Clinical experience of percutaneous femoral venous catheterization in critically ill preterm infants less than 1,000 grams

Cardiovascular Intervention in Neonates Using an Umbilical Vein Approach

Cardiovascular catheterization has been applied in infant treatment for several decades. To date, considerable research attention has been paid to cardiovascular catheterization in small neonates. However, peripheral vascular routes of catheterization are possible obstacles for interventionists. Umbilical vein catheterization has been reported as a route for neonates, although few attempts have been made to investigate this approach. This study aimed to retrospectively review cardiovascular intervention using the umbilical vein approach as applied to infants admitted to a tertiary center from 2017 to 2020. Details including the perinatal variables, indication diagnoses, and procedure devices were collected. The enrollment included a total of 16 cases representing 17 intervention events, with infants born at a gestation age of 22–39 weeks and body weight ranging from 478 to 3685 g at the time of the procedure. The postnatal age ranged from 1 to 27 days. The catheter sizes ranged from 4 to 11 Fr. Indications included being admitted for patent ductus arteriosus occlusion (n = 15), balloon pulmonary valvuloplasty (n = 3), balloon atrial septostomy (BAS) (n = 3), pulmonary valve (PV) perforation (n = 1), and two interventions for catheter placement for continuous venovenous hemofiltration. The success rate for cardiovascular catheterization was 88.2% (15/17). There were two patients for which cannulation failed due to ductus venosus closure: one intraabdominal hemorrhage complication during continuous venovenous hemofiltration (CVVH), and one cardiac catheterization failure of PV perforation due to failure to insert the guiding catheter into the right ventricular outflow tract. Based on these findings, we conclude that cardiac catheterization and the placement of a large-sized catheter through an umbilical vein in a small infant represents a safe and time-saving method when catheterization is required.

Percutaneous Inserted Venous Catheter via Femoral Vein in Extremely Low-Birth-Weight Infants: A Single-Center Experience

OBJECTIVE

This study aimed to assess the applicability of the insertion of small diameter catheters through the femoral vein in extremely low-birth-weight (ELBW) infants.

STUDY DESIGN

All femoral small diameter catheters (Silastic or femoral arterial catheter [FAC]) inserted in ELBW infants in a tertiary level neonatal intensive care unit were retrospectively reviewed. Success rate, dwelling time, and percutaneously inserted central venous catheter-related complications were recorded.

RESULTS

Thirteen small diameter catheters were inserted in seven ELBW infants. Mean gestational age at birth was 25⁺³ weeks (standard deviation [SD] ± 2.12) and mean birth weight was 686 g (SD ± 204.9). Mean weight at the first time of insertion was 1,044 g (SD ± 376.3). In two occasions, a FAC was used instead of a Silastic. In most cases (11/13, 84.6%), the patient was intubated prior to the procedure. The mean dwelling time was 16.7 days (SD ± 9.8). Most of the inserted small diameter catheters were removed electively (8/12, 66.7%), except for one episode of clinical sepsis from coagulase-negative Staphylococcus and three cases of accidental line extravasation. No other complications were reported. The success rate was 92.3%.

CONCLUSION

Femoral venous catheterization using small diameter catheters in ELBW infants may be promising when other routes have been exhausted. Our results support that it is a feasible technique that can be performed at the bedside with successful results when conducted by experienced personnel.

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.

Complications associated with 2 different types of percutaneously inserted central venous catheters in very low birth weight infants

OBJECTIVE

To identify the prevalence and risk factors for complications associated with percutaneously inserted central venous catheters (PICCs) and evaluate the effect of different catheter types and their indwelling time on catheter-related complications.

DESIGN

Retrospective cohort study.

SETTING

A 49-bed neonatal intensive-care teaching hospital in Taiwan.

PATIENTS

Between 2004 and 2007, 518 single-lumen PICCs (defined as "old type") and 290 PICCs with a stiffening stylet and a thicker introducer ("new type") were inserted in a total of 534 neonates with a birth body weight of 1,500 g or less.

RESULTS

Independent risk factors of catheter-related sepsis (CRS) were longer duration for PICC placement and PICC inserted at femoral site (compared with nonfemoral sites) (odds ratio [OR], 1.53 [95% confidence interval {CI}, 1.07-2.25]; P = .044). An independent predictor of catheter-related noninfectious complications was time spent for PICC insertion of more than 60 minutes (compared with less than 30 minutes) (OR, 1.96 [95% CI, 1.08-3.53]; P = .026). New-type PICCs were significantly associated with a higher rate of femoral site insertion, catheter-related noninfectious complications, and longer time for successful insertion than old-type PICCs. The hazard rates of CRS according to indwelling time, determined over 5-day periods by survival analysis, showed 0.05% for catheters in place for 4 days or less; 0.27% for 5-9 days; 0.40% for 10-14 days; 0.68% for 15-19 days; 1.18% for 20-24 days; 3.96% for 25-29 days; and 10.45% for 30 or more days.

CONCLUSIONS

Different catheters do influence the complication rates. Spending more than 60 minutes for successful PICC insertion and PICCs indwelling for more than 30 days are associated with higher rates of catheter-related complications.

Vascular access in the neonate

Up to recently, inserting venous or arterial 'lines' in the neonate was essentially based on clinical skill and experience. The recent advent of portable ultrasound (US) machines with paediatric probes has resulted in the development of new approaches that, if correctly learned and used, should allow quicker and safer vascular access in this population. Both classic and new techniques are reviewed on the basis of literature and authors' experience.

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 catheter placement in children: a prospective study of complications in a Brazilian public hospital

Central venous access is frequently used in infants and children with a wide variety of conditions. This report evaluates our experience and the complications from central venous catheters (CVC) placed percutaneously in children at a public hospital of a developing country-Brazil. To identify associated complications, data were collected prospectively and 155 consecutive catheterizations in children at a public hospital over a nearly 8-month period were analyzed. Data collected included sex, age, weight, primary diagnosis, indication for placement, presence of blood coagulation disturbance, hospital department for procedure, type of anesthesia, type of catheter (diameter, lumen number, material), site of catheterization, number of attempts, number of puncture sites, complications during puncture, the time catheter remained in place, later complications (mechanical, infectious) and reason for catheter removal. A total of 155 catheters were placed in 127 patients. There were 130 neck lines and 25 groin lines. The success rate was 81.9% at the initially chosen puncture site and rose to 100% with the inclusion of the second site. Perioperative complications occurred in nine (5.8%) cases, including six (3.9%) hematomas and three (1.9%) arterial puncture. There was no pneumothorax, hemothorax or hydrothorax. During the time the catheter remained in place, there were 51 (32.9%) complications, of which 33 (21.3%) were mechanical and 18 (11.6%) suspected catheter-related infection. These complications were responsible for the removal of the catheter. Despite the relatively high complication rate there were no catheter-related deaths. Body weight was significantly lower for children who underwent more than one puncture site (P=0.01). Age, sex, type of catheter and primary diagnosis were not associated with complications. Knowledge of anatomy and familiarity with the Seldinger technique highly increase the catheterization success rate, with few surgical complications. A better nursing care of CVC is emphasized. The available modern venous catheters at a public hospital in Brazil have contributed to improve the quality of pediatric medical care. Nowadays, the percutaneous CVC is the preferred method in pediatric patients.

Radiographic inguinal curl may indicate paraspinal misplacement of percutaneously inserted central venous catheters: report of three cases

BACKGROUND

Misplacement of percutaneously inserted central venous catheters (PCVCs) into the paraspinal venous plexus can result in devastating outcomes. Several cases have been reported in the literature together with an explanation of the mechanism.

OBJECTIVE

To describe three premature babies with their PCVCs inserted through the left saphenous vein that ended up in the lumbar spinal dural venous plexus.

RESULTS

Plain radiographs obtained to check positions showed an unusual 360 degrees curl of the PCVC in the left inguinal area.

CONCLUSION

We believe that misplacement of the catheter into the paraspinal venous plexus could be diagnosed with great accuracy if such a curl is seen.

[Vascular access in emergency paediatric anaesthesia]

There is very little literature to guide the young practitioner in caring for a child that needs emergency surgery and has difficult venous access. Questionnaires were sent to 89 members of the Swiss Paediatric Anaesthesia Society and to the heads of Anaesthesia Departments of Swiss teaching hospitals. Two typical case records were presented, both of which were characterised by the fact that 2-3 peripheral venous cannulation attempts were unsuccessful. Case A: a young child with a fracture of the radius and case B an infant with upper gastrointestinal ileus. The anaesthetists were then questioned regarding their preferences for optimal treatment. The majority would proceed with further attempts and, if these still failed, intramuscular or inhalational induction of anaesthesia was suggested as a reasonable choice for case A. However, for case B, a femoral venous or intraosseous access to the venous system was judged to be the safest method. On the basis of our inquiry and a literature search, a priority list was developed to suggest the best possible techniques for vascular access and alternative anaesthesia induction techniques for emergency paediatric procedures.

The optimal insertion length of central venous catheter via the femoral route for open-heart surgery in infants and children

BACKGROUND

The recommended insertion length of central venous (CV) catheter via the internal jugular or subclavian vein has been determined in infants and children. However, the insertion length via the femoral vein has not been well-studied. This study determined the optimal insertion length of CV catheter via the femoral vein.

METHODS

Infants and children, who had undergone cardiac catheterization via the right femoral vein, were the subjects of the study. After routine cardiac catheterization, the distance from the femoral puncture site to the third lumbar vertebral body (L3) level, was measured and recorded. The femoral-L3 length was termed as the optimal insertion length.

RESULTS

This length was measured in 78 infants and children (age: 1-101 months, weight: 3.1-33.8 kg). The body weight of the patient and the length correlated well: the optimal insertion length (cm) = 0.45 x body weight (kg) + 8.13, coefficient of determination (R2) = 0.84.

CONCLUSIONS

It has been recommended to place the tip of the catheter below the level of renal veins to avoid blocking free flow of those veins. Therefore, we chose the mid-point, L3 level as the optimal tip position of the femoral venous catheter. The length derived from the above formula could be used as a guideline for CV catheter insertion via the femoral vein in infants and children.

Clinical review: vascular access for fluid infusion in children

The current literature on venous access in infants and children for acute intravascular access in the routine situation and in emergency or intensive care settings is reviewed. The various techniques for facilitating venous cannulation, such as application of local warmth, transillumination techniques and epidermal nitroglycerine, are described. Preferred sites for central venous access in infants and children are the external and internal jugular veins, the subclavian and axillary veins, and the femoral vein. The femoral venous cannulation appears to be the most safe and reliable technique in children of all ages, with a high success and low complication rates. Evidence from the reviewed literature strongly supports the use of real-time ultrasound techniques for venous cannulation in infants and children. Additionally, in emergency situations the intraosseous access has almost completly replaced saphenous cutdown procedures in children and has decreased the need for immediate central venous access.

Central venous catheter techniques in infants and children

PURPOSE OF REVIEW

The placement of central venous catheters is often necessary to facilitate optimal anaesthetic and perioperative management or for the long-term management of chronic underlying diseases. Insertion may be a challenge in selected patients, and the risk of infection, thrombosis, and other complications may result in significant risk factors.

RECENT FINDINGS

Ultrasound visualization of the cervical veins with Valsalva manoeuvres significantly increases the rate and safety of central venous cannulation, and decreases needle passes in paediatric patients even with experienced operators. Pericardial effusion with tamponade is a more frequent phenomenon than generally realized, and accurate location of the catheter-tip position is essential. The femoral venous approach has proved to be safe even in premature babies. Clear guidelines for infection control and the prevention of intravascular catheter-related infections in children have been established; however, the high incidence of nosocomial catheter-related infections requires effective prevention strategies. The impact of antimicrobial-impregnated central venous catheters on the prevention of bloodstream infections in children is not yet clear. Routine use of prophylactic antibiosis (i.e. vancomycin) to prevent catheter-related infection cannot be recommended. Thrombolytic therapy with recombinant tissue plasminogen activator is safe, efficient, well tolerated and effective for lysis of catheter-induced intravascular and intracardiac thrombi even in neonates. Embolized catheter fragments can be retrieved in neonates and children by non-surgical interventions using standard procedures applied by paediatric cardiologists.

SUMMARY

Despite a variety of new techniques, the major problem of central venous catheterization in neonates and children remains the prevention of catheter-related infection and infection control.