Central venous lines in neonates: a study of 2186 catheters

A survey of central venous catheter practices in Australian and New Zealand tertiary neonatal units

BACKGROUND

Infection is the most common problem with central venous catheters (CVCs) in neonates. There are two published guidelines, including the Centers for Disease Control and Prevention (CDC), for the prevention of intravascular catheter-related infection that describes evidence-based practice to reduce nosocomial infection.

OBJECTIVE

Our aims were to survey current medical and nursing management of central venous catheters in tertiary neonatal intensive care units in Australia and New Zealand and to compare with the CDC evidence-based practice guideline.

METHODS

A cross sectional survey was performed across 27 Australian and New Zealand neonatal units in September 2012. Two web-based questionnaires were distributed, one to medical directors related to the insertion of CVCs while CVC "maintenance" surveys were sent to nurse unit managers.

RESULTS

Seventy percent (19/27) medical management and 59% (16/27) on nursing management surveys were completed. In all neonatal intensive care units (NICUs) there were guidelines for CVC maintenance and for 18 out of 19 there were guidelines for insertion. In the seven units using femoral lines, three had a guideline on insertion and four for maintenance. CVC insertion was restricted to credentialed staff in 57.9% of neonatal units. Only 26.5% used full maximal sterile barriers for insertion. Skin disinfection practices widely varied. Dressing use and dressing change regimens were standardised; all using a semi-permeable dressing. Duration of cleaning time of the access point varied significantly; however, the majority used a chlorhexidine with alcohol solution (68.8%). Line and fluid changes varied from daily to 96 h. The majority used sterile gloves and a sterile dressing pack to access the CVC (68.8%). In the majority of NICUs stopcocks were used (62.5%) with a needle-less access point attached (87.5%). In less than 50% of NICUs education was provided on insertion and maintenance.

CONCLUSION

There is diversity of current practices and some aspects vary from the CDC guideline. There is a need to review NICU current practices to align with evidence based guidelines. The introduction of a common guideline may reduce variations in practice.

Complications of peripherally inserted central venous catheter in Japanese neonatal intensive care units

BACKGROUND

The aim of this study was to investigate the incidence and risk factors of peripherally inserted central venous catheter (PICC)-related complications using a multicenter case survey.

METHOD

A prospective cohort study was carried out by 19 neonatal intensive care units (NICUs) in Japan from February 2005 to March 2007. A total of 975 case records were collected. PICC-related complications including pericardial effusion/cardiac tamponade pleural effusion/ascites, catheter removal difficulties, catheter-related bloodstream infection (CR-BSI), and symptomatic catheter-related thrombosis were collected from case record forms. As for precautions during insertion, institutions were classified into three groups: those with maximum barrier precautions; standard precautions; and no specific precautions.

RESULTS

PICC complications occurred in 27 cases (2.9%) among 946 PICC. The incidence was 1.6% for CR-BSI, and 0.1% for cardiac tamponade. CR-BSI rate per 1000 catheter-days was 1.1 with maximum barrier precautions at catheter insertion, 1.2 with standard precautions, and 1.8 with no specific precautions. Multiple logistic regression analysis showed that proximal placement (odds ratio [OR], 3.88; 95% confidence interval [CI]: 1.42-10.60, P = 0.008) and longer placement duration (OR, 1.35; 95%CI: 1.14-1.60, for each week, P = 0.0005) independently contributed to overall complications.

CONCLUSION

The incidence of cardiac tamponade was rare in this multicenter prospective study. Longer duration and proximal placement may be risk factors for PICC complications. In this cohort, the CR-BSI rate was low irrespective of the degree of barrier precautions at insertion.

Neonatal extravasation injury: prevention and management in Australia and New Zealand-a survey of current practice

Background

Extravasation injury remains an important cause of iatrogenic injury in neonatal intensive care. This study aims to describe the current approach to extravasation injury (EI) prevention and management in Neonatal Intensive Care Units (NICUs) in Australia and New Zealand.

Methods

A literature review regarding extravasation injury in the newborn was carried out to inform questionnaire design. An internet-based survey was then conducted with the clinical directors of the 27 tertiary NICUs in Australia and New Zealand.

Results

The survey received a 96% response rate. Approximately two thirds of Australian and New Zealand NICUs have written protocols for prevention and management of extravasation injury. Considerable practice variation was seen for both prevention and treatment of EI. 92% of units had experienced cases of significant EI.

Conclusions

Australian and New Zealand tertiary neonatal units clearly recognise EI as an important cause of iatrogenic morbidity and mortality. Significant variation still exists among units with regards to guidelines for both prevention and management of EI. We recommend that neonatal staff should remain vigilant, ensuring that guidelines for the prevention and treatment of EI are available, and rigorously followed.

Central venous catheters in premature babies: radiological evaluation, malpositioning and complications

Central venous catheters are important in the care for prematurely born children in the neonatal intensive care unit. The purpose of this pictorial essay is to illustrate correct positioning, malpositioning and possible complications of such devices.

Dimension and overlap of femoral and neck blood vessels in neonates

INTRODUCTION

Neonates frequently require access to their central blood vessels. However, limited data exist relating to the size and the anatomical relation of the femoral and neck vessels for neonates of different postmenstrual ages.

HYPOTHESIS

1) The size of central blood vessels increases with postmenstrual age of the neonate. 2). External rotation with abduction at the hip will decrease the degree of overlap between the femoral artery and vein. 3) The degree of overlap decreases with increasing postmenstrual age.

DESIGN

Prospective descriptive cohort study.

MEASUREMENTS AND MAIN RESULTS

Femoral and neck vessel sizes were assessed using ultrasound for three postmenstrual age groups: group A (26 ± 1 wks), group B (32 ± 1 wks), and group C (38 ± 1 wks). The degrees of overlap (major, >50% overlap; minor, ≤50% overlap; no overlap) between the femoral vessels were assessed at the level of the inguinal ligament and 1 cm below the inguinal ligament in a straight hip and in external rotation with abduction of the hip positions. A total of 52 nonconsecutive subjects (group A, seven; group B, 21; group C, 24) were studied. The mean blood vessel dimensions increased with increasing postmenstrual age. Correlation of blood vessel size to growth measurements was better in group A + group B compared to group C. Overlap between the femoral vein and the femoral artery across the neonatal age groups at the level of the inguinal ligament ranged from 57% to 79% and from 43% to 98% at 1 cm below the inguinal ligament. The degree of overlap did not decrease with positioning of the lower extremity in external rotation with abduction of the hip. In the neck blood vessels, the majority of observations showed either minor or major overlap of neck blood vessels in all three groups (group A, 79%; group B, 86%; group C, 90%).

CONCLUSIONS

Central blood vessel size increases with increasing postmenstrual age. Correlation of blood vessel size to anthropometric measurements was better in the premature neonates compared to term neonates. A high degree of overlap exists within the femoral and cervical blood vessels. In the femoral vessels, the degree of overlap did not decrease with external rotation with abduction of the hip at any postmenstrual age.

Management of neonatal thrombosis

Neonates have one of the highest risks for thromboembolism among pediatric patients. This risk is attributable to a combination of multiple genetic and acquired risk factors. Despite a significant number of these events being either life threatening or limb threatening, there is limited evidence on appropriate management strategy. Most of what is recommended is based on uncontrolled studies, case series, or expert opinion. This review begins with a discussion of the neonatal hemostatic system, focusing on the common sites and imaging modalities for the detection of neonatal thrombosis. Perinatal and postnatal risk factors are presented and management options discussed.

Vascular catheter-related complications in newborns

Babies in Neonatal Intensive Care Unit have more frequent invasive procedures such as heel prick samples for gases, bilirubin levels or if ventilated suction down the endotracheal tube is more frequent and still invasive. Central and peripheral vascular catheters are essential to serve many important functions for sick neonates. However, there is growing recognition of potential risks, such as infection, thrombosis, vasospasm, phlebitis, infiltration and so on, associated with their use. Based on current evidence, this paper reviews the common complications of vascular catheters and their corresponding preventive or treatment approaches in newborns.

Catheter management in neonates with bloodstream infection and a percutaneously inserted central venous catheter in situ: removal or not?

BACKGROUND

This study investigated whether removal of a percutaneously inserted central venous catheter (PICC) is compulsory in neonates with bloodstream infection (BSI), and also examined the risk factors for infectious complications when a PICC is retained in these patients.

METHODS

This was a cohort study of neonates with a PICC who developed a BSI between 2001 and 2007. BSI was defined according to Centers for Disease Control and Prevention criteria.

RESULTS

Of the 234 neonates in the cohort, 99 had early removal of PICC (ER-PICC, defined as removal within 3 days after the onset of clinical sepsis), and 135 had late removal of PICC (LR-PICC, defined as retention for more than 3 days after the onset of clinical sepsis). Resolution of clinical sepsis within 2 days was more frequent in the ER-PICC group compared with the LR-PICC group (80.8% vs 57.8%; P < .001). There was no significant difference between the 2 groups in terms of infectious complications and case fatalities, but the LR-PICC group had a significantly higher incidence of recurrence within 1 month after BSI (P = .002). Inappropriate initial antibiotic treatment was the only variable independently associated with infectious complications (odds ratio, 11.4; 95% confidence interval, 3.34∼39.2; P < .001).

CONCLUSIONS

PICCs should be removed in neonates with BSI, because retention of PICCs for more than 3 days is associated with delayed resolution of clinical sepsis and a higher incidence of recurrence within 1 month.

Early removal versus expectant management of central venous catheters in neonates with bloodstream infection

BACKGROUND

Uncertainty exists regarding the management of central venous catheters (CVCs) in neonates with bloodstream infections. Early CVC removal may reduce the risk of persistent or complicated infection and its associated morbidity and mortality. However, since CVCs provide secure vascular access to deliver nutrition and medications, the possible harms of early removal versus expectant management need to be considered.

OBJECTIVES

To determine the effect of early removal versus expectant management of CVCs on morbidity and mortality in neonates with bloodstream infections..

SEARCH STRATEGY

We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials ((CENTRAL), The Cochrane Library, 2011, Issue 1), MEDLINE (1966 to January 2011), EMBASE (1980 to January 2011), CINAHL (1982 to January 2011), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials that compared early removal versus expectant management of CVCs in neonates with bloodstream infections.

DATA COLLECTION AND ANALYSIS

We used the standard methods of the Cochrane Neonatal Review Group.

MAIN RESULTS

We did not identify any eligible randomised controlled trials.

AUTHORS' CONCLUSIONS

There are no trial data to guide practice regarding early removal versus expectant management of CVCs in neonates with bloodstream infections. While observational data generally indicate that early removal is associated with a lower incidence of persistent or complicated infection, caution should be exercised in applying these findings to practice because of inherent biases in the study design. A simple and pragmatic randomised controlled trial is needed to resolve the uncertainty about optimal management in this common and important clinical scenario.

Risk factors of catheter-related bloodstream infection with percutaneously inserted central venous catheters in very low birth weight infants: a center's experience in Taiwan

BACKGROUND

Infected percutaneously inserted central venous catheters (PICCs) are a problem in hospitalized patients, especially in the neonatal intensive care unit. The objective of this study was to assess the risk of infection and other PICC-associated complications in very low birth weight infants.

METHODS

Between January 2005 and December 2006, we studied 412 PICCs inserted in 267 neonates with a birth body weight ≤ 1500g. PICC-related bloodstream infections and other complications were recorded and analyzed.

RESULTS

These 412 PICCs were inserted for a mean duration of 16.6 ± 9.9 (SD) days. The most common catheter-related complications were catheter-related blood-stream infection (CRBSI; incidence: 8.3 per 1000 catheter days), followed by catheter occlusion (4.0 per 1000 catheter days), catheter site inflammation (3.5 per 1000 catheter days), and phlebitis (3.1 per 1000 catheter days). The most common pathogen of CRBSI was coagulase-negative staphylococcus (40.1%). Significant risk factors of CRBSI included catheters inserted at femoral sites (increased risk of CRBSI compared with nonfemoral catheters: 1.76; 95% confidence interval, 1.01-3.07, p = 0.045) and a longer duration of PICC placement (p < 0.001). A low birth body weight and gestational age were not found to significantly affect the risk of CRBSI.

CONCLUSION

It is important to avoid inserting a PICC at the femoral site. Strict catheter care protocol should also be applied to reduce local site bacterial colonization and removal of PICCs as soon as they are no longer essential for patient care to reduce the incidence of infection.

A silver-alginate-coated dressing to reduce peripherally inserted central catheter (PICC) infections in NICU patients: a pilot randomized controlled trial

OBJECTIVE

Our aim was to evaluate the safety of a silver-alginate-containing dressing to reduce peripherally inserted central catheter (PICC) infections in neonatal intensive care unit (NICU) patients.

STUDY DESIGN

Patients were randomized 3:1 to receive a patch containing silver, alginate and maltodextrin or standard of care. Patches were placed under the regular transparent retention dressing at the PICC exit site at insertion and were replaced with every dressing change at least every 2 weeks until PICC discontinuation. All study infants were monitored for adverse skin reactions.

RESULT

A total of 100 infants were followed up for 1922 person-days, including 75 subjects with 89 PICCs who received the patch. The median birth weight (1330 g) and median gestational age (30 weeks) was lower in the patch group when compared with the controls (P=0.001 and 0.005, respectively). Study patients received the patch with their PICC at a median age of 5 days; the patch stayed in place for a median of 13 days. We noted no adverse skin reactions and found no evidence that the patch alters the microbiology of PICC-associated infections.

CONCLUSION

This pilot trial suggests that silver-alginate-coated dressings are skin safe and their inclusion in future trials aimed at reduction of PICC-associated bloodstream infections in the NICU should be considered.

Pericardial effusion in a preterm infant resulting from umbilical venous catheter placement

Pericardial effusion in neonates is a rare occurrence associated with malpositioning of central venous catheters. This report describes a case of pericardial effusion in which echocardiographic determination of line position, typically considered one of the most reliable means of placement verification, was misleading. The infant ultimately did well after pericardiocentesis, with complete resolution of symptoms and no further complications.

Complication rates with central venous catheters inserted at femoral and non-femoral sites in very low birth weight infants

OBJECTIVE

To compare the complication rates of femoral versus nonfemoral sites of percutaneously inserted central venous catheters (PICCs) in very low birth weight infants.

METHODS

Between 2004 and 2006, 518 PICCs inserted in 334 neonates with a birth body weight>or=1500 g were studied. 278 catheters were inserted at nonfemoral sites, and 240 catheters at a femoral site. All catheter-related complications were recorded and analyzed.

RESULTS

The infants with femoral PICCs had a significantly higher rate of catheter-related sepsis (CRS) than those with nonfemoral PICCs (22.5% vs. 12.2%, P=0.002) and the incidence rate was also significantly higher (10.9 vs. 6.8 episodes per 1000 catheter days, P=0.012). The infants with nonfemoral PICCs had significantly higher rates of phlebitis, catheter site inflammation, and need for early removal than those with femoral PICCs. Multiple logistic regression analysis showed that the significant contributors to CRS were duration of the PICC placement (P<0.001) and insertion of the PICC at a femoral site (P=0.010).

CONCLUSIONS

Because of a higher rate of CRS, the femoral site should not be considered for the placement of PICCs in VLBW infants, when possible.

Central venous lines and how to manage them

The importance of vascular access in neonatal clinical practice is increasing, because of the survival of a larger number of premature babies, who require administration of long-term intravenous fluids and medications than in the past. In these newborn central venous lines are preferred to peripheral lines, particularly Peripherally Inserted Central Venous Catheter (PICC). Despite of the benefits of this device, PICC complications can negatively affect morbidity and mortality of the neonate. This article describes the principal strategies and recommendations for the success of the PICC insertion procedure and for its better management.

The evaluation and management of postnatal thromboses

In the pediatric population, neonates have the highest risk for thromboembolism (TE), most likely due to the frequent use of intravascular catheters. This increased risk is attributed to multiple risk factors. Randomized clinical trials dealing with management of postnatal thromboses do not exist, thus, opinions differ regarding optimal diagnostic and therapeutic interventions. This review begins with an actual case study illustrating the complexity and severity of these types of cases, and then evaluates the neonatal hemostatic system with discussion of the common sites of postnatal thrombosis, perinatal and prothrombotic risk factors, and potential treatment options. A proposed step-wise evaluation of neonates with symptomatic postnatal thromboses will be suggested, as well as future research and registry directions. Owing to the complexity of ischemic perinatal stroke, this topic will not be reviewed.

Rare but serious complications of central line insertion

Discussions on the complications of central venous catheterization in children typically focus on infectious and the more common mechanical complications of pneumothorax, hemothorax, or thrombosis. Rare complications are often more life-threatening, and inexperience may compound the problem. Central venous catheter complications can be broken down into early or late, depending on when they occur. The more serious complications are typically mechanical and occur early, but delayed presentations of pericardial effusions, cardiac tamponade, and pleural effusions may be of equal severity, and delay in diagnosis can be catastrophic. Careful insertion techniques, as well as continued vigilance in the correct position and function of central venous catheters, are imperative to help prevent serious complications.

The evaluation and management of neonatal coagulation disorders

Neonatal hemostatic abnormalities can present diagnostic and therapeutic challenges to the physician. Developmental deficiencies and/or increases of certain coagulation proteins, coupled with acquired or genetic risk factors, can result in a hemorrhagic or thromboembolic emergency. The timely diagnosis of a congenital hemorrhagic or thrombotic disorder can avoid significant long-term sequelae. However, due to the lack of randomized clinical trials addressing the management of neonatal coagulation disorders, treatment strategies are usually empiric and not evidence-based. In this chapter, we will review the neonatal hemostatic system and will discuss the most common types of hemorrhagic and thrombotic disorders. Congenital and acquired risk factors for hemorrhagic and thromboembolic disorders will be presented, as well as current treatment options. Finally, suggested evaluations for neonates with either hemorrhagic or thromboembolic problems will be reviewed.

Complications of percutaneously inserted central venous catheters in Japanese neonates

BACKGROUND

To determine institutional policies concerning percutaneously inserted central venous catheter (PICC) utilization and also frequencies of complications such as pericardial effusion (PCE), cardiac tamponade (CT), pleural effusion, ascites, venous thrombosis, and catheter removal difficulties.

METHODS

Nationwide postal questionnaire survey was carried out that included institutional policies on PICC and numbers of complications recorded from January 1999 to December 2003.

RESULTS

A total of 98 replies were received from 193 neonatal intensive care units (NICU) in Japan. As a catheter tip location, positions outside of the heart were highly preferred, while only 9% accepted a right atrial position. Twenty-eight cases of PCE or CT were reported, representing an estimated frequency of 0.07-0.11% of PICC insertions. Pleural effusion/ascites and removal difficulties (36 and 35 cases, respectively) were encountered in approximately 0.09-0.14% of insertions.

CONCLUSIONS

Frequency of PCE/CT appeared comparable to previously reported occurrences. Also, pleural effusion/ascites and removal difficulty appeared to be rare complications.

Pleural effusion due to intra-abdominal extravasation of parenteral nutrition

An 8-week-old preterm boy experienced respiratory deterioration due to unilateral pleural effusion. Intra-abdominal extravasation of parenteral fluid with leakage into the pleural cavity was suspected based on biochemical analysis of the effluent. Perforation of the central venous catheter in the peritoneal cavity was subsequently confirmed by contrast roentgenography. As in peritoneal dialysis and hepatic hydrothorax, pleuroperitoneal communication needs to be considered in patients exhibiting pleural effusion with a central venous line below the diaphragm.

The reliability of 2D and colour Doppler ultrasound in localising longline position

BACKGROUND

The position of percutaneously inserted central venous catheters (longlines) in neonates is critical, as malpositioned longlines are associated with potentially fatal complications.

AIM

To determine if cardiac ultrasound (two-dimensional (2D) and colour Doppler) is useful in evaluating longline position, when compared with the position identified by contrast radiography.

SETTING

Single level 3 neonatal unit.

PARTICIPANTS

Forty-four neonates undergoing insertion of 24-gauge silastic longlines between July 2004 and September 2005.

METHODS

Infants who had a longline inserted underwent echocardiography by a novice and an experienced operator. Operators identified longline position using a 2D then colour Doppler echocardiography during a rapid bolus infusion of saline. The position was identified from contrast radiography by two independent observers.

RESULTS

Using 2D echocardiography, the novice and experienced operators could identify 41 and 59% of longlines, respectively. However, only 34% of longlines were identified by both operators. In 15 infants whose longline positions were identified by both operators, there was agreement in only eight infants (53%). Colour Doppler improved the experienced operator's success but did not assist the novice operator. For radiographs, there was 68% agreement on longline position between observers. The experienced echocardiographer located three (7%) longlines within the heart that from radiographs were thought to be in a proximal central vessel.

CONCLUSIONS

This technique is experience-dependent and complements rather than replaces the use of contrast radiography. However, some infants with an apparently acceptable longline position on contrast radiography have longlines located within the heart on echocardiography.

Peripheral insertion of double-lumen central venous catheter using the Seldinger technique in newborns

OBJECTIVE

To report the experience of peripheral insertion of double-lumen central catheters (PIDLCC) in preterm and term newborn infants and to analyze the technical characteristics of the procedure and any observed complications.

STUDY DESIGN

Retrospective review of 61 newborns that had a PIDLCC between 2003 and 2006. The study comprised clinical data analysis, anthropometrics, indications, duration, complications and reasons for withdrawal of the catheters.

RESULT

Weight of the patients was <1 kg in 10%, and >2 kg in 75%. Catheters tip placement was as aimed, mostly superior cava vein (SCV), in 65.5%, and subclavian vein in remaining 34.5% and average duration of catheterization was 13.5+/-9.6 and 8.9+/-5.8 days, respectively. Blood sampling through both lumens was possible especially when the tip was at SCV. Reasons for catheter withdrawal were end of indication (45.9%), phlebitis/edema (21.3%), suspected infection (3.2%), accidental withdrawal (3.2%) and rupture of proximal end (3.2%). In three (4.9%) patients, withdrawal was due to serious complications (two cases of pleural leakage of infusion fluid and one breakage of the metallic guide). About 16.3% of the patients died with the catheter still in situ. Infection findings were positive tip culture (14.7%) and catheter-related sepsis (3.2%).

CONCLUSION

Insertion of PIDLCC is possible in neonates. The incidence of complications, mostly mechanical, requires careful evaluation of indications, and strict adherence to the procedure of insertion and manipulation.

Complications of vascular catheters in the neonatal intensive care unit

Insertion of an intravascular catheter is the most common invasive procedure in the neonatal ICU. With every passing decade, technological innovations in catheter materials and sizes have allowed vascular access in infants who are smaller and sicker for purposes of blood pressure monitoring, blood sampling, and infusion of intravenous fluids and medications. There is, however, growing recognition of potential risks to life and limb associated with the use of intravascular catheters. This article reviews complications of venous and arterial catheters in the neonatal ICU and discusses treatment approaches and methods to prevent such complications, based on current evidence.

Aspiration of parenteral nutrition -- a previously unreported complication of central venous access in an infant: a case report

Introduction

The insertion of percutaneous central venous catheters is a common procedure in neonatal intensive care nurseries. Placement of the catheter tip in a large central vein is most desirable. Occasionally, due to difficult venous access, catheter tips are left in places that are less than ideal.

Case presentation

A female infant with a complicated gastroschisis developed signs of short bowel syndrome post surgery. She was treated with a combination of parenteral nutrition and enteral feeds. A central venous line was inserted through a scalp vein. The tip was noted to be in a vessel at the level of the mandible. She subsequently became unwell with large milky pharyngeal aspirates and episodes of bradycardia. Chest radiography revealed aspiration. The central venous line was removed because of presumed extravasation. This is the first reported case of parenteral nutrition extravasation into the pharynx causing aspiration in an infant.

Conclusion

This complication may have been prevented by recognising that the tip of the catheter was not correctly placed. When catheters are in unusual positions it may be useful to obtain a second radiograph from a different angle or an ultrasound scan to confirm the positioning of the catheter tip.

Randomized controlled trial of vascular access in newborns in the neonatal intensive care unit

OBJECTIVE

To compare the effectiveness of two methods of vascular access in newborns.

DESIGN

Randomized controlled trial.

SETTING

Neonatal intensive care unit in Regional Hospital of Valdivia, Chile.

PARTICIPANTS

Seventy-four high-risk newborns.

INTERVENTIONS

Peripherally inserted central catheter and peripheral intravenous catheter.

MAIN OUTCOME MEASURES

Length of neonatal intensive care unit stay and incidence of sepsis and phlebitis. RESULTS/DATA ANALYSIS: There were no statistically significant differences in the length of the neonatal intensive care unit stay and in the incidence of sepsis between groups. There was a significant higher incidence of phlebitis in the peripheral intravenous catheter group.

CONCLUSIONS

Although there was not a significant effect of the kind of catheter on length of neonatal intensive care unit stay, the peripherally inserted central catheter is recommended because of the decreased risk of phlebitis and the decreased number of venipuncture attempts and catheters needed to complete intravenous therapy.

Percutaneous central venous catheters versus peripheral cannulae for delivery of parenteral nutrition in neonates

BACKGROUND

Parenteral nutrition for neonates may be delivered via a short peripheral cannula or a central venous catheter. The latter may either be inserted via the umbilicus or percutaneously. Because of the complications associated with umbilical venous catheter use, many neonatal units prefer to use percutaneously inserted catheters following the initial stabilisation period. The method of parenteral nutrition delivery may affect nutrient input and consequently growth and development. Although potentially more difficult to place, percutaneous central venous catheters may be more stable than peripheral cannulae, and need less frequent replacement. These delivery methods may also be associated with different risks of adverse events, including acquired systemic infection and extravasation injury.

OBJECTIVES

To determine the effect of infusion via a percutaneous central venous catheter versus a peripheral cannula on nutrient input, growth and development, and complications including systemic infection, or extravasation injuries in newborn infants who require parenteral nutrition.

SEARCH STRATEGY

The standard search strategy of the Cochrane Neonatal Review Group was used. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2007), MEDLINE (1966 - February 2007), EMBASE (1980 - February 2007), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised controlled trials that compared the effect of delivering parenteral nutrition via a percutaneous central venous catheter versus a peripheral cannulae in neonates.

DATA COLLECTION AND ANALYSIS

Data were extracted the data using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by each author, and synthesis of data using relative risk, risk difference and mean difference.

MAIN RESULTS

Four trials eligible for inclusion were found. These trials recruited a total of 368 infants and reported a number of different outcomes. One study showed that the use of a percutaneous central venous catheter was associated with a decreased risk of cumulative nutritional deficit during the trial period: Mean difference in the percentage of the prescribed nutritional intake actually received: -7.1% (95% confidence interval -11.02, -3.2). In another trial, infants in the percutaneous central venous catheter group needed significantly fewer catheters/cannulae per infant during the trial period: Mean difference in the number of catheters/cannulae per infant: -3.2 (95% confidence interval -5.13, -1.27). Meta-analysis of data from all four trials did not find any evidence of an effect on the incidence of systemic infection: Typical relative risk: 0.94 (95% confidence interval 0.70, 1.25); typical risk difference: -0.02 (95% confidence interval -0.12, 0.08).

AUTHORS' CONCLUSIONS

Data from one small study suggest that the use of a percutaneous central venous catheter to deliver parenteral nutrition in newborn infants improves nutrient input. The significance of this in relation to long-term growth and developmental outcomes is unclear. Another study suggested that the use of a percutaneous central venous catheter rather than a peripheral cannula decreases the number of catheters/cannulae needed to deliver the nutrition. No evidence was found to suggest that percutaneous central venous catheter use increased the risk of adverse events, particularly systemic infection.

Pericardial effusion associated with an appropriately placed umbilical venous catheter

Central venous catheterization is widely used in neonatal intensive care units to support tiny preterm babies. Pericardial effusion (PCE) and cardiac tamponade are uncommon but potentially fatal complications of percutaneous, umbilical and surgically placed central venous catheters related to intracardiac position or migration. This report describes a case of PCE arising from fluid infused via umbilical venous catheter. The case study highlights two important aspects: one, occurrence of PCE in a baby with satisfactory position of the umbilical catheter, and second, the life-saving application of basic echocardiography by bedside caregivers for the diagnosis and treatment of this critical condition.

Randomized trial of percutaneous central venous lines versus peripheral intravenous lines

OBJECTIVE

To compare the occurrence of systemic infection or death in preterm infants with elective percutaneous central line (PCVL) placement versus peripheral intravenous catheter (PIV) placement.

STUDY DESIGN

A total of 96 infants < or =1250 g or < or =30 weeks gestation were randomized by 4 days of age to elective placement of a PCVL or continued use of PIV catheters. The primary outcome of systemic infection (defined as a positive blood or cerebrospinal fluid (CSF) culture treated for at least 5 days) or death was monitored until the infants did not require intravenous (iv) support for 7 consecutive days.

RESULTS

Systemic infection or death occurred in 17/46 (39%) infants in the PCVL group and 14/50 (28%) in the PIV group (relative risk (RR)=1.32 with 95% confidence interval (CI) 0.70, 2.53; risk difference (RD)=0.09 with 95% CI -0.10, 0.28). The PCVL group had significantly fewer skin punctures for iv access.

CONCLUSION

There was no significant difference in systemic infection or death (expressed either as a combined outcome or as separate component outcomes) between the groups. The number of skin punctures was significantly reduced in the PCVL group.

Prevention of catheter-related bloodstream infections in the neonatal intensive care setting

Nosocomial infection causes substantial morbidity and mortality among neonates treated in the neonatal intensive care setting. Colonization and subsequent infection of central venous catheters leading to catheter-related bloodstream infection is among the most common causes of nosocomial sepsis in this patient population. Prevention of catheter-related bloodstream infection is a major challenge and numerous strategies have been attempted in this context with varying success. Given the dynamic epidemiology of nosocomial infection among neonates and the emergence of antimicrobial resistance, novel prevention strategies are urgently required.

Risk management, or just a different risk?

BACKGROUND

National reporting of adverse incidents has resulted in a number of clinical alerts being issued. Despite a lack of evidence, these alerts are often accompanied by a mandatory requirement to alter practice. There is likely to be clinician resistance to such a method of change management, particularly where evidence of safety is missing.

AIM

To determine the level of implementation within neonatal units of an alert requiring the change from litmus to pH paper to test nasogastric tube position.

METHOD

A questionnaire sent to all neonatal units in the United Kingdom with more than 12 cots.

RESULTS

From the 207 questionnaires sent, there were 165 (80%) responses. Fifty five percent of units were still using litmus. All continued to use supplementary tests not recommended in best practice statements issued at the time of the alert. There was considerable variation in the pH value at which it was considered safe to feed.

CONCLUSIONS

Nine months after the alert, more than half the units had not changed to pH paper, and supplementary methods of testing were still being used. The wide range of pH values highlights the uncertainty about the "normal" gastric pH in the newborn. The evidence that, in neonatal units, changing to pH paper is safer than the long established use of litmus is lacking. Recommendations for change in practice must be based on good information and not seen just as a "knee jerk" response to adverse incidents.

Arterielle und zentralvenöse Katheter bei Neugeborenen und Säuglingen

In neonates and infants, arterial and central venous catheters are of vital importance to optimize perioperative surveillance during surgery as well as postoperative care in the intensive care unit. The insertion of umbilical venous (UVC) and umbilical arterial catheters (UAC) in neonates in the first days of life is relatively simple and associated with a low procedure-related risk. As with other centrally placed catheters, correct positioning must be verified and the catheters should not be used for more than 5-7 days. Peripherally inserted central catheters (PICC) are commonly used in neonates and can be an alternative to conventional central venous lines in older infants. In order to minimize the risk associated with catheter malposition, correct position must always be verified by appropriate imaging studies or ECG guidance. Surgically placed Broviac catheters are mainly used in patients with a long-term need for central venous access. Finally, it has been shown that adherence to strict guidelines for insertion and handling can significantly reduce catheter-associated infections.

A randomized trial comparing long-term and short-term use of umbilical venous catheters in premature infants with birth weights of less than 1251 grams

BACKGROUND

Umbilical vein and percutaneous central venous catheters are often used in preterm infants, but they can lead to complications, including infection.

OBJECTIVE

We hypothesized that long-term umbilical vein catheter use would result in fewer infections than short-term umbilical vein catheter use followed by percutaneous central venous catheter placement.

DESIGN/METHODS

Infants < or = 1250 g with umbilical vein catheters placed at admission were randomly assigned to a long-term (umbilical vein catheter up to 28 days) or short-term (umbilical vein catheter for 7-10 days followed by percutaneous central venous catheter) group. Catheter infection was defined as symptoms and > or = 1 positive blood culture for definite pathogens or >1 positive culture for other organisms, with a catheter in place. Clinically significant echocardiogram findings were defined as thrombi threatening vascular occlusion, crossing/blocking heart valves, or otherwise felt to be significant by the cardiologist. The primary outcome was time from birth to catheter infection, analyzed by the log-rank test.

RESULTS

There were 106 subjects in the short-term group and 104 in the long-term group with birth weights of 915 +/- 198 and 931 +/- 193 g and gestational ages of 27.8 +/- 2.0 and 27.7 +/- 2.2 weeks, respectively. The distribution of time to catheter infection did not differ between the groups. The overall incidence of catheter infection was 13% in the short-term group and 20% in the long-term group. Median age at catheter infection was 11.5 days in the short-term group and 14 days in the long-term group. There were 7.4 infections per 1000 catheter-days in the short-term group and 11.5 per 1000 in the long-term group. Seven infections in the short-term group were in umbilical vein catheters, and 18 infections in the long-term group were in umbilical vein catheter. Echocardiograms detected 4 infants in the short-term group and 7 infants in the long-term group with significant thrombosis. All significant thrombi were at the site of the umbilical vein catheter tip. No thrombus caused hemodynamic compromise, no child had clinical symptoms of thrombosis, and none required therapy. Of the 45 small-for-gestational-age infants in the study, 9 developed thrombi (short-term group, 4; long-term group, 5). The incidence of thrombi was higher in the small-for-gestational-age group (20%) versus other study subjects (9%). There were no differences in time to full feedings or to regain birth weight or in the incidence of necrotizing enterocolitis or death.

CONCLUSIONS

Infection and complication rates were similar between infants managed with an umbilical vein catheter in place for up to 28 days compared with infants managed with an umbilical vein catheter replaced by a percutaneous central venous catheter after 7 to 10 days. Umbilical vein catheter durations beyond the current Centers for Disease Control and Prevention-recommended limit of 14 days may be reasonable.

Cathéters centraux et épanchements péricardiques en période néonatale : étude rétrospective multicentrique

OBJECTIVE

To evaluate the use of neonatal central venous catheters (CVC) in 38 french neonatal units and occurrence of pericardial effusion (PCE) over the past 5 years.

MATERIALS AND METHODS

We surveyed 38 units with a questionnaire and studied the cases of PCE in five units.

RESULTS

Response rate was 89% (34/38). Accepted CVC tip positions were: junction of right atrium (RA) and vena cava (VC) 76%, VC 58%, RA 11%. Fifty percent of the centers had been exposed to PCE. 16 cases of PCE were studied. Median gestational age was 31 weeks (range: 26.1 to 40 weeks). Median time from insertion: 3.2 days (range: 0.4-13.5). In all cases CVC tip was intracardiac at insertion with inadequate withdrawing in 13 cases. Sudden cardiac collapse was reported in eight cases, and unexplained cardiorespiratory instability in six cases. Echography showed PCE in 14 cases. One diagnosis was post-mortem. CVC was withdrawn in 12 patients and 13 underwent pericardiocentesis. Four patients died and two had neurological sequelae.

CONCLUSION

PCE was associated with intracardiac CVC tip. The CVC tip should be controlled with radiography or echography outside the cardiac silhouette. PCE diagnosis must be considered in face of unexplained cardiovascular decompensation of neonate with CVC.

The cobweb sign: percutaneous silastic long line tip placement in tributaries of superficial veins

We report a method for preventing misplacement of percutaneous silastic catheters in superficial vein tributary or venous plexus. Catheters inserted less than the length calculated by surface anatomy measurement due to resistance were studied in three patients. Contrast X-rays (Omnipaque, Nycomed Imaging AS, Oslo, Norway) of the catheters was performed to confirm the catheter tip placement position. On initial assessment, the catheter tip placement was thought to be satisfactory and infusion of TPN commenced. Following signs of extravasation, re-examination of the contrast X-rays demonstrated that multiple thin rays of omnipaque could be traced in different directions like a cobweb. In the third infant, we recognised the "cobweb" sign and prospectively withdrew the catheter tip 2 cm. Repeat contrast X-ray confirmed that the catheter tip was in a major superficial vein, infusion continued without further complication. We conclude that when the "cobweb" sign is noticed then the catheter should be removed or withdrawn 2 to 3 cm and repeat contrast X-ray performed..