Abstract
Peripherally inserted central catheter line entrapment is a rare complication in the neonatal intensive care unit and only a small number of cases have been reported. While studies have suggested recommendations for removal, there is still a need for surgical intervention in some cases. This is a case of a premature infant with long term peripherally inserted central catheter line placement with fibrin sheath formation that required multiple attempts before successful noninvasive removal and a review of the cases with difficult peripherally inserted central catheter removal in newborns.
Keywords
Introduction
Peripherally inserted central catheter (PICC) lines are an essential tool for premature infants due to difficulty in maintaining peripheral IV access for an extended period of time. Almost all neonates requiring long term TPN will have a PICC line during their stay in the NICU. It is common for the line to stay in for weeks at a time until infant transition to full enteral feeds. While there are many case reports that discuss complications of PICC lines, there are only a limited number of cases that described difficult central line removals in the NICU population.
Complications with central line removal in neonates were first described in 1990 by Gladman [1]. After thorough review of the literature, it appears that there are total 17 cases–including present case that have been reported [1–6]. In this report, we discuss a premature infant with long term PICC line placement that required multiple attempts before successful removal with fibrin sheath formation, and a review of recent cases of difficult PICC removal in the neonatal population.
Case report
A 25 week gestation infant was admitted to the NICU for respiratory distress syndrome (RDS) and persistent pulmonary hypertension (PPHN). At 27 weeks corrected age a PICC was placed in the right saphenous vein due to need for a stable line. The catheter used was a Premicath 1Fr/28G polyurethane catheter, Vygon that was 25 cm in length. Two attempts were made before a line was successfully placed and confirmed in optimal position on x-ray. The PICC was used for TPN and medication administration. The line remained in for a total of 40 days. As the patient was tolerating full feeds and stable on CPAP the team decided to remove the line. On first attempt, it was difficult to remove beyond 20 cm. There was stretching and tightening of skin above the ankle with removal attempts. On x-ray the remaining 5 cm of the catheter remained in the right mid-thigh. Gentle tension, massaging and warm compresses were utilized without success. Due to risks of breaking, line was left in place overnight with sustained gentle tension and was started on heparin drip. The next day, line removal was attempted again and this time with gentle traction the line was successfully removed. The patient was closely monitored after the procedure and remained stable without complications. The end of the PICC line was found to have 2 cm of fibrin covering (Fig. 1).
28G catheter with distal 2 cm covered in fibrin sheath.
Complications with central line removal in neonates is a rare complication, however it might be more common than perceived because many cases likely go unreported. Difficulty in removing a central line in neonates was first documented in 1990 by Gladman [1], and the only systemic review in neonates including 10 cases was completed by Serrano [2] in 2007. To the best of our knowledge, there are seven new cases –including the case reported in this article –that have been reported since 2007 [3–6]. We summarized characteristics of 14 reported cases in Table 1. We couldn’t include 3 cases from Japan [6], as very few details were reported regarding difficulty with PICC removal. Continued data is necessary as there is no standard of care regarding removal of the line. It is also unclear under what circumstances surgical intervention is indicated and remains a clinical decision on a case-to-case basis.
Characteristics of the reported cases with entrapped PICC
Characteristics of the reported cases with entrapped PICC
Following are few mechanisms that can lead to in this complication. Vasospasm - This is noted to be the most common cause in general population, but it has been only reported as a possible cause in one of the neonatal cases documented. This is likely due to the fact that most vasospasms are due to irritation to vessel wall and most will likely resolve with time. This may be why these cases are less likely to be reported and rarely would require surgical intervention. It is likely that vasospasms occur in addition to other causes leading to a more complex picture [7, 8]. Infection leading to adhesions - Adhesions are often biofilm growth on the end of the catheter. Based on the review of 14 cases, this seem to be one of the most common causes in the neonatal population with 7 of the 14 case reported as being septic [1, 2]. Fibrin sheaths/thrombosis - these occur due to reactions between the catheter, vessel wall and blood elements. There were two cases reported with fibrin sheaths and one report of thrombosis [9–12].
Risk factors
While there are many risk factors that have been speculated, on review there were three factors that were repeatedly addressed in case reports and/or proven via prospective studies. These include sepsis [1, 2], length of catheter duration as this increases infection risk [3, 6] and extremely or VLBW infants [2, 6]. It is likely improper catheter position is also a risk factor as it can lead to complications although there is insufficient evidence as this time. Additional factors to consider include, TPN and possibly catheter size. TPN, specifically infusing through small blood vessels, can result in thrombus formation and this risk is compounded by high osmolality of TPN further predisposing to endothelial damage resulting in clot formation [10].
Interventions
In Serrano’s review, six of the ten cases were required surgical intervention [2]. Among the cases described after 2006, three of the four also required surgical intervention [3–5]. This data suggests that the need for surgical intervention may be a more common practice in the neonatal population than expected. On review of 14 cases documented [1–5, 12–14], it was noted that there was a variation in duration and location of placement, almost all neonates were on TPN and half were found to be septic. There was no clear association between any of these factors and the mode of removal of PICC line-surgical versus non-surgical.
As for when to consider surgical intervention there are currently no clear guidelines. In one case from a study in 1998 [10], gentle traction was applied for 6 days in a neonate before successful non-surgical removal. Recommendations made in Dr. Marx’s review in 1995 [7] suggests waiting 12–24 hours if there is still resistance after 20–30 minutes of initial attempts. Although in some cases that resulted in surgical intervention, except for one case it was not clear how long the non-surgical measures were tried. In that case, traction was applied for 3 days before the line was removed surgically [5]. In regards to the fibrin sheath, it is difficult to say if this complication requires more surgical intervention in comparison to other underlying causes. We speculate that unlike vasospasms that can resolve with time, infectious adhesions and fibrin sheaths will persist and therefore are more likely to require further interventions.
In conclusion, progress has been made in identifying causes and risk factors associated with difficult PICC removal. Specifically in neonates, the long term need for PICC placement and the frequent use of TPN may increase the risk of entrapment resulting in difficult removal. Regarding treatment methods, there is a need to further investigate the following: 1) guidelines regarding when surgical intervention is indicated, and 2) safe duration of observation before surgical intervention in stable neonates without signs of sepsis. Based on current research and the outcome of this case, we recommend to consider waiting at least 24–36 hour prior to considering surgical intervention as long as the patient is aseptic and clinically stable.
Disclosure statements
The authors have no conflicts of interest relevant to this article.