Peripherally Inserted Central Catheter in a Neonate

Field: Medicine (Health Sciences)

A 2-week-old, 24 weeks gestational age female infant has a peripherally inserted central catheter (PICC) inserted in her right leg for management of ongoing medical issues, including necrotizing enterocolitis.Amidst the other tubes and lines, the PICC appears to be located in the inferior vena cava.Among the infant’s ongoing medical problems are sepsis and pleural effusions, which are chylous. At 4 weeks of age, the original PICC is still in place.Do you see the final ending point of the PICC?Contrast is infused through the PICC to clarify placement.The endpoint of the lower extremity PICC was a vertebral vein, as evidenced by the contrast filling the spinal canal. Although the first radiograph showed the PICC ending at what was believed to be an appropriate position, in retrospect, it did not proceed toward the right side, as would be expected if the PICC were in the inferior vena cava. A lateral radiographic view was not obtained initially, but the subsequent lateral view showed the PICC heading posteriorly through the vertebral bodies into the spinal canal.PICCs are used widely in the neonatal intensive care unit to deliver medications and parenteral nutrition. Larger PICCs (3 French or larger) also can be used for blood product administration and drawing of blood. When prolonged treatment is necessary, placement of a PICC obviates the need for repeated venipuncture, which can be associated with pain and stress. However, there are potential risks to PICC placement and use.PICCs generally are inserted into veins in the arms, legs, or scalp, and less commonly into veins on the dorsal surfaces of the hands and feet. (1) Common insertion sites in the arm are the basilic, cephalic, median cubital, and axillary veins. Common insertion sites in the leg are the greater and lesser saphenous and popliteal veins. Common insertion sites in the scalp are the temporal and posterior auricular veins.When the PICC is inserted into an upper extremity, the catheter tip should end in the inferior third of the superior vena cava. When the PICC is inserted into a lower extremity, the catheter tip should end in the inferior vena cava at a level above the fourth or fifth lumbar vertebral body or the interiliac crest line, but not in the heart. (2) Nowlen and colleagues(3) recommend that the tip of a central venous catheter remain within the vena cava and 1 cm away from the cardiac silhouette in preterm infants and 2 cm away from the silhouette in term infants. In one study, noncentral catheter tip placement resulted in an eightfold increase in the likelihood of a complication occurring. (4)Although considered common practice by some, placement of the catheter tip inside of the right atrium is not recommended(5) because such placement has been associated with cardiac dysrhythmias. Placing the catheter tip too cephalad in the superior vena cava risks the occurrence of thrombosis. (6)Catheter tip migration has been demonstrated with body movement. (6) Such migration can result in incorrect placement of the catheter tip in the right atrium. An anecdotal report related a patient death to catheter migration to the brain. (5)A variety of complications can occur with PICC use during insertion, while the PICC is indwelling, and after it has been removed. (1) Complications include catheter occlusion, catheter-related blood stream infection, migration/dislodgement, phlebitis, mechanical damage to the catheter, catheter-related venous thrombosis, pleural effusion, pericardial effusion/tamponade, extravasation, catheter retention, catheter embolization, and cardiac arrhythmia. (1,5–9)To minimize such complications, initial radiographs to confirm catheter tip location always should include an anteroposterior and a lateral view. An initial lateral view in this case would have demonstrated misplacement. Once the PICC has been placed successfully, standardized documentation tools should be used for frequent assessment of the appearance of the insertion site, the skin color and condition along the path of the catheter, the length of the external catheter, and the ability to flush and withdraw. (1,8) Other steps that can minimize complications include keeping in mind that the catheter tip can migrate with body movement, not placing the catheter tip in the right atrium, and obtaining serial radiographs throughout the period of PICC use to confirm correct PICC placement. (5,6)JoDee M. Anderson, MD, Division of Neonatal Medicine, Oregon Health & Science University, Portland, OR