574000
research-article2015
PENXXX10.1177/0148607115574000Journal of Parenteral and Enteral NutritionBlackwood et al
Case Series
Peripherally Inserted Central Catheters Complicated by Vascular Erosion in Neonates Brian P. Blackwood, MD1,2; Kathryn N. Farrow, MD, PhD1,3; Stan Kim, MD1,3; and Catherine J. Hunter, MD1,3
Journal of Parenteral and Enteral Nutrition Volume XX Number X Month 201X 1–6 © 2015 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0148607115574000 jpen.sagepub.com hosted at online.sagepub.com
Abstract Peripherally inserted central catheters (PICCs) are widely used in the pediatric population, and their use continues to grow in popularity. These catheters provide a reliable source of venous access to neonatal patients but can also be the cause of life-threatening complications. There are several well-documented complications such as infections, catheter thrombosis, vascular extravasations, and fractured catheters. However, the complication of vascular erosion into the pleural space using both small and silicone-based catheters is rarely described. After obtaining institutional review board approval, we identified 4 cases to review of PICCs complicated by vascular erosions in the past 2 years. Herein, we also review the current literature of PICC complications. Getting the catheter tip as close to the atrial-caval junction as possible and confirmation of this placement are of the utmost importance. The thick wall of the vena cava near the atrium seems to be less likely to perforate; in addition, this position provides increased volume and turbulence to help dilute the hyperosmolar fluid, which seems to also be a factor in this complication. A daily screening chest x-ray in patients with upper extremity PICCs and ongoing parenteral nutrition (PN) are not necessary at this time given the overall low rate of vascular erosion and concerns regarding excessive radiation exposure in pediatric populations. However, a low threshold for chest x-ray imaging in patients with even mild respiratory symptoms in the setting of upper extremity PN is recommended. (JPEN J Parenter Enteral Nutr. XXXX;xx:xx-xx)
Keywords parenteral nutrition; vascular access; peripherally inserted central catheter (PICC); vascular erosion; neonate
Peripherally inserted central catheters (PICCs) are widely used in pediatric populations, and their use continues to grow in popularity.1 In some institutions, PICCs are preferred to peripheral intravenous line placements. Reasons cited for preferred PICC use include a decreased number of painful procedures and needle sticks, without a significant increase in the rate of sepsis.2 In many centers, PICCs are also preferred to surgical catheter placement (ie, cut-down procedures) because of their less invasive method of placement and the fact that they are more costeffective.3 In addition, advances in image-guided placement (by ultrasounds or fluoroscopy) have improved the safety and efficiency of PICC placement, even in low-birth-weight neonates.3 Vascular erosion of PICCs is a recognized complication but rarely reported. Although the catheter material, the catheter tip position, and the composition of fluid within the catheter may contribute to the risk of erosion or complication, there is no clear consensus which factor(s) are most important. After obtaining institutional review board approval, we identified 4 cases of PICCs complicated by vascular erosions in the past 2 years. Each occurred within 1 month of catheter placement. Herein, we also review the current literature of PICC complications in the pediatric population.
Patient A Patient A is a baby girl born at 36 2/7 weeks weighing 2.64 kg, with a prenatal diagnosis of polyhydramnios and a postnatal
finding of pure long gap esophageal atresia. Her gastrostomy tube was complicated by wound infection and skin breakdown, requiring a period of gastrostomy tube rest and parental nutrition (PN). A Cook 3 Fr silicone single-lumen right brachial PICC was placed by interventional radiology and advanced to a length of 10 cm. The tip of the catheter was seen projecting into the superior vena cava (Figure 1A). The patient was started on PN with a glucose infusion rate (GIR) of 8.4 mg/kg/min with dextrose 10% at 12.4 mL/h and intralipid 20% at 0.6 mL to be advanced to a goal GIR of 11.9 mg/kg/min with dextrose
From the 1Department of Pediatric Surgery, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois; 2Department of General Surgery, Rush University Medical Center, Chicago, Illinois; and 3 Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Evanston, Illinois. Financial disclosure: Financial support provided by Children’s Research Institute Funds. Received for publication November 23, 2014; accepted for publication January 18, 2015. Corresponding Author: Catherine J. Hunter, MD, Ann and Robert H. Lurie Children’s Hospital of Chicago, 225 E Chicago Ave, Box 63, Chicago, IL 60611, USA. Email: [email protected]
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Figure 1. Patient A. (A) White arrow indicates the initial placement of the right-sided peripherally inserted central catheter. (B) Black arrow indicates the distal migration of the catheter tip. A new right-sided pleural effusion is seen.
16.5% at 11 mL/h (3 g protein/kg/d) and intralipid 20% at 2 mL/h (3.6 g fat/kg/d). Seven days after PICC placement, there was an acute clinical deterioration characterized by increased oxygen requirements and respiratory distress. A chest X-ray revealed a new large right-sided pleural effusion (Figure 1B). The position of the PICC was concerning for malposition with distal migration of the catheter, and it appeared to be the source of the effusion. Image-guided thoracentesis was performed, and approximately 55 mL of PN and lipids was aspirated. The right-sided PICC was removed, and a Cook 3 Fr single-lumen left brachial PICC was placed and advanced 10 cm. The effusion resolved, and gastrostomy feeds were restarted and advanced to goal. Two months later, the child underwent a successful primary esophageal atresia repair and has been without cardiorespiratory sequalae at 11-month follow-up.
Patient B Patient B is twin male born at 33 weeks gestational age weighing 2.0 kg. He was treated medically at an outside hospital neonatal intensive care unit for feeding intolerance and Bell’s stage IIA necrotizing enterocolitis before being discharged home. At 3 months of age, he presented to our institution with persistent nonbilious emesis and abdominal distention. X-rays revealed distended bowel (Figure 2A), and he was admitted with a presumptive diagnosis of a bowel obstruction. He failed nonsurgical management and required an exploratory laparotomy and resection of a stricture. Given the need for nutrition while awaiting return of bowel function, a Cook 3 Fr silicone single-lumen right brachial PICC was placed at bedside with ultrasound guidance and advanced to a length of 11 cm (Figure 2B). He was started on PN with a GIR of 8.3 mg/ kg/min with dextrose 10% at 8.3 mL/h and intralipid 20% at 1.0 mL/h advanced to a goal GIR of 10 mg/kg/min with
dextrose 14% at 18.5 mL/h (4 g protein/kg/d) and intralipid 20% at 3 mL/h (3.3 g fat/kg/d). Two weeks postoperatively, the patient had evidence of a postoperative bowel obstruction, necessitating a second surgery and lysis of adhesions. Although extubated postoperatively, the patient required reintubation secondary to respiratory distress. Chest x-ray revealed a new right-sided pleural effusion (Figure 2C). The PICC location appeared to have moved peripherally, when compared with imaging after insertion. Thoracentesis revealed 137 mL of white milky fluid composed of PN and lipids. A 3 Fr left femoral vein central line was then placed. The infant’s status improved, and he was successfully extubated several days later. At 6-month follow-up, he was in excellent health.
Patient C Patient C is an ex-34-week baby boy born weighing 2.1 kg with a prenatal diagnosis of gastroschisis. He remained nothing per os (NPO) as the bowel was reduced over 5 days. On his third hospital day, a Footprint 1.9 Fr single-lumen left basilic PICC was placed under ultrasound guidance and advanced to 15 cm. The catheter was malpositioned and pulled back to a length of 10 cm (Figure 3A). PN was started with a GIR of 11 mg/kg/min with dextrose 14% at 10.4 mL/h, and intralipid 20% at 1.5 mL/h was started and advanced to a goal GIR of 13 mg/kg/min with dextrose 16.5% (3.5 g protein/kg/d) and intralipid 20% at 3.0 mL/h (3.2 g fat/kg/d). The following day, the PICC was deemed to be in a suboptimal position, and interventional radiology was consulted to place a new PICC at a different site. With fluoroscopic-guidance, a 3 Fr silicone single-lumen right brachial PICC was placed to a length of 9 cm (Figure 3B). The PN fluid was continued in the new PICC, and the original PICC was removed. After complete reduction of the bowel, hours before the scheduled abdominal wall closure, the patient experienced an acute respiratory decompensation and near-code event. Chest x-ray showed bilateral whiteout and ultrasound revealed bilateral pleural effusions (Figure 3C). He was intubated and placed on the jet ventilator. A milky-appearing fluid was aspirated from both pleural cavities, which was biochemically consistent with PN and lipids. This event occurred only 3 days after the PICC was placed. Bilateral 10 Fr chest tubes were placed, with resolution of the tension hydrothorax (Figure 3D). The PICC line was discontinued. Three days after this acute event, his abdominal wall defect was closed. The patient was advanced slowly on feeds and was doing well at 3-month follow-up.
Patient D Patient D is a female twin, born at 24 weeks gestation weighing 630 g. At 1 week of life, the infant was transferred to our institution with a presumptive diagnosis of necrotizing enterocolitis. The patient was started on intravenous antibiotics and made NPO. A PICC was then placed for vascular access.
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Figure 2. Patient B. (A) Distended bowel concerning for obstruction. (B) White arrow indicates initial placement of the rightsided peripherally inserted central catheter. (C) Black arrow indicates distal migration of the catheter tip. A new right-sided pleural effusion is seen.
Figure 3. Patient C. (A) White arrow indicates initial placement of left peripherally inserted central catheter (PICC) after adjustment. (B) Initial placement of right PICC. (C) Black arrow indicates distal migration of the catheter, bilateral pleural effusions. (D) Chest tube placement for pleural effusions.
Figure 4. Patient D. (A) White arrow indicates initial placement of the right-sided peripherally inserted central catheter. (B) Black arrow indicates distal migration of the catheter tip. New rightsided pleural effusion is seen.
A Footprint 1.9 Fr silicone single-lumen right cephalic PICC was placed at bedside after a failed initial attempt at the left basilic site. The final catheter length was 7.75 cm (Figure 4a). The fluids infused into the catheter were GIR of 11 mg/kg/min with dextrose 11% at 3.8 mL/h and intralipid 20% at 0.15 mL/h
and advanced to a goal GIR of 13 mg/kg/min with dextrose 14% at 3.5 mL/min/d (4 g protein/kg/d) and intralipid 20% at 0.4 mL/h (3 g fat/kg/d). Twenty-six days after the PICC was placed, the patient was noted to have increasing respiratory requirements. A chest X-ray was obtained that showed a new right-sided pleural effusion and stable positioning of the right-sided PICC (Figure 4B). A right thoracentesis aspirated 40 mL of milky fluid. PN was discontinued through the PICC, and a tunneled 2.7 Fr Broviac catheter was placed by surgical cut-down. She tolerated the procedure well, and PN was resumed. After resolution of clinical necrotizing enterocolitis, enteral feeds were restarted and advanced slowly without complication. The patient was discharged and doing well at 2 months of age.
Discussion PICCs have become an essential component in the armamentarium of devices used to care for premature infants. They provide a reliable source of venous access in these fragile patients, allowing reliable access for intravenous therapy and nutrition,
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as well as limiting the need for peripheral needle sticks. As with all venous access devices, PICCs have complications associated with their placement and use. These include infections, catheter thrombosis, extravasation, catheter malposition, fractured catheters, pleural effusions, cardiac tamponade, and death.4 While vascular erosion and extravasation are reported, such complications in smaller softer catheters are less common and the mechanism of injury ill-defined. A recent study by Gibson et al1 showed an increase in PICC usage over the past 10 years. A separate study looked at 279 PICCs and noted a complication rate of 11.9/1000 PICC days.5 In another review of 441 PICCs, 129 (29%) required discontinuation secondary to the development of complications. The most common complications reported were accidental dislodgement (8%), suspected infection (8%), and occlusion (7%).6 A study of 139 PICCs placed in 124 infants found a slightly higher rate of occlusion at 12.7% and also found dislodgement to be a rare complication.7 Research focusing on PICC outcomes has examined patient characteristics, catheter site location, catheter tip position, and characteristics of the catheter itself. Although younger children are reported to be at greater risk of PICC complications,8 studies specific to the neonatal population have found no difference in complication rates in low-birth-weight patients versus verylow-birth-weight patients.9 In our series, all patients were premature and all 4 were low birth weight, suggesting that, indeed, low-birth-weight neonates may be at a higher risk for PICC vascular erosion as compared with those neonates who are not low birth weight. It has been postulated that the site of catheter insertion may correlate with complication type and rate. A review of 559 neonates with 626 PICC lines, in which 374 were in the upper extremity and 252 were in the lower extremity, found no significant difference in complications requiring PICC removal based on location.4 Very-low-birth-weight patients with PICCs placed at a femoral site have significantly higher rates of catheterrelated sepsis than those with nonfemoral PICCs, suggesting that catheter site is important at least with regard to the incidence of line sepsis.10 However, it has been shown that these catheter-related bloodstream infections in very-low-birthweight patients can be reduced simply by having a dedicated PICC team and standardized PICC maintenance.11 Given that the vascular erosion of the PICCs in our case series all occurred with upper extremity catheters, the use of a lower extremity site, when feasible, could help avoid this complication. The upper extremity catheters are recommended to have the tip placed centrally at the atrial-caval junction, but this can often be difficult to achieve.12 Upper extremity PICCs have been shown to be more likely to have a noncentral catheter tip,4 and noncentral catheter tips are associated with higher rates of infiltration and mechanical obstruction as compared with those that are centrally placed.13 Specifically, catheters in the midclavicular region have higher rates of complication. This suggests that infiltration is more likely to occur when the catheter
tip is located more distally in the superior vena cava, perhaps as a result of the hyperosmolar fluid being run into a more thinwalled vessel. All 4 patients in our series had catheter tips that were located distal to the atrial-caval junction at the time of vessel erosion. Placing the catheter tips as close to the right atrium as possible and ensuring that they remain there could potentially solve this problem as the wall of the vena cava is much thicker there and would be less likely to erode. Arm movements in the neonate may significantly change the catheter tip position in upper extremity PICCs, based on findings from a study of 280 radiographs from 60 neonates.14 In our series, 3 of the 4 patients were awake and active during the time period from PICC placement leading up to the vascular erosion. We postulate that arm movements may have played a role in catheter tip movement and migration, perhaps contributing to erosion. Catheter characteristics, including size and composition, may also play a role in PICC complications, and these factors have been studied as well. As expected, the size of the catheter affects occlusion rates, with smaller catheter lumens being more prone to blockage. Specifically, 2-French catheters have a reported occlusion rate of 11% as compared with 3-French catheters, which have a rate of 4%.6 However, there is no correlation between catheter size and vascular erosion. Even the smallest, most pliable catheters have been shown to have complications of vascular erosion.13,15 As seen in our case series, 1 patient had a catheter erosion with a 1.9 Fr catheter. A significant difference has been shown between cuffed and uncuffed central lines. Cuffed catheters provide longer durability and lower rates of infection, malposition, and thrombosis when compared with uncuffed PICC lines.16 In a study of 1650 PICC lines, the complication of PICC fracturing was examined. Eleven patients were found to have catheter fractures that required interventional radiology procedures to retrieve catheter fragments. They found that catheter insertion site, size, and infused material were not significant predisposing factors for catheter fracture.17 While erosion does not appear to be limited to a single type of vascular catheter, the material from which the catheter is made may contribute to this complication. In a small retrospective study, 11 neonates developed catheter erosion, 6 of which resulted in death. Erosion was more common in patients with polyethylene catheters versus other catheter composition, such as the silicone catheters seen in our series.18 Hyperosmolar solutions have been postulated to be potentially more harmful and contributory to vascular erosion; however, based on current data, there is not enough evidence to recommend a cutoff in osmolarity for peripheral or central PN.19 Of note, all 4 patients in our case series were receiving infusions of hyperosmolar fluid, which may have played a role in the complications described. As mentioned previously, the vascular erosion could be secondary to the concentrated hyperosmolar fluid being directed toward a more thin-walled section of the superior vena cava. Placement of the catheter tip closer to the right atrium could potentially help solve this problem as
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Table 1. Summary of Patients. Gestational Age at Birth
Age at Complication
Birth Weight
Catheter
Catheter Material
36 2/7 wk 33 weeks 34 wk 24 wk
10 d 3 mo 6d 37 d
2.64 kg 2.0 kg 2.1 kg 630 g
Cook 3 Fr single lumen Cook 3 Fr single lumen 3 Fr single lumen Footprint 1.9 Fr single lumen
Silicone Silicone Silicone Silicone
Patient
Insertion Site
Infusion Material
Cathether Days to Complication
Complication
Tip Position at Complication
A B C D
Right brachial Right brachial Right brachial Right cephalic
D10, IL 20% D14, IL 20% D14, IL 20% D11, IL 20%
7 14 3 26
Patient A B C D
Right pleural effusion Right pleural effusion Bilateral pleural effusion Right pleural effusion
Right subclavian Right subclavian Right subclavian Right subclavian
D10, dextrose 10%; D11, dextrose 11%; D14, dextrose 14%; IL, intralipid.
the vena cava is thicker here. Also, the increased volume and turbulence as blood enters the atrium could help disperse the hyperosmolar fluid. Erosion events can also involve the pericardium and the abdomen.20 There are 6 cases reported of pericardial effusion as a result of PICC vascular erosion, all of which resulted in death.18 In another study, 2 patients were found to have pericardial effusions from PICCs, and both died after developing bradycardia and hypotension. Autopsy revealed PN in the pericardial sac in both patients.21 Although exceedingly rare, cardiac perforation has also been reported.22 And in a report of 4 PICC-related erosions in which hydrothorax or hydroperitoneum occurred after 48 hours, all catheter tips were noted to have had changed position from a prior x-ray.23 This again highlights the crucial role of maintaining the optimal catheter tip position in the care and safety of PICCs.
Conclusion PICCs play a major role in the care of neonatal patients, and the number of lines placed is likely to continue to increase with time. PICCs provide a reliable source of venous access to neonatal patients but can also be the cause of life-threatening complications. There are several well-documented complications such as infections, catheter thrombosis, vascular extravasations, and fractured catheters. However, the complication of vascular erosion into the pleural space using both small and silicone-based catheters is rarely described. These silicone-based catheters are typically soft and pliable, making erosion secondary to pressure seem unlikely. In addition, the smaller the PICCs, the more flexible they tend to be and one would think less likely to perforate. However, catheters as small as 1.9 Fr have been shown to have this complication. Ensuring optimal catheter tip placement prior to initiation of PN appears crucial, as well as limiting PICC movement after placement. Getting the catheter tip as close to the atrial-caval
junction as possible and confirmation of this placement are of the utmost importance. The thick wall of the vena cava near the atrium seems to be less likely to perforate; in addition, this position provides increased volume and turbulence to help dilute the hyperosmolar fluid, which seems to also be a factor in this complication. For the same reasons, the use of a lower extremity PICC site could also help decrease the incidence of this complication, but use of a dedicated PICC team and standardized PICC maintenance are crucial in preventing catheter-related sepsis associated with the lower extremity site. Physicians should be very vigilant of the position of these catheters. Daily screening chest x-ray in patients with upper extremity PICCs and ongoing PN is not necessary at this time given the overall low rate of vascular erosion and concerns regarding excessive radiation exposure in pediatric populations. However, there should be a low threshold for chest x-ray imaging in patients with even mild respiratory symptoms in the setting of upper extremity PN. A summary of the patients described in our series may be referenced in Table 1.
Acknowledgments Thank you to Dr Walter J. Chwals for comments and insight into the preparation of this article.
References 1. Gibson C, Connolly BL, Moineddin R, Mahant S, Filipescu D, Amaral JG. Peripherally inserted central catheters: use at a tertiary care pediatric center. J Vasc Interv Radiol. 2013:24:1323-1331. 2. Janes M, Kalyn A, Pinelli J, Paes B. A randomized trial comparing peripherally inserted central venous catheters and peripheral intravenous catheters in infants with very low birth weight. J Pediatr Surg. 2000:35:1040-1044. 3. Arul GS, Livingstone H, Bromley P, Bennett J. Ultrasound-guided percutaneous insertion of 2.7 Fr tunnelled Broviac lines in neonates and small infants. Pediatr Surg Int. 2010;26:815-818.
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4. Wrightson DD. Peripherally inserted central catheter complications in neonates with upper versus lower extremity insertion sites. Adv Neonatal Care. 2013;13:198-204. 5. Levy I, Bendet M, Samra Z, Shalit I, Katz J. Infectious complications of peripherally inserted central venous catheters in children. Pediatr Infect Dis J. 2010;29:426-429. 6. Thiagarajan RR, Ramamoorthy C, Gettmann T, Bratton SL. Survey of the use of peripherally inserted central venous catheters in children. J Pediatr. 1997;99:E4. 7. Bulbul A, Okan F, Nuhoglu A. Percutaneously inserted central catheters in the newborns: a center’s experience in Turkey. J Matern Fetal Neonat Med. 2010;23:529-535. 8. Barrier A, Williams DJ, Connelly M, Creech CB. Frequency of peripherally inserted central catheter complications in children. Pediatr Infect Dis J. 2013;31:519-521. 9. Ozkiraz S, Gokmen Z, Anuk Ince D, et al. Peripherally inserted central venous catheters in critically ill premature neonates. J Vasc Access. 2013;14:320-324. 10. Tsai MH, Chu SM, Lien R, et al. Complications associated with 2 different types of percutaneously inserted central venous catheters in very low birth weight infants. Infect Control Hosp Epidemiol. 2011;32:258-266. 11. Taylor T, Massaro A, Williams L, et al. Effect of a dedicated percutaneously inserted central catheter team on neonatal catheter-related bloodstream infection. Adv Neonatal Care. 2011;11:122-128. 12. Oliver G, Jones M. Evaluation of an electrocardiograph-based PICC tip verification system. Br J Nurs. 2013;22:S24-S28. 13. Jain A, Deshpande P, Shah P. Peripherally inserted central catheter tip position and risk of associated complications in neonates. J Perinatol. 2013;33:307-312.
14. Nadroo AM, Glass RB, Lin J, Green RS, Holzman IR. Changes in upper extremity position cause migration of peripherally inserted central catheters in neonates. J Pediatr. 2002;110:131-136. 15. Evans M, Lentsch D. Percutaneously inserted polyurethane central catheters in the NICU: one unit’s experience. Neonatal Netw. 1999;18:37-46. 16. Toh LM, Mavili E, Moineddin R, et al. Are cuffed peripherally inserted central catheters superior to uncuffed peripherally inserted central catheters? A retrospective review in a tertiary pediatric center. J Vasc Interv Radiol. 2013;24:1316-1322. 17. Chow LM, Friedman JN, Macarthur C, et al. Peripherally inserted central catheter (PICC) fracture and embolization in the pediatric population. J Pediatr. 2003;142:141-144. 18. Keeney SE, Richardson CJ. Extravascular extravasation of fluid as a complication of central venous lines in the neonate. J Perinatol. 1995;15: 284-288. 19. Pittiruti M, Hamilton H, Biffi R, MacFie J, Pertkiewicz M; ESPEN. ESPEN guidelines on parenteral nutrition: central venous catheters (access, care, diagnosis and therapy of complications). Clin Nutr. 2009;28:365-377. 20. Meeks SL, Ciambotti JM, Rodgers BM, Gordon PV. Extravasation of hyperalimentation into the liver parenchyma from a peripherally inserted central catheter. J Pediatr Surg. 2003;38:E8. 21. Nadroo AM, Lin J, Green RS, Magid MS, Holzman IR. Death as a complication of peripherally inserted central catheters in neonates. J Pediatr. 2001;138:599-601. 22. Beardsall K, White DK, Pinto EM, Kelsall AW. Pericardial effusion and cardiac tamponade as complications of neonatal long lines: are they really a problem? Arch Dis Child Fetal Neonatal. 2003;88:F292-F295. 23. Krasna IH, Krause T. Life-threatening fluid extravasation of central venous catheters. J Pediatr Surg. 1991;26:1346-1348.
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research-article2015
PENXXX10.1177/0148607115574000Journal of Parenteral and Enteral NutritionBlackwood et al
Case Series
Peripherally Inserted Central Catheters Complicated by Vascular Erosion in Neonates Brian P. Blackwood, MD1,2; Kathryn N. Farrow, MD, PhD1,3; Stan Kim, MD1,3; and Catherine J. Hunter, MD1,3
Journal of Parenteral and Enteral Nutrition Volume XX Number X Month 201X 1–6 © 2015 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0148607115574000 jpen.sagepub.com hosted at online.sagepub.com
Abstract Peripherally inserted central catheters (PICCs) are widely used in the pediatric population, and their use continues to grow in popularity. These catheters provide a reliable source of venous access to neonatal patients but can also be the cause of life-threatening complications. There are several well-documented complications such as infections, catheter thrombosis, vascular extravasations, and fractured catheters. However, the complication of vascular erosion into the pleural space using both small and silicone-based catheters is rarely described. After obtaining institutional review board approval, we identified 4 cases to review of PICCs complicated by vascular erosions in the past 2 years. Herein, we also review the current literature of PICC complications. Getting the catheter tip as close to the atrial-caval junction as possible and confirmation of this placement are of the utmost importance. The thick wall of the vena cava near the atrium seems to be less likely to perforate; in addition, this position provides increased volume and turbulence to help dilute the hyperosmolar fluid, which seems to also be a factor in this complication. A daily screening chest x-ray in patients with upper extremity PICCs and ongoing parenteral nutrition (PN) are not necessary at this time given the overall low rate of vascular erosion and concerns regarding excessive radiation exposure in pediatric populations. However, a low threshold for chest x-ray imaging in patients with even mild respiratory symptoms in the setting of upper extremity PN is recommended. (JPEN J Parenter Enteral Nutr. XXXX;xx:xx-xx)
Keywords parenteral nutrition; vascular access; peripherally inserted central catheter (PICC); vascular erosion; neonate
Peripherally inserted central catheters (PICCs) are widely used in pediatric populations, and their use continues to grow in popularity.1 In some institutions, PICCs are preferred to peripheral intravenous line placements. Reasons cited for preferred PICC use include a decreased number of painful procedures and needle sticks, without a significant increase in the rate of sepsis.2 In many centers, PICCs are also preferred to surgical catheter placement (ie, cut-down procedures) because of their less invasive method of placement and the fact that they are more costeffective.3 In addition, advances in image-guided placement (by ultrasounds or fluoroscopy) have improved the safety and efficiency of PICC placement, even in low-birth-weight neonates.3 Vascular erosion of PICCs is a recognized complication but rarely reported. Although the catheter material, the catheter tip position, and the composition of fluid within the catheter may contribute to the risk of erosion or complication, there is no clear consensus which factor(s) are most important. After obtaining institutional review board approval, we identified 4 cases of PICCs complicated by vascular erosions in the past 2 years. Each occurred within 1 month of catheter placement. Herein, we also review the current literature of PICC complications in the pediatric population.
Patient A Patient A is a baby girl born at 36 2/7 weeks weighing 2.64 kg, with a prenatal diagnosis of polyhydramnios and a postnatal
finding of pure long gap esophageal atresia. Her gastrostomy tube was complicated by wound infection and skin breakdown, requiring a period of gastrostomy tube rest and parental nutrition (PN). A Cook 3 Fr silicone single-lumen right brachial PICC was placed by interventional radiology and advanced to a length of 10 cm. The tip of the catheter was seen projecting into the superior vena cava (Figure 1A). The patient was started on PN with a glucose infusion rate (GIR) of 8.4 mg/kg/min with dextrose 10% at 12.4 mL/h and intralipid 20% at 0.6 mL to be advanced to a goal GIR of 11.9 mg/kg/min with dextrose
From the 1Department of Pediatric Surgery, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois; 2Department of General Surgery, Rush University Medical Center, Chicago, Illinois; and 3 Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Evanston, Illinois. Financial disclosure: Financial support provided by Children’s Research Institute Funds. Received for publication November 23, 2014; accepted for publication January 18, 2015. Corresponding Author: Catherine J. Hunter, MD, Ann and Robert H. Lurie Children’s Hospital of Chicago, 225 E Chicago Ave, Box 63, Chicago, IL 60611, USA. Email: [email protected]
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Journal of Parenteral and Enteral Nutrition XX(X)
Figure 1. Patient A. (A) White arrow indicates the initial placement of the right-sided peripherally inserted central catheter. (B) Black arrow indicates the distal migration of the catheter tip. A new right-sided pleural effusion is seen.
16.5% at 11 mL/h (3 g protein/kg/d) and intralipid 20% at 2 mL/h (3.6 g fat/kg/d). Seven days after PICC placement, there was an acute clinical deterioration characterized by increased oxygen requirements and respiratory distress. A chest X-ray revealed a new large right-sided pleural effusion (Figure 1B). The position of the PICC was concerning for malposition with distal migration of the catheter, and it appeared to be the source of the effusion. Image-guided thoracentesis was performed, and approximately 55 mL of PN and lipids was aspirated. The right-sided PICC was removed, and a Cook 3 Fr single-lumen left brachial PICC was placed and advanced 10 cm. The effusion resolved, and gastrostomy feeds were restarted and advanced to goal. Two months later, the child underwent a successful primary esophageal atresia repair and has been without cardiorespiratory sequalae at 11-month follow-up.
Patient B Patient B is twin male born at 33 weeks gestational age weighing 2.0 kg. He was treated medically at an outside hospital neonatal intensive care unit for feeding intolerance and Bell’s stage IIA necrotizing enterocolitis before being discharged home. At 3 months of age, he presented to our institution with persistent nonbilious emesis and abdominal distention. X-rays revealed distended bowel (Figure 2A), and he was admitted with a presumptive diagnosis of a bowel obstruction. He failed nonsurgical management and required an exploratory laparotomy and resection of a stricture. Given the need for nutrition while awaiting return of bowel function, a Cook 3 Fr silicone single-lumen right brachial PICC was placed at bedside with ultrasound guidance and advanced to a length of 11 cm (Figure 2B). He was started on PN with a GIR of 8.3 mg/ kg/min with dextrose 10% at 8.3 mL/h and intralipid 20% at 1.0 mL/h advanced to a goal GIR of 10 mg/kg/min with
dextrose 14% at 18.5 mL/h (4 g protein/kg/d) and intralipid 20% at 3 mL/h (3.3 g fat/kg/d). Two weeks postoperatively, the patient had evidence of a postoperative bowel obstruction, necessitating a second surgery and lysis of adhesions. Although extubated postoperatively, the patient required reintubation secondary to respiratory distress. Chest x-ray revealed a new right-sided pleural effusion (Figure 2C). The PICC location appeared to have moved peripherally, when compared with imaging after insertion. Thoracentesis revealed 137 mL of white milky fluid composed of PN and lipids. A 3 Fr left femoral vein central line was then placed. The infant’s status improved, and he was successfully extubated several days later. At 6-month follow-up, he was in excellent health.
Patient C Patient C is an ex-34-week baby boy born weighing 2.1 kg with a prenatal diagnosis of gastroschisis. He remained nothing per os (NPO) as the bowel was reduced over 5 days. On his third hospital day, a Footprint 1.9 Fr single-lumen left basilic PICC was placed under ultrasound guidance and advanced to 15 cm. The catheter was malpositioned and pulled back to a length of 10 cm (Figure 3A). PN was started with a GIR of 11 mg/kg/min with dextrose 14% at 10.4 mL/h, and intralipid 20% at 1.5 mL/h was started and advanced to a goal GIR of 13 mg/kg/min with dextrose 16.5% (3.5 g protein/kg/d) and intralipid 20% at 3.0 mL/h (3.2 g fat/kg/d). The following day, the PICC was deemed to be in a suboptimal position, and interventional radiology was consulted to place a new PICC at a different site. With fluoroscopic-guidance, a 3 Fr silicone single-lumen right brachial PICC was placed to a length of 9 cm (Figure 3B). The PN fluid was continued in the new PICC, and the original PICC was removed. After complete reduction of the bowel, hours before the scheduled abdominal wall closure, the patient experienced an acute respiratory decompensation and near-code event. Chest x-ray showed bilateral whiteout and ultrasound revealed bilateral pleural effusions (Figure 3C). He was intubated and placed on the jet ventilator. A milky-appearing fluid was aspirated from both pleural cavities, which was biochemically consistent with PN and lipids. This event occurred only 3 days after the PICC was placed. Bilateral 10 Fr chest tubes were placed, with resolution of the tension hydrothorax (Figure 3D). The PICC line was discontinued. Three days after this acute event, his abdominal wall defect was closed. The patient was advanced slowly on feeds and was doing well at 3-month follow-up.
Patient D Patient D is a female twin, born at 24 weeks gestation weighing 630 g. At 1 week of life, the infant was transferred to our institution with a presumptive diagnosis of necrotizing enterocolitis. The patient was started on intravenous antibiotics and made NPO. A PICC was then placed for vascular access.
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Figure 2. Patient B. (A) Distended bowel concerning for obstruction. (B) White arrow indicates initial placement of the rightsided peripherally inserted central catheter. (C) Black arrow indicates distal migration of the catheter tip. A new right-sided pleural effusion is seen.
Figure 3. Patient C. (A) White arrow indicates initial placement of left peripherally inserted central catheter (PICC) after adjustment. (B) Initial placement of right PICC. (C) Black arrow indicates distal migration of the catheter, bilateral pleural effusions. (D) Chest tube placement for pleural effusions.
Figure 4. Patient D. (A) White arrow indicates initial placement of the right-sided peripherally inserted central catheter. (B) Black arrow indicates distal migration of the catheter tip. New rightsided pleural effusion is seen.
A Footprint 1.9 Fr silicone single-lumen right cephalic PICC was placed at bedside after a failed initial attempt at the left basilic site. The final catheter length was 7.75 cm (Figure 4a). The fluids infused into the catheter were GIR of 11 mg/kg/min with dextrose 11% at 3.8 mL/h and intralipid 20% at 0.15 mL/h
and advanced to a goal GIR of 13 mg/kg/min with dextrose 14% at 3.5 mL/min/d (4 g protein/kg/d) and intralipid 20% at 0.4 mL/h (3 g fat/kg/d). Twenty-six days after the PICC was placed, the patient was noted to have increasing respiratory requirements. A chest X-ray was obtained that showed a new right-sided pleural effusion and stable positioning of the right-sided PICC (Figure 4B). A right thoracentesis aspirated 40 mL of milky fluid. PN was discontinued through the PICC, and a tunneled 2.7 Fr Broviac catheter was placed by surgical cut-down. She tolerated the procedure well, and PN was resumed. After resolution of clinical necrotizing enterocolitis, enteral feeds were restarted and advanced slowly without complication. The patient was discharged and doing well at 2 months of age.
Discussion PICCs have become an essential component in the armamentarium of devices used to care for premature infants. They provide a reliable source of venous access in these fragile patients, allowing reliable access for intravenous therapy and nutrition,
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as well as limiting the need for peripheral needle sticks. As with all venous access devices, PICCs have complications associated with their placement and use. These include infections, catheter thrombosis, extravasation, catheter malposition, fractured catheters, pleural effusions, cardiac tamponade, and death.4 While vascular erosion and extravasation are reported, such complications in smaller softer catheters are less common and the mechanism of injury ill-defined. A recent study by Gibson et al1 showed an increase in PICC usage over the past 10 years. A separate study looked at 279 PICCs and noted a complication rate of 11.9/1000 PICC days.5 In another review of 441 PICCs, 129 (29%) required discontinuation secondary to the development of complications. The most common complications reported were accidental dislodgement (8%), suspected infection (8%), and occlusion (7%).6 A study of 139 PICCs placed in 124 infants found a slightly higher rate of occlusion at 12.7% and also found dislodgement to be a rare complication.7 Research focusing on PICC outcomes has examined patient characteristics, catheter site location, catheter tip position, and characteristics of the catheter itself. Although younger children are reported to be at greater risk of PICC complications,8 studies specific to the neonatal population have found no difference in complication rates in low-birth-weight patients versus verylow-birth-weight patients.9 In our series, all patients were premature and all 4 were low birth weight, suggesting that, indeed, low-birth-weight neonates may be at a higher risk for PICC vascular erosion as compared with those neonates who are not low birth weight. It has been postulated that the site of catheter insertion may correlate with complication type and rate. A review of 559 neonates with 626 PICC lines, in which 374 were in the upper extremity and 252 were in the lower extremity, found no significant difference in complications requiring PICC removal based on location.4 Very-low-birth-weight patients with PICCs placed at a femoral site have significantly higher rates of catheterrelated sepsis than those with nonfemoral PICCs, suggesting that catheter site is important at least with regard to the incidence of line sepsis.10 However, it has been shown that these catheter-related bloodstream infections in very-low-birthweight patients can be reduced simply by having a dedicated PICC team and standardized PICC maintenance.11 Given that the vascular erosion of the PICCs in our case series all occurred with upper extremity catheters, the use of a lower extremity site, when feasible, could help avoid this complication. The upper extremity catheters are recommended to have the tip placed centrally at the atrial-caval junction, but this can often be difficult to achieve.12 Upper extremity PICCs have been shown to be more likely to have a noncentral catheter tip,4 and noncentral catheter tips are associated with higher rates of infiltration and mechanical obstruction as compared with those that are centrally placed.13 Specifically, catheters in the midclavicular region have higher rates of complication. This suggests that infiltration is more likely to occur when the catheter
tip is located more distally in the superior vena cava, perhaps as a result of the hyperosmolar fluid being run into a more thinwalled vessel. All 4 patients in our series had catheter tips that were located distal to the atrial-caval junction at the time of vessel erosion. Placing the catheter tips as close to the right atrium as possible and ensuring that they remain there could potentially solve this problem as the wall of the vena cava is much thicker there and would be less likely to erode. Arm movements in the neonate may significantly change the catheter tip position in upper extremity PICCs, based on findings from a study of 280 radiographs from 60 neonates.14 In our series, 3 of the 4 patients were awake and active during the time period from PICC placement leading up to the vascular erosion. We postulate that arm movements may have played a role in catheter tip movement and migration, perhaps contributing to erosion. Catheter characteristics, including size and composition, may also play a role in PICC complications, and these factors have been studied as well. As expected, the size of the catheter affects occlusion rates, with smaller catheter lumens being more prone to blockage. Specifically, 2-French catheters have a reported occlusion rate of 11% as compared with 3-French catheters, which have a rate of 4%.6 However, there is no correlation between catheter size and vascular erosion. Even the smallest, most pliable catheters have been shown to have complications of vascular erosion.13,15 As seen in our case series, 1 patient had a catheter erosion with a 1.9 Fr catheter. A significant difference has been shown between cuffed and uncuffed central lines. Cuffed catheters provide longer durability and lower rates of infection, malposition, and thrombosis when compared with uncuffed PICC lines.16 In a study of 1650 PICC lines, the complication of PICC fracturing was examined. Eleven patients were found to have catheter fractures that required interventional radiology procedures to retrieve catheter fragments. They found that catheter insertion site, size, and infused material were not significant predisposing factors for catheter fracture.17 While erosion does not appear to be limited to a single type of vascular catheter, the material from which the catheter is made may contribute to this complication. In a small retrospective study, 11 neonates developed catheter erosion, 6 of which resulted in death. Erosion was more common in patients with polyethylene catheters versus other catheter composition, such as the silicone catheters seen in our series.18 Hyperosmolar solutions have been postulated to be potentially more harmful and contributory to vascular erosion; however, based on current data, there is not enough evidence to recommend a cutoff in osmolarity for peripheral or central PN.19 Of note, all 4 patients in our case series were receiving infusions of hyperosmolar fluid, which may have played a role in the complications described. As mentioned previously, the vascular erosion could be secondary to the concentrated hyperosmolar fluid being directed toward a more thin-walled section of the superior vena cava. Placement of the catheter tip closer to the right atrium could potentially help solve this problem as
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Table 1. Summary of Patients. Gestational Age at Birth
Age at Complication
Birth Weight
Catheter
Catheter Material
36 2/7 wk 33 weeks 34 wk 24 wk
10 d 3 mo 6d 37 d
2.64 kg 2.0 kg 2.1 kg 630 g
Cook 3 Fr single lumen Cook 3 Fr single lumen 3 Fr single lumen Footprint 1.9 Fr single lumen
Silicone Silicone Silicone Silicone
Patient
Insertion Site
Infusion Material
Cathether Days to Complication
Complication
Tip Position at Complication
A B C D
Right brachial Right brachial Right brachial Right cephalic
D10, IL 20% D14, IL 20% D14, IL 20% D11, IL 20%
7 14 3 26
Patient A B C D
Right pleural effusion Right pleural effusion Bilateral pleural effusion Right pleural effusion
Right subclavian Right subclavian Right subclavian Right subclavian
D10, dextrose 10%; D11, dextrose 11%; D14, dextrose 14%; IL, intralipid.
the vena cava is thicker here. Also, the increased volume and turbulence as blood enters the atrium could help disperse the hyperosmolar fluid. Erosion events can also involve the pericardium and the abdomen.20 There are 6 cases reported of pericardial effusion as a result of PICC vascular erosion, all of which resulted in death.18 In another study, 2 patients were found to have pericardial effusions from PICCs, and both died after developing bradycardia and hypotension. Autopsy revealed PN in the pericardial sac in both patients.21 Although exceedingly rare, cardiac perforation has also been reported.22 And in a report of 4 PICC-related erosions in which hydrothorax or hydroperitoneum occurred after 48 hours, all catheter tips were noted to have had changed position from a prior x-ray.23 This again highlights the crucial role of maintaining the optimal catheter tip position in the care and safety of PICCs.
Conclusion PICCs play a major role in the care of neonatal patients, and the number of lines placed is likely to continue to increase with time. PICCs provide a reliable source of venous access to neonatal patients but can also be the cause of life-threatening complications. There are several well-documented complications such as infections, catheter thrombosis, vascular extravasations, and fractured catheters. However, the complication of vascular erosion into the pleural space using both small and silicone-based catheters is rarely described. These silicone-based catheters are typically soft and pliable, making erosion secondary to pressure seem unlikely. In addition, the smaller the PICCs, the more flexible they tend to be and one would think less likely to perforate. However, catheters as small as 1.9 Fr have been shown to have this complication. Ensuring optimal catheter tip placement prior to initiation of PN appears crucial, as well as limiting PICC movement after placement. Getting the catheter tip as close to the atrial-caval
junction as possible and confirmation of this placement are of the utmost importance. The thick wall of the vena cava near the atrium seems to be less likely to perforate; in addition, this position provides increased volume and turbulence to help dilute the hyperosmolar fluid, which seems to also be a factor in this complication. For the same reasons, the use of a lower extremity PICC site could also help decrease the incidence of this complication, but use of a dedicated PICC team and standardized PICC maintenance are crucial in preventing catheter-related sepsis associated with the lower extremity site. Physicians should be very vigilant of the position of these catheters. Daily screening chest x-ray in patients with upper extremity PICCs and ongoing PN is not necessary at this time given the overall low rate of vascular erosion and concerns regarding excessive radiation exposure in pediatric populations. However, there should be a low threshold for chest x-ray imaging in patients with even mild respiratory symptoms in the setting of upper extremity PN. A summary of the patients described in our series may be referenced in Table 1.
Acknowledgments Thank you to Dr Walter J. Chwals for comments and insight into the preparation of this article.
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4. Wrightson DD. Peripherally inserted central catheter complications in neonates with upper versus lower extremity insertion sites. Adv Neonatal Care. 2013;13:198-204. 5. Levy I, Bendet M, Samra Z, Shalit I, Katz J. Infectious complications of peripherally inserted central venous catheters in children. Pediatr Infect Dis J. 2010;29:426-429. 6. Thiagarajan RR, Ramamoorthy C, Gettmann T, Bratton SL. Survey of the use of peripherally inserted central venous catheters in children. J Pediatr. 1997;99:E4. 7. Bulbul A, Okan F, Nuhoglu A. Percutaneously inserted central catheters in the newborns: a center’s experience in Turkey. J Matern Fetal Neonat Med. 2010;23:529-535. 8. Barrier A, Williams DJ, Connelly M, Creech CB. Frequency of peripherally inserted central catheter complications in children. Pediatr Infect Dis J. 2013;31:519-521. 9. Ozkiraz S, Gokmen Z, Anuk Ince D, et al. Peripherally inserted central venous catheters in critically ill premature neonates. J Vasc Access. 2013;14:320-324. 10. Tsai MH, Chu SM, Lien R, et al. Complications associated with 2 different types of percutaneously inserted central venous catheters in very low birth weight infants. Infect Control Hosp Epidemiol. 2011;32:258-266. 11. Taylor T, Massaro A, Williams L, et al. Effect of a dedicated percutaneously inserted central catheter team on neonatal catheter-related bloodstream infection. Adv Neonatal Care. 2011;11:122-128. 12. Oliver G, Jones M. Evaluation of an electrocardiograph-based PICC tip verification system. Br J Nurs. 2013;22:S24-S28. 13. Jain A, Deshpande P, Shah P. Peripherally inserted central catheter tip position and risk of associated complications in neonates. J Perinatol. 2013;33:307-312.
14. Nadroo AM, Glass RB, Lin J, Green RS, Holzman IR. Changes in upper extremity position cause migration of peripherally inserted central catheters in neonates. J Pediatr. 2002;110:131-136. 15. Evans M, Lentsch D. Percutaneously inserted polyurethane central catheters in the NICU: one unit’s experience. Neonatal Netw. 1999;18:37-46. 16. Toh LM, Mavili E, Moineddin R, et al. Are cuffed peripherally inserted central catheters superior to uncuffed peripherally inserted central catheters? A retrospective review in a tertiary pediatric center. J Vasc Interv Radiol. 2013;24:1316-1322. 17. Chow LM, Friedman JN, Macarthur C, et al. Peripherally inserted central catheter (PICC) fracture and embolization in the pediatric population. J Pediatr. 2003;142:141-144. 18. Keeney SE, Richardson CJ. Extravascular extravasation of fluid as a complication of central venous lines in the neonate. J Perinatol. 1995;15: 284-288. 19. Pittiruti M, Hamilton H, Biffi R, MacFie J, Pertkiewicz M; ESPEN. ESPEN guidelines on parenteral nutrition: central venous catheters (access, care, diagnosis and therapy of complications). Clin Nutr. 2009;28:365-377. 20. Meeks SL, Ciambotti JM, Rodgers BM, Gordon PV. Extravasation of hyperalimentation into the liver parenchyma from a peripherally inserted central catheter. J Pediatr Surg. 2003;38:E8. 21. Nadroo AM, Lin J, Green RS, Magid MS, Holzman IR. Death as a complication of peripherally inserted central catheters in neonates. J Pediatr. 2001;138:599-601. 22. Beardsall K, White DK, Pinto EM, Kelsall AW. Pericardial effusion and cardiac tamponade as complications of neonatal long lines: are they really a problem? Arch Dis Child Fetal Neonatal. 2003;88:F292-F295. 23. Krasna IH, Krause T. Life-threatening fluid extravasation of central venous catheters. J Pediatr Surg. 1991;26:1346-1348.
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