110 Neonatal Peripherally Inserted Central Catheter Lines

Clinical Presentation

A 28-week (1.2 kg) premature neonate presented soon after birth with a distended abdomen, and appeared clinically to be septic. The patient required intubation and ventilation. On examination, there was paucity of bowel sounds. Patient was transferred to a tertiary care center. Abdominal radiography and ultrasonography were performed. Conservative management with total parenteral nutrition and antibiotics were prescribed, which required secure central venous access. What would you use?

Figure 110A

Figure 110B

Radiologic Findings

A radiograph of the abdomen shows pneumatosis in the right lower quadrant and air in the portal veins (Fig. 110A). The air in the portal veins was confirmed on ultrasonography. The bowel demonstrates poor peristalsis, decreased vascularity, and pneumatosis (Fig. 110B); all features consistent with necrotizing enterocolitis.

Diagnosis

Necrotizing enterocolitis requiring initial conservative therapy and probable surgery. A peripherally inserted central catheter was placed.

Discussion

Background

Peripherally inserted central catheters (PICCs) are an increasingly used modality in the neonatal intensive care unit. PICCs are inserted into a peripheral vein, usually in the upper arm, and are threaded into the central circulation. This provides stable access to a central vein, eliminating the need for repeated peripheral intravenous punctures, which are associated with pain and complications. It has been suggested that a PICC line is more cost effective than a central venous line (CVL) when venous access is required for up to 21 days. If one compares an image-guided PICC line placement and an image-guided CVL placement, the risks and benefits are a little more complicated to determine, and the PICC line may actually be associated with increased risk for venous complications. A CVL should be used when more long-term access is required. PICC designs include single and double lumen varieties. They are constructed from silicone or polyurethane and are radiopaque. We use cuffed silicone catheters for children and neonates, as we feel that these catheters are more secure, and there are no sutures to remove. The catheters are available in various lumen sizes, the most commonly used being the no. 3 French, followed by the no. 2 French. The placement of these catheters is increasingly performed by pediatric interventional radiologists because imaging guidance increases the options and success rate of placement.

Indications

Reduction of the number of venipuncture procedures during prolonged treatment course as peripheral intravenous lines have a very short life span. Repeated venipuncture is recognized as one of the greatest stresses for a hospitalized child. A PICC line can remain in situ for months, dramatically reducing the number of required needle sticks; a stable vascular access is maintained, and home treatment may be possible in certain cases.
Total parenteral nutrition: PICC lines allow for the administration of a high-calorie, dense, and concentrated parenteral nutrition with little venous irritation. This is especially important when managing premature and low birth weight babies.
Administration of irritant medications: the ability to deliver medications with a low or high pH (<6 or >8) or hyperosmolar or vesicant properties. Such medications include many chemother-apeutic and antibiotic agents.
Obtaining repeated blood samples