The Great Debate in Neonatal PICCs

FANNP 24TH NATIONAL NNP SYMPOSIUM: CLINICAL UPDATE AND REVIEW
A6a
The Great Debate in Neonatal PICCs:
Catheter Tip Location and What IS
Central?
Elizabeth Sharpe, DNP, ARNP, NNP-BC, VA-BC
Neonatal Nurse Practitioner
St. Mary’s Medical Center, West Palm Beach, FL
The speaker has disclosed that she is a clinical education consultant for Argon Medical Devices, which could be perceived as having a
bearing on her presentation of this subject. She has no significant financial interest or relationship with any other companies or the
manufacturer(s) of any commercial product and/or service that will be discussed as part of this presentation.
Session Summary
The presenter will review of the latest evidence, including anatomical, hemodynamic and pharmacologic
implications of catheter tip location, and the potential risks for serious complications associated with
suboptimal tip location. Also, a look at new technological advances.
Session Objectives
Upon completion of this presentation, the participant will be able to:
 identify the difference between central and non-central catheter tip locations;
 identify the implications of catheter tip locations;
 name three complications that occur due to movement of the catheter tip location;
 identify two risk factors for malposition;
 identify at least two preventive strategies to minimize complications.
References
Eifinger, F., Brisken, K., Roth, B. & Koebke, J. (2011). Topographical anatomy of central venous system in extremely lowbirth weight neonates less than 1000 grams and the effect of central venous catheter placement. Clinical Anatomy,
24(6): 711-716.
Kugelman, A., Inbar-Sanado, E., Shinwell, E., Makhoul, I., Meiron, L., Zangen, S., Wattenberg, O., Kaplan, T., Riskin, A. &
Bader, D. (2008). Iatrogenesis in neonatal intensive care units: Observational and interventional, prospective,
multicenter study. Pediatrics, 120(3): 550-555.
Nadroo, A., Lin, J., Green, R., Magid, M. & Holman, I. (2001). Death as a complication of peripherally inserted central
catheters in neonates. Journal of Pediatrics, 138(4): 599-601.
Nowlen, T., Rosenthal, G., Johnson, G., Tom, D. & Vargo, T. (2002). Pericardial effusion and tamponade in infants with
central catheters. Pediatrics, 110(1): 137-142.
Pettit, J. (2002). Assessment of infants with peripherally inserted central catheters: Part 1. Advances in Neonatal Care,
2(6): 304-315.
A6a: THE GREAT DEBATE IN NEONATAL PICCs
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FANNP 24TH NATIONAL NNP SYMPOSIUM: CLINICAL UPDATE AND REVIEW
Pettit, J. & Wyckoff, M. (2007). Peripherally inserted central catheters guidelines for practice (2nd ed). Glenview, IL:
National Association of Neonatal Nurses.
Warren, M., Thompson, K., Popek, E., Vogel, H. & Hicks, J. (2013). Pericardial effusion and cardiac tamponade in
neonates: Sudden unexpected death associated with total parenteral nutrition via central venous catheterization.
Annals of Clinical & Laboratory Science, 43(2): 163-171.
Session Outline
See presentation handout on the following pages.
A6a: THE GREAT DEBATE IN NEONATAL PICCs
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FANNP 24TH NATIONAL NNP SYMPOSIUM: CLINICAL UPDATE AND REVIEW
Disclosures
The Great Debate in Neonatal PICC’s
• Clinical Education Consultant for Argon Medical Devices
• Acknowledgements for Images Permissions
k
l d
f
i i
– Argon Medical Devices – Lumos Catheter Systems
Catheter Tip Location & What IS Central?
Elizabeth Sharpe, DNP, ARNP, NNP‐BC, VA‐BC FANNP, October 2013
What are the indications for PICCs?
Transitioning from umbilical lines
Premature infants < 1500 gms
Hyperosmolar ( > 600 mOsm/L) Irritant medications
pH <5 or >9 (INS 2011)
pH <5 or >9 (INS, 2011) More than 6 days of hyperosmolar IV therapy (CDC,2011)
• GI, congenital cardiac defects
• Limb anomalies, birth injuries
•
•
•
•
•
•
Osmosis and Cell Volume
Hypotonic
Isotonic
Hypertonic
Review
•
•
•
•
Chemistry
Physics
Anatomy
Physiology
Medication
pH
Osmolarity
Irritant
Ampicillin
250 mg/ml SW
100 mg/ml SW
8.0‐10.0
1215 mOsm/L
X
Gentamicin
3.0‐5.5
262 mOsm/L
Meropenem
7.3‐8.3
~300 mOsm/L
Phenobarbitol
9.2‐10.2
> 9000 mOsm/L
Piperacillin/ tazobactam
5‐6
270‐445 mOsm/L
293 mOsm/L
X
Vancomycin
2.5‐4.5
249 mOsm/L
X
Acyclovir
10.5‐11.6
278 mOsm/L
X
Courtesy & ©Argon Medical Devices
A6a: THE GREAT DEBATE IN NEONATAL PICCs
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FANNP 24TH NATIONAL NNP SYMPOSIUM: CLINICAL UPDATE AND REVIEW
References
Infusate
mOsm/L
Normal saline
308 mOsm/L
D 5 %
260 mOsm/L
D 10 %
10 %
505 O /L
505 mOsm/L
D 12.5 %
625 mOsm/L
TPN
> 800 mOsm/L
Site for images:
http://www.cincinnatichil
drens.org/service/v/vascul
ar‐access/default/
Where is the optimal central PICC tip location?
• What is Central?
• lower
lower ½ to 1/3 of SVC lower ½ to 1/3 of SVC
½ to 1/3 of SVC • IVC IVC above/at level of above/at level of diaphragm
Infusion Nursing Society, 2011, National Assn. Neonatal Nursing, 2007, FDA, 1989
Catheter Tip Location
A matter of interpretation
1
1
neonatologist
radiologist
?
1 Xray
Retrospective review of 27 films to assess CVC location:
Radiologist & Junior Doctor = 96% (Bagchi, 2002)
Review of 106 radiographs by 3 observers had only 37%
agreement (Odd, 2004), 2 Neo’s & radiologist
Courtesy & ©Argon Medical Devices
Bagchi et al. 2002. Arch Dis Child Fetal Neonatal Ed. 87-F233.
Odd et al. 2003. Arch Dis Child Fetal Neonatal Ed. F41-F43.
How do you determine tip location? Cardiac silhouette
Carina
Vertebra/vertebral body units
Eifinger et al. Clin Anatomy, June 2011
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FANNP 24TH NATIONAL NNP SYMPOSIUM: CLINICAL UPDATE AND REVIEW
Vessel & catheter sizes
Diameter/Length
700 grams
900 grams
Term
Adult
Basilic 1.1 +/‐ 0.3 mm
6 mm
Cephalic
1.2 +/‐ 0.2 mm
8 mm
Subclavian
2.6 +/‐ 0.4 mm
19 mm
Brachiocephalic
3.3 +/‐ 0.5 mm
19 mm
Brachiocephalic to cavoatrial junction
Superior Vena Cava
1.5 cms
~ 4 mm/
1.5 cm
20 6‐8 mm/7cms
mm/1.5‐
2.5 cm
Catheter Measurement
4.1 +/‐ 0.7 mm
Vessel diameters are in millimeters
Vessel lengths are in centimeters
1 Fr or 29 g
0.33 mm
2 Fr or 26 g
0.67 mm
3 Fr or 19 g
1.1 mm
Cardiovascular surgeons, Dr. Robert Anderson, Eifinger et al, 2011, Clinical Anatomy
• “The CVC tip should remain outside the cardiac silhouette but still within the vena cavae:
– Approximately 1 cm outside the cardiac silhouette in premature infants – Approximately 2 cm in term infants
• Complication rates related to catheter tip placement
– N= 1266 PICCs in 1053 patients
– Mean age 6.49 +/‐ 2 years
– Central (SVC, RA, IVC at/above diaphragm)
• Central group had 3.8% of complications
– Noncentral (all other tip locations)
• Retrospective case reviews of 61 patients
• Mean gestational age 30 weeks
• Mean birth weight 1 kg
Nowlen et al. Pediatrics Vol. 110 No. 1 July 2002
Racadio, Doellman, Johnson, Bean & Jacobs, Pediatrics, 2001
Pediatric Complication Rates: Central vs. Noncentral. Complication
Central
(SVC, RA, IVC > diaphragm)
N = 1096
• Noncentral group had 28.8% of complications
• Patients with catheter tips in noncentral locations were 8x more likely to experience a complication!
Noncentral
(subclavian, brachiocephalic)
N = 169
Phlebitis
1.5%
10.0%
Occlusion
1.7%
6.5%
Leaking
.1%
11.2%
Mechanical
.3%
1.2%
Infection
.2%
0
Total
3.8%
28.8%
The noncentral group had shorter mean PICC duration than the central group (9.3 days vs. 16.4 days) and was 8 times more likely to develop a complication
Racadio et al. Pediatrics 2001
A6a: THE GREAT DEBATE IN NEONATAL PICCs
Should we settle?
• Complications associated with central and non‐
central venous catheters in a NICU
– N= 91 noncentral (PINCCs) and 889 central (PICCs) in 750 neonates
– Complication rates: PINCCs 44% vs PICCs 25.2%
– Phlebitis, infection, leakage, occlusion, infiltration
– Most common complication in PINCCs was infiltration
• PINCCs were more than twice as likely to develop a complication compared to PICCs
Colacchio, Deng, Northrup, Bizzarro, J Perinatology, 2012
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FANNP 24TH NATIONAL NNP SYMPOSIUM: CLINICAL UPDATE AND REVIEW
More on tip location
• PICC tip position and risk of associated complications in neonates
– N=319 infants: Central 203, Noncentral 116
– Central catheters had lower rates of complication 30 vs 46 6% vs noncentral
complication 30 vs. 46.6% vs noncentral catheters
– Midclavicular placement: between lateral and medial border of clavicle
– Midclavicular placement was 3x more likely to develop infiltration or mechanical complications
Risk factors related to tip location
• Noncentral PICC tip locations, age < 1 year and PICU exposure were risk factors for PICC removal. • N = 2574 PICCs in 1807 patients (median age 5 years))
• Central = SVC or IVC • Noncentral catheters were more likely to have complications needing removal than central (43.8% vs. 16.2%) Jumani, Advani, Reich, Gosey & Milstone, JAMA Pediatrics 2013
Jain, Deshpande, Shah, J Perinatology AOP, 2012
The latest on Tip Position
• N = 237 PICCs in 200 neonates, 207 central, 30 noncentral
• Central = SVC or IVC
• Noncentral + subclavian, CAJ, RA, iliac, axillary vein
i
• Mean dwell time: 11.7 days in central vs. 9.8 days in noncentral
• Noncentral had higher incidence of removal due to extravasation.
Importance of Radiographic Monitoring
• Catheter tip position should be confirmed
by x-ray or other imaging modality and
rechecked periodically (FDA, 1989)
• Catheters with tips located outside the
SVC/IVC are from 2 to 8 x more likely to
develop a complication (Colacchio et al.,
2012, Jain et al., 2012, Racadio et al,
2001)
Costa, Bueno, Alves & Kimura, JOGNN, 2013
Implications for Practice
• Radiographic monitoring and consistent
patient positioning support accurate
catheter tip confirmation.
• Accurate knowledge of the catheter tip
location is crucial in prevention of catheterrelated complications, as catheters whose
tips are located outside the SVC/IVC have
increased risk of complications.
A6a: THE GREAT DEBATE IN NEONATAL PICCs
Keys to Consistent Monitoring of Catheter Tip Location
• Consistent positioning of the extremity to bring catheter tip to deepest location
– Upper extremity adducted if basilic vein
– Upper extremity abducted if cephalic vein
Upper extremity abducted if cephalic vein
– Lower extremity flexed
• In situ patient dynamics can impact catheter tip location
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FANNP 24TH NATIONAL NNP SYMPOSIUM: CLINICAL UPDATE AND REVIEW
What can you do when the catheter is unable to be inserted into central placement?
Midclavicular
• If catheter tip is in brachiocephalic or subclavian, may use as a peripheral as a p
y measure if temporary
blood returns and catheter flushes
• May withdraw catheter to appropriate midline placement.
• Peripheral limitations ( no > D12.5)
Common malpositions
NANN Guidelines for Practice, 2007
Malposition Management
• Withdrawal of catheter
– Advantages: Removal from undesirable location, ?
– Disadvantages:
• Break into sterile site, manipulate catheter, increase risks for infection, skin trauma, inadvertent overdislodgement, stress
• Sacrifices optimal tip location in superior vena cava (INS, AVA, NANN, FDA)
• Repositioning Maneuvers
– Advantages: less traumatic, less invasive, less stress, can achieve optimal tip location
– Disadvantages: Are there any?
– Gravity + hemodynamic flow + infusion induced movement
After catheter adjusted, is a follow up x‐ray required? • Yes!
• “Verify new catheter tip
catheter tip location via radiologic means after all repositioning efforts”
•
FDA, INS 2011, NANN 2007
A6a: THE GREAT DEBATE IN NEONATAL PICCs
Risk factors for malposition
• In situ patient dynamics
– Coughing, crying
– Changes in thoracic or abdominal cavity pressures
– Unfavorable positioning (consider counter‐gravity)
• Iatrogenic mechanical dynamics
– High frequency oscillator/jet ventilation
High frequency oscillator/jet ventilation
– Infusion induced catheter movement due to forceful flushing
• Securement failure
– Improper or inadequate securement, loose dressing
Pearls for Placement: Turn head towards ipsilateral side for upper extremity insertion. Level the bed.
Pearls for PICC Placement
• Premeditate to medicate?
• Coordinate with planned extubation or ventilatory support changes
• Coordinate with volume expansion, after fluid status optimized
• Coordinate after blood products support (PRBCs, platelets)
• Place before anticipated surgery
• Place before hypothermia protocol initiated
• Timing is everything!
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FANNP 24TH NATIONAL NNP SYMPOSIUM: CLINICAL UPDATE AND REVIEW
Thank you!
• elsharpe@bellsouth.net
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