Presented at the Neonatal Society 2014 Autumn Meeting.
Job S, Damodaran S, Brooke P, Mo J, Pickworth F, Clarke P
Neonatal Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
Background: Percutaneously-inserted central venous catheters (PCVCs) are vital for successful management of neonates in intensive care. One potential complication of PCVCs is inadvertent lodgement in an ascending lumbar vein (ALV). Associated morbidity of this specific malposition has included epidural extravasation of parenteral nutrition, seizures, quadriplegia, and death (1). However the incidence of ALV catheter malposition is unknown. The aims of our study were to determine the incidence of PCVC malposition in the ALV, whether left-sided catheterisation has a predilection for this malposition, and the prevalence of routine radiopaque contrast use in UK tertiary-level neonatal units for checking PCVC position after insertion.
Methods: A bespoke in-house clinical database was developed to log details of all PCVCs inserted in our neonatal unit. This ‘long line database’ has been in daily use since 2007 and records catheter insertion date and type, intended use, tip location verified by radiography after routine injection of radiopaque contrast, removal date and reason, and any complications. We interrogated this database for cases of suspected ALV malposition and crossreferenced with a separate, prospectively-maintained list of suspected or reported cases compiled since 2005. All radiographs of suspected or radiologically-reported ALV malposition underwent further independent review by two senior radiologists. In February 2013 we conducted by telephone a national survey of UK tertiary-level neonatal unit practices regarding use of radiopaque contrast for checking PCVC position.
Results: 1113 PCVCs were inserted in our NICU over 9.5 years (January 2005 to June 2014). Of the 39 cases of suspected ALV catheter malposition, 9 were excluded after radiological review. 30 cases were confirmed, indicating an incidence of ~3 ALV malposition cases per year in our NICU. 23 (77%) involved the left ALV and 7 (23%) involved the right ALV. Affected babies had a median (range) birth gestational age 27 weeks (24-40 weeks) and birth weight 1099 g (515-3930 g). Of 818 PCVC insertions logged in the long line database, 386 (47.2%) involved lower limb catheterisations and included 25 of the confirmed ALV cases. The incidence of ALV malposition for lower limb-inserted PCVCs (25/386) was therefore 6.5% (95% CI: 4.2% to 9.4%). The risk of ALV catheter malposition was much higher with left lower limb inserted catheters (left lower limb 19/160 vs. right lower limb 6/226, p=0.0006). Only 27 (52%) centres used contrast (11 routinely for all PCVCs inserted; 16 only after insertion of 28-Gauge catheters).
Conclusion: We present the largest ever reported series of ALV catheter malpositions. Our data derive from a single centre that has routinely used radiopaque contrast to verify the initial position of inserted catheters. ALV malposition affects approximately 1 in every 15 lower-limb inserted PCVCs, and we confirm that left-sided catheterisation has a significantly higher predilection for the ALV. The routine use of contrast may facilitate the early recognition of this potentially-dangerous malposition.
Corresponding author: Paul.Clarke@nnuh.nhs.uk
1. Clarke P, et al. J Paediatr Child Health 2003; 39: 386-9.