Keywords
central line, complication, risk factors, neonate, Saudi Arabia
Inserting a peripherally inserted central venous catheter (PICC) in neonatal intensive care units (NICUs) is becoming essential. Therefore, this study aimed to assess the prevalence and risk factors of PICC line-related complications.
A retrospective observational cross-sectional study was conducted in the Neonatal Intensive Care Unit between 2012 and 2019 at King Fahd Hospital of the University (KFHU), Khobar, Saudi Arabia. In total, 120 neonates were included in this study. Data on PICC line-related complications, including infection, thrombosis, occlusion, leakage, pericardial effusion, and neonatal death, were collected from medical records. Risk factors for PICC line-related complications were assessed using the chi-square test.
PICC complications occurred in 28 (23.3%) of the 120 PICCs. The incidence of proven infection was (11.7%), leakage (10%), local infection (4.2%), and thrombosis (0.8%), and there were no deaths. The rate of complications was higher among neonates with low gestational age (24-26 weeks), extremely low birth weight, stay for 30 days or more, and older age (aged 10-14 days).
Findings from this study showed that one out of five neonates with PICC at the NICU experienced a PICC line-related complication, with infections and leakage being the most common complications. In the current study, PICC line-related complications were significantly associated with neonatal birth weight, gestational age, and length of stay.
central line, complication, risk factors, neonate, Saudi Arabia
Peripherally inserted central catheter (PICC) access is an intermediate or long-term vascular access with the tip situated in the junction of the superior vena cava and right atrium that has been inserted in one of the deep arm veins, such as the basilic, brachial, or cephalic.1,2 PICCs may require blood samples, parenteral nutrition (PN), and the administration of medications such as antibiotics or chemotherapy.3,4 At acute care institutions worldwide, more than 2.5 million people receive PICCs placed every year.5 Due to the convenience of bedside insertion and decreased risk of harm during installation, PICCs are increasingly being utilized in hospitalized children.6 They are also known to reduce problems related to commonly used central catheters such as severe hematomas, air emboli, and pneumohemothorax.7 Neonatal clinical practice usually involves PICC utilization in the Neonatal Intensive Care Unit (NICU).8 PICCs are the most frequently used type of central line for long-term intravenous access in many NICUs.9 Although PICCs can be used to provide a number of benefits, several studies have shown that they can also result in a variety of complications. These complications include central line-associated bloodstream infection (CLABSI), which is the most common type of infection in the NICU,10 in addition to hematological complications like bleeding, embolism, and thrombosis; and complications relating to the cardiovascular and pulmonary systems, including cardiac tamponade, myocardial perforation, pleural effusion, and pneumothorax; and tissue-related issues, including hematomas, phlebitis, pain, local hardening, infiltration, leakage, and necrosis.8,11 Prior studies have outlined the risk factors for PICC complications in newborns which include young age, disease severity, catheter dwell duration, catheter tip location, catheter insertion site, exposure to neonatal or pediatric ICUs, and birth weight were among the contributing factors; nevertheless, reports in Saudi neonates are rare.10,12,13 The detection of PICCs related complications is necessary to decrease the time it takes for patients to improve, lower the expense of healthcare, and lower the frequency of different PICC-related problems.5 Few studies have been conducted on the complications associated with PICC use in newborns; those that have been conducted were short-term observations that concentrated on the risk factors for infection rather than the incidence of complications.8 Thus, it is crucial to conduct research to evaluate the prevalence of PICCs related complications in newborns. To the best of our knowledge, no studies have been conducted in Saudi Arabia regarding the prevalence of PICCs related complications in neonates admitted to the NICU. Concurrently, several sick neonates are treated in the NICU at our hospital, and many receive PICCs. Therefore, we conducted a retrospective analysis of the data from our NICU to determine the prevalence of complications and risk factors associated with the use of PICC in severely sick neonates.
This study aimed to determine the prevalence and risk factors of PICC-related complications.
The purpose of this study was to examine PICC usage in our hospital for critically ill neonates to determine whether there is a connection between various catheter and patient factors and the prevalence of complications.
To accelerate patient recovery, reduce healthcare costs, and reduce the incidence of various PICC-related issues, PICC-related complications must be identified.
A Retrospective observational cross sectional study was carried out for all neonates who undergone PIC insertion and were concurrently hospitalized to the Neonatal Intensive Care Unit (NICU), the Neonatal Department, during the period of 2012 to 2019 at at King Fahd Hospital of the University (KFHU), Khobar, Saudi Arabia.
Incomplete records, patients who signed for discharge or transfer to another hospital, patients who had the PICC removed within 48 hours of insertion, and patients who passed away from illness while in the hospital. who had serious infections prior to PICC insertion, such as necrotizing enterocolitis or sepsis. Data collection:
During 2021 and 2022, data was collected from the King Fahd Hospital of the University (KFHU), Khobar, Saudi Arabia's medical records from NICU data registry. The following data were obtained: biographical details, basic laboratory tests, admission or discharge results, and final diagnosis. A 5% significance level was used when comparing different etiologies using the Chi-square test. Sex, gestational age, birth weight, age at insertion, site of insertion of the central line, vein, length of stay, and complications (infection, thrombosis, occlusion, leakage, pericardial effusion, and neonatal death)
The information was collected, examined, and entered into version 21 of the Statistical Package for Social Sciences (SPSS: An IBM Company). With an alpha threshold of 0.05, all statistical techniques were two-tailed, and significance was determined if the P value was less than or equal to 0.05. For the study variables, which included neonates' personal information, gestational age, birth weight, PICC-related data, and reasons for PICC insertion, descriptive analysis was carried out by prescribing frequency distribution and percentage. PICC-related complications were graphed. Cross-tabulation for showing distribution of PICC-related complications by neonate's personal data and PICC-related clinical data and length of stay using Pearson’s chi-square test for significance and exact probability test if there were small frequency distributions.
( Table 1) A total of 120 neonates were included in this study. The gestational age ranged from 24 to 30 weeks, with a mean GA of 27.2 1.9 weeks. Exact of 84 (70%) patients had extremely low birth weight, and 36 (30%) had very low birth weight, with a mean birth weight of 855 ± 237 g. A total of 64 (53.3%) patients were males and 56 (46.7%) were females. Regarding age in days, 28 (23.3%) were aged 1-7 days, 63 (52.5%) were aged 8-9 days, and 29 (24.2%) were aged 10-14 days with a mean of 8.3 ± 2.1 days.
( Table 2) PICC related data among neonates who underwent PICC insertion, Neonatal Intensive Care Unit, Maternity & Children's hospital in Al-Ahsa. The PICC was on the right side in 60 patients (50%) and on the left side in 60 patients (50%). PICC was present in the basilic vein in 60 neonates and the cephalic vein in 60 neonates. The number of attempts was 1 in 50 (41.7%) patients, 2 in 51 (42.5%) patients, and 3 in 19 (15.8%) patients. The tip of the catheter was located at the junction of the heart in 115 (95.8%) patients. The end of usage was the most reported cause of PICC (114; 95%), followed by breakage (3.3%) and infection (1.7%). The length of stay ranged from 14 to 46 days with a mean days of 25.1 ± 6.4 days.
( Figure 1) PICC-related complications among Neonatal Intensive Care Unit, Maternity & Children's hospital in Al-Ahsa. Exact 28 (23.3%) patients had PICC-related complications. The most reported complications were proven infection (11.7%), leakage (10%), local infection (4.2%), and thrombosis (0.8%). None of the neonates died.
( Table 3) Distribution of PICC-related complications by neonate's personal and clinical data. Exact of 36.4% of neonates with gestational age 24-26 weeks had PICC-related complications compared to 20% of others with GA of 29-30 weeks with reported statistical significance (P=.024). In addition, 28.6% of neonates with ELBW had PICC-related complications compared to 11.1% of those with VLBW (P=.038). A total of 48.3% of neonates aged 10-14 days had PICC-related complications compared to 21.4% of others aged 1-7 days (P=.001). PICC-related complications were detected among all cases that had PICC due to breakage compared to none of the infected patients (P=.001). In addition, 66.7% of neonates who stayed for 30 days or more had PICC-related complications compared to 14.1% of others stayed for 21-29 days (P=.001).
Personal data | PICC related complications | p-value | |||
---|---|---|---|---|---|
Yes | No | ||||
No | % | No | % | ||
Gestational age | .024*$ | ||||
24-26 | 16 | 36.4% | 28 | 63.6% | |
27-28 | 4 | 11.1% | 32 | 88.9% | |
29-30 | 8 | 20.0% | 32 | 80.0% | |
Birth weight | .038* | ||||
Extremely low birth weight | 24 | 28.6% | 60 | 71.4% | |
Very low birth weight | 4 | 11.1% | 32 | 88.9% | |
Gender | .644 | ||||
Male | 16 | 25.0% | 48 | 75.0% | |
Female | 12 | 21.4% | 44 | 78.6% | |
Age in days | .001* | ||||
1-7 days | 6 | 21.4% | 22 | 78.6% | |
8-9 days | 8 | 12.7% | 55 | 87.3% | |
10-14 days | 14 | 48.3% | 15 | 51.7% | |
Site of PICC line | 1.000 | ||||
Right | 14 | 23.3% | 46 | 76.7% | |
Left | 14 | 23.3% | 46 | 76.7% | |
Vein | 1.000 | ||||
Basilic | 14 | 23.3% | 46 | 76.7% | |
Cephalic | 14 | 23.3% | 46 | 76.7% | |
Number of attempts | .065 | ||||
1 | 17 | 34.0% | 33 | 66.0% | |
2 | 8 | 15.7% | 43 | 84.3% | |
3 | 3 | 15.8% | 16 | 84.2% | |
Tip of C | .368$ | ||||
At junction of the heart | 26 | 22.6% | 89 | 77.4% | |
Middle, no in proper place | 2 | 40.0% | 3 | 60.0% | |
Reason | .001*$ | ||||
End the usage | 24 | 21.1% | 90 | 78.9% | |
Breakage | 4 | 100.0% | 0 | 0.0% | |
Infected | 0 | 0.0% | 2 | 100.0% | |
Length of stay | .001* | ||||
14-20 | 8 | 23.5% | 26 | 76.5% | |
21-29 | 10 | 14.1% | 61 | 85.9% | |
30+ | 10 | 66.7% | 5 | 33.3% |
Peripherally inserted central catheters (PICC) are medical devices commonly used in neonatal intensive care units (NICUs) for delivering intravenous (IV) therapy.14 However, despite their widespread use, PICCs also have a number of complications, especially in neonates. Common complications associated with PICCs in neonates include catheter-associated bloodstream infections, thrombosis, displacement, and breakage.15,16 In recent years, peripherally inserted central catheters (PICCs) have become increasingly common in neonates. While PICCs can provide important access to medication and nutrition, they are not without risks.17 The current study aimed to assess the frequency, type, and risk factors of PICC-related complications among neonates. Regarding the PICC clinical data, half of the neonates were on the right side of the basilic vein among 60 neonates. Less than half of the patients needed one attempt at PICC insertion. The tip of the catheter was at the junction of the heart in most neonates. End of usage was the most reported cause of PICC removal. The length of stay ranged from 14 to 46 days with a mean days of 25.1 ± 6.4 days. Wrightson DD15 reported that PICCs were removed due to complications, and non-central tips were found to be statistically significant in upper-extremity PICCs.
As for PICC-related complications, about one-fourth of the study neonates experienced any PICC-related complications, with the most reported complications including proven infection, leakage, local infection, and thrombosis. None of the neonates died. Higher complication rates were detected among neonates with less GA, ELBW, older age, and longer duration of NICU stay. According to Ohki et al.,18 CR-BSI was the most common complication (1.8% of all PICC placements and 1.6 per 1000 catheter-days), accounting for 2.9% of all PICC placements. Furthermore, Cartwright19 reported a lower incidence (5.4%), while Neubauer20 reported a higher incidence (5.6%). Numerous studies have reported similar results for reported complications, primarily blood stream infections.13,21,22 Similar to the current study, other research found that low birth weight is a risk factor for PICC-related complications in the NICU. Wen et al. showed that low weight gain in premature babies is linked to both infectious and non-infectious PICC complications.10 Moreover, prior research has determined that the size of the NICU25; PICC duration20 tip location24; and prematurity or severity of infant condition23 are risk factors for PICC complications. Additionally, Beardsall et al. discovered that institutions that performed fewer catheterizations had a significantly higher incidence of PCE/CT.25 PICC complications in children were more common with non-centrally placed catheters than with centrally placed catheters, according to a study by Racadio et al.24
This study has some limitations. First, because this was an observational study, bias may have been present. Additionally, there was no routine monitoring of the line tip location or ultrasound detection of the thrombosis. Second, these complications might not have been recorded because some catheter infections might have been treated with antibiotics, while the PICC was still in situ. Finally, because this was a single-center trial, our results might not be generalizable. Larger prospective studies involving several locations are required to elucidate the connection between these potential risk variables and PICC problems.
In conclusion, the current study showed that about one in five neonates with PICC experienced any complications where catheter-related infection and embolization were the most frequent. LBW, low GA, and more hospitalization days were associated with a higher PICC related complications.
The study design was approved by the institutional review board of King Fisal University, Al Ahsa, Saudi Arabia (KFU-REC-2024-NOV-ETHICS307), Approval:08/11/2024. Consent was obtained from or waived by IRB committee. Participants’ information was kept confidential and anonymous.
Figshare: The Prevalence Of Peripherally Inserted Central Catheter Complications Among Neonate: DOI: https://doi.org/10.6084/m9.figshare.27174807.v2.26
The project contains the following underlying data:
Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).
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