Journal of Perinatology (2014) 34, 461–463 © 2014 Nature America, Inc. All rights reserved 0743-8346/14 www.nature.com/jp

ORIGINAL ARTICLE

Peripherally inserted central venous catheters: frequency of complications in premature newborn depends on the insertion site P Panagiotounakou1, G Antonogeorgos2, E Gounari3, S Papadakis1, J Labadaridis1 and AK Gounaris4 OBJECTIVE: The use of peripherally inserted central venous catheters (PICC lines) has reduced the mortality and morbidity of premature newborns. The usual sites of insertion are the veins in the upper arms but other locations are being used as well. STUDY DESIGN: To examine whether using the axillary vein as a site of insertion of a PICC line affects the frequency of complications. Our study has a clinical trial design. A total of 62 neonates that had a PICC line inserted were recruited and randomly divided equally in two groups: in Group A (mean birth weight, standard deviation (s.d.) = 1353 (142) g), the PICC line was inserted through the axillary vein, and in Group B (birth weight = 1308 (112) g), the PICC line was inserted in other sites further from the axillary vein. The outcomes measured were the total PICC line-related complications, the reason for removing the catheter, the number of total attempts until successful insertion and the mean duration of stay of the catheter. The likelihood of having an adverse outcome was assessed with Mantel–Haenszel odds ratio (OR). RESULT: Premature neonates with axillary PICC lines were 12 times less likely to have line-related complications (inflammation, blockage, edema, infection) as compared with any other site of insertion (OR = 95%, confidence interval (CI) = 0.10 (0.01 to 0.8)) and they were seven times more likely to have the PICC line removed because they achieved full enteral nutrition as compared with the other causes (OR 95%, confidence interval (CI) = 10.35 (4.88 to 21.96)). There was no statistical difference between the two groups in the number of attempts until successful PICC line insertion (P = 0.667) and the mean duration of stay of the PICC line (P = 0.97). CONCLUSION: The use of the axillary vein as a site of insertion of a PICC line was correlated with significantly less complications in premature newborns as opposed to the other sites of insertion. Journal of Perinatology (2014) 34, 461–463; doi:10.1038/jp.2014.36; published online 13 March 2014 Keywords: long line; PICC line; central catheter; total parenteral nutrition; intravenous line; premature infant

INTRODUCTION The use of central catheters through a peripheral vein (peripherally inserted central catheter lines—PICC lines) for administering intravenous fluids reduces significantly the complications compared with the use of peripheral venous catheters and improves the quality of life of the premature neonate.1,2 The criteria for PICC line insertion are usually the need for long-term administration of total parenteral nutrition, or the failure to insert an umbilical venous catheter in a proper position. Safer positions for the tip of the catheter are the inferior and superior vena cava, and the acceptable ones are between the clavicle and right atrium.3 The implementation of the PICC line in the clinical practice has been correlated with fewer complications compared with other types of central catheters.4 The complications of PICC lines (occlusion, inflammation, edema and infection) are either due to the catheter itself or more rarely are due to the position of the catheter tip, the latter being usually more severe.5,6 One study has demonstrated that the use of the axillary vein facilitates the insertion of PICC line.7 As the distance between the axillary vein and the end point of the tip of the catheter is shorter, we hypothesized that the use of the axillary vein is linked to fewer complications related to insertion in other sites. Thus, the main objective of our study is to examine the possible benefits of implementing the axillary vein

for the utilization of the PICC line compared with all the other insertion sites. The secondary objectives were (a) the examination of all the possible causes for the catheter’s removal, (b) if there was any difference in the number of attempts until successful PICC line insertion and (c) the duration of stay of the catheter. METHODS This study has a randomized clinical trial design. We included 62 preterm neonates that would need long-term hospitalization in our Neonatal Intensive Care Unit and we divided them in two groups. Group A had PICC lines inserted through the axillary vein and Group B had PICC lines inserted through other insertion sites, primarily the antecubital fossae and forearms. The randomization of the neonates was done between the 1st and 2nd day of life with the use of sealed envelopes, which were assigning the neonate to one of the two groups randomly. To keep the veins of the participating infants intact, we avoided using any one of the upper limbs in the first days for blood sampling or for inserting peripheral venous catheters. The criteria for inclusion in the study and the insertion of a long line in the preterm neonates, taking in consideration the severity of their clinical condition, were the need for administration of parenteral fluids for more than one week, or the failure to place an umbilical venous catheter in the inferior vena cava in the first two days of life. We excluded any neonate to whom a PICC line was not inserted within the first three attempts. In our study, we initially included 68 neonates but only 62 finally fulfilled our criteria.

NICU-General Hospital ‘Agios Panteleimon’, Piraeus, Greece; 2Department of Dietetics and Nutritional Science, Athens, Greece; 31st Pediatric Department, ‘Agia Sophia’ University Hospital, Athens, Greece and 4Neonatal Clinic-NICU, University Hospital of Larissa, Larissa, Greece. Correspondence: Professor AK Gounaris, Neonatal Clinic-NICU, University Hospital of Larissa, 52 Karaiskaki Street, Larissa 41222, Greece. E-mail: [email protected] Received 15 July 2013; revised 11 January 2014; accepted 23 January 2014; published online 13 March 2014 1

Peripherally inserted central venous catheters and placement P Panagiotounakou et al

462 According to the group that the neonate was assigned to, an initial attempt was made to insert the PICC line in the preselected site. If the insertion was not successful after three attempts, the neonate would leave the study and the PICC line would have been inserted in any other feasible site available. The PICC line insertions were performed by the same team of experienced nursing and medical staff (four persons) during the morning hours. The insertion was done in the incubators using aseptic technique. We did not use the special 20-gauge butterfly needle that is included in the PICC line package as this can cause local tissue trauma and hemorrhage. We modified the method using a 20-gauge cannula. In our modified technique, after successfully catheterizing the vein, we remove the peripheral catheter needle and cut the catheter carefully at the site of the beck. The remaining catheter is then used as a guide for the insertion of the PICC line at a premeasured length, sometimes needing to move the corresponding limb of the baby to facilitate advancing the line. After successfully inserting the PICC line, we carefully remove the peripheral catheter, clean the insertion site and cover it with tegaderm, a transparent medical dressing manufactured by 3M (3M Health Care, Neuss, Germany). The proper location of the tip was confirmed by an X-ray. Parenteral nutrition administered to the 62 neonates of the study contained heparin at a concentration of 0.5 units ml−1 to prolong the PICC line patency. In both study groups, the following variables were recorded during the hospitalization time of the neonates: (a) the number of complication (blockage, local inflammation, edema, infection), (b) the reasons for removing the PICC line, (c) the number of attempts before the successful insertion of the PICC line and (d) the mean duration of stay of the catheter (in days). Informed consent was obtained from the parents of all the neonates included. Our study protocol was approved by the Ethics Committee of ‘Agios Panteleimon’ General Hospital-Piraeus.

Table 1.

Group A

RESULTS The clinical characteristics of the two groups are presented in Table 1. A total of 18 PICC lines of group A were inserted in the right axillary vein and 13 in the left. In group B, 26 PICC lines were inserted in the upper limbs, 17 in the right and 9 in the left (forearm, basilic veins), 1 in the external jugular, 1 in the posterior auricular and 3 in the lower limbs (saphenous vein). Neonates with PICC line inserted via the axillary vein were 12 times less likely to have line-related complications compared with the other group (OR (95% CI):0.10 (0.01 to 0.8)) (Table 2) and were 7 times more likely to have the PICC line removed because of achieving full enteric feeds as opposed to other reasons (blockage, local inflammation, edema). (OR (95% CI):10.35 (4.88 to 21.96)) (Table 3). There was no statistical significant difference between the groups in the number of attempts until successful insertion and the mean total duration of stay of the PICC line, which for group A was 12.9 days (range 3 to 31), (P = 0.667) and group B was 13.6 days (range 3 to 26), (P = 0.97) (Table 4). One blood culture in group A and two in group B were positive but this was no cause for the removal of the catheters. Two catheters from group A and one from group B were positive after the removal. Journal of Perinatology (2014), 461 – 463

P

Group B

Birth weight (mean (s.d.), g)

1353 1308 0.8 (142) (112) Gestational age (mean (s.d.), weeks) 30.5 29.5 0.344 (0.69) (0.72) Boys (n, %) 14 (45.2) 15 (48.4) 0.5 Respiratory distress syndrome (n, %) 14 (45.2) 19 (61.3) 0.432 Necrotizing enterocolitis (n, %) 4 (12.9) 1 (3.2) 0.231 Congenital bowel defects (n, %) 3 (9.7) 1 (3.2) 0.34 PICC line placement age (mean, range) 7.1 (1–18) 6.3 (1–16) 0.673 in days Positive blood culture 1 (3.2) 2 (6.4) 0.229

Table 2.

Distribution of PICC lines placement complications

Complications None Occlusion Local edema Local inflammation Infection

Table 3.

STATISTICAL ANALYSIS Quantitative data are presented as mean value, standard deviation (s.d.) and extreme values (min and max). The assumption of the normality of the distribution of the quantitative variables was examined using Kolmogorov–Smirnoff and Shapiro–Wilks tests; it was met for all of them. Categorical data are presented as absolute and relative frequencies. Associations between categorical and quantitative variables were examined using Student’s t-test for independent variables. Correlations between categorical variables were assessed with the Pearson’s chi-square test, or when this was not applicable, the Fisher’s exact test. Moreover, we calculated the Mantel–Haenszel odds ratio (OR) and the corresponding 95% confidence intervals (CI) in order to estimate the risk of complications associated with different sites of insertion of the PICC line. All statistical tests are two-sided and the significance level was set to 0.05. The Statistical Package of Social Sciences (SPSS) v13 was used for all the statistical analyses.

Basic characteristics of the study neonates

Group A (n, %)

Group B (n, %)

P

30 (96.7) 1 ( 3.2) 0 (0) 0 (0) 0

24 (77.4) 0 (0) 3 (10.0) 4 (13.3) 0

0.007

Distribution of PICC lines removal cause

Removal cause Full enteral feeding Accidental catheter removal Occlusion Local edema/inflammation

P

Group A (n, %) Group B (n, %) 29 (93.6) 1 (3.2) 1 (3.2) 0 (0)

22 (70.9) 2 (6.4) 0 (0.0) 7 (22.5)

0.022

Table 4. Distribution of the number of attempts until successful insertion and total duration of stay in days of PICC lines

Number of attempts until successful insertion (mean, range) Dwell time (mean, range) in days

Group A

Group B

P

1.26 (1–3) 12.9 (3–31)

1.32 (1–3) 13.6 (3–25)

0.667 0.97

DISCUSSION According to the most recent literature, using central lines significantly reduces the number of complications compared with administration of parenteral fluids via peripheral lines.1 Furthermore, PICC lines cause less complications (occlusion, inflammation, infection) compared with other central catheters (Broviac etc.) and only umbilical venous catheters in one paper showed less frequent complications compared with PICC lines.4,8,9 Our study, to the best of our knowledge, is the first to show the importance of the insertion site of a PICC line and the superiority of the axillary vein as the primary point of insertion. The use of heparin in the parenteral infusions administered via the PICC line has been shown to prolong the total duration of stay of the catheter10 and in a randomized controlled trial (HILLTOP trial) have found that heparin in doses 0.5 IV ml − 1 in total parenteral nutrition reduces the incidence of culture positive catheter-related sepsis.11 Nevertheless, the insertion and use of PICC lines is linked to complications. The most usual PICC line-related complications are local inflammation at the site of the insertion of the catheter (redness with swelling), catheter occlusion and sepsis. The use of vancomycin has been shown in the literature to reduce © 2014 Nature America, Inc.

Peripherally inserted central venous catheters and placement P Panagiotounakou et al

PICC line-related infections.12 Rarely can an infection due to a PICC line present itself after the removal of the catheter.13 The wrong placement of the tip of the catheter must be avoided, as it increases considerably the risk of severe complications.6 However, PICC lines can also cause complications; they still remain safer from other methods of administering parenteral solutions. The aim to reduce these complications even further is reasonable. Our results show that PICC line-related complications can be linked to the site of insertion of the PICC line and that the use of the axillary vein in the neonates of our study significantly reduces the frequency of complications. Neonates with PICC line inserted via the axillary vein were 12 times less likely to have line-related complications compared with the other sites of insertion, and were seven times more likely to have the PICC line removed because of achieving full enteric feeds. In our subjects, the prevalence for non-elective removal of the PICC line was low compared with a recent published study.14 The absence of infections as a cause of removal of catheters in the neonates of our study seems to be a result of the relatively short duration of catheter stay, due to rapid full enteric feeding. It has been demonstrated that the frequency of PICC line-related infections (central line-associated bloodstream infections) is linked to the total duration of stay of the catheter.15 Furthermore, a recent study correlates the position of the tip of the PICC line catheter to the frequency of complications, with safest positions being the superior and inferior vena cava, but to our knowledge there is no other study correlating the site of the PICC line insertion with the frequency of complications.3 In our study, the explanation for fewer complications from the PICC lines that were inserted through the axillary vein could be that, the catheter is inserted in a larger vessel and relatively closer to the end point of insertion. In our subjects, the use of the axillary vein did not facilitate insertion of the catheter, a result which is opposite with the findings reported in the study of Messeri et al.7 To conclude, in the neonates of our study, the use of the axillary vein as the primary site of PICC line insertion significantly reduced the PICC line-related complications, without increasing the number of attempts before the successful insertion. Further large-scale studies are needed to verify these positive results.

CONFLICT OF INTEREST The authors declare no conflict of interest.

© 2014 Nature America, Inc.

463 REFERENCES 1 Liossis G, Bardin C, Papageorgiou A. Comparison of risks from percutaneous central venous catheters and peripheral lines in infants of extremely low birth weight: cohort controlled study of infants o 1000 g. J Matern Fetal Neonatal Med 2003; 13: 171–174. 2 Colacchio K, Deng Y, Northrup V, Bizzarro MJ. Complications associated with central and non-central venous catheters in a neonatal intensive care unit. J Perinatol 2012; 32(12): 941–946. 3 Jain A, Deshpande P, Shah P. Peripherally inserted central catheter tip position and risk of associated complications in neonates. J Perinatol 2013; 33(4): 307–312. 4 Gunst M, Matsushima K, Vanek S, Gunst R, Shafi S, Frankel H. Peripherally inserted central catheters may lower the incidence of catheter-related blood stream infections in patients in surgical intensive care units. Surg Infect (Larchmt) 2011; 12(4): 279–284. 5 Liu H, Han T, Zheng Y, Tong X, Piao M, Zhang H. Analysis of complication rates and reasons for non elective removal of PICCs in neonatal intensive care unit preterm infants. J Infus Nurs 2009; 32(6): 336–340. 6 Lussky RC, Trower N, Fisher D, Engel R, Cifuentes R. Unusual misplacement sites of percutaneous central venous lines in the very low birth weight neonate. Am J Perinatol 1997; 14: 63–67. 7 Messeri A, Calamandrei M. Percutaneous central venous catheterization in small infants: axillary vein can facilitate the insertion rate. Paediatr Anaesth 2000; 10: 527–530. 8 Ragavan M, Gazula S, Yadav DK, Agarwala S, Srinivas M, Bajpai M et al. Peripherally inserted central venous lines versus central lines in surgical newborns-a comparison. Indian J Pediatr 2010; 77(2): 171–174. 9 Ghien LY, Macnab Y, Aziz K, Andrews W, McMillan DD, Lee SK et al. Variations in central venous catheter-related infection risks among Canadian neonatal intensive care units. Pediatr Infect Dis J 2002; 21: 505–511. 10 Uslu S, Ozdemir H, Comert S, Bolat F, Nuhoglu A. The effect of low-dose heparin on maintaining peripherally inserted percutaneous central venous catheters in neonates. J Perinatol 2010; 30(12): 794–799. 11 Birch P, Ogden S, Hewson M. A randomized controlled trial of heparin in total parenteral nutrition to prevent sepsis associated with neonatal long lines: the Heparin Long Line Total Parenteral Nutrition (HILLTOP trial). Arch Dis Child Fetal/ Neonatal Ed 2010; 95(4): F252–F257. 12 Lodha A, Furlan AD, Whyte H, Moore AM. Prophylactic antibiotics in the prevention of catheter-associated bloodstream bacterial infection in preterm neonates: a systematic review. J Perinatol 2008; 28(8): 526–533. 13 Van den Hoogen A, Brouwer MJ, Gerards LJ, Fleer A, Krediet TG. Removal of percutaneously inserted central venous catheters in neonates is associated with the occurrence of sepsis. Acta Paediatr 2008; 97(9): 1250–1252. 14 Costa P, Kimura AF, de Vizzotto MP, de Castro TE, West A, Dorea E. Prevalence and reasons for non-elective removal of PICC in neonates. Rev Gaucha Enferm 2012; 33 (3): 126–133. 15 Milstone AM, Reich NG, Advani S, Yuan G, Bryant K, Coffin SE et al. Catheter dwell time and CLABSIs in neonates with PICCs: a multicenter cohort study. Pediatrics 2013; 132(9): 1609–1615.

Journal of Perinatology (2014), 461 – 463

Peripherally inserted central venous catheters: frequency of complications in premature newborn depends on the insertion site.

The use of peripherally inserted central venous catheters (PICC lines) has reduced the mortality and morbidity of premature newborns. The usual sites ...
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