Complications of umbilical venous catheters in neonates: A safety reappraisal
Chun‐Yan Yeung
Abstract
Umbilical venous catheters (UVC) are frequently used for fluid resuscitation, blood sampling and transfusions, administration of intravenous medication, central venous pressure monitoring, and parenteral nutrition in neonates, particularly premature neonates, in the neonatal intensive care unit (NICU). Although it is considered relatively safe, an indwelling UVC is associated with complications that may cause morbidity and mortality. Blood stream infection is the most common serious adverse event, with reported incidence ranging from 3% to more than 36% depending on the diagnostic criteria applied and the demographics of the population studied.1Butler-O'Hara M. D'Angio C.T. Hoey H. Stevens T.P. An evidence based catheter bundle alters central venous catheter strategy in newborn infants.J Pediatr. 2012; 160: 972-977Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar, 2Konstantinidi A. Sokou R. Panagiotounakou P. Lampridou M. Parastatidou S. Tsantila K. et al.Umbilical venous catheters and peripherally inserted central catheters: are they equally safe in VLBW infants? A non-randomized single center study.Medicina (Kaunas). 2019; 55: 442Crossref Scopus (11) Google Scholar, 3Soares B.N. Pissarra S. Rouxinol-Dias A.L. Costa S. Guimarães H. Complications of central lines in neonates admitted to a level III neonatal intensive care unit.J Matern Fetal Neonatal Med. 2018; 31: 2770-2776Crossref PubMed Scopus (21) Google Scholar Other potentially serious complications of UVC use include thromboembolism, air embolism, arrhythmia, hydrothorax, blood loss during catheterization or due to vessel perforation, malposition or migration of the UVC tip within the peritoneal or pleural spaces or within the portal venous system, and detachment of the cannula.4Gordon A. Greenhalgh M. McGuire W. Early planned removal of umbilical venous catheters to prevent infection in newborn infants.Cochrane Database Syst Rev. 2017; 10: CD012142PubMed Google Scholar,5Arnts I.J. Bullens L.M. Groenewoud J.M. Liem K.D. Comparison of complication rates between umbilical and peripherally inserted central venous catheters in newborns.J Obstet Gynecol Neonatal Nurs. 2014; 43: 205-215Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar Among the complications of UVC, hepatic complications were seldom discussed in the literature. In a case series and literature review, Grizelj et al. reported a 0.8% incidence rate with UVC-developed severe hepatic injury.6Grizelj R. Vukovic J. Bojanic K. Loncarevic D. Stern-Padovan R. Filipovic-Grcic B. et al.Severe liver injury while using umbilical venous catheter: case series and literature review.Am J Perinatol. 2014; 31: 965-974Crossref PubMed Scopus (39) Google Scholar All cases had the UVC malpositioned within the liver circulation. All the presentations were life threatening, with acute abdominal distension (hepatomegaly or ascites) being the most consistent sign; however, the incidence might be underestimated. In this issue of Pediatrics and Neonatology, Chen et al. evaluated the complications of UVC placement in their institution and assessed the sonographic appearance, risk factors, and clinical outcomes of UVC-related hepatic extravasation (HE) in neonates.7Chen H.J. Chao H.C. Chiang M.C. Chu S.M. Hepatic extravasation complicated by umbilical venous catheterization in neonates -- a 5-year, single-center experience.Pediatr Neonatol. 2020; 61: 16-24Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar In a 5-year retrospective study where 33 neonates were enrolled with a diagnosis age ranging from 2 to 25 days, 78.8% of them had UVC malpositioning shown on initial radiography. A total of 33 patients had HE, and the rate of UVC-related hepatic injury in their series was 2.49%. The mean time to resolution of HE was 2.25 months. Of these, 7 (21.2%) patients showed hepatic vascular thrombosis at follow-up. In terms of statistical analyses, patients with HE had lower birth body weight than those without HE. The rate of HE in patients with UVC malpositioning was significantly higher than that in patients with proper UVC positioning. The authors attributed the higher HE incidence to faculty limitation. Junior resident doctors were frequently the first-line physicians who positioned the UVC. The authors suggested that real-time abdominal ultrasound (US) could facilitate the detection of UVC malpositioning and HE diagnosis along with delaying the complications. A shorter duration of UVC placement was associated with favorable outcomes of UVC-related HE in neonates. Previous studies have highlighted the importance of confirming the position of an UVC tip by US examination. However, methods for preventing insertion of UVC into the portal circulation under US guidance have not yet been established. Kishigami et al. reported 15 cases in which a UVC was successfully passed through the ductus venosus by compressing the upper abdomen near the portal sinus of the liver to align the umbilical vein and ductus venosus under US guidance.8Kishigami M. Shimokaze T. Enomoto M. Shibasaki J. Toyoshima K. Ultrasound-guided umbilical venous catheter insertion with alignment of the umbilical vein and ductus venosus.J Ultrasound Med. 2019; https://doi.org/10.1002/jum.15106Crossref PubMed Scopus (8) Google Scholar The UVC was inserted into the correct position in 14 cases (93%) without complications. Given the high incidence of complications associated with UVC, it is usually replaced by peripherally inserted central catheters (PICC) later for vascular access in NICU. However, the question is whether it is necessary or safer to shorten the duration of UVC use and start PICC earlier. Shalabi et al. reported that UVC use in preterm infants was associated with an increased rate of length of stay after a median period of 5 days, and an alternative access point was usually required after UVC removal.9Shalabi M. Adel M. Yoon E. Aziz K. Lee S. Shah P.S. Risk of infection using peripherally inserted central and umbilical catheters in preterm neonates.Pediatrics. 2015; 136: 1073-1079Crossref PubMed Scopus (38) Google Scholar In their study, despite a longer UVC indwelling time (3–25 days), the incidence of blood stream infection was 2.7%, and there was no statistical difference compared to PICC use, which was 2.9%. Konstantinidi et al. also compared the incidence of PICC and UVC complications in very low birth weight infants.2Konstantinidi A. Sokou R. Panagiotounakou P. Lampridou M. Parastatidou S. Tsantila K. et al.Umbilical venous catheters and peripherally inserted central catheters: are they equally safe in VLBW infants? A non-randomized single center study.Medicina (Kaunas). 2019; 55: 442Crossref Scopus (11) Google Scholar They found no significant differences between the 2 study groups with regard to demographic characteristics, causes for catheter removal, catheter indwelling time, or the incidence of nosocomial infection. The use of UVC and PICC seemed to be equally safe. Regarding catheter tip colonization, however, no catheter tip was found colonized in PICC group compared with 29.72% of catheter tips in UVC group. The difference between the 2 groups was statistically significant. Therefore, prolonged duration of UVC placement indeed implies a higher potential risk of infection. Are there any other feasible strategies to lower the incidence of UVC complications? Shahid et al. from McMaster University developed guidelines standardizing the use of umbilical catheters in children's hospital in Hamilton.10Shahid S. Dutta S. Symington A. Shivananda S. McMaster University NICU Standardizing umbilical catheter usage in preterm infants.Pediatrics. 2014; 133: e1742-e1752Crossref PubMed Scopus (44) Google Scholar They supposed that the absence of guidelines on UVC use and inability to predict the hospital course might sway the frontline staff to overuse UVC in preterm infants. The proportion of infants receiving UVC was significantly lower in the postintervention phase than in the preintervention phase. Besides, there was a significant reduction rather than an increase in the proportion of infants receiving PICC or surgical central venous catheters during the sustainment phase. The incidence of central line–associated bloodstream infection was similar in both the preintervention and sustainment phases. Implementation of guidelines standardizing the use of UVC in the NICU seems to be helpful. Fewer infants were exposed to the risks of UVC and fewer resources were used. In conclusion, UVCs are frequently used and are inevitable for vascular access in NICU. They are associated with serious complications and should be judiciously used. We believe that hepatic injuries may be a more common complication of malpositioned UVCs than previously reported. An appreciation of the incidents should alert the clinicians to screen for potential complications and to ensure ideal catheter placement. Acute onset of abdominal distension in a neonate having a UVC should prompt ultrasonographic evaluation of the position of the catheter tip. The development and implementation of guidelines standardizing the use of UVC in the NICU should be helpful. Efforts to remove the UVC at the earliest possible time should be an utmost goal for neonatologists and nurses in NICU to prevent UVC-related complications. Further research to develop feasible strategies for decreasing the complications associated with UVC is mandatory. The author declares that he has no financial conflicts of interest related to the subject matter or materials discussed in the manuscript.