Total parenteral alimentation via indwelling umbilical catheters in the newborn period

Total parenteral alimentation (TPA) was delivered to 80 infants via indwelling umbilical artery and to 9 via indwelling umbilical venous catheters. The primary indication for catheter placement and maintenance was monitoring of arterial blood gases (umbilical venous catheter tip in left atrium) in a group of sick neonates requiring increased inspired oxygen or assisted ventilation. Results were compared with those from 23 infants who had tunnelled jugular catheters for a variety of chronic medical and surgical problems preventing gastric or intestinal feeding. A mean weight gain was achieved in both groups. Mortality and morbidity rates were similar in both groups. The most common complications were infection and thrombotic phenomena. Metabolic complications were few. It is concluded that infusing TPA solutions via indwelling umbilical catheters presents no greater risk than infusion via tunnelled jugular catheters, and provides a method for supplying adequate caloric intake for growth during the acute stage of illness.     

Central venous catheter insertion by femoral vein: safety and effectiveness for the pediatric patient

Prospective observations made during surveillance of routine central venous catheterizations for hemodynamic monitoring were evaluated to determine the safety and effectiveness of femoral insertion of central venous catheters and to demonstrate the feasibility of teaching pediatric residents to perform this procedure. During a 19-month period of observation, 29 pediatric patients requiring a central venous catheter underwent attempted percutaneous femoral vein catheterization. Femoral catheterization was successful in 86% of patients attempted, and insertions by pediatric residents were successful in 68% of patients attempted. Arterial puncture was the only significant complication of insertion, occurring in 14%, and was not associated with adverse sequelae. During 33 months of observations, complications of indwelling femoral central venous catheters did not significantly exceed the frequency for internal and external jugular, subclavian, and antecubital central venous catheters. During more than 4 years of observation, the significant complications associated with indwelling femoral central venous catheters were swelling of the leg or documented thrombosis in 11% of 74 critically ill patients. These observations indicate safety and effectiveness of femoral central venous catheters which compares favorably to central venous catheter insertion by other routes. In contrast to previous reports of central venous catheter insertion via subclavian and internal jugular veins, we observed no cardiorespiratory compromise as a result of femoral central venous catheter complications. Skill in this technique is a feasible educational goal for pediatric residents.     

Umbilical vascular catheters: Localization by two-dimensional echocardio/aortography

Summary Umbilical vascular catheters are often necessary in the care of critically ill neonates. Position of the catheter tip is usually determined by roentgenography. Location of the umbilical arterial or venous catheter was determined by 2-dimensional echocardio/aortography in 55 consecutive infants and was compared to localization by thoraco-abdominal roentgenography. Most of the infants (76%) had respiratory distress syndrome or congenital heart disease. Echoaortographic localization of the umbilical arterial catheter correlated very closely (N = 50, r = .90) with roentgenographic determination. For localization of the tip of the umbilical venous catheters, echocardiography was more accurate than roentgenography (employing contrast echocardiography for confirmation of cardiac chamber position). Two-dimensional echocardio/aortographic localization of the tip of indwelling umbilical vascular catheters is as accurate as roentgenography in the arterial system and more accurate than x-ray for umbilical venous catheters. Echocardio/aortography is superior to roentgenography (in localizing the catheter tip) because it 1) avoids ionizing radiation, 2) makes positioning of the patient unnecessary, 3) allows visualization of the catheter in relation to cardiovascular structures, and 4) may allow demonstration of intraarterial thrombo-emboli.     

Reduced thrombus formation with silicone elastomere (silastic) umbilical artery catheters.

This report describes clinical experience with a radiopaque silicone elastomere (Silastic) umbilical artery catheter. Twenty infants, ten with polyvinyl chloride (PVC) umbilical artery catheters and ten with Silastic umbilical artery catheters, all positioned at the aortic bifurcation, had aortograms performed at the time of catheter removal. Catheter-associated thrombus formation was observed in nine of the ten infants (90%) with PVC umbilical artery catheters and in one of the ten infants(10%) with Silastic catheters. The incidence of lower extremity vasospasm associated with the two catheters was not significantly different. Aortic pressure tracing recorded through Silastic catheters were accurate, but slightly damped. Autopsies were performed on five additional infants who died with indwelling Silastic umbilical artery catheters. None of the catheters, nor their surrounding tissues, showed evidence of thrombus formation on either gross or microscopic examination. It is our experience that radiopaque silicone elastomere tubing can be used as an umbilical artery catheter and appears to have the advantage of being less thrombogenic than the standard PVC tubing currently in general use.     

Umbilical artery catheterization in newborns. I. Thrombosis in relation to catheter type and position.

Seventy-one sick newborn infants, who had an umbilical artery catheterized, were randomized in one of four catheter groups: long end-hole-, short end-hole-, long side-hole- or short side-hole catheter. A long catheter means a high position of the catheter tip (Th6--11) and a short catheter a low position of the tip (L3--5). An angiography through the indwelling catheter in order to diagnose thrombosis was performed before the catheter was withdrawn. Dissection of the aorta and its brances was performed on infants who died. The total frequency of thromboses was 26%. There were no thromboses among infants with long end-hole catheters while infants with short end-hole catheters had thrombosis in 26%, long side-hole catheters in 33% and short side-hole catheters in 64%. Long end-hole catheters functioned better than the others. Only 6 of 16 infants with thrombosis had physical signs from the legs, while 12 infants without thrombosis had similar signs.     

Central venous catheterization in infants and children with congenital heart diseases: Experiences with 500 consecutive catheter placements

Summary In a prospective study results of central venous catheter (CVC) placements in a consecutive group of 500 patients with less than 20 kg body weight undergoing cardiac surgery were evaluated. The incidence of previous cardiac surgery was 21% and the incidence of factors preventing the primary puncture of the right jugular or innominate vein was 13.4%. The anesthesiologists were free to select the catheterization technique, site of puncture, and catheter type. All CVC insertions were performed prior to surgery under continuous circulatory monitoring and optimal positioning of the anesthetized patient.Ninety-six percent of all catheterizations were successful, 81% of them on the first attempt. In the 4% of cases where catheterization failed, a CVC had to be placed by the surgeon. Of all catheters, 66% were positioned via the right internal jugular (IJV) or innominate vein (IV), 8% via the left, 16% via an external jugular vein (EJV), and 5% via other veins. Seventy-six percent of CVC insertions were performed with the Seldinger technique. Of the four catheter types used in this study, double lumen catheters were most frequently selected (38%). Placement of 22-ga single lumen catheters was preferred in infants with less than 5 kg body weight, in spite of their tendency to kink. Observed complications (10% arterial puncture, 4% hematoma, and 1% intrathoracic bleeding) never required immediate surgical intervention. Careful selection of appropriate catheters, as well as extensive experience and knowledge of the anatomical structures involved in special heart defects, helped to keep the risk of complications low.     

UMBILICAL ARTERY CATHETERIZATION IN NEWBORNS I. Thrombosis in Relation to Catheter Type and Position

Abstract. Seventy-one sick newborn infants, who had an umbilical artery catheterized, were randomized in one of four catheter groups: long end-hole-, short end-hole-, long side-hole- or short side-hole catheter. A long catheter means a high position of the catheter tip (Th_6–11) and a short catheter a low position of the tip (L_3–5). An angiography through the indwelling catheter in order to diagnose thrombosis was performed before the catheter was withdrawn. Dissection of the aorta and its branches was performed on infants who died. The total frequency of thromboses was 26%. There were no thromboses among infants with long end-hole catheters while infants with short end-hole catheters had thrombosis in 26%, long side-hole catheters in 33% and short side-hole catheters in 64%. Long end-hole catheters functioned better than the others. Only 6 of 16 infants with thrombosis had physical signs from the legs, while 12 infants without thrombosis had similar signs.     

Use of double-lumen umbilical vein catheters in a neonatal intensive care unit]

BACKGROUND: The aim of the study was to compare the success/failure rate and complications of insertion into the umbilical vein, of either double-lumen catheters (Charrière diameter 04, length 13 and 30 cm) or single-lumen catheters (Charrière diameter 05, length 40 cm) in a population of neonates admitted to a neonatal intensive care unit. The numbers of insertions of additional peripheral venous catheters were also compared. PATIENTS AND METHODS: The population was divided into two groups according to the severity of the respiratory failure. Group 1 (n = 52): normal hemodynamic parameters and moderate respiratory failure (FiO2 < 0.6): only single-lumen catheters were used. Group 2 (n = 56): low systemic pressure requiring vascular filling and/or inotropic drugs infusion and/or severe respiratory failure (FiO2 > 0.6): in this group, either single-lumen catheters or double-lumen catheters were inserted. RESULTS: The success rate of insertion of double-lumen catheters and of single-lumen catheters were similar (61% vs 71%: P = 0.7). Nineteen double-lumen catheters were inserted in the group 2. The average duration of double-lumen umbilical catheterization was not significantly different from simple-lumen catheterization (4.9 +/- 2.2 vs 4.6 +/- 2.2 days). Complications relating to the umbilical venous catheterization were uncommon: three catheter obstructions (two with single-lumen catheter, one with double-lumen catheters), two nosocomial infections (both with single-lumen catheter), one hydropericardium (with single-lumen catheter). In group 2, more peripheral venous catheters were required during the first 72 hours of life after insertion of single-lumen catheter than after insertion of double-lumen catheters (average number of peripheral venous catheters per infant: 1.6 +/- 0.83 vs 1 +/- 0.35 respectively; P < 0.01). CONCLUSION: Feasibility and complication rate of umbilical double-lumen catheters were similar to those of single-lumen catheters. The use of umbilical double-lumen catheters reduces the need of peripheral venous catheters.     

A new technique for transumbilical insertion of central venous silicone catheters in newborn infants

AIM: A new technique allowing placement of umbilical silicone venous catheters (USVC) is described and compared with percutaneous silicone venous catheters (PSVC). METHODS: Data were retrospectively recorded for 198 infants with USVC and 141 infants with PSVC. RESULTS: Overall rate of complications was low and comparable in both groups: thrombosis 1.2%, catheter-related sepsis 3.5% and mechanical obstruction 5%. CONCLUSION: A new device allows safe introduction of silicone catheters into the umbilical vein.     

Complications associated with indwelling catheters

Between 1983 and 1985, 170 consecutive patients received doxorubicin-containing adjuvant chemotherapy through central venous catheters, and four via a long indwelling catheter in the antecubital fossa. The objective of this retrospective study is to determine the acute and chronic complications associated with indwelling catheters. Ninety-four (56%) patients did not experience any complications. The incidence of acute complications was 2%, which included three pneumothorax. Twenty-nine (17%) patients experienced chronic complications. Of those, 20 (12%) developed infectious complications, and 9 (19%) developed thrombus. In addition, 12 (7%) developed multiple complications, and 32 (19%) patients had other local complications at the catheter site, which included allergic reactions and catheter breakage. Each of these complications was resolved with appropriate treatment. None of the patients died from complications of the indwelling catheter.     

Complications associated with indwelling catheters.

Between 1983 and 1985, 170 consecutive patients received doxorubicin-containing adjuvant chemotherapy through central venous catheters, and four via a long indwelling catheter in the antecubital fossa. The objective of this retrospective study is to determine the acute and chronic complications associated with indwelling catheters. Ninety-four (56%) patients did not experience any complications. The incidence of acute complications was 2%, which included three pneumothorax. Twenty-nine (17%) patients experienced chronic complications. Of those, 20 (12%) developed infectious complications, and 9 (19%) developed thrombus. In addition, 12 (7%) developed multiple complications, and 32 (19%) patients had other local complications at the catheter site, which included allergic reactions and catheter breakage. Each of these complications was resolved with appropriate treatment. None of the patients died from complications of the indwelling catheter.     

Factors associated with umbilical catheter-related sepsis in neonates

To determine factors associated with risk for umbilical catheter-related sepsis, we studied neonates with one or more catheters in place for more than 3 days. Among 225 infants with 357 umbilical catheters, catheter-related sepsis occurred in 14 infants (6%). Catheter-related sepsis occurred in 5% of infants with umbilical arterial catheters and in 3% of infants with umbilical venous catheters. Staphylococcal species accounted for 71% of cases of catheter-related sepsis. Multiple logistic regression analysis revealed that very low birth weight and longer duration of antibiotic therapy were significantly associated with risk for umbilical arterial catheter-related sepsis. Increased risk for umbilical venous catheter-related sepsis was best predicted by the simultaneous occurrence of higher birth weight and infusion of hyperalimentation solution. Catheter duration correlated with duration of antibiotic therapy and with infusion of hyperalimentation solution for both types of catheters; however, in the multivariable analysis, duration of catheterization was not found to be a significant independent predictor of risk for catheter-related sepsis for either type of catheter.     

Efficacy of thromboresistant umbilical artery catheters in reducing aortic thrombosis and related complications

Previous in vitro and in vivo reports suggest that catheters constructed of polyurethane with heparin bonded to the surface (HB-PU) are less thrombogenic than catheters made of polyvinyl chloride (PVC). A randomized trial sufficiently large (power 80%) to detect a reduction in the incidence of umbilical artery (UA) catheter complications, including aortic thrombus formation, from 45% to 20% was conducted in 125 infants. The infants were monitored for complications possibly related to the use of a UA catheter, such as systemic hypertension and abnormalities of lower extremity perfusion. The presence of aortic thrombi was assessed by ultrasound study 3.5 +/- 1.2 (SD) days and 11.1 +/- 2.3 days after insertion of the catheter. The use of HB-PU umbilical catheters did not lead to a significant reduction in the incidence of complications and aortic thrombi compared with the use of PVC catheters. The lack of reduction may have been related to the prolonged duration of catheter use in both groups. A much larger study would have been required to detect a smaller, but perhaps clinically significant, reduction in catheter-associated complications.     

Phrenic nerve injury after image-guided insertion of a tunnelled right internal jugular central venous catheter

Central venous catheters (CVC) are now commonly inserted by radiologists. Although complications are infrequent, they must be avoided where possible and recognized when they occur. We present a 10-year-old boy who developed right hemidiaphragmatic paralysis, requiring surgical plication, following US-guided insertion of a tunnelled right internal jugular CVC. The needle trajectory for internal jugular puncture must be planned to avoid the phrenic nerve.     

The umbilical arterial catheter: a formula for improved positioning in the very low birth weight infant.

OBJECTIVE:: An umbilical arterial catheter is often used to monitor blood pressure and take frequent blood samples in the very low birth weight newborn infant requiring neonatal intensive care. Incorrect placement of the umbilical arterial catheter increases catheter complications, and adjustment of catheter position after radiograph increases infant handling and infection risk. Current methods overestimate insertion length in very low birth weight babies. We suggest a new formula for calculating insertion length that is more appropriate for today's neonatal intensive care population. The Umbilical Arterial Catheter Calculation Study, Australian Perinatal Trials Register PT0398, was set up to investigate this technical change. Our hypothesis was that the new formula would improve the siting of umbilical arterial catheters in very low birth weight infants. DESIGN:: Randomized control trial. SETTING:: Tertiary referral neonatal intensive care unit. PATIENTS:: All infants <1500 g who were free from major cardiovascular malformations and who received an umbilical arterial catheter for clinical reasons were eligible for the study. INTERVENTIONS:: Infants were randomized to current practice, using a nomogram derived from Dunn (control), or to the new formula: insertional length (cm) = (4 x birth weight [kg]) + 7. Primary outcome was correct catheter position (T6-10) on initial radiograph. MEASUREMENTS AND MAIN RESULTS:: Seventy-four randomized infants had catheters successfully inserted. There were no significant differences between the groups in birth weight, gestational age, or gender. There was a significant increase in correctly sited catheters (p = .003) with the new formula. Overinsertion of the umbilical arterial catheter was significantly less likely (p < .0001). Underinsertion was not significantly increased. Umbilical arterial catheter manipulation after radiograph was decreased from 50% to 5% (p = .007). There was no increase in adverse effects. CONCLUSIONS:: The use of the new formula results in better overall placement and in significantly less overinsertion of umbilical artery catheters in very low birth weight infants.     

Coagulation-associated complications of indwelling arterial and central venous catheters during heparin prophylaxis - a prospective study

A prospective observational study was carried out to investigate complications of arterial and venous indwelling catheters. All patients of a mixed NICU/PICU admitted during a 12-month period were enrolled in this study with a stringent protocol of catheter prophylaxis, using heparin via continuous infusion in a dose of 100 IU/kg/day body weight or at least 100 IU/kg/day for each arterial and/or central venous catheter. Patients were regularly monitored for edema, thrombus, ischemia and catheter obstruction, i.e. complications amenable to heparinization. A total of 292 catheters in 130 patients were recorded. Patients' weight ranged between approximately 600 g to 10,000 g. Depending on the insertion site or type of catheter the frequency of complications was as follows: edema 0-12%; catheter obstruction 7-24%; ischemia 28-40%. No case of persistent thrombosis was detected. Conclusion A stringent protocol of heparinization leads to a low incidence of complications potentially amenable to anticoagulation.     

A comparative study of two different percutaneous venous catheters in newborn infants

Between 1985 and 1988 the use of percutaneous venous catheters in the intensive care of newborn infants was evaluated. A total of 140 polyurethane catheters used in 91 patients were compared with 143 silicone catheters in 121 neonates. Patients of both series were comparable regarding sex, weight, gestational age and severity of disease. Insertion technique, puncture site care and infusions remained the same for both observation periods. Peripheral insertion of silicone catheters required more venous cutdowns but threading them to a central vein or the right atrium was more often successful. Fewer local complications (i.e. reddening or swelling along the peripheral venous access) resulted in a longer catheter duration and a less frequent need for an additional venous access in the silicone group. On the other hand, silicone catheters caused more technical problems (i.e. rupture or obstruction). Upon removal, more silicone than polyurethane catheter tips were colonized with bacteria. This was independent of catheter duration and was never followed by clinical signs of infection. The silicone catheter gave better results, especially in very small newborn infants of low gestational age, but was associated with more technical problems.     

植入式中心静脉给药装置在儿童肿瘤应用中常见并发症的预防和处理

目的讨论植入式中心静脉给药装置（化疗泵）在恶性肿瘤患儿治疗中常见并发症的预防和处理。方法1999年6月～2004年6月，共计79例肿瘤患儿安装化疗泵并经泵化疗。60例经颈外静脉切开插管．导管头端置于上腔静脉；10例经颈内静脉插管；9例锁骨下静脉穿刺插管，泵体置于侧胸壁皮下。结果79例患儿平均带泵天数721d。其间10例发生导管阻塞，1例置泵1年后泵体处皮肤磨损。79例经泵抽血培养98次，其中有菌生长17次。结论全麻下经颈外静脉切开插管为安装化疗泵的首选方法。化疗泵安装和应用的规范化是减少和预防并发症发生的主要措施，并发症的预防和及时有效的处理是化疗泵安装得以全面推广的可靠保证。     

Cardiomegaly in a premature neonate after venous umbilical catheterization

Umbilical venous catheters allow rapid central access in neonates, but may be associated with various complications. We present a case of a newborn with pericardial effusion following umbilical venous catheterization. An extremely low birth weight infant was intubated for respiratory distress syndrome and had umbilical venous and arterial lines in place. Massive cardiomegaly was noted on the subsequent chest X-ray. Echocardiography revealed a large pericardial effusion without signs of tamponade. After removing the catheter, the effusion gradually resolved. While pericardial effusion is a well-known complication of percutaneous long central lines, only a few case reports have documented sudden cardiovascular compromise associated with umbilical venous catheters. Pericardial effusion may be asymptomatic and should be suspected in infants with central catheters and progressive cardiomegaly. The prompt removal of catheters and, if signs of cardiac tamponade are present, emergency pericardiocentesis may prove to be life-saving.     

Indwelling umbilical arterial catheter: a preferred sampling site for blood culture

Indwelling umbilical arterial catheter was evaluated prospectively as an alternative site for blood culture sampling. In 282 infants, 318 paired blood cultures were obtained from the peripheral vein and from the indwelling umbilical arterial line. Duration of umbilical catheter placement ranged from 0.5 to 196 hours; in 17% of the infants, catheters were in place for between 24 and 196 hours. In 13 blood culture pairs the same pathogens were found and had been obtained from the peripheral vein and the umbilical arterial line. Two pairs were positive for discrepant organisms. A total of 11 pairs were positive in one site only, with five positive from peripheral vein only and the other six from the umbilical arterial catheter. However, most of these single-site positive blood cultures were apparently true positives based on supporting laboratory data for infection. Contamination rates were 1.3% and 0.9% for peripheral vein and umbilical arterial catheter blood cultures, respectively. Thus, in sick neonates, the indwelling umbilical arterial line was an alternative and perhaps a preferred site for blood culture sampling.