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.

( 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).

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 DD ¹⁵ 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, Cartwright ¹⁹ reported a lower incidence (5.4%), while Neubauer ²⁰ 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 NICU ²⁵ ; PICC duration ²⁰ tip location ²⁴ ; and prematurity or severity of infant condition ²³ 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

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.