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Do Not Pull Too Hard

K Elmalik, M McCullagh

Department of Paediatric Surgery

University Hospital Lewisham

London, United Kingdom

 

Correspondence:

Khalid Elmalik

Department of Paediatric Surgery ,Sheffield Children’s Hospital,Sheffield; S10 2TH

United Kingdom

Phone: 0044 7930490450; Fax: 0044 114 2260543, Email: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Abstract

Fine bore catheters inserted peripherally intended for central delivery of total parenteral nutrition are known to be associated with many complications – blockage, infection, accidental dislodgement and others. We present a patient in whom the removal resulted in a problem not frequently described. The inserted long line snapped on attempted removal and required operative retrieval. These peripherally inserted central catheters will continue to be used in the successful management of low birth weight infants. Suggestions are made regarding how to avoid this problem.

Key words: peripherally inserted central catheter (PICC), total parenteral nutrition (TPN)

  

Case Report

An infant (born at 25 weeks gestation weighting 1.01kg) was transferred to our unit at seven weeks of age. He had previously a 2 French central catheter percutaneously inserted into his left long saphenous vein at the ankle at 2 days of age, to provide total parenteral nutrition TPN.

When this was no longer required, attempts to remove it (following local protocols) had resulted in it snapping and retraction of the catheter under the skin. X-ray confirmed the fragment located in the groin area (fig.1).

The following day under general anaesthesia, the left groin was explored via a transverse incision. The saphenofemoral junction was identified. Attempts to remove the fragment by pulling it distally through the saphenous vein were unsuccessful. The catheter was removed through a venotomy proximal to the saphenofemoral junction and pulling the fragment proximally. The baby hed a smooth postoperative recovery.

Discussion

Peripherally inserted central catheters (PICC) are vital in the management of premature neonates. They provide secure access for the administration of TPN and medications. Shaw first described the technique of inserting a central catheter peripherally in the early 1970s [1] with Dalcourt and Bose later modifying the technique with a much higher success rate[2].

The reported list of morbidities associated with PICC’s use range from common to extremely rare [3,4,5,6] and are cations can occur at any time from insertion, whilst in situ and during removal and even after removal. Hence utmost care should be exercised during insertion and removal. While the catheter in place, monitoring is crucial to identify adverse events early.

The complication reported here is fairly uncommon, with a reported resistance of PICC during removal being less than 1%[7]. Difficult removal has been found to be experienced with catheters that functioned less than 4 weeks and had associated Staphylococcus epidermidis in blood cultures [8].

Through sharing our experience from the management of this case we would like to offer our recommendations to the reader to avoid this complication recurring in the future:

- Despite difficulties experienced by other authors during the removal of a catheter which has been in place less than 28 days [8], we do not advocate elective removal of functioning catheters before 4 weeks if they are still  functioning and in demand.

- Once the line is no longer needed it should be removed as soon as possible.

- Excessive traction should not be applied during removal. Any resistance should be appropriately investigated.

- For investigation, contrast studies are superior to plain X-ray [9,10]. They can be used to determine the site and integrity of the catheter, and identify or exclude any knots, coils (visible on X-ray, Fig. 2).

- If the line is palpable, massage along its course to aid release may be a viable option.

- A coil within the subclavian vein, from a PICC via the upper limb, has been shown to spontaneously correct, therefore a period of observation is recommended before any major undertaking [11].

- The presence of a coil or knot and resistance on traction during removal should alert the clinician to the risk that further force may break the line. Once the line has broken it can recoil and migrate away from the entry site, making removal a very difficult and tedious task.

This neonate quickly developed venous congestion of the lower limb from obstruction of the saphenofemoral junction by the PICC fragment, compromising venous return from the leg. We elected not to anticoagulate the infant due to the risk of intra-cranial bleeding.

do not pull 1 do not pull 2
Figure 1. X-ray showing a catheter fragment in the left groin Figure 2. X-ray showing the catheter with a coil in the left groin

Conclusion

If you are faced with a stubborn PICC that requires more than average traction for removal, with a visible coil on X-ray do not pull too hard! Seek assistance from a Paediatric surgeon as elective surgical retrieval would be a safer and more reasonable option than the emergency exploration for a snapped fragment which may not be retrievable

 

 

REFERENCES

1. Shaw JCL. Parenteral nutrition in the management of sick, low birth weight infants. Paediatr Clin North Am 1973; 20: 333-358

2. Dalcourt JL, Bose CL. Percutaneous insertion of silastic central venous catheters in newborn infants. Paediatrics 1982; 70: 484-486

3. Pettit J. Assessment of infants with peripherally inserted central catheters: Part 1. Detecting the most frequently occurring complications. Advances in neonatal care 2002; 2(6): 304-315

4. Pettit J. Assessment of infants with peripherally inserted central catheters: Part 2. Detecting the most frequently occurring complications. Advances in neonatal care 2003; 3(1): 14-26

5. Cupitt J. An unusual complication of a central venous catheter in a neonate. Paediatr Anaesth 2000; 10: 665-668

6. Clarke P, Wadhawan R, Smyth J, Emmerson AJ. Parenteral nutrition relieved by lumbar puncture following left saphenous vein catheterisation. J Paediatr Child Health 2003; 39: 386-389

7. Wall J, Kierstead VL,. Peripherally inserted central catheters: resistance to removal: a rare complication. J Intraven Nurs 1995; 18(5): 251-254

8. Galdman G, Sinha S, Sims DG, Chiswick ML. Staphylococcus epidermidis and retention on neonatal percutaneous central venous catheters. Arch Dis Child 1990; 65(8): 915

9. Reece A, Ubhi T, Craig AR, Newell SJ. Positioning long lines: contrast versus plain radiography. Arch Dis Child Fetal Neonatal Ed 2001; 84: F129-F130

10. Odd DE, Page B, Battin MR, Harding JE. Does radio-opaque contract improve radiographic localisation of percutaneous central venous lines? Arch Dis Child Fetal Neonatal Ed 2004; 89: F41-F43

11. Rastogi S, Bhutada A, Sahni R, Berdon WE, Wung JT. Spontaneous correction of malpositioned percutaneous central venous line in infants. Paediatr Radiol 1998; 28: 694-696