Intravascular Catheter Complications in the Neonatal Intensive Care Unit
Section snippets
Thromboembolic events
Intravascular catheters can cause thromboembolic events by damaging the endothelium and by introduction of a foreign surface with thrombogenic properties. Newborns are at a higher risk for thromboembolic events because of their underdeveloped clotting mechanisms, small vessel diameters, and critical underlying disease, when compared with adults or even older children. These complications occur from arterial and venous central catheters, although they are uncommon with peripheral intravenous
Vascular spasm
Although vasospasm can occur from radial artery catheters, the event occurs most commonly with UAC insertion. The onset usually occurs within minutes or a few hours of the catheter insertion. This is in contrast to similarly-appearing thromboembolic events that usually occur days or weeks after catheter insertion.
The distal extremities usually present with a blue, purple, or mottled discoloration. Progressive ischemia results in a change to a white or pale discoloration with extension of the
Infections
All central and peripheral catheters are potential sources of nosocomial infection, although the risk seems to be greatest with central catheters [17]. Catheter infection rates in newborns have been reported to be between 3.7 per 1000 catheter days [18] and 10 per 1000 catheter days [18], [19], [20]. The risk of infection increases with younger gestational age [19], [21] and with increased duration of catheter use [22], [23]. Risk of infection also is associated with the degree of manipulation
Umbilical artery catheters
UACs are used extensively in critically ill neonates. UACs facilitate frequent arterial blood sampling, continuous blood pressure monitoring, and serve as a route for infusion of intravenous fluids and medications. Because of the many risks of UACs, however, they should not be used solely as a route of fluid and medication administration; if an infant does not require frequent arterial blood sampling or continuous blood pressure monitoring, there is almost no justification for leaving a UAC
Umbilical venous catheters
UVCs also are used extensively in NICUs. UVCs are used to infuse emergency medications during a neonatal resuscitation [50]. Theoretically, the catheters can be used for central venous pressure monitoring, although this monitoring is performed rarely in NICUs today. UVCs also can be used to perform either partial or total blood exchange transfusions; however, probably the most common use of UVCs is as a long-term central venous access for infusion of medications and intravenous fluids.
As with
Peripherally-inserted central catheters
PICC catheters are inserted into a peripheral vein and are advanced into a central vein—either the SVC or the IVC—depending on the insertion site. PICC catheters are useful for the very small premature infant or the critically ill infant who requires long-term intravenous fluid or pharmacologic therapy. Catheter-related infections and thromboembolic events are similar to those that were described previously.
PICC complications are similar to those of UVCs. Beardsall and colleagues [79] found
Peripheral arterial catheters
Peripheral arterial catheters are useful to obtain arterial blood for laboratory analysis and to monitor arterial blood pressures. They only should be used for blood sampling—no fluid other than heparinized saline flush solution ever should be administered into a peripheral artery catheter. These catheters usually are placed in the radial artery or the posterior tibial artery. Placement in the temporal artery was performed commonly in the 1970s [86], although the procedure has been abandoned
Peripheral intravenous catheters
Complications of peripheral intravenous catheters include hematoma, phlebitis [96], infection, sepsis [97], and thromboembolic events that are due to the forcible flushing of clots adherent to the catheter tip. Although hematomas probably are the most common of these complications, they usually are of little clinical significance because they resolve without treatment and without sequelae. Catheter-related infections and thromboembolic events are discussed elsewhere in this article.
Summary
Arterial and venous catheters serve a wide range of functions for newborns in NICUs. Despite their many valuable uses, each type of catheter carries the potential for significant risk and substantial damages, including death and dismemberment. Proper insertion technique and prompt recognition and management of catheter complications will minimize catheter-related injury. Ten recommendations for catheter risk reduction are offered in Box 1.
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