Complications of Vascular Catheters in the Neonatal Intensive Care Unit

https://doi.org/10.1016/j.clp.2007.11.007Get rights and content

Insertion of an intravascular catheter is the most common invasive procedure in the neonatal ICU. With every passing decade, technological innovations in catheter materials and sizes have allowed vascular access in infants who are smaller and sicker for purposes of blood pressure monitoring, blood sampling, and infusion of intravenous fluids and medications. There is, however, growing recognition of potential risks to life and limb associated with the use of intravascular catheters. This article reviews complications of venous and arterial catheters in the neonatal ICU and discusses treatment approaches and methods to prevent such complications, based on current evidence.

Section snippets

Peripheral venous catheters

Complications of peripheral venous catheters include thrombophlebitis, infection, and extravasation or inadvertent infiltration of intravenously administered solutions into subcutaneous tissue. Thrombophlebitis from peripheral venous catheters is an uncommon complication in NICU, probably because the average dwell time for such catheters is relatively short, ranging from 9 to 133 hours [2]. Thrombophlebitis can be relatively benign, with redness and tenderness over the course of the vein

Central venous catheters

CVCs provide stable intravenous access to infants who need long-term parenteral alimentation or medications [23]. In the NICU, CVCs may be in the form of umbilical venous catheters or percutaneous CVCs, also known as PICCs. PICCs have become much more prevalent than cut-downs or open surgical techniques, because the procedure is simpler to perform, relatively rapid, less expensive, and requires only mild sedation or pain relief. The catheters, made of silicone, polyurethane, or polyethylene,

Arterial catheters

Indwelling radial or ulnar arterial catheters (peripheral arterial line catheters) or UAC are placed in newborn infants for monitoring purposes, whereas carotid artery catheterization is performed for extracorporeal membrane oxygenation, and the femoral artery frequently is used for cardiac catheterization. Temporal artery catheterization is not recommended, because of potential neurologic complications. Injury to adjacent structures during insertion is a potential complication of peripheral

Position of the catheter

UACs usually are placed with the catheter tip in one of two positions: a high position at a level between thoracic vertebrae 6 and 9 (see Fig. 1A), which positions the tip above the origin of the celiac axis, and a low position at the level of lumbar vertebra 3 or 4, which positions the tip just above the aortic bifurcation but below major aortic branches [103]. Meta-analysis of five randomized, controlled trials and one alternate assignment study showed that high-placed UACs with the tip above

Peripheral artery catheterization

For more than 30 years many authors have advocated percutaneous catheterization of peripheral arteries (eg, the radial, ulnar, and posterior tibial arteries) as being a safer alternative to umbilical arterial catheterization [124], [125], [126], [127]. In the NICU, the radial and posterior tibial arteries are the primary sites for cannulation. Because of potential risk of ischemic injury to the entire hand or arm, the ulnar, brachial, and axillary arteries generally are used for cannulation

Summary

Arterial and venous catheters remain indispensable in neonatal intensive care despite the risk of numerous complications, with short- and long-term implications. Although catheter materials and designs continue to improve, simple precautions taken during the insertion and vigilance in the maintenance of catheters may help reduce complication rates. Box 1, Box 2 provide basic guidelines for prevention of complications, based on currently available evidence.

References (139)

  • C.H. Van Ommen et al.

    Venous thromboembolism in childhood: a prospective two year registry in the Netherlands

    J Pediatr

    (2001)
  • M. Roy et al.

    Accuracy of Doppler ultrasonography for the diagnosis of thrombosis associated with umbilical venous catheters

    J Pediatr

    (2002)
  • D.S. Schwartz et al.

    Umbilical venous catheterization and the risk of portal vein thrombosis

    J Pediatr

    (1997)
  • P. Monagle et al.

    Antithrombotic therapy in children. The seventh ACCP conference on antithrombotic and thrombolytic therapy

    Chest

    (2004)
  • F. Alvarez et al.

    Portal obstruction in children. I. Clinical investigation and hemorrhage risk

    J Pediatr

    (1983)
  • I. Morag et al.

    Portal vein thrombosis in the neonate: risk factors, course and outcome

    J Pediatr

    (2006)
  • A.F. Wong et al.

    Treatment of peripheral tissue ischemia with topical nitroglycerine ointment in neonates

    J Pediatr

    (1992)
  • A.L. Garden et al.

    An unending supply of “unusual” complications from central venous catheters

    Paediatr Anaesth

    (2004)
  • L.S. Franck et al.

    The safety and efficacy of peripheral intravenous catheters in ill neonates

    Neonatal Netw

    (2001)
  • E.A. Khan et al.

    Suppurative thrombophlebitis in children: a ten year experience

    Pediatr Infect Dis J

    (1997)
  • C.E. Wilkins et al.

    Extravasation injuries in regional neonatal units

    Arch Dis Child Fetal Neonatal Ed

    (2004)
  • M. Subhani et al.

    Phentolamine use in a neonate for the prevention of dermal necrosis caused by dopamine: a case report

    J Perinatol

    (2001)
  • A.S. Brown et al.

    Skin necrosis from extravasation of intravenous fluids in children

    Plast Reconstr Surg

    (1979)
  • L.A. Montgomery et al.

    Guideline for IV infiltrations in pediatric patients

    Pediatr Nurs

    (1999)
  • R.J. Kumar et al.

    Management of extravasation injuries

    ANZ J Surg

    (2001)
  • P.A. Harris et al.

    Limiting the damage of iatrogenic extravasation injury in neonates

    Plast Reconstr Surg

    (2001)
  • P.A. Falcone et al.

    Nonoperative management of full- thickness intravenous extravasation injuries in premature neonates using enzymatic debridement

    Ann Plast Surg

    (1989)
  • S.W.S. Laurie et al.

    Intravenous extravasation injuries: the effectiveness of hyaluronidase in their treatment

    Ann Plast Surg

    (1984)
  • W.V. Raszka et al.

    The use of hyaluronidase in the treatment of intravenous extravasation injuries

    J Perinatol

    (1990)
  • K.E. Zenk et al.

    Nafcillin extravasation injury. Use of hyaluronidase as an antidote

    Am J Dis Child

    (1981)
  • O. Chandavasu et al.

    A new method for the prevention of skin sloughs and necrosis secondary to intravenous infiltration

    Am J Perinatol

    (1986)
  • J. Davies et al.

    Preventing the scars of neonatal intensive care

    Arch Dis Child

    (1994)
  • K.A. Denkler et al.

    Reversal of dopamine extravasation injury with topical nitroglycerine ointment

    Plast Reconstr Surg

    (1989)
  • J. Ramasethu

    Prevention and management of extravasation injuries in neonates

    NeoReviews

    (2004)
  • S.J. Phelps et al.

    Risk factors affecting infiltration of peripheral venous lines in infants

    J Pediatr

    (1987)
  • P.S. Shah et al.

    Heparin for prolonging peripheral intravenous catheter use in neonates

    Cochrane Database Syst Rev

    (2005)
  • S.B. Ainsworth et al.

    Percutaneous central venous catheters versus peripheral cannulae for delivery of parenteral nutrition in neonates

    Cochrane Database Syst Rev

    (2007)
  • S.P. Wardle et al.

    Percutaneous femoral arterial and venous catheterization during neonatal intensive care

    Arch Dis Child Fetal Neonatal Ed

    (2001)
  • A. Citak et al.

    Central venous catheters in pediatric patients—subclavian approach as the first choice

    Pediatr Int

    (2002)
  • T.T. Nowlen et al.

    Pericardial effusion and tamponade in infants with central catheters

    Pediatrics

    (2002)
  • K. Beardsall et al.

    Pericardial effusion and cardiac tamponade as complications of neonatal long lines: are they really a problem?

    Arch Dis Child Fetal Neonatal Ed

    (2003)
  • J.C. Darling et al.

    Central venous catheter tip in the right atrium: a risk factor for neonatal cardiac tamponade

    J Perinatol

    (2001)
  • D.W. Cartwright

    Central venous lines in neonates: a study of 2186 catheters

    Arch Dis Child Fetal Neonatal Ed

    (2004)
  • S.J. Fletcher et al.

    Safe placement of central venous catheters: where should the tip of the catheter lie?

    Br J Anaesth

    (2000)
  • M. Pezzati et al.

    Central venous catheters and cardiac tamponade in preterm infants

    Intensive Care Med

    (2004)
  • M.S. Perry et al.

    Extravasation of hyperalimentation into the spinal epidural space from a central venous line

    Neurology

    (2006)
  • J. Baker et al.

    A rare complication of neonatal central venous access

    Arch Dis Child Fetal Neonatal Ed

    (2002)
  • A.M. Nadroo et al.

    Extravasation of parenteral alimentation fluid into the renal pelvis—a complication of central venous catheter in a neonate

    J Perinatol

    (2001)
  • S. Rastogi et al.

    Spontaneous correction of the malpositioned percutaneous central venous line in infants

    Pediatr Radiol

    (1998)
  • K. Al Tawil et al.

    Peripherally inserted central venous catheters in newborn infants: malpositioning and spontaneous correction of catheter tips

    Am J Perinatol

    (2006)
  • Cited by (114)

    • Incomplete limb ischemia as a complication in a pediatric patient with toxic-shock syndrome

      2019, Journal of Pediatric Surgery Case Reports
      Citation Excerpt :

      The positioning of these can take place in different vessels, preferably in the radial artery. Another possibility of the positioning is the femoral artery, used when an installation of the IACs in the other vessels is not possible [11–13]. It has been shown before that the application of indwelling vessel catheters is the main cause of thrombosis in children [14,15].

    View all citing articles on Scopus
    View full text