Abstract
Background
Peripherally inserted central catheters (PICCs) are increasingly used in neonates but perforations can result in devastating complications such as pericardial and pleural effusions. Identifying risk factors may guide surveillance and reduce morbidity and mortality.
Objective
To determine the risk factors for PICC perforation in neonates.
Materials and methods
Retrospective case:control (1:2) study of neonates admitted between 2004-2014. Charts and imaging were reviewed for clinical and therapeutic risk factors.
Results
Among 3,454 PICCs, 15 cases of perforation (incidence 0.4%, 5 pericardial effusions, 10 pleural effusions) were matched to 30 controls, based on gestation and insertion date. Timing of perforations post-insertion was median 4 days for pericardial effusions and 21.5 days for pleural effusions. A risk factor for pericardial effusion was lower weight at PICC insertion compared with controls. There were no statistically significant differences between cases and controls in catheter material, insertion site, PICC size and lumen number. Among upper limb PICCs, pericardial effusions were associated with tip positions more proximal to the heart at insertion (P=0.005) and at perforation (P=0.008), compared with controls. Pleural effusions were associated with tip positions more distal from the heart at perforation (P=0.008). Within 48 h before perforation, high/medium risk infusions included total parenteral nutrition (100% cases vs. 56.7% controls, P=0.002) and vancomycin (60% cases vs. 23.3% controls, P=0.02).
Conclusion
PICC-associated pericardial effusions and pleural effusions are rare but inherent risks and can occur at any time after insertion. Risk factors and etiologies are multifactorial, but PICC tip position may be a modifiable risk factor. To mitigate this risk, we have developed and disseminated guidelines for target PICC positions and routinely do radiographs to monitor PICCs for migration and malposition in our NICU. The increased knowledge of risk profiles from this study has helped focus surveillance efforts and facilitate early recognition and treatment.
Similar content being viewed by others
References
Hogan M (1999) Neonatal vascular catheters and their complications. Radiol Clin North Am 37:1109–1125
Menon G (2003) Neonatal long lines. Arch Dis Child Fetal Neonatal Ed 88:F260–F262
Pettit J (2002) Assessment of infants with peripherally inserted central catheters: part 1. Detecting the most frequently occurring complications. Adv Neonatal Care 2:304–315
Camara D (2001) Minimizing risks associated with peripherally inserted central catheters in the NICU. MCN Am J Matern Child Nurs 26:17–21
Pettit J (2003) Assessment of infants with peripherally inserted central catheters: part 2. Detecting less frequently occurring complications. Adv Neonatal Care 3:14–26
Beardsall K, White DK, Pinto EM et al (2003) Pericardial effusion and cardiac tamponade as complications of neonatal long lines: are they really a problem? Arch Dis Child Fetal Neonatal Ed 88:F292–F295
Nadroo AM, Glass RB, Lin J et al (2002) Changes in upper extremity position cause migration of peripherally inserted central catheters in neonates. Pediatrics 110:131–136
Otten TR, Stein PD, Patel KC et al (2003) Thromboembolic disease involving the superior vena cava and brachiocephalic veins. Chest 123:809–812
Chopra V, Anand S, Hickner A et al (2013) Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta-analysis. Lancet 382:311–325
Department of Health (2001) Review of four neonatal deaths due to cardiac tamponade associated with the presence of a central venous catheter. HMSO, London
Nowlen TT, Rosenthal GL, Johnson GL et al (2002) Pericardial effusion and tamponade in infants with central catheters. Pediatrics 110:137–142
Booth SA, Norton B, Mulvey DA (2001) Central venous catheterization and fatal cardiac tamponade. Br J Anaesth 87:298–302
Gravenstein N, Blackshear RH (1991) In vitro evaluation of relative perforating potential of central venous catheters: comparison of materials, selected models, number of lumens and angles of incidence to simulated membrane. J Clin Monit 7:1–6
Orme RM, McSwiney MM, Chamberlain-Webber RF (2007) Fatal cardiac tamponade as a result of a peripherally inserted central venous catheter: a case report and review of the literature. Br J Anaesth 99:384–388
Clark E, Giambra BK, Hingle J et al (2013) Reducing risk of harm from extravasation: a 3-tiered evidence based list of pediatric peripheral intravenous infusates. J Infus Nurs 36:37–45
Schuster M, Nave H, Piepenbrock S et al (2000) The carina as a landmark in central venous catheter placement. Br J Anaesth 85:192–194
Baskin KM, Jimenez RM, Cahill AM et al (2008) Cavoatrial junction and central venous anatomy: implications for central venous access tip position. J Vasc Interv Radiol 19:359–365
Towbin R (2008) The bowed catheter sign: a risk for pericardial tamponade. Pediatr Radiol 38:331–335
Leipälä JA, Petäjä J, Fellman V (2001) Perforation complications of percutaneous central venous catheters in very low birthweight infants. J Paediatr Child Health 37:168–171
Soe A (2007) Central venous catheterization in newborn infants. Infantry 3:172–175
Cartwright DW (2004) Central venous lines in neonates: a study of 2186 catheters. Arch Dis Child Fetal Neonatal Ed 89:F504–F508
Pezzati M, Filippi L, Chiti G et al (2004) Central venous catheters and cardiac tamponade in preterm infants. Intensive Care Med 30:2253–2256
Madhavi P, Jameson R, Robinson MJ (2000) Unilateral pleural effusion complicating central venous catheterization. Arch Dis Child Fetal Neonatal Ed 82:F248–F249
Barbosa M, Rocha G, Flor-de-Lima F, Guimaraes H (2015) Neonatal pleural effusions in a Level III Neonatal Intensive Care Unit. JPNIM 4:e040123
Sridhar S, Thomas N, Kumar ST, Jana AK (2005) Neonatal hydrothorax following migration of a central venous catheter. Indian J Pediatr 72:795–796
Shenoy R (2008) Cardiac tamponade following central line in premature neonate: case report and review of the literature. Internet J Pediatr Neonatal 10:1–4
Shih YT, Su PH, Chen JY et al (2011) Common etiologies of neonatal pleural effusion. Pediatr Neonatol 52:251–255
Srinivasan HB, Tjin-A-Tam A, Galang R et al (2013) Migration patterns of peripherally inserted central venous catheters at 24 hours postinsertion in neonates. Am J Perinatol 30:871–874
Connolly B, Mawson JB, MacDonald CE et al (2000) Fluoroscopic landmark for SVC-RA junction for central venous catheter placement in children. Pediatr Radiol 30:692–695
Johnson ND (2012) Lower limb PICC tip target position https://www.cincinnatichildrens.org/-/media/cincinnati%2520childrens/home/service/v/vascular-access/hcp/lower%2520limb%2520picc.pdf%3Fla%3Den+&cd=1&hl=en&ct=clnk&gl=ca&client=safari. Accessed 17 Aug 2017
Johnson ND (2012) Upper limb PICC tip target position https://www.cincinnatichildrens.org/-/media/cincinnati%2520childrens/home/service/v/vascular-access/hcp/upper%2520limb%2520picc.pdf%3Fla%3Den+&cd=2&hl=en&ct=clnk&gl=ca&client=safari. Accessed 17 Aug 2017
Fletcher SJ, Bodenham AR (2000) Safe placement of central venous catheters: where should the tip of the catheter lie? Br J Anaesth 85:188–191
Wrightson DD (2013) Peripherally inserted central catheter complications in neonates with upper versus lower extremity insertion sites. Adv Neonatal Care 13:198–204
Gaballah M, Krishnamurthy G, Keller MS et al (2014) US-guided placement and tip position confirmation for lower-extremity central venous access in neonates and infants with comparison versus conventional insertion. J Vasc Interv Radiol 25:548–555
Gaballah M, Krishnamurthy G, Berman JI et al (2015) Lower extremity vascular access in neonates and infants: a single institutional experience. Vasc Interv Radiol 26:1660–1668
Nadroo AM, Lin J, Green RS et al (2001) Death as a complication of peripherally inserted central catheters in neonates. J Pediatr 138:599–601
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflicts of interest
None
Rights and permissions
About this article
Cite this article
Sertic, A.J., Connolly, B.L., Temple, M.J. et al. Perforations associated with peripherally inserted central catheters in a neonatal population. Pediatr Radiol 48, 109–119 (2018). https://doi.org/10.1007/s00247-017-3983-x
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00247-017-3983-x