Central Lines and Their Complications in Neonates

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This entry is adapted from the peer-reviewed paper 10.3390/children11010026

Central lines are essential devices in NICUs, used primarily in preterm neonates and critically ill term neonates. They are typically divided into non-tunnelled, tunnelled and totally implanted. In light of the increasing use of central lines in the NICU setting, monitoring of the risk factors associated with complications has to be an important part of neonatal care quality management.

central lines complications neonate

1. Introduction

In Neonatal Intensive Care Units (NICUs), central lines are essential devices, particularly in preterm neonates and in term neonates who are critically ill or require surgical interventions ^[1]. In very low birth weight babies (VLBW), in which enteral nutrition is a challenge due to gastrointestinal immaturity, parenteral nutrition is an important modality to improve nutrition and minimise growth failure, which is associated with various short-term morbidities and poor long-term outcomes ^[2]. In this population of neonates, central lines are used for administering intravenous fluids and parenteral nutrition, as well as hypertonic or locally toxic medications ^[3]. In other neonatal populations, central lines are useful for monitoring the haemodynamic status, administering parenteral nutrition, blood products and chemotherapeutic agents, or the infusion of other fluids ^[4]. Although lifesaving, the use of central lines is associated with mechanical and infectious complications ^[5].

2. Central Line Types

Central lines are typically divided into non-tunnelled (centrally or peripherally inserted), tunnelled and totally implanted ^[5]. The latter two are of limited use in the neonatal setting ^[6]. Depending on the policy of each particular unit, the first central line of choice immediately after birth is an umbilical venous catheter (UVC), sometimes alongside an umbilical arterial catheter (UAC). There is no good research to date that would definitively answer the question of how long the UVC can be left in place. However, based on some best practice reports, if there is a continuous need for a UVC beyond 5–7 days, an effort should be made to replace it with another central line ^[7]. A less invasive alternative to a central catheter, which is usually inserted through a large vein, such as the femoral, jugular or subclavian vein, is a peripherally inserted central catheter (PICC). PICCs are fine and pliable catheters that are inserted through a peripheral vein, with the tip preferably lying in a central vein, usually the superior vena cava ^[8]. They were first described in the 1970s and have been used extensively ever since due to their favourable features ^[9].

Compared with PICCs, UVCs are less expensive and easier to insert but are of limited use because of the short duration of dwell time ^[3]. Despite the CDC recommendations of keeping the UVC in situ for no longer than two weeks, and in the absence of other quality evidence, most centres choose to replace the UVC after 7 days ^[10]^[11]^[12]. On the other hand, if longer-term access is needed, the use of PICCs seems to reduce the rate of complications, particularly if combined with a PICC maintenance team ^[13].

In light of the use of PICCs becoming essential in the NICU setting, monitoring of the risk factors associated with complications has to be an important part of neonatal care quality management ^[14]. Complications, which range from tissue (i.e., phlebitis, necrosis) to systemic (i.e., pneumothorax, cardiac tamponade, sepsis), can cause injury to the neonates, as well as increase the costs of health services because of increases in the length of stay in the NICU ^[15]^[16]^[17]^[18]. Therefore, it is important to be aware of the potential complications, clinical presentations and preventive strategies. This topic will be discussed in the following sections.

3. Complications of Central Lines

While having central line access is vitally important in NICU patients, its presence is associated with significant morbidity and mortality ^[19]^[20]. Complications can be divided into mechanical and non-mechanical. Mechanical complications are related to the insertion technique or can be the result of narrower lumens, predisposing them to obstruction and thrombosis ^[1]. The main non-mechanical complication is, of course, central line-associated bloodstream infection (CLABSI) ^[21]. Studies on the use of PICCs in the NICU have shown that catheter-related complications occur on average in up to 30% of PICCs placed ^[22]^[23]. One study showed that the most common complication related to the use of PICC was phlebitis, followed by infection, leakage and occlusion ^[22]. Effusion occurred in around 2% of cases ^[22].

3.1. Mechanical Complications of Central Lines

There are several ways in which central lines can fail mechanically, some related to the insertion technique, some to the medication used and some to the mechanical properties of the catheter itself ^[24]. Mechanical complications range from infiltration, occlusion, thrombosis, misplacement, and migration to breakage with subsequent extravasation and phlebitis ^[24]^[25]. Fortunately, acute life-threatening events such as pericardial effusion, cardiac tamponade and massive pleural effusion are rare and occur in infants with such catheters with an incidence of about 1–3% ^[26]^[27].

3.1.1. Pleural Effusion

Many case reports have reported total parenteral nutrition (TPN) extravasation in the pleural space as the most common aetiology of pleural effusions as a central line complication in neonates ^[25]^[28]. The effusion is usually unilateral, with bilateral pleural effusions being very rarely described ^[25]. In cases of pleural effusions in neonates with central lines, TPN extravasation should be carefully differentiated from a chylothorax due to a completely different course of management ^[25]. There are several mechanisms of central line-related pleural effusion that have been proposed over the years ^[25]. Among them are vessel perforation or retrograde flow passage through the lymphatic duct induced by catheterisation, mechanical vein erosion and hyperosmotic injury of the endothelium, which increases permeability and the risk of thrombosis of the pulmonary vessels ^[25]^[29]. While pleural effusion associated with the presence of a central line is a relatively rare complication, it has been described with a frequency of 0.4 per 1000 catheter days for a PICC line, while only four cases have been described associated with a UVC ^[28]. Misplacement of PICC during insertion has usually been reported as the aetiology ^[30]. Premature infants might be more inclined to vessel wall erosion, especially when PICCs are positioned in the upper extremities ^[29]. Frequent arm movements can also be problematic in that they can change the position of the catheter tip, thus increasing the risk of superior vena cava erosion when administering hyperosmolar fluid ^[25].

3.1.2. Pericardial Effusion

One of the most severe and life-threatening complications of a central line is an effusion of fluids in the pericardial sac with consequent cardiac tamponade ^[8]^[31]. The incidence of pericardial effusion and cardiac tamponade is about 0.07–2%; however, mortality can be as high as 75% without pericardiocentesis and only around 8% when pericardiocentesis is performed ^[32]^[33]. One of the reasons why pericardial effusion is more common in preterm and term neonates is that the thin wall of the heart is more easily damaged, with myocardium even being absent in some sections of the atrial wall ^[34]. In addition to the weakness of the myocardium wall, there is also greater fragility in the vessel walls, as evidenced by the fact that pericardial effusions generally occur in smaller infants and in infants of lower gestational ages, whereas pericardial effusion in older children and especially adults is much less likely ^[8]^[35]^[36]. Perforation of the myocardium can occur at the time of cannulation, either directly or secondary to wire use ^[34]. However, this seems to be an exception, and the more common cause of pericardial effusion is actually secondary to endocardial damage from repeated contact of the catheter tip with the myocardium, which results in the formation of a thrombus and adherence of the catheter tip to the myocardial wall. This brings the hyperosmolar fluid in direct contact with the myocardial wall, resulting in osmotic injury ^[34]. Interestingly, the lateral wall of the superior vena cava seems to be more fragile than the medial wall, meaning there is an increased risk of erosion when the tip of the catheter abuts the lateral wall or creates an acute angle ^[8]^[37]. While erosion of the vessel wall can occur directly from the force of the jet, it can also occur without prior trauma just from the nature of the infusate ^[8]^[37]. In particular, total parenteral nutrition seems to present the highest risk of damaging the vessel and cardiac wall, leading to pericardial effusion ^[34]^[38]^[39].

3.1.3. Portal Vein Thrombosis

Previously, portal vein thrombosis has been considered a rare occurrence; however, with the increasing use of routine ultrasound, it has been recognised more commonly, with incidences of between 0 and 50% reported in the literature ^[40]^[41]. In addition to the insertion of a UVC, risk factors include the infusate composition, low birth weight, hypoxia, sepsis and congenital malformations, among others ^[42]. Most thrombi spontaneously resolve; however, portal vein thrombosis is an important cause of portal hypertension later in childhood ^[43]. The highest rate of complications is seen if the tip of the UVC is placed in the left portal vein, and there is no particular risk if the UVC is placed outside of the portal system ^[42]. Even if UVCs are initially placed appropriately, they can migrate into the portal vein, which is why regular ultrasound monitoring of tip position is important to reduce the risk of a potentially severe complication ^[41].

3.1.4. Thrombosis

Neonates, in general, have the highest risk of thromboembolic complications, and this is especially true in critically ill children ^[44]. The most important risk factor for thrombosis in neonates is the presence of a central catheter ^[45]. Additionally, there are several risk factors that predispose neonates with inserted central lines to thrombosis, such as low birth weight, prematurity, prolonged dwell time of more than 6 days, UVC malplacement, mechanical ventilation, surgery and multiple vein punctures ^[44]^[46]^[47]. The incidence of thrombosis associated with PICC lines has been cited in the literature as between 0.3 and 28.3% ^[48]. On the other hand, thrombosis has been described in 75% of children with UVCs ^[49]. However, these thrombi are usually asymptomatic and resolve spontaneously, which is why routine ultrasound screening is not recommended ^[49]. When installed, the central line promotes thrombosis by increasing the absorption of proteins, adhesion of leukocytes and platelets, and increasing thrombin production ^[45]. Another important mechanism of thrombosis in neonates with central lines is CLABSI, which will be discussed in the following section ^[50].

3.2. Central Line-Associated Bloodstream Infection (CLABSI)

CLABSI is defined as a bloodstream infection confirmed by a laboratory, not related to an infection of another site, and that occurs within 48 h of catheter placement or removal ^[51]. The most common causative organism is coagulase-negative staphylococcus. CLABSI is a major cause of morbidity and mortality in the NICU setting ^[52]. Preterm neonates are especially susceptible due to their poor skin integrity, an increased need for invasive procedures, immature immunity and prolonged stay in the NICU ^[53]. The incidence of CLABSI in neonates with UVCs is 5–10%, with the highest rates occurring in neonates weighing less than 1500 g ^[11]^[54]. Despite its risks, obtaining a central line is vital for the survival of these babies, which is why there is a continuous strive towards a zero rate of CLABSI ^[52]. Ways of achieving that will be discussed in the following section on recommendations for the use of central lines.

Typical complications related to central lines in neonates are summarised in Table 1.

Table 1. Incidences of typical complications in relation to typical catheters.

Type of Complication	Typical Catheter Type	Risk Factors	Incidence (%)	Incidence (per 1000 Catheter Days)
CLABSI	UVC	low birth weight, dwell time		3.2–21.8 ^[55]
	UVA		NA
	PICC		NA
Pleural effusion	UVA	NA	NA	NA
	UVC	TPN, tip migration	4 cases	NA
	PICC	TPN, more distal tip	0.29 ^[8]	0.4 ^[28]
Pericardial effusion	UVC PICC	tip migration TPN, more proximal tip	0.22–0.67 ^[56]	NA
Portal vein thrombosis	UVC	low birth weight, dwell time, infusate, sepsis	0–50 ^[41]	NA
Thrombosis	UVC	dwell time	75 ^[49]	NA
Thrombosis	PICC	sepsis	0.3–28.3 ^[48]	NA

NA—not available.

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