Percutaneously implanted silastic catheters in the neonate

In 21 infants requiring total parenteral nutrition 23 Silastic central venous catheters were placed by percutaneous insertion into the basilic vein. Weight of the infants was 1770 g (980-3540 g), age at time of insertion 1,6 days (1-16 d), gestational age 32 weeks (29-39) weeks. Catheters remained in place between 3 and 37 days, total 451 patient days. No problems as infection or thrombophlebitis or caval obstruction occurred.     

Percutaneous central venous catheterization. Three years' experience in a neonatal intensive care unit

Prolonged venous access is desirable in very-low-birth-weight infants and infants for whom feedings are contraindicated. We prospectively evaluated 481 small-diameter venous catheters placed percutaneously in 317 patients over 3 years. Of 478 catheters, 241 (50%) were placed in infants weighing 1 kg or less. Mean catheter stay was 13 days (range, less than 1 to 77 days). Almost half (49%) of the central and thoracic catheters (91% of placements) were removed nonelectively: 43% due to problems such as leaking or clotting and 6% to suspicion of sepsis or venous occlusion. Of the 23 episodes of possible sepsis in the 478 catheter stays, six (1.3%) were confirmed catheter-related sepsis; 12 (2.5%) were confirmed alternate locus sepsis. Three factors specific to percutaneous central venous catheter-related sepsis were prolonged catheter stay (3 to 5 weeks), Staphylococcus epidermidis, and weight less than or equal to 1 kg. Four factors specific to alternate locus sepsis were presence of an alternate infection site, earlier infection (1 to 2 weeks), extremely low birth weight, and prolonged clinical instability. Percutaneous central venous catheterizations reduced the need for the stress of repeated venipuncture, resulting in lower complication rates than those reported with surgically placed central venous catheters, and leading to identification of risk factors specific to catheter sepsis and alternate locus sepsis.     

Pericardial effusion complicating a percutaneous central venous line in a neonate

A premature infant developed pericardial effusion four days after the insertion of a 25-gauge silastic percutaneous central venous catheter. The effusion contained parenteral nutrition fluid and resolved rapidly after withdrawal of the catheter. Pericardial effusion is a potential complication of percutaneous, as well as surgically placed, central venous catheters.     

Central venous silicone elastomer catheter placement by basilic vein cutdown in neonates

There is a need for central venous access in small premature infants and other neonates when enteral feeding is not tolerated or is contraindicated. We placed 83 small (0.635-mm od) silicone elastomer catheters by basilic vein cutdown through a subcutaneous tunnel in 79 patients during a 12-month period. Thirty-five patients (44%) weighed less than 1,000 g. Each patient on whom the procedure was attempted had successful placement of a catheter, and they remained in place a mean of 20 days (range three to 82). Patients had a mean weight gain of 15 g per day of catheter use. Sixty-two catheters (75%) were removed electively, 13 (16%) secondary to complications, six (7%) because of patient deaths (none catheter related), and two (2%) were accidentally dislodged. Two episodes of catheter-related sepsis (0.12 episodes per 100 days of catheter use) caused by Candida albicans and Staphylococcus epidermidis were encountered. Other complications included one subclavian vein thrombosis, eight catheter occlusions, and two local arm inflammations. This technique proved to be a safe, easy, and inexpensive method to administer parenteral nutrition to neonates, especially those weighing less than 1,000 g.     

Persistently low blood retinol levels during and after parenteral feeding of very low birth weight infants: examination of losses into intravenous administration sets and a method of prevention by addition to a lipid emulsion

Very low birth weight infants have little storage of hepatic retinol and are, therefore, highly dependent upon an exogenous supply. The recent association between low serum retinol level and bronchopulmonary dysplasia and the persistently low serum levels of retinol during total parenteral nutrition prompted a prospective study to evaluate serial changes in serum retinol levels during 1 month of total parenteral nutrition (retinol dose 455 micrograms/d) and again during 1 month of total enteral feeding (retinol dose 200 to 300 micrograms/d) in the same infants. Infants were divided into two groups. Group 1 consisted of infants weighing less than 1,000 g (n = 24) and group 2 consisted of infants weighing 1,000 to 1,500 g (n = 17). Although initial mean levels of retinol were similar in both groups (14.8 +/- 0.9 and 13.5 +/- 0.7 micrograms/dL), there was wide variation between infants. In group 1 infants, there was a significant (P less than .01) decline in retinol level by the second week of life (to 9.2 +/- 1 micrograms/dL), which persisted during total parenteral nutrition, but increased to 13.4 +/- 2 after 1 week of enteral feeding. This level was maintained throughout enteral feeding. In group 2 infants, there was no significant change in serum retinol level throughout the study. During total parenteral nutrition, several infants had retinol levels below 10 micrograms/dL, a level associated with signs of retinol deficiency in older children. Because losses of retinol are known to occur in smaller volume total parenteral nutrition solutions, it was speculated that losses of retinol in our patients were due to retinol losses in the total parenteral nutrition delivery system.(ABSTRACT TRUNCATED AT 250 WORDS)     

Percutaneous central iv access in the neonate: experience with 535 silastic catheters

We examined 535 central venous catheterizations performed in a neonatal intensive care unit. A total of 273 catheters were positioned using intra-atrial ECG monitoring. With an average indwelling time of 23 days, we noted one complication for every 153 indwelling catheter days. A diagnosis of sepsis was confirmed on 22 occasions (4.1 %). Sepsis occurred more often in infants with a birth weight < 1000 g (6.9%) compared with infants 1000g (3.1%). The risk of phlebitis was highest when the saphenous vein was used as the puncture site. The lowest risk of phlebitis was when the basilic vein was chosen. Five cases of thrombosis, two of myocardial perforation and one intravascular catheter breakage were registered. Catheter placement under ECG monitoring proved to be a very suitable method for reducing the incidence of malpositioning. There were no side effects specific to the ECG method. The ECG method can be used safely and makes radiological control usually unnecessary. Central venous catheters, newborn infant, parenteral nutrition, silicone catheters     

27-gauge percutaneous catheters: use in nutritional management of very-low-birth-weight and severely premature newborns in a neonatal intensive care unit]

Percutaneous central venous catheterization for parenteral feeding is a permanent problem in the management of very low birth weight neonates. Usually, 23-gauge catheters (diameter: 0.6 mm) are used. In our unit, we have started to use 27-gauge catheters (diameter 0.35 mm) since 1995. The aim of this study was to report our experience with this materiel. SUBJECT AND METHODS: Between September 1, 1997 and January 30, 2000, 352 catheter implantations were performed using 27-gauge infusing sets in 200 premature infants (gestational age less than or equal to 33 weeks [mean 29.2], weight less than or equal to 1,500 g [mean: 1, 152.5 g]). Data were reviewed retrospectively with the view to determine the modality of use and complications. Peculiar insertion modalities were prospectively evaluated in the 50 last included infants (92 catheters). RESULTS: In 97% of cases, the physician needed no help to insert the catheter. In 99.5% of cases (199 neonates), the insertion was successful (the procedure failed in one case). The mean duration procedure was 26 min (range 10 to 85 min). The mean age at insertion of the first catheter was 29 hours (range 0 to 216). Mean catheter maintenance duration was 15 days (range 1 to 53). In 31 cases, documented sepsis related to the catheter were noted (8.8% or 5.8 infections for 1,000 catheter-days). Endocarditis was observed in one case. A pericardial effusion was diagnosed in two cases. No death related to the catheter was noted. CONCLUSION: In our experience, 27-gauge catheter implantation is an easy and safe procedure. We noted no major maintenance problems. Complications were not observed more frequently than those usually encountered with 23-gauge catheters. We conclude that 27-gauge catheter utilization is an attractive alternative for percutaneous central venous catheterization, in very low birth weight neonates.     

Nutritional support of very-low-birth-weight infants requiring prolonged assisted ventilation

We studied the influence of nutritional support on weight loss and time to regain birth weight (BW) (less than 1500 g) in infants requiring prolonged assisted ventilation. A total of 134 infants admitted between 1980 and 1982 were reviewed. Birth weight, gestational age, lowest recorded daily weight and percentage of loss, days to recover BW, energy intake, and nutrient source during the BW-recovery period were determined. A decrease in weight loss (13% to 10%) and in mean (+/- SD) recovery time (20.9 +/- 7.3 days to 13.8 +/- 6.4 days) in very-low-birth-weight, critically ill infants was noted. The use of parenteral feeding routes increased, as well as tolerance of initial enteral feedings following parenteral support. We attribute the decreased convalescence period for BW recovery to improved nutrition secondary to the increased use and earlier initiation of parenteral nutrition.     

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.     

Percutaneous catheterization of the axillary vein in infants and children

The axillary vein was evaluated as an alternative access site for central venous catheterization in critically ill infants and children. Children were placed in the Trendelenberg position (when possible) with arm abducted 100 to 130 degrees. The vein was entered parallel and inferior to the artery. Success rate for catheterization was 79% (41/52). Catheter diameter range was 3 to 8.5 F and catheter length range was 5 to 30.5 cm. Median patient weight was 7.0 kg (3.0 to 59 kg). Median age was 0.91 years (14 days to 9 years). All central lines ended in the subclavian, innominate, or superior vena cava. Median catheter duration was 8 days (2 to 22 days). A total of 338 patient catheter-days were studied. Central venous pressure was successfully monitored in five of five attempts. Complications with insertion (3.8% of attempts) included one pneumothorax and one hematoma. Complications during catheter duration (9.8% of catheters, 1.1% per catheter-day) included one instance each of venous stasis, venous thrombosis, catheter sepsis, and parenteral nutrition infiltration. No complication contributed to a patient mortality. Success and complication rates were comparable with those in jugular catheterization studies in children. The axillary approach is an acceptable route for central venous catheterization in critically ill infants and children.     

Survival after an acute pericardial tamponade as a result of percutaneously inserted central venous catheter in a preterm neonate

Percutaneously inserted central venous catheters (PICC) are used in premature infants to deliver intravenous fluids, total parenteral nutrition (TPN) and medications. This article reports a case in which the baby developed pericardial tamponade within 3 hours of starting TPN through a PICC. This was successfully treated with percutaneous subxiphoid pericardiocentesis. Pericardial tamponade should be suspected in any infant with a PICC line in place, and who suddenly develops shock like symptoms, non-attributable to usual causes.     

The use of a crystalline amino acid mixture for parenteral nutrition in low-birth-weight infants.

Thirty-six preterm, sick, low-birth-weight neonates were given either total or partial parenteral nutrition. The patients were divided into three groups according to their birth weights: group A -less than 1,000 gm, 12 patients: group B--between 1,000 and 1,500 gm, 15 patients: group C--more than 1,500 gm, 9 patients. The solution for total parenteral nutrition contained 20% glucose and 2.6% crystalline amino acids plus appropriate amounts of vitamins and minerals. The volume of infusate given was usually 125 ml/kg/day, but varied depending on the clinical condition of the patient; occasionally it was as high as 150 to 175 ml/kg/day. Infusate of one-half strength was administered initially; its concentrations of glucose and amino acids were increased to three quarters and full strength gradually, if tolerated. The solution for total parenteral nutrition was infused into the superior vena cava via a central venous catheter; that for partial parenteral nutrition was given into a peripheral vein to supplement inadequate oral feedings. The period of parenteral nutrition lasted from 5 to 49 days, with an average of 13.2 days. The intake of 500 mg of nitrogen as crystalline amino acids and 100 kcal as glucose was capable of achieving body weight gain. Positive nitrogen balance of various degrees was also observed. Hyperglycemia of a slight to moderate degree was observed in nine patients; only three required insulin therapy. Two patients had thrombotic occlusion of the central venous catheter. The conclusion was reached that total parenteral nutrition or partial parenteral nutrition, when properly managed, is a safe procedure in small, premature infants. The amino acid solution given as a nitrogen source along with adequate calories was effective in promoting weight gain and nitrogen balance; it was apparently well tolerated by low-birth-weight neonates.     

Insulin-like growth factor I (somatomedin C) in premature infants on total parenteral nutrition. Relations with nutritional status and protein-energy intakes]

Insulin-like growth factor I (IGF I) is like prealbumin and transferrin a marker of nutritional status. Its level increases with gestational age. The levels of IGF I (96 times), transferrin (86 times) and prealbumin (69 times) were measured in blood samples from 26 premature infants aged 8 to 78 days (gestational age: 28 to 34 weeks, birth weight: 840 to 1,800 g). At the time of sampling, all the infants were on total parenteral nutrition (360 +/- 42 kJ/kg/day and 2.5 +/- 0.3 g of proteins/kg/day). The results were analysed with reference to anthropometric parameters (weight, height, head circumference, skinfolds and arm circumference). There was no correlation between plasma IGF I and anthropometric measurements. There were significant correlations between IGF I and transferrin (p less than 0.01), prealbumin (p less than 0.05), protein intake (p less than 0.01) an energy intake (p less than 0.05). Plasma IGF I increased at the end of the first week of parenteral nutrition in all the 5 infants having initial low values. The plasma IGF I was not correlated with the duration of parenteral nutrition in the 26 infants after the second week of nutrition. IGF I measurement is useful for evaluating the protein nutritional status of premature infants on total parenteral nutrition.     

Percutaneous Silastic catheters in newborn and premature infants. A report of experiences with 497 catheters in 5 years]

BACKGROUND AND METHODS. Central catheters are an important prerequisite for adequate parenteral nutrition in preterm infants. However, a variety of complications have been shown to be associated with central lines: septicemica, thrombotic complications, mechanical complications. In this retrospective analysis we summarize our recent experience with central silastic catheters. RESULTS. Within a five-year-period (1986-1990). 497 silastic-catheters were inserted in 366 high risk neonates (mean birthweight 1360 g; 1060-1740 g, 25.-75. percentile) treated at the NICU, Department of Pediatrics, University of G?ttingen. 451 catheters which were placed in a central position, were removed after an average duration of 11 days (mean; 8-18 days, 25.-75. percentile). During the observation period, 62.8 percent of the catheters were purposely removed. Making use of the Kaplan-Meier-curve, we calculated how long the catheter could stay without complications; 50% of all catheters could be expected to be in place for 25 days. The incidence of septicemia was 1.9%, bacterial contamination of the catheters was evident in 22% of all central lines. The most predominant microorganisms responsible for catheter-contamination were coagulase-negative staphylococci. In addition, catheters were removed because of signs of phlebitis or suspected thrombotic complications (11.1%), and mechanical complications (dislocation, occlusion; 11.7%). Due to malposition of the central catheter two preterm infants developed pericardial effusions. There was no correlation between the site where the catheter was inserted and these complications. CONCLUSION. Central silastic catheters wherever clinically indicated are a valuable adjunct in the parenteral nutrition on high risk neonates.     

Staphylococcus epidermidis and retention of neonatal percutaneous central venous catheters.

The percutaneous insertion of central venous catheters has become an established practice on many neonatal units. We describe four low birthweight babies, whose catheters became tethered in the vein, and discuss the management of this unusual complication.     

Central venous lines in neonates: a study of 2186 catheters

OBJECTIVE: To describe the use of percutaneously inserted silicone central venous lines (CVLs) in neonates at the Royal Brisbane and Women's Hospital, Australia. DESIGN: Data for all infants admitted from 1 January 1984 until 31 December 2002 who had a CVL were examined in the neonatal database, completed from paper records and patient charts where necessary. Autopsy reports of all babies who died with a catheter in place were reviewed. RESULTS: There were 18,761 admissions, 2186 catheters in 1862 babies for a total of 35,159 days (median 14 days, range 1-99 days). The tip was in the right atrium for 1282 (58.6%) of the catheters. A total of 142 babies (7.6%) died with a CVL in place, 89 (4.8%) with the catheter tip in the right atrium. Thirty two of these 89 babies had an autopsy. No autopsies reported tension in the pericardium or milky fluid resembling intralipid. One case (0.05% of catheters) of non-lethal pericardial effusion occurred in a baby whose catheter was inappropriately left coiled in the right atrium. There were no cases of pleural effusion related to CVL use. Most (1523, 69.7%) were removed electively. Septicaemia occurred during the life of 116 catheters (5.3%). CONCLUSION: This is the largest series of percutaneously inserted silicone central venous catheters reported. It illustrates the safety of these catheters in this context. It highlights the value of keeping prospective records on such catheters. Catheters with their tips in the right atrium and not coiled did not cause pericardial effusion. Strict insertion and management principles for CVLs should be adhered to.     

Percutaneous silicone catheters in the newborn infant

246 percutaneous insertions of silastic venous catheters were performed in 189 newborn infants. This technique makes perfusion in newborn easier and safer, with less complication risks and less work for nurses. Furthermore silastic venous catheters insure a better observation of neonatological care methods. As a consequence it improves the vital prognosis and the quality of newborn survival in the newborn intensive care unit.     

Incidence of catheter-related infections within 30 days from insertion of Hickman-Broviac catheters

AIM: To evaluate the incidence of surgical site infections and bacteremias occurring within 30 days from insertion of partially implanted central venous catheters. PATIENTS AND METHODS: Four hundred eighteen devices positioned in children with cancer or undergoing bone marrow transplant were followed prospectively. RESULTS: During a follow-up of 12,394 catheter-days, a total of 13 infectious episodes were documented, with an overall incidence of 3.1% and 1.05 episodes/1,000 catheter-days. Coagulase-negative staphylococci represented the causative pathogens of all episodes. Overall, surgical wound infections occurred in 1.4% of all catheters, with a rate of 0.48/1,000 catheter-days, while isolated bacteremias were observed in 1.7% of all inserted devices, with a rate of 0.57/1,000 catheter-days. CONCLUSIONS: Infections are rare events within 30 days from insertion of partially implanted central venous catheters and coagulase-negative staphylococci represent the most frequently isolated cause of these complications.     

Pediatric parenteral amino acid mixture in low birth weight infants

A mixture of amino acids designed to maintain normal plasma amino acid concentrations in infants and children requiring parenteral nutrition was evaluated in 28 low birth weight (LBW) infants (birth weight, 750 to 1750 g; postnatal age, 1 to 4 weeks) who required parenteral nutrients for optimal nutritional management. Sixteen babies received only parenteral nutrients for five to 21 days. Ten of these received a typical regimen by peripheral vein (1.91 +/- 0.16 g/kg/d of amino acids and 44.7 +/- 4.4 kcal/kg/d) and six received a typical regimen through a central vein (2.39 +/- 0.11 g/kg/d of amino acids and 95.9 +/- 14.5 kcal/kg/d). Mean weight gain of the peripheral vein subgroup was 10.3 +/- 10.6 g/kg/d; mean nitrogen balance was 230 +/- 66 mg/kg/d. Both the mean rate of weight gain (17.2 +/- 5.1 g/kg/d) and the mean rate of nitrogen retention (267 +/- 49 g/kg/d) of the central vein subgroup were similar to intrauterine rates. In these two subgroups as well as the total population, plasma concentrations of all amino acids except phenylalanine were within the 95% confidence limits of the plasma concentrations observed in LBW infants fed sufficient amounts of human milk to result in a rate of weight gain similar to the intrauterine rate. However, although plasma tyrosine and cyst(e)ine concentrations were within the 95% confidence limits of the plasma concentrations goals, the LBW infant's ability to use N-acetyl-L-tyrosine and cysteine HCl appears to be even less than that of the term infant and older child. In toto, these data support the efficacy of the amino acid mixture evaluated for LBW infants. Of equal importance, they suggest that the LBW infant's ability to use parenterally delivered amino acids is not as limited as commonly thought.     

Pulmonary edema. A rare complication of the percutaneous insertion of silastic central venous catheters

Seven newborn infants (birth weight 920 to 1,900 g) who developed pulmonary oedema as a complication of the use of percutaneous silastic central venous catheters are described. Clinical symptoms occurred three to forty days after catheter placement. In each case, radiographic detection, performed by the injection of radiopaque dye, localized the tip of the catheter in the pulmonary artery or in its collateral branches. Clinical symptoms decreased after catheter replacement in the right atrium. The casistic examination allows the Authors to suggest some aetiopathogenetic hypothesis.