malpositions and catheter-related complications can be monitored over time.

KEY POINTS

· Conventional radiology cannot be considered the "gold standard" for ECC tip location.. · Ultrasound is more accurate and reduces insertion time reducing the rate of primary malposition.. · Ultrasound can be performed in real time and it is the best technique for ECC tip location in infants..

The SIECC protocol: A novel insertion bundle to minimize the complications related to epicutaneo-cava catheters in neonates

Epicutaneo-cava catheters are the most widely used central venous catheters in the neonate, but their insertion and management are potentially associated with several complications, both during placement (failure to proceed with the catheter, primary malposition, etc.) and during maintenance (infection, venous thrombosis, catheter dislocation, secondary malposition, etc.). Recent studies have identified methods and techniques that may be effective in minimizing the risk of most of these complications. This paper proposes a structured, sequential insertion bundle-nicknamed "the SIECC protocol" (SIECC = Safe Insertion of Epicutaneo-Cava Catheters)-which includes seven evidence-based strategies which have been proven to increase the safety, effectiveness, and cost-effectiveness of the procedure.

Ultrasound-Guided Centrally Inserted Central Catheter (CICC) Placement in Newborns: A Safe Clinical Training Program in a Neonatal Intensive Care Unit

BACKGROUND

Centrally inserted central catheters (CICCs) are increasingly used in neonatal care. CICCs have garnered attention and adoption owing to their advantageous features. Therefore, achieving clinical competence in ultrasound-guided CICC insertion in term and preterm infants is of paramount importance for neonatologists. A safe clinical training program should include theoretical teaching and clinical practice, simulation and supervised CICC insertions.

METHODS

We planned a training program for neonatologists for ultrasound-guided CICCs placement at our level III neonatal intensive care unit (NICU) in Modena, Italy. In this single-centre prospective observational study, we present the preliminary results of a 12-month training period. Two paediatric anaesthesiologists participated as trainers, and a multidisciplinary team was established for continuing education, consisting of neonatologists, nurses, and anaesthesiologists. We detail the features of our training program and present the modalities of CICC placement in newborns.

RESULTS

The success rate of procedures was 100%. In 80.5% of cases, the insertion was obtained at the first ultrasound-guided venipuncture. No procedure-related complications occurred in neonates (median gestational age 36 weeks, IQR 26-40; median birth weight 1200 g, IQR 622-2930). Three of the six neonatologists (50%) who participated in the clinical training program have achieved good clinical competence. One of them has acquired the necessary skills to in turn supervise other colleagues.

CONCLUSIONS

Our ongoing clinical training program was safe and effective. Conducting the program within the NICU contributes to the implementation of medical and nursing skills of the entire staff.

Point-of-care ultrasound for vascular access in neonates and children

Ultrasound plays a major role in neonatal/pediatric vascular access, both for venous access and for arterial access, not only just for the insertion of intravascular catheters, but also for many other issues related to this type of maneuver. This "global use of ultrasound" includes a systematic and consistent adoption of this technology for several steps of vascular access: (a) the pre-procedural assessment/evaluation of the vessels, (b) the ultrasound-guided puncture and cannulation of arteries and veins, (c) the real-time diagnosis of immediate, puncture-related complications, (d) the so-called "tip navigation" (i.e., real-time intra-procedural assessment of the direction and trajectory of the guidewire and/or of the catheter inside the vasculature), (e) the so-called "tip location" (i.e., intra-procedural or post-procedural assessment of the proper position of the tip of the catheter), and (f) the early diagnosis and/or management of most non-infective late complications.

CONCLUSION

Therefore, any vascular access expert (nurse or physicians) should have documented competency in the use of ultrasound. This knowledge should include the use of ultrasound for assessment of vessels, for catheter insertion, for proper placement of the tip, and for real-time detection of complications.

WHAT IS KNOWN

• Ultrasound is obviously useful for vascular access procedures in neonates and children.

WHAT IS NEW

• Recent evidence suggests that ultrasound is useful for many purposes in the field of vascular access (preprocedural scan, ultrasound-guided puncture, tip navigation, tip location, diagnosis of most non-infective complications). • Recent evidence also suggests that radiological methods no longer play any role in the insertion of vascular accesses in neonates and children.

Rapid Superficial Vein Assessment (RaSuVA): A pre-procedural systematic evaluation of superficial veins to optimize venous catheterization in neonates

BACKGROUND

Placement of peripheral intra-venous cannulas and epicutaneo-caval catheters is routinely performed in in Neonatal Intensive Care Unit (NICU), and both devices require visible superficial veins easy to cannulate. NICU patients are intrinsically characterized by poor and fragile vein asset, so that puncture and cannulation of superficial veins is often a challenge even for trained clinicians and cannulation frequently results in a stressful, painful, difficult procedure.

METHODS AND RESULTS

Rapid Superficial Vein Assessment is meant to offer a systematic pre-procedural evaluation of all superficial veins of the newborn, so to allow a rational choice of the best insertion site, tailored on the single patient, and optimized for the specific type of venous access device. The superficial veins are examined systematically, both with and without NIR technology, exploring seven skin areas in the following order: (1) medial malleolus, (2) lateral malleolus, (3) retro-popliteal fossa, (4) back of the hand and wrist, (5) antecubital fossa, (6) anterior scalp surface, and (7) posterior scalp surface.

CONCLUSIONS

The aim of the protocol is to increase the first attempt success rate and reduce the duration of the procedure, the number of attempts for single patient and possibly to limit complications, stress, and pain in neonates.

Central Lines and Their Complications in Neonates: A Case Report and Literature Review

Central lines are essential devices in NICUs, used primarily in preterm neonates and critically ill term neonates. They are typically divided into non-tunnelled, tunnelled and totally implanted. In light of the increasing use of central lines in the NICU setting, monitoring of the risk factors associated with complications has to be an important part of neonatal care quality management. Presented here is a case of a preterm neonate with cardiac tamponade caused by UVC tip migration. Among complications of central lines are CLABSI, with an incidence of 3 to 21 per 1000 catheter days, and portal vein thrombosis, which is common but probably under-recognised, whereas other mechanical complications such as pericardial and pleural effusions are rare, with an incidence of less than 1%. Complications can cause injury to the neonates, as well as increase the costs of health services because of increases in the length of stay in the NICU. It is recommended that the catheter tip location is confirmed either by X-ray or ultrasonography. In order to minimise the risk of CLABSI, the use of bundles is recommended. Certain recommendations need to be followed when using different types of catheters. Future research is aimed at novel ways of central line securement to minimise mechanical complications and the use of antimicrobial catheters to reduce the rate of CLABSI.

Cyanoacrylate glue as part of a new bundle to decrease neonatal PICC-related complications

A "bundle" is defined as a combination of evidence-based interventions that, if followed collectively and reliably, improve patient outcomes. The aim of this quasi-experimental study, conducted in a level-III NICU in Belgium, was to assess the impact of central line dressing and maintenance bundle implementation on the rate of catheter-related mechanical complications. We performed a quality improvement (QI) project. Prior to bundle implementation, neonatal PICC lines were secured by Steri-Strip® and occlusive dressing. We implemented a new PICC bundle consisting of the use of glue, sutureless device (Griplock®), and a transparent dressing to secure the catheter to the skin. We compared the rate of infections, mechanical complications, and dislocations before and after bundle implementation (periods 1 and 2, respectively). The use of glue resulted in a significantly decreased rate of central line-associated bloodstream infection (CLABSI) (p < 0.001), dislocations, and mechanical complications (p < 0.0001). During period 2, there was a significant increase for the average number of days the catheter stayed in place (p < 0.05). We did not observe catheter breakage or patient skin irritations attributable to the use of glue (not even in ELBW infants).

CONCLUSION

The implementation of the new bundle to secure neonatal PICCs in our NICU was associated with a significant reduction in CLABSI and dislodgment rates, without glue-related complications. Active surveillance of CVC placement procedure, positioning, and management, as well as analysis of related complications is crucial for improving patient safety. Continuous implementation of up-to-date central line bundles based on best practice recommendations is a key for quality improvement in NICUs.

WHAT IS KNOWN

• Stable vascular access is crucial in the NICU. Neonatal PICC securement issues can have serious consequences and are associated with device failure.

WHAT IS NEW

• Catheter securement with tissue adhesive is safe and effective in reducing failure and complication rates in the neonatal population.

Femoral venous access: State of the art and future perspectives

In the past 5 years, non-dialysis femoral venous access has changed in terms of indications, techniques of insertion, and expected incidence of complications. To the traditional non-emergency indication for femoral catheters-obstruction of the superior vena cava-many other indications have been added, both in intensive and non-intensive care. The insertion technique has evolved, thanks to ultrasound guided venipuncture, tunneling, and ultrasound based intraprocedural tip location. Insertion of femorally inserted central catheters may be today regarded as a procedure with an extremely low intraprocedural and post-procedural risk. The risk of infection is reduced by the possibility of the exit site at mid-thigh, by the use of cyanoacrylate glue for sealing the exit site, and by appropriate intraprocedural strategies of infection prevention. The risk of catheter-related thrombosis is low, due to several concomitant strategies: a proper match between vein diameter and catheter caliber; an accurate intraprocedural assessment of tip location by ultrasound and/or intracavitary ECG; the consistent use of ultrasound guided venipuncture and micro-introducer kits; an adequate stabilization of the catheter at the exit site. The risk of mechanical complications and the risk of lumen occlusion are minimized when using polyurethane, power injectable catheters. All these novelties have brought a revolution in the field of femoral venous access, so that this route may be considered as safe and effective as other approaches to central venous catheterization.

Complications of epicutaneo-caval catheters: Pericardial effusion and cardiac tamponade in three preterm infants

In the neonatal intensive care units (NICU), epicutaneo-caval catheters (ECCs) are common alternative vascular routes. Pericardial effusion (PCE) and cardiac tamponade (CT) are rare but serious complications in infants with ECCs. It may be asymptomatic or present with a variety of significant clinical signs, including dyspnea, bradycardia, sudden asystole, and hypotension. If untreated, PCE can be fatal. This report presents, three cases of ECC-associated PCE/CT during NICU stay. All three patients were born before 30 weeks of gestation and weighed less than 1500 g. Echocardiography was used for diagnosis all patients. PCE/CT was detected incidentally in one patient and after hemodynamic deterioration in the other two. In one patient, CT was developed due to catheter malposition, and the other two patient, the catheter tip was found in the right atrium. PCE did not recur in any of the patients after pericardial fluid was drained and the catheters were removed. No PCE/CT-related deaths were observed. In all three patients, X-ray was used to evaluate the location of the catheter tips. However, after clinical deterioration, echocardiography showed that in the first two cases the tips were actually in the right atrium. Real-time ultrasound was suggested with strong evidence to evaluate the location of the catheter tip and to detect secondary malapposition. PCE/CT should be considered in the presence of unexplained and refractory respiratory distress, abnormal heart rate and blood pressure, and metabolic acidosis in a neonate with ECC. Early diagnosis and prompt pericardiocentesis are essential to reduce mortality and improve prognosis. Prospective studies with educational interventions should be designed to demonstrate that the use of point-of-care ultrasound (POCUS) can be easily acquired and may reduce complications.

The accessibility and safety of inserting proximal basilic and axillary veins central lines in neonates

Objectives

to evaluate the accessibility, success rate, and attributable complications and to describe the maneuver for central line insertion via proximal basilic or axillary veins in neonates.

Methods

This retrospective study included all infants admitted to the neonatal intensive care unit and had an axillary central line inserted or attempted. Success rate, complications, and outcomes were reviewed.

Results

Axillary central line was attempted in 85 infants and was successful in 78 infants with a success rate of 91.7%. The median postnatal age of patients was 8 days (2 days-92 days), and the median weight of patients at the procedure was 2600 g (590 g-3900 g). The median corrected gestational age of patients at the procedure was 36 weeks (23 weeks-46 weeks). No serious complication was observed in any of the 85 infants.

Conclusion

This study demonstrated a high success rate for insertion of proximal basilic and axillary veins central lines in neonates with difficult vascular access. This procedure was feasible in very low birth and extremely low birth preterm infants, especially in those who failed previous central line attempts.

The Role of Ultrasound in Epicutaneo-Caval Catheter Insertion in Neonates: Systematic Review, Meta-Analysis and Future Perspectives

Chest and abdominal X-rays after the insertion of an epicutaneo-caval catheter in infants are the standard method of checking the tip location in many neonatal intensive care units. The role of ultrasound in the tip location of the epicutaneo-caval catheter in neonates has been the subject of many recent studies. This systematic review investigates the accuracy of epicutaneo-caval catheter tip location by comparing ultrasound and conventional radiology. We performed a systematic literature search in multiple databases. The selection of studies yielded nineteen articles. The systematic review and meta-analysis were performed according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-analysis). The analyses showed that ultrasound is a better imaging technique for epicutaneo-caval catheter tip location in the neonatal intensive care unit than conventional radiology. By improving operator training and selecting a standardized echography protocol, ultrasound could become the gold standard for visualizing the epicutaneo-caval catheter tip in the neonatal intensive care unit. This would have some important benefits: (1) increased accuracy in tip location (2); a more rapid use of the central venous access (3); and a significant reduction in radiation exposure.

Securement of Umbilical Venous Catheter Using Cyanoacrylate Glue: A Randomized Controlled Trial

OBJECTIVE

To evaluate the role of cyanoacrylate glue in reducing dislodgement of umbilical venous catheters (UVCs).

STUDY DESIGN

This was a single-center, randomized, controlled, nonblinded trial. All infants requiring an UVC according to our local policy were included in the study. Infants with a UVC with a centrally located tip as verified by real-time ultrasound examination were eligible for the study. Primary outcome was the safety and efficacy of securement by cyanoacrylate glue plus cord-anchored suture (SG group) vs securement by suture alone (S group), as measured by reduction in dislodgment of the external tract of the catheter. Secondary outcomes were tip migration, catheter-related bloodstream infection, and catheter-related thrombosis.

RESULTS

In the first 48 hours after UVC insertion, dislodgement was significantly higher in the S group than in the SG group (23.1% vs 1.5%; P < .001). The overall dislodgement rate was 24.6% in the S group vs 7.7% in the SG group (P = .016). No differences were found in catheter-related bloodstream infection and catheter-related thrombosis. The incidence of tip migration was similar in both groups (S group 12.2% vs SG group 11.7%).

CONCLUSIONS

In our single-center study, cyanoacrylate glue was safe and effective for securement of UVCs, and particularly effective in decreasing early catheter dislodgments.

TRIAL REGISTRATION

UMIN-CTR Clinical Trial; Registration number: R000045844.

Modified Seldinger technique for neonatal epicutaneo-caval catheter insertion: A non-randomised retrospective study

BACKGROUND

Epicutaneo-Caval Catheters (ECCs) are critical for good neonatal care. No previous studies have evaluated which insertion method provides the highest likelihood of success.

METHODS

This study aimed to compare the success rates and cost of modified Seldinger technique (MST) and split needle technique (SNT). MST was introduced to St Michael's Neonatal Unit, SNT was already in use. Routinely documented data on ECC insertion was retrospectively collected from the clinical notes. Practitioners were able to use their preferred insertion method. A sub-group analysis of success rates in patients born at ⩾35-weeks GA was performed.

RESULTS

There was a significantly higher first pass (53% vs 26%; p = 0.014) and overall (72% vs 40%; p = 0.0046) successful ECC insertion rate with fewer venipunctures per successful ECC with MST (2.5 vs 6.5; p = 0.002). Logrank test demonstrated a significantly higher successful ECC insertion with MST for patients of all GA (p = 0.003) and for neonates born at ⩾35 weeks (p = 0.015). The cost per successful MST ECC was £156.41 versus £152.51 for SNT.

CONCLUSION

In this uncontrolled retrospective study, there was a higher chance of successful ECC insertion with MST, with a reduced number of venipunctures and similar costs per successful ECC. Further work in randomised studies is needed to verify this finding and should focus on other clinical outcomes, including rates in central line associated blood stream infections.

Application of epicutaneo-cava catheters with 24G indwelling needles in very low birth weight infants: a safe and simple innovative technique

Background

Epicutaneo-cava catheter (ECC) is an ideal venous access for very low birth weight (VLBW) infants. However, because veins of VLBW infants are thin, ECC catheter is difficult to insert, and the success rate of puncture is low. This study aimed to use ECC with 24G indwelling needles to improve the outcomes of VLBW infants.

Methods

This retrospective study enrolled 121 VLBW infants (birthweight <1,500 g) who required ECC catheterization and were admitted to the Neonatal Intensive Care Unit of the Children's Hospital of Zhejiang University School of Medicine between January 2021 and December 2021. The patients were divided into the indwelling needle group and the conventional technique group according to the technique of ECC. The demographic and treatment data of the two groups were collected, and the success rate of first attempt cannulation of ECC and catheter-related complications of the two groups were analyzed and compared.

Results

There were no significant differences in gender, age, and body weight between the two groups on the day of ECC insertion and venipuncture site. It can be seen through model analysis that the success rate of first-attempt cannulation of ECC in the indwelling needle group was significantly higher than in the conventional technique group. In contrast, average catheterization time and catheterization-related bleeding risk in the indwelling needle group were significantly lower than in the conventional technique group (p = 0.00,and 0.00, respectively). Infection during catheter placement, indwelling catheter duration and catheter-related infection between the two groups (p > 0.05).

Conclusion

Application of ECC with 24G indwelling needles in VLBW infants can improve the success rate of first attempt cannulation of ECC, reduce the time of catheterization and the risk of bleeding, which may be popularized for widespread application.

Tamponade and massive pleural effusions secondary to peripherally inserted central catheter in neonates-A complication to be aware of

Background

Peripherally inserted central catheters (PICC) are frequently used in neonatal intensive care units (NICU) to assist premature and critically ill neonates. Massive pleural effusions, pericardial effusions, and cardiac tamponade secondary to PICC are extremely uncommon but have potentially fatal consequences.

Objective

This study investigates the incidence of tamponade, large pleural, and pericardial effusions secondary to peripherally inserted central catheters in a neonatal intensive care unit at a tertiary care center over a 10-year period. It explores possible etiologies behind such complications and suggests preventative measures.

Study design

Retrospective analysis of neonates who were admitted to the NICU at the AUBMC between January 2010 and January 2020, and who required insertion of PICC. Neonates who developed tamponade, large pleural, or pericardial effusions secondary to PICC insertion were investigated.

Results

Four neonates developed significant life-threatening effusions. Urgent pericardiocentesis and chest tube placement were required in two and one patients, respectively. No fatalities were encountered.

Conclusion

The abrupt onset of hemodynamic instability without an obvious cause in any neonate with PICC in situ should raise suspicion of pleural or pericardial effusions. Timely diagnosis through bedside ultrasound, and prompt aggressive intervention are critical.

The ABBA project (Assess Better Before Access): A retrospective cohort study of neonatal intravascular device outcomes

Background

Venous access devices (VADs) play a vital role within the neonatal intensive care unit. However, there are significant risks associated with the use of VADs, with complications such as infection, thrombosis, device occlusion, and infiltration/extravasation frequently contributing to device-related failures and increasing the risk of significant patient harm or injury. This study aimed to explore the relationships between risk factors and different venous access device complications in the neonatal setting, and then use that evidence to develop an algorithm based on observational data.

Methods

This is a retrospective, single-center cohort study that was conducted in a large 112-bed neonatal intensive care unit in Qatar. We examined venous access device data from January 2016 to December 2018 for all term and preterm neonates. Descriptive statistics were used to summarize the outcomes, which included a mean and its standard deviation or median and an interquartile range for continuous variables regarding normal distribution, and absolute numbers with percentages for discrete variables.

Results

The authors recorded a total of 23,858 VADs inserted during the study period. Of these, 21,313 (89%) were peripheral intravenous catheters, 689 (3%) were extended dwell-peripheral intravenous catheters, 1,335 (6%) were epicutaneo-caval catheters, and 521 (2%) were umbilical venous catheters. In total, 51,179 catheter days were registered, with 2.17 catheter days reported per patient. Peripheral device dwell times were significantly shorter when compared with central venous catheter devices (P < 0.001), with mean dwell times of 22 days ± 23 h and 236 days ± 183 h, respectively. After insertion, a complication occurred in 11,177 (51%) of peripheral VADs and 221 (12%) of central VADs. The type of device inserted [P < 0.001, hazard ratio (HR) = 0.52, 95% confidence interval (CI): 0.50-0.54], reason/indication for intravenous therapy (P < 0.001, HR = 0.85, 95% CI: 0.82-0.87), and the side of insertion of the device (P < 0.001, HR = 1.25, 95% CI: 1.24-1.27) had a significant relationship with outcomes.

Conclusions

Four subgroups of VADs were identified (peripheral intravenous catheters, extended dwell-peripheral intravenous devices, epicutaneo-caval catheters, and umbilical venous catheters) with outcome-related differences. Central venous access devices (epicutaneo-caval catheters and umbilical venous catheters) had lower complications compared with peripheral VADs. Proper venous access device selection, early insertion, and early removal approaches remain crucial to preventing venous access device complications. Peripheral intravenous devices should be used carefully and closely watched for early detection of complications.

Retrospective Study of the Application Value Analysis of Ultrasound-Guided Technology in Peripheral Deep Venous Catheterization of Neonates

Objective

To investigate the application value analysis of ultrasound-guided technology in peripheral deep venous catheterization of neonates.

Method

A total of 94 neonates who underwent peripheral deep venous catheterization treatment from March 2020 to August 2021 in our hospital were selected and divided into the study group and the control group according to the simple randomized method, and each group had 47 cases. The control group was performed peripheral deep venous catheterization through X-ray examination, while the study group was performed peripheral deep venous catheterization through ultrasound-guided technology. The catheter placement, catheter retention time and adjustment times, the incidence of complications (limb swelling, pain, fluid leakage, and phlebitis), and the intervention satisfaction of family members were counted.

Results

The success rate of one-time catheterization in the study group was higher than that in the control group, the operation time was shorter than that in the control group, and the amount of bleeding was less than that in the control group. The indwelling time of catheter in the study group was longer than that in the control group, and the number of adjustments was less than that in the control group. The incidence of complications in the study group was lower than that in the control group. The intervention satisfaction of family members in the study group was higher than that in the control group.

Conclusion

Peripheral deep venous catheterization in neonates through ultrasound-guided technology can reduce operation time and blood loss and ensure the success rate of one-time catheterization, resulting in a long indwelling time of catheter, low number of adjustments, and low incidence of complications, which has safety and high intervention satisfaction of family members.

Cyanoacrylate Securement in Neonatal PICC Use: A 4-Year Observational Study

BACKGROUND

Within every neonatal clinical setting, vascular access devices are considered essential for administration of fluids, nutrition, and medications. However, use of vascular access devices is not without danger of failure. Catheter securement adhesives are being evaluated among adult populations, but to date, studies in neonatal settings are scant.

PURPOSE

This research describes the prevalence of peripherally inserted central catheter failure related to catheter securement before and after the introduction of tissue adhesive for catheter securement. The identified modifiable risks might be used to evaluate efficacy, to innovate neonatal practice and support future policy developments.

METHOD AND SETTING

This was a retrospective observational analysis of routinely collected anonymized intravenous therapy-related data. The study was carried out at the tertiary neonatal intensive care unit (112 beds) of the Women's Wellness and Research Center of Hamad Medical Corporation, Doha, Qatar.

RESULTS

The results showed that the use of an approved medical grade adhesive for catheter securement resulted in significantly less therapy failures, compared with the control group. This remains significant after adjusting for day of insertion, gestational age, birth weight, and catheter type.

IMPLICATIONS FOR PRACTICE AND RESEARCH

In parallel with currently published international literature, this study's findings support catheter securement with an octyl-based tissue adhesive in use with central venous catheters. When device stabilization is most pertinent, securement with tissue adhesive is a safe and effective method for long-term vascular access among the neonatal population.

Ultrasound Guided Catheter Tip Location in Neonates: A Prospective Cohort Study

OBJECTIVE

To assess point-of-care-ultrasound (POCUS) guided catheter tip location in a neonatal cohort after insertion of percutaneously inserted central catheters (PICCs) from the upper part of the body.

STUDY DESIGN

This was a prospective, observational study on PICC tip location. Tip site was assessed by radiological landmarks or direct ultrasound (US) visualization of the cardiovascular structures.

RESULTS

One hundred eighteen PICCs (28Gauge/1French) were studied in 102 neonates (mean postmenstrual age 31 weeks, range 25-43 weeks; mean weight at positioning 1365 g, range 420-4180 g). Feasibility of POCUS guided tip location was 92.3% in our population. Failures were significantly associated with mechanical ventilation (aOR 5.33; 95% CI 1.13-29.5; P = .038). Agreement between US and radiographic methods was found in 88 of 109 cases (80.7%). Fifteen of 21 discordant cases led to a change in clinical management.

CONCLUSIONS

POCUS guided localization of small bore PICC is a non-invasive and effective alternative to the conventional radiogram. The latter should be recommended when US examination fails to locate the catheter tip.

Ten years of clinical experience with cyanoacrylate glue for venous access in a 1300-bed university hospital

In the past decade, cyanoacrylate glue has been progressively introduced into the clinical practice of venous access devices used for different purposes. Glue has been used to increase device stabilisation (to reduce the risk of catheter dislodgement), to seal the exit site (to both reduce local bleeding and decrease the risk of bacterial contamination) and to close skin incisions required for the insertion of tunnelled catheters or totally implanted venous ports. For many of these purposes, the efficacy and cost-effectiveness of cyanoacrylate glue has been demonstrated, while some indications are still controversial. This article reports on 10 years of clinical experience with cyanoacrylate glue in a large university hospital, and provides a narrative review of the scientific evidence on the benefits of glue in venous access that has been accumulating over the past decade.

Peripherally inserted central catheters versus non-tunnelled ultrasound-guided central venous catheters in newborns: a retrospective observational study

OBJECTIVES

We aimed to compare the success rates and other catheter-related parameters between peripherally inserted central catheters (PICCs) and non-tunnelled ultrasound-guided central venous catheters (USG-CVCs) including femoral, jugular, brachiocephalic and subclavian lines.

DESIGN

This was a retrospective observational study.

SETTING

The study was performed in a level III neonatal intensive care unit (NICU) in Qatar, as a single-site study.

PARTICIPANTS

This study included 1333 neonates who required CVC insertion in the NICU from January 2016 to December 2018. Of those, we had 1264 PICCs and 69 non-tunnelled USG-CVCs.

OUTCOME MEASURES

The success rate and other catheter-related complications in the two groups.

RESULTS

The overall success rate was 88.4% in the USG-CVCs (61/69) compared with 90% in the PICCs (1137/1264) group (p=0.68). However, the first prick success rate was 69.4% in USG-CVCs (43/69) compared with 63.6% in the PICCs (796/1264) group. Leaking and central line-associated blood stream infection (CLABSI) were significantly higher in the USG-CVC group compared with the PICC group (leaking 16.4% vs 2.3%, p=0.0001) (CLABSI 8.2% vs 3.1%, p=0.03). CLABSI rates in the PICC group were 1.75 per 1000 catheter days in 2016 and 3.3 in 2017 compared with 6.91 in 2016 (p=0.0001) and 14.32 in 2017 (p=0.0001) for the USG-CVCs. USG-CVCs had to be removed due to catheter-related complications in 52.5% of the cases compared with 29.9% in PICCs, p=0.001. In 2018, we did not have any non-tunnelled USG-CVCs insertions in our NICU.

CONCLUSIONS

The overall complication rate, CLABSI and leaking are significantly higher in non-tunnelled USG-CVCs compared with the PICCs. However, randomised controlled trials with larger sample sizes are desired. Proper central venous device selection and timing, early PICC insertion and early removal approach, dedicated vascular access team development, proper central venous line maintenance, central line simulation workshops and US-guided insertions are crucial elements for patient safety in NICU.

Ultrasound to guided epicutaneo-caval catheter insertion in newborn infants

OBJECTIVE

Recently, ultrasound (US) has been increasingly used for epicutaneo-caval catheter (ECC) tip positioning; however, the selection of blood vessels for ECC still depends on the operator's subjective judgment. This study aimed to explore the value of US in decision-making regarding the great saphenous vein (GSV), tip navigation, and tip location of ECC.

METHODS

Catheterization through the GSV of the lower extremity was selected. The running condition of the GSV was assessed by using US, and the angle between the GSV and the femoral vein was observed and measured. We selected the GSV with a smaller angle to the femoral vein for ECC catheterization.

RESULTS

ECC catheterization under ultrasound guidance increased the success rate at the time of catheterization from 82.5% to 100% (increased by 17.5%) and shortened the catheterization time from 56.1 ± 5.30 min to 31.5 ± 2.58 min on average (shortened by 44%). The incidence rate of catheter-related complications decreased by 58.2% catheter days from 6.80/1,000 to 2.84/1,000.

CONCLUSION

ECC insertion under the guidance of US has numerous advantages, including significantly improving the success rate of one-time catheterization, shortening the time of catheterization, and reducing catheter-related complications.

Does the antimicrobial-impregnated peripherally inserted central catheter decrease the CLABSI rate in neonates? Results from a retrospective cohort study

BACKGROUND

The use of antimicrobial-impregnated peripherally inserted central catheters (PICCs) has been introduced in the last few years to neonatal units aiming to reduce central line-associated bloodstream infection (CLABSI).

METHODS

This retrospective observational study aimed to compare the CLABSI rates and other catheter-related parameters including the insertion success rates and catheter-related complications in the antimicrobial-impregnated and conventional (ordinary) PICCs in NICU between 2017 and 2020.

RESULTS

Our dedicated PICC team including physicians and nurses inserted 1,242 conventional (PremiCath and NutriLine) and 791 antimicrobial-impregnated PICCs (PremiStar) over the study period from 2017 to 2020. Of those 1,242 conventional PICCs, 1,171 (94.3%) were 1 Fr single lumen and only 71 (5.7%) were 2 Fr double lumen. The mean ± SD [median (IQR)] for the birth weight in all babies who had a PICC line was 1,343.3 ± 686.75 [1,200 (900, 1,500)] g, while the mean ± SD for the gestational age was 29.6 ± 4.03 [29 (27, 31)] weeks. The mean ± SD [median (IQR)] age at the time of insertion for all catheters was 9.3 ± 21.47 [2 (1, 9)] days, while the mean ± SD [median (IQR)] dwell time was 15.7 ± 14.03 [12 (8, 17)] days. The overall success rate of the PICC insertion is 1,815/2,033 (89.3%), while the first attempt success rate is 1,290/2,033 (63.5%). The mean ± SD [median (IQR)] gestational age, birth weight, age at catheter insertion, and catheter dwell time were 28.8 ± 3.24 [29, (26, 31)] weeks, 1,192.1 ± 410.3 [1,150, (900, 1,450)] g, 6.3 ± 10.85 [2, (1, 8)] days, and 17.73 ± 17.532 [13, (9, 18)] days in the antimicrobial-impregnated catheter compared with 30.1 ± 4.39 [29, (27, 32)] weeks (P < 0.001), 1,439.5 ± 800.8 [1,240, (920, 1,520)] g (P < 0.001), 11.1 ± 25.9 [1, (1, 9)] days (P < 0.001), and 14.30 ± 10.964 [12, (8, 17)] days (P < 0.001), respectively, in the conventional PICCs. The use of the antimicrobial-impregnated catheter was not associated with any significant reduction in the CLABSI rate (per 1,000 days dwell time), either the overall [P = 0.11, risk ratio (RR) (95% CI): 0.60 (0.32, 1.13)] or the yearly CLABSI rates.

CONCLUSIONS

The use of miconazole and rifampicin-impregnated PICCs did not reduce the CLABSI rate in neonates compared with conventional PICCs. However, it has a higher overall rate of elective removal after completion of therapy and less extravasation/infiltration, occlusion, and phlebitis compared with the conventional PICCs. Further large RCTs are recommended to enrich the current paucity of evidence and to reduce the risk of bias. Neonatal PICCs impregnation by other antimicrobials is a recommendation for vascular access device manufacturers.

A Survey of the Practice Status Quo of Ultrasound-Guided ECC Tip Location for Neonatal Patients in 31 Provinces of China

OBJECTIVE

To investigate the status quo of implementing ultrasound (US)-guided epicutaneo-caval catheters (ECC) tip location for neonatal patients in 31 provinces.

METHODS

The convenience sampling method was used to investigate the nursing managers and ECC (or intravenous therapy) nurses of 91 hospitals in 31 provinces from October 29 to November 10, 2021.

RESULTS

The survey involved a total of 182 medical staff, including 91 managers and 91 nurses, and 91 institutions, including 22 children's hospitals, 49 general hospitals and 21 maternal and child health care hospitals. Sixteen hospitals (17.6%) carried out US-guided ECC for neonatal patients; 176 subjects (96.7%) of the 91 hospitals had known about or heard of the technology of US-guided ECC. The low awareness of operators of the tip location of ECC catheters in children under ultrasound guidance (OR = 2.690, 95% CI = 1.163-6.221), limited conditions in existing wards (OR = 2.953, 95% CI = 1.285-6.790), and insufficient funds (OR = 2.836, 95% CI = 1.149-7.004) were the independent risk factors responsible for the failure to carry out ultrasonic-guided location of ECC tips in newborns.

CONCLUSION

The popularity of neonatal US-guided ECC location was seriously hindered by factors such as a low awareness rate of the project, the low qualification certification rate of the nursing staff, a flawed performance allocation system, and the lack of a professional team, among other factors.

Ultrasound guided percutaneous catheterization of the brachiocephalic vein by small caliber catheter: An alternative to epicutaneo-caval catheter in newborn and premature infants

BACKGROUND

Umbilical Venous Catheter (UVC) and Epicutaneo-Caval Catheters (ECC) are reference catheters in the neonatal period. However, many factors such as the corpulence of neonates, poor venous capital, and anatomical variants can complicate ECC insertion or make it impossible. In newborns with failed ECC insertion, we developed an hybrid technique that combines the insertion of a long-lasting silicone or polyurethane small caliber catheter, usually used as a ECC in newborns, with the ease and speed of ultrasound guided puncture of the brachiocephalic vein (BCV).

METHODS

Three years retrospective single center experience of ultrasound guided BCV insertion of silicon or polyurethane small caliber central catheter in a tertiary neonatal intensive care in case of insertion fail of ECC.

RESULTS

Twenty-one echo guided BCV-ECC insertions were performed in 20 newborns. Median age was 16 days (range: 0-110 days), median weight was 1700 g (range: 605-4960 g) at insertion. In most cases, insertion was on the left side (17/21). No failures were noted. Only one attempt was necessary in all cases. Insertion time, when noted, was always of <45 min. The median duration of use of these catheters was 11 days (range 3-35 days). No complication was noted during insertion or catheter use, including catheter-related infections and thrombosis.

CONCLUSION

Echo guided percutaneous catheterization of the brachiocephalic vein with a long lasting silicone or polyurethane small caliber catheter is a safe alternative to the ECC if insertion has failed. However, it requires a mastery of ultrasound-guided insertion technique in term and premature neonates.

Parenteral nutrition extravasation into the abdominal wall mimicking an abscess

Objectives

Peripherally inserted central catheters (PICC) are used in the neonatal intensive care unit (NICU) setting for medication and nutrition administration. PICCs are easy to place and may remain inserted up to several weeks. Serious complications are rare. Cases of infection, dysfunction, thrombosis, malposition into other vessels, catheter migration, vessel erosion, perforation into pleura, pericardium, abdomen and even into the epidural space with extravasation have been reported [1, 2].

Case presentation

We present the case of a preterm infant with a right leg inserted PICC with the tip supposedly being placed in the external iliac vein with further catheter migration into the abdominal wall during the course of treatment.

Conclusions

Our patient developed extravasation of lipid infusion, which was initially misinterpreted as an abscess due to signs of local inflammation.

Distal superficial femoral vein versus axillary vein central catheter placement under ultrasound guidance for neonates with difficult access: A randomized clinical trial

BACKGROUND

Epicutaneo-caval catheters (ECCs) are extensively used in premature and ill neonates. This prospective, randomized, observational study aimed to compare the outcomes of ECC placement in the distal superficial femoral and axillary veins in neonates with difficult ECC access.

METHODS

In a neonatal intensive care unit at a tertiary referral center, 60 neonates with difficult ECC access were randomized into two groups with catheters placed using the ultrasound-guided modified dynamic needle tip positioning (MDNTP) technique: distal superficial femoral vein (DSFV) and axillary vein (AV) groups.

RESULTS

The first attempt success rate was significantly higher in the DSFV group than in the AV group [23/30 (76.7%) vs 11/30 (36.7%), p = 0.001; odds ratio (OR), 0.176; 95% confidence interval (CI) 0.057-0.543]. The mean procedural duration was significantly shorter in the DSFV group than in the AV group [mean: 308.5 (standard deviation: 81.1) s vs 522.74 (134.8) s, t = -7.17, p < 0.001]. The incidence of complications was significantly lower in the DSFV group than in the AV group [4/30 (13.3%) vs 12/30 (40.0%), p = 0.019; OR, 4.333; 95% CI 1.203-15.604]. The number of attempts was significantly fewer in the DSFV group than in the AV group (p = 0.012).

CONCLUSIONS

The distal superficial femoral and axillary veins are two alternative and safe access points for ECC placement in premature neonates (weight < 2.5 kg) with difficult access. However, access through the distal superficial femoral vein was quicker, easier, and had fewer complications than through the axillary vein.

Use of cyanoacrylate glue for the sutureless securement of epicutaneo-caval catheters in neonates

INTRODUCTION

Epicutaneo-caval catheters (ECC) are pivotal for drug and fluid infusion in neonates. Given the intrinsic importance of the catheter for the patients' health and the need to avoid stressful and painful procedures on premature or critically ill newborns with fragile and poor vein asset, it is clearly necessary an accurate bundle for ECC insertion and management to avoid complications that may lead to non-elective ECC removal. Among others, dislodgment is an acknowledged complication, and conventionally adopted fixing devices seem alone unsatisfying in relation to ECC securement.

OBJECT

To evaluate the usefulness of medical Cyanoacrylate Glue (CG) as a solution to strengthen conventional ECC securement.

METHODS

Since the use of CG has become part of our ECC insertion bundle in 2018, the present study compares all term and preterm neonates admitted in our NICU in 2018 who required an ECC for any cause (92 cases) with an historical cohort formed by all neonates who required an ECC in 2017 (80 patients).

RESULTS

CG added to usual securement devices is effective in reducing ECC accidental dislodgment. Moreover, it is easy and safe to apply and remove, limits bleeding and oozing at the puncture site, and may also be an effective antimicrobial mechanical barrier.

When the course deviates from expected: Misplacement of an epicutaneo-caval catheter in a neonate

Central venous access, a common and essential component of the care of the critically ill neonate, is associated with complications such as infection, thrombosis, and bleeding. Unintentional arterial cannulation of a venous catheter is a rare but potentially dangerous complication. In the report, we describe the accidental cannulation of an artery with an epicutaneo-caval catheter in an extremely low birth weight infant. We discuss the physical and radiological findings that raise the suspicion of an arterial placement of a catheter, the diagnostic tools to confirm the misplacement, the potential complications, and strategies to prevent it.

How to minimize central line-associated bloodstream infections in a neonatal intensive care unit: a quality improvement intervention based on a retrospective analysis and the adoption of an evidence-based bundle

Central line-associated bloodstream infection (CLABSI) is a significant cause of morbidity and mortality in neonatal intensive care units (NICUs). A "bundle" is defined as a combination of evidence-based interventions that provided they are followed collectively and reliably, are proven to improve patient outcomes. The aim of this quasi-experimental study was to assess the impact of new central line insertion, dressing, and maintenance "bundles" on the rate of CLABSI and catheter-related complications. We performed a quality improvement (QI), prospective, before-after study. In the first 9-month period, the old "bundles" and pre-existing materials were used/applied. An intervention period then occurred with changes made to materials used and the implementation of new "bundles" related to various aspects of central lines care. A second 6-month period was then assessed and the CLABSI rates were measured in the NICU pre- and post-intervention period. The QI measures were the rate of CLABSI and catheter-related complications. Data are still being collected after the study to verify sustainability. The implementation of the new "bundles" and the change of certain materials resulted in a significantly decreased rate of CLABSI (8.4 to 1.8 infections per 1000 central venous catheter (CVC) days, p = 0.02,) as well as decreased catheter-related complications (47 to 10, p < 0.007).Conclusions: The analysis of pre-existing "bundles" and the implementation of updated central line "bundles" based on best practice recommendations are crucial for reducing the rate of CLABSI in the NICU. The implementation of the new evidence-based central line "bundles" was associated with a significant reduction in CLABSI rate in our unit soon after implementation. What is Known: • Central line-associated bloodstream infection (CLABSI) is a major cause of morbidity and mortality in the neonatal population. • The implementation of evidence-based "bundles" in the NICU is associated with a reduction in the incidence of CLABSI. What is New: • For the improvement in quality care in the NICU, audits are necessary to assess the existing systems. • The "Plan-Do-Study-Act cycle" is an effective tool to use when tackling challenges in an existing system. Using this tool assisted in the approach to reducing CLABSI in our NICU.

Catheter-related venous thrombosis in NICU: A case-control retrospective study

INTRODUCTION

Newborns treated in a neonatal intensive care unit (NICU) are susceptible to several complications one of them being vein thrombosis.

AIM

The study aims to evaluate risk factors of catheter-related venous thrombosis, clinical manifestations, treatment, and the outcomes of thrombotic events (TE) during the neonatal period.

METHODS

This work is a case-control retrospective study performed on patients in the tertiary NICU between January 2013 and June 2016. The analysis includes data from infants with CVC diagnosed with thrombosis and infants with CVC, not being diagnosed with thrombosis (control group). Statistica 10 software was used for statistical analysis.

RESULTS

Vein thrombosis was diagnosed in 19 NICU infants including 16 cases of catheter-related vein thrombosis (84% of complicated cases). Other statistically significant risk factors were asphyxia, infection, and the duration of CVC use. The incidence of thrombosis in our population increased during the study which may result from a statistically significant increase in the number of inserted CVC (294 vs 435), and more frequent diagnosis of incidental thrombosis (1 vs 9).

CONCLUSION

Vein catheterization, asphyxia, infection, and prolonged CVC use are critical risk factors for thrombosis in the neonatal period. Given the hereinbefore mentioned increased number of central line catheterizations in the NICU, it would be useful to conduct a prospective study with a scheduled routine ultrasound protocol applied not only as a tool to diagnose thrombosis but also to prevent it by determining a proper catheter for a particular vein.

Centrally inserted central catheters in preterm neonates with weight below 1500 g by ultrasound-guided access to the brachio-cephalic vein

OBJECTIVE

Central venous access in critically ill newborns can be challenging. Ultrasound-guided brachio-cephalic vein catheterization is a relatively new procedure, recently introduced in several neonatal intensive care units. The aim of this study is to evaluate the safety and feasibility of such a technique in preterm babies.

DESIGN

Retrospective analysis of prospectively collected data on ultrasound-guided central venous catheter insertion in preterm neonates.

SETTING

Neonatal intensive care unit.

PATIENTS

Critically ill preterm neonates with weight below 1500 g requiring a central access.

INTERVENTIONS

Ultrasound-guided brachio-cephalic vein catheterization.

MAIN RESULTS

Thirty centrally inserted catheters were placed in 30 neonates. The success rate of the procedure was 100%. No case of accidental arterial or pleural puncture was registered during the study period.

CONCLUSION

The brachio-cephalic vein can be safely catheterized in preterm newborns requiring intensive care after appropriate training.

Effect of implementing an Epicutaneo-Caval Catheter team in Neonatal Intensive Care Unit

Background:

Until the 1980s, central vascular access in the Neonatal Intensive Care Unit was predominantly delivered by umbilical catheters and only and if needed by surgical cutdowns or subclavian vein catheterization through blind percutaneous venipuncture. In the early 1980s, epicutaneo-caval catheters were successfully introduced.

Methods:

In our Neonatal Intensive Care Unit, a dedicated team to insert epicutaneo-caval catheters was formally established in January 2017, including 12 neonatologists and 1 neonatal nurse practitioner. A before- versus after-intervention study was designed to determine whether the establishment of the epicutaneo-caval catheter insertion team is associated with increased success rates and a decreased risk of catheter-related complications. Success rates and other catheter-related parameters were traced from 2016 onward. Collected data were analyzed for three consecutive years: 2016, 2017, and 2018.

Results:

The epicutaneo-caval catheter team inserted 1336 catheters over 3 years. Both first prick (from 57.7% to 66.9%; p = 0.023) and overall success (from 81.7% to 97.6%; p < 0.0001) rates significantly improved. In 2018, the number of tunneled or surgically inserted central venous catheters came down to zero (p < 0.0001). Overall catheter-related complications were significantly lower following the epicutaneo-caval catheter team’s establishment (p < 0.0001) while there was no significant decrease noted (p = 0.978) in central line–associated bacterial stream infection rates.

Conclusion:

A dedicated epicutaneo-caval catheter team is a promising intervention to increase success rates and significantly decrease catheter-related complications in Neonatal Intensive Care Unit. Standardizing epicutaneo-caval catheter placement is important; however, standardizing catheter maintenance seems essential to the improvement of central line–associated bacterial stream infection rates.

In defense of the use of peripherally inserted central catheters in pediatric patients

Central venous access devices have revolutioned the care of children affected by malignancies, facilitating management of complex and prolonged infusive therapies, reducing pain and discomfort related to repeated blood samples and indiscriminate venipunctures, thus reducing also psychological stress of both patients and families. In this respect, peripherally inserted central catheters have been disseminated for use, even in pediatric oncology patients, for their many advantages: easy and non-invasive placement with no risk of insertion-related complications, as well as easy removal; reduced need for general anesthesia both for insertion and removal; adequate prolonged performance also for challenging therapies (e.g. stem cell transplantation); and low rate of late complications. Nonetheless, concerns have been recently raised about use of such devices in children with cancer, especially regarding a presumed (but not demonstrated) high risk of catheter-related venous thrombosis. Are we facing a new witch (or peripherally inserted central catheter) hunt? The choice of the central venous access device-particularly in oncologic children-should be based on an evaluation of clinical advantages and risks, as provided by appropriate and scientifically accurate clinical studies.

Pre-procedural ultrasound-guided evaluation of left internal jugular vein and brachiocephalic vein: Experience on infants <1 year

Pre-procedural evaluation of central veins prior to cannulation with ultrasound is essential to reduce the complication rates as well as to increase the success rates. The left brachiocephalic vein has been suggested to be considered as first choice in infants including the neonates due to its larger diameter and ease of access with supraclavicular, ultrasound-guided, in-plane technique. There are few studies on neonates and infants comparing the diameter of brachiocephalic vein with internal jugular vein being its most common alternative. The aim of the present report is to share our observations pertaining to the pre-procedural measurements of the diameters of left internal jugular vein and brachiocephalic vein in infants <1 year. The measurements were analysed in accordance with the weights of the infants (<2500 g and ⩾2500 g). In infants <2500 g, the brachiocephalic vein was larger than the internal jugular vein (4.0 ± 0.7 (3.2-5.2) mm vs 3.2 ± 0.7 (1.9- 4.3) mm, p = 0.032), whereas the diameters of two major veins were similar in infants ⩾2500 g (4.8 ± 1.2 (2.3-6.4) mm vs 5.1 ± 0.9 (2.8-6.7) mm, p = 0.363). Our observations support the suggestion of the brachiocephalic vein to be considered as the first choice for large-bore cannulation due to its larger diameter as well as its other advantages, especially in neonates <2500 g.