Nabelvenenkatheter - Retrospektive Analyse der Nabelvenenkatheterlagen über einen 10-Jahres-Zeitraum

The incidence and mortality rate of catheter-related neonatal pericardial effusion: A meta-analysis

BACKGROUD

Neonatal pericardial effusion (PCE) is one of the most severe complications of central catheters in neonates with its rapid progression and high mortality. We aim to estimate the overall incidence and mortality of catheter-related neonatal PCE, more importantly, to identify possible predictors for clinical reference.

METHODS

We searched MEDLINE, Embase, Cochrane Library, Web of Science, china national knowledge infrastructure, Wanfang Data, and Sinomed databases for subject words "central catheter," "neonate," "pericardial effusion" and their random words till June 8, 2020. This meta-analysis is based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Possible predictors of occurrences and deaths were extracted and assessed cooperatively. The pooled incidence rate of catheter-related neonatal PCE was calculated using a random effects model.

RESULTS

Twenty-one cohort studies and 99 cases were eligible. Pooled incidence is 3·8‰[2.2‰, 6.7‰]. Polyurethane catheters generate significantly more neonatal PCE than silicone counterparts (P < .01). 27% of the patients die. The mortality of patients with bradycardia is higher than others (P < .05). Catheters with a guidewire result in more deaths than umbilical venous catheter (UVC) and peripherally inserted central catheters (PICC) (P < .05). Without pericardiocentesis, mortality increases (P < .01). The difference of deaths between reposition and removing the catheter is insignificant (P > .05).

CONCLUSION

Central catheters in Seldinger Technique (with a guidewire) put neonates at greater risk of PCE and consequent death. Silicone catheters excel at avoiding deadly catheter-related PCE, which could be a better choice in neonatal intensive care units (NICU). When catheter-related PCE occurs, timely diagnosis and pericardiocentesis save lives.

Real-Time Ultrasound Guidance for Umbilical Venous Cannulation in Neonates With Congenital Heart Disease

OBJECTIVES

Umbilical venous cannulation is the favored approach to perinatal central access worldwide but has a failure rate of 25-50% and the insertion technique has not evolved in decades. Improving the success of this procedure would have broad implications, particularly where peripherally inserted central catheters are not easily obtained and in neonates with congenital heart disease, in whom umbilical access facilitates administration of inotropes and blood products while sparing vessels essential for later cardiac interventions. We sought to use real-time, point-of-care ultrasound to achieve central umbilical venous access in patients for whom conventional, blind placement techniques had failed.

DESIGN

Multicenter case series, March 2019-May 2021.

SETTING

Cardiac and neonatal ICUs at three tertiary care children's hospitals.

PATIENTS

We identified 32 neonates with congenital heart disease, who had failed umbilical venous cannulation using traditional, blind techniques.

INTERVENTIONS

Real-time ultrasound guidance and liver pressure were used to replace malpositioned catheters and achieve successful placement at the inferior cavoatrial junction.

MEASUREMENTS AND MAIN RESULTS

In 32 patients with failed prior umbilical venous catheter placement, real-time ultrasound guidance was used to successfully "rescue" the line and achieve central position in 23 (72%). Twenty of 25 attempts (80%) performed in the first 48 hours of life were successful, and three of seven attempts (43%) performed later. Twenty-four patients (75%) were on prostaglandin infusion at the time of the procedure. We did not identify an association between patient weight or gestational age and successful placement.

CONCLUSIONS

Ultrasound guidance has become standard of care for percutaneous central venous access but is a new and emerging technique for umbilical vessel catheterization. In this early experience, we report that point-of-care ultrasound, together with liver pressure, can be used to markedly improve success of placement. This represents a significant advance in this core neonatal procedure.

Streptococcus gallolyticus subspecies pasteurianus causing early onset neonatal sepsis complicated by solitary liver abscess in a preterm infant

Streptococcus gallolyticus ssp pasteurianus (SGp) is an uncommon but increasingly recognized cause of neonatal sepsis and meningitis. Liver abscess in neonates is extremely rare. But liver abscess due to SG has never been reported in the literature. We present the first case of liver abscess due to SGp in a late preterm infant. A female infant was born at 36 weeks via normal vaginal delivery to a mother with unremarkable antenatal history. She had progressively worsening respiratory distress since birth and was intubated at 13 h of life. One dose of surfactant was delivered and ventilation continued. Parenteral crystalline Penicillin and Gentamicin were initiated and her blood culture at birth grew SGp. She had a spike of fever on day 5 of life. An ultrasound (US) scan of the abdomen was included in the septic work up. A multi-septated cystic liver abscess was noted in the right lobe of the liver. As there was inadequate response to appropriate intravenous antibiotics, needle aspiration and biopsy were performed on day 35 of life. Aspirate was sterile and histopathology confirmed a liver abscess. The patient continued to be treated with antibiotics for 8 weeks with serial US scans of the liver showing resolution of the abscess. Increasing awareness among paediatric and neonatal fraternity about these new emerging bacterial infections can facilitate early diagnosis and treatment.

Understanding umbilical venous catheter insertion practices through a prospective multicenter observational study

OBJECTIVE

To understand practices of umbilical venous catheter (UVC) insertion in tertiary level neonatal intensive care units (NICU) and investigate the outcomes of subsequent attempts following a failed initial attempt.

STUDY DESIGN

Prospective, multi-center observational study of UVC insertions at tertiary level NICUs between March 2019 and January 2020.

RESULTS

Of the 101 UVCs inserted at 4 centers, seventy-two (71%) were central at the first attempt and 50% were central at subsequent attempts. Patients with at least 1 failed attempt at insertion were less likely to have a centrally placed UVC (p = .009). Manipulations were less likely to be required when UVC was centrally placed during the first attempt. Maneuvers such as posterior liver mobilization used during insertion were likely to be associated with successful central placement of UVC (p = .0243). The time to complete the procedure was significantly less when the UVC was central at the first attempt (34.2 ± 20.2 vs 46.9 ± 33.8) (p = .0292). Gestational age, birth weight, and age of the baby at the insertion of the UVC, experience of the provider, and type of catheter were comparable among groups. The Shukla formula was most commonly used by providers to measure the depth of UVC placement.

CONCLUSION

Repetitive attempts and manipulations were less likely to be beneficial in the successful central placement of UVC in neonates. Additionally, repetitive attempts at insertion prolonged the overall duration of the procedure.

Application of a modified electrocardiogram-guided technique for umbilical venous catheterisation in neonates: A retrospective trial

AIM

To investigate the effectiveness and safety of modified electrocardiogram (ECG)-guided technique in umbilical venous catheterisation in neonates.

METHODS

Sixty-six critically ill neonates underwent umbilical venous catheterisation with (ECG group) or without (control group) ECG guidance from January 2017 to March 2019. We retrospectively analysed and compared the rate of correct tip placement on first try, unplanned extubation rate and incidence of catheter-related complications between the two groups.

RESULTS

There were 33 patients in each group. The ECG group showed significantly higher rate of correct tip placement on first try (P < 0.001), lower unplanned extubation rate (P < 0.001), but identical incidence of catheter-related complications (P = 0.492) comparing with the control group.

CONCLUSION

The ECG-guided technique is an effective and safe method for umbilical venous catheterisation. The connecting method we modified made this technique more practical and can be promoted to areas without access to specific ECG adaptors.

Hepatic extravasation complicated by umbilical venous catheterization in neonates: A 5-year, single-center experience

BACKGROUND

Care of newborns in the neonatal intensive care unit generally involves umbilical venous catheterization (UVC) for central vein access to enable medical needs. The study aimed to evaluate the sonographic appearance, risk factors, and outcomes of UVC-related hepatic extravasation (HE) in neonates.

METHODS

A 5-year retrospective study where 33 neonates were enrolled with a diagnosis age ranging from 2 to 25 days. 78.8% of the subjects had UVC malpositioning shown on initial radiography. All neonates sonographically diagnosed with HE, and follow-up ultrasound (US) was performed.

RESULTS

The main findings of HE on US were hyperechoic or heterogeneous lesions of a lobulated (51.7%) or wedge shape (48.3%), located mainly in the left lobe (72.7%). The mean time to resolution of HE was 2.25 months. Seven (21.2%) patients showed hepatic vascular thrombosis at follow-up. Two (6%) patients had abnormal liver function, which subsequently normalized.

CONCLUSION

Malposition of the UV catheter was the predisposing factor for UVC-related HE in neonates. US facilitates detection of UVC malpositioning and diagnosis of HE, as well as delayed complications. A shorter duration of UVC placement is associated with favorable outcomes of UVC-related HE in neonates.

Learning Curves for Training in Ultrasonography-Based Examination of Umbilical Catheter Placement: A Piglet Study

BACKGROUND

The training required for accurate assessment of umbilical catheter placement by ultrasonography (US) is unknown.

OBJECTIVE

To describe the learning curve and provide an estimate of the accuracy of physicians' US examinations (US skills) and self-confidence when examining umbilical catheter tip placement.

METHODS

Twenty-one physicians with minimal experience in US completed a 1.5-hour eLearning module. Ten piglets with catheters inserted in the umbilical vessels were used as training objects. Following eLearning each physician performed up to twelve 10-min US examinations of the piglets. Expert examinations were reference standards. Sensitivity and specificity of physicians' skills in detecting catheter tip placement by US was used to describe the learning curve. Self-confidence was reported by Likert scale after each examination.

RESULTS

Physicians' detection of a correctly placed and misplaced umbilical artery catheter tip increased by an odds ratio of 1.6 (95% CI: 1.1, 2.3) and 3.6 (95% CI: 1.7, 7.8) per examination performed. A sensitivity of 0.97 (95% CI: 0.80, 0.99) and specificity of 0.95 (95% CI: 0.84, 0.99) was reached after 6 examinations. For the venous catheter, US skills in detecting a misplaced catheter tip increased with an odds ratio of 2.4 (95% CI: 1.2, 4.8) per US examination. Overall, performance and self-confidence plateaus were reached after 6 examinations.

CONCLUSION

We found steep learning curves for targeted US examination of umbilical catheter placement. eLearning followed by 6 examinations was found to be adequate training to perform with a sufficiently high accuracy and self-confidence to allow for point-of-care use.

[Ultrasound-guided umbilical venous catheterisation: A cost-effectiveness analysis]

INTRODUCTION

Although the use of ultrasound for the insertion of central catheters has proven to be cost-effective in adults, it is not known if this is the case in the neonatal population. This study compared the cost-effectiveness of ultrasound-guided umbilical venous catheterisation with conventional catheterisation in a neonatal intensive care unit of a Public University Hospital.

PATIENTS AND METHODS

A retrospective observational study was conducted on newborns that required an umbilical venous catheter before completing their first 24hours of extra-uterine life. Two retrospective cohorts were formed, including one with ultrasound-guided catheterisation and the other with conventional catheterisation. The effectiveness was measured using 2 variables: placement of ideal position and insertion without complications. The cost of human and material resources (consumable and non-consumable), the cost-effectiveness ratio, and the incremental cost-effectiveness ratio were estimated, as well as carrying out a sensitivity analysis.

RESULTS

Catheter obstruction was more frequent in guided catheterisation than in conventional catheterisation (7.7% vs. 0%, p=.04) and catheter dysfunction was higher in the latter (79% vs. 3.8%, p<.0001). The cost-effectiveness ratio of the guided catheterisation was €153.9, and €484.6 for the conventional one. The incremental cost-effectiveness ratio was €45.5. The sensitivity analysis showed a €2.6 increase in the cost-effectiveness ratio of the guided catheterisation and €47 in the conventional one.

CONCLUSIONS

The use of ultrasound to guide umbilical catheterisation is more efficient than conventional catheterisation since, despite using more economic resources, it offers greater effectiveness.

Duration to Establish an Emergency Vascular Access and How to Accelerate It: A Simulation-Based Study Performed in Real-Life Neonatal Resuscitation Rooms

OBJECTIVES

To compare the duration to establish an umbilical venous catheter and an intraosseous access in real hospital delivery rooms and as a secondary aim to assess delaying factors during establishment and to provide recommendations to accelerate vascular access in neonatal resuscitation.

DESIGN

Retrospective analysis of audio-video recorded neonatal simulation training.

SETTINGS

Simulation training events in exact replications of actual delivery/resuscitation rooms of 16 hospitals with different levels of care (Austria and Germany). Equipment was prepared the same way as for real clinical events.

SUBJECTS

Medical teams of four to five persons with birth-related background (midwives, nurses, neonatologists, and anesthesiologists) in a realistic team composition.

INTERVENTIONS

Audio-video recorded mannequin-based simulated resuscitation of an asphyxiated newborn including the establishment of either umbilical venous catheter or intraosseous access.

MEASUREMENTS AND MAIN RESULTS

The duration of access establishment (time from decision to first flush/aspiration), preparation (decision to start of procedure), and the procedure itself (start to first flush/aspiration) was significantly longer for umbilical venous catheter than for intraosseous access (overall duration 199 vs 86 s). Delaying factors for umbilical venous catheter establishment were mainly due to the complex approach itself, the multitude of equipment required, and uncertainties about necessary hygiene standards. Challenges in intraosseous access establishment were handling of the unfamiliar material and absence of an intraosseous access kit in the resuscitation room. There was no significant difference between the required duration for access establishment between large centers and small hospitals, but a trend was observed that duration for umbilical venous catheter was longer in small hospitals than in centers. Duration for intraosseous access was similar in both hospital types.

CONCLUSIONS

Vascular access establishment in neonatal resuscitation could be accelerated by infrastructural improvements and specific training of medical teams. In simulated in situ neonatal resuscitation, intraosseous access is faster to establish than umbilical venous catheter. Future studies are required to assess efficacy and safety of both approaches in real resuscitation settings.

Investigation of umbilical venous vessels anatomy and diameters as a guideline for catheter placement in newborns

Umbilical cord catheters (UCC) are important for the primary care of critically ill newborns. To analyze anatomical variations of the umbilical vein (UV) and its further course, we performed abdominal spiral-CT examinations on stillborns. The aim of the study was to explore the high incidence of mal-positioned UCCs and to improve their positioning. Eighteen stillborns were investigated (29.2 weeks ± 6.7 weeks (IQR)). CTs were performed using either air or contrast medium injection into the UV. We measured the diameter at the narrowest points of (i) the umbilical vein, (ii) the segmental portal vein, (iii) the left portal vein, (iv) the umbilical recess, and (v) the ductus venosus. The branching angles between (a) the umbilical vein and intrahepatic veins and (b) the ductus venosus and umbilical recess were measured. The diameter of the UV increases from 3.4 to 11 mm (median [IQR]:4.6 mm [4.2-6.9]: r²  = 0.64). The left portal vein has a larger diameter (3.6 mm [2.6-4.55]; r²  = 0.43) than the left segmental portal vein (2.3 mm [1.8-2.75]; r²  = 0.23). The diameter of the ductus venosus (2.5 mm [1.6-3.4]; r²  = 0.59) is half that of the umbilical recess (5.1 mm [3.3-6.2]; r²  = 0.43). The most obtuse angle is formed by the junction between the umbilical recess and ductus venosus (151° [133-159]; r²  = 0.001). The branch angle from the outgoing UV into the left portal vein is more obtuse (128° [123-144]; r²  = 0.0001) than that of the segmental portal vein (115° [105-119]; r²  = 0.0001). To avoid mal-positioning, our data suggest the use of a soft catheter. The UV and its extensions are wide enough to admit a 4 Fr. catheter without complete obstruction. Clin. Anat. 31:269-274, 2018. © 2017 Wiley Periodicals, Inc.

Venobiliary fistula related to umbilical venous catheter in a newborn

We present a case of venobiliary fistula due to umbilical venous catheter (UVC). UVC was inserted the day before surgery in a newborn who was scheduled for type IIIB jejunal atresia surgery. The UVC was superimposed on the liver. It was noted that the gastric drainage became chylous and increased to 790 and then 1977 mL daily. I.v. contrast tomography with 650 mL contrast showed that the opaque substance was dispersed around the catheter and a venobiliary fistula formed, with the administered fluid accumulating in the duodenum. Rapid improvement was seen in the clinical picture after the UVC was removed. Venobiliary fistula may develop in patients with UVC that is not placed appropriately, and can direct the fluid administered from the UVC to the gastrointestinal system through the choledochal duct. The importance of contrast computed tomography in the diagnosis of venobiliary fistula in the newborn is also emphasized.

Fluoroscopy-guided Umbilical Venous Catheter Placement in Infants with Congenital Heart Disease

OBJECTIVE

The objective of this study was to (1) describe the technical aspects of fluoroscopy-guided umbilical venous catheter placement (FGUVCP); and (2) determine the procedural success rate, factors contributing to procedural failure, and risks of the procedure.

BACKGROUND

Umbilical venous catheters are advantageous compared with femoral venous access, but can be difficult to place at the bedside.

MATERIALS AND METHODS

This was a retrospective chart review from a single tertiary care referral institution.

RESULTS

FGUVCP was successful in 138 of 180 patients (76.7%) over a seven-year period. Patients in whom FGUVCP was successful were younger at the time of procedure compared with patients in whom FGUVCP was unsuccessful (median 18.2 vs. 22.2 hours, P = .03). The optimal age cutoff to predict FGUVCP success was 20 hours with a high positive predictive value (82.4%) but low negative predictive value (32.5%). No other variables were associated with procedural failure, though functional univentricular heart and older gestational age trended toward statistical significance. Median radiation time, contrast exposure, and blood loss were 3.2 minutes, 1 mL, and 1 mL, respectively. A total of 10 complications in 10 patients were associated with FGUVCP.

CONCLUSIONS

FGUVCP is a safe and highly successful way to obtain central venous access in neonates with congenital heart disease. Older age at the time of procedure is associated with procedural failure, but utilization of an age cutoff may not be clinically useful.

Rates of intracardiac umbilical venous catheter placement in neonates

OBJECTIVES

To review umbilical venous catheter (UVC) placement in neonates who underwent targeted neonatal echocardiography (TNE) and to correlate catheter tip placement on TNE and anteroposterior thoracoabdominal radiography.

METHODS

We conducted a retrospective analysis of 51 neonates who had UVC positions assessed by TNE and radiography in a neonatal intensive care unit (NICU). A single operator performed all TNE examinations. The final radiographic catheter placement was taken from the image closest to the time of echocardiography. Fisher exact, χ(2), and t tests were used as appropriate.

RESULTS

Among the 51 neonates who had catheters placed for 24 hours or more, TNE was performed on 48 in the first 48 hours, 2 at day 6, and 1 at day 9. Thirty-six neonates were extremely low birth weight (ELBW; <1000 g). Twenty-nine had good catheter tip positions, and 22 had catheters inside the heart (10 in the right atrium [RA], 3 at the foramen ovale, and 9 in the left atrium [LA]). Twenty neonates with catheter tips in the heart were ELBW, including 8 with catheters in the LA. The ELBW neonates were more likely to have catheters in the heart than non-ELBW neonates (20 of 36 versus 2 of 15; P= .01; odds ratio [OR], 8.1; confidence interval [CI], 1.59-41.3). Good placement on TNE varied widely in relation to thoracic vertebral landmarks on radiography: from the T7-8 interspace to T11. When radiography showed a catheter tip at T9-T10, there was no difference in the proportion of neonates with a good catheter position versus malposition (8 of 22 versus 8 of 29; P = .55; OR, 0.67; CI, 0.20-2.19).

CONCLUSIONS

A high proportion of ELBW neonates in a busy NICU had UVCs placed with the tips in the RA or LA despite common placement practices. We recommend adding TNE to radiography to position UVCs, especially in ELBW neonates.

Revised formula to determine the insertion length of umbilical vein catheters

The method of Shukla is commonly used to predict the insertion length of umbilical vein catheters (UVCs) but often leads to over-insertion. Malposition of UVCs can lead to complications. In this study, we compared the formula of Shukla, i.e., (3 x birthweight in kg + 9) / 2 + 1 cm with a revised formula, i.e., (3 x birthweight in kg + 9) / 2 cm in determining the insertion length of UVCs. A cohort where the revised formula was used for UVC placement (revised group) was compared with a historical cohort using the conventional formula (Shukla group). We evaluated the position of UVCs stated as the corresponding vertebra level with a radiograph of the infant's chest and abdomen immediately after insertion in both groups. Positioning of the catheter tip above the ninth or below the tenth thoracic vertebra was considered too high or too low, respectively. Median position of 93 UVCs placed according to Shukla was lower (seventh thoracic vertebra, interquartile range (IQR) 6-9) when compared to 92 UVCs placed according to the revised formula (eighth thoracic vertebra (IQR 7-9)). UVCs were more often over-inserted using the Shukla formula (73%) when compared to the revised formula (54%). One UVC in the Shukla group (1%) and two UVCs in the revised group (2%) were placed too low (p = NS).

CONCLUSION

The revised formula reduces the rate of over-insertion of UVCs without increasing the rate of inadequate lower positioning.