PICC Malposition Case Study

Wolfe, DM. A Previously undescribed etiology for oliguria in a premature Infant with a Peripherally Inserted Central Catheter. Advances in Neonatal Care (April 2010); 10: 56-59. |PDF|

Purpose/Background Peripherally inserted central catheter use has become widespread in the management of premature infants as a means to provide long-term intravenous therapy and nutritional support until enteral feedings can be established. Peripherally inserted central catheters are not without complications.

RESULTS This article describes the case of a premature infant with oliguria with the suspected etiology of a malpositioned catheter tip at a location where it was either occluding/blocking the renal vein(s) or causing damage to the kidney(s) from administration of hypertonic total parenteral nutrition solution directly into the renal vein(s).

CONCLUSIONS Peripherally inserted central catheter position should be verified radiographically and evaluated serially in any infant, even more so in an infant with symptoms of oliguria and possible sepsis.

Comments: There are multiple case studies describing PICC complications from malposition (here are two: http://tinyurl.com/29jdtow , http://tinyurl.com/2a3ph8v ) and most centers likely have their own non-published stories to tell as well. As these and other authors note, it has become a very routine procedure in the NICU, but perhaps we need more standardized maintenance protocols.

There is currently no recommendation from the NANN Guidelines regarding the preferred order of sites to access, although they do list site options in the order of; "Veins of the arm", Veins of the scalp and neck", then "Veins of the legs". Lately lower extremity PICC malposition case studies have received most of the recent print. Should it be standard protocol to verify lower extremity PICC insertion by obtaining both an AP and lateral film? Some authors also recommend the addition of contrast, not only to determine tip placement, but the direction of infusate flow. Should a weekly x-ray to confirm stable tip placement (regardless of insertion site) be part of the protocol? We certainly do not want to risk more radiation exposure, but it may be the safer practice. One thing is certain, we should be removing all central lines as early as possible, which means we need to continue to focus on consistent early feeding practices to alleviate the need for a central line.

Please add a comment regarding the PICC protocol in your center – we will all benefit from comparing our practices.

Mindy Morris

When we are not sure of the exact position of the line (e.g. inside vs outside the Rt atrium) we ask for an US scan.

UserName: Shany Eilon
Institution: Soroka Medical center
telephone: +97286400508
email: eshany@bgu.ac.il

Date: 09 Jul 2010
Time: 21:58:47

I don't think that removing the catheter as early as possible is the solution without lower risks. In our patients we have the problem of nosocomial infections that are more frequently associated with peripheral venous access than with PICC, maybe because of the frequent need of a puncture of a vein. We should think of the more frequent painful stimuli as well. Not an easy decision to make.

UserName: Thomas Strahleck
Institution: Olgahospital
telephone: +4971127804
email: t.strahleck@klinkum-stuttgart.de

The topic of regular surveillance for placement of PICCs is important, but also probably unanswerable. PICC tips are not fixed, but rather move as the arm moves. We have experienced cases where the tip was documented to be in the mid-SVC, and then some time later, was in the right atrium, mid-internal jugular, or crossing over to the opposite side subclavian. I do not know how the position can change so drastically other than with arm position. As to the current article, I am not sure where one would want to keep the tip of a CVL when placed in the lower extremity. Surgeons argue if it should be in the right atrium or just somewhere in the IVC. In the IVC, the tip may be anywhere, such as near the renal veins or a mesenteric vein. I worry about any catheter that stays in the heart.

UserName: David J Burchfield, MD
Institution: University of Florida
telephone: 352-273-8985
email: burchdj@peds.ufl.edu

With ref to early removal of the line- I remove all lines when on 110-120 mls/kg orally as this is enough for hydration. This allows the line to be removed 24 or more hrs earlier.