Peripherally inserted central catheters in infants and children – indications, techniques, complications and clinical recommendations

Abstract

Venous access required both for blood sampling and for the delivery of medicines and nutrition is an integral element in the care of sick infants and children. Peripherally inserted central catheters (PICCs) have been shown to be a valuable alternative to traditional central venous devices in adults and neonates. However, the evidence may not extrapolate directly to older paediatric patients. In this study, we therefore review the indications, methods of insertion and complications of PICC lines for children beyond the neonatal age to provide clinical recommendations based on a search of the current literature. Although the literature is heterogeneous with few randomised studies, PICCs emerge as a safe and valuable option for intermediate- to long-term central venous access in children both in and out of hospital. Insertion can often be performed in light or no sedation, with little risk of perioperative complications. Assisted visualisation, preferably with ultrasound, yields high rates of insertion success. With good catheter care, rates of mechanical, infectious and thrombotic complications are low and compare favourably with those of traditional central venous catheters. Even in the case of occlusion or infection, fibrinolytics and antibiotic locks often allow the catheter to be retained.

Fatores de risco para infecção de corrente sanguínea associada ao cateter central de inserção periférica em neonatos

“…These catheters have a diameter between 1.9 and 3Fr for neonates, are single or double-lumen, made of polyurethane or silicone. (1) The PICC is indicated for intermittent or continuous infusion of intravenous solutions, for short or long term, with vesicant and irritant characteristics, pH <5 or> 9, and solutions with osmolality higher than 600mOsm/L. (2) However, this use is not without risk.…”

<b> Instrumento para avaliação do paciente candidato ao cateter venoso central de inserção periférica valvulado/ Instrument to evaluate the patient candidate to valved peripherally inserted central venous cateter<b>

“…Essas características específicas do CCIP devem ser orientadas para o paciente e seu familiar, verificando a sua compreensão e a sua concordância antes do procedimento (1,3,12,15) . A fala a seguir corrobora os achados na literatura.…”

“…A utilização do CCIP vem sendo difundida no Brasil a partir dos anos 1990, em unidades neonatais, pediátricas, oncológicas e mais recentemente nos cuidados domiciliares (1,2) . A sua expansão está relacionada: à redução do índice de infecção em comparação com outros cateteres centrais; à redução do uso de anestésicos; à realização do procedimento no leito; e à diminuição de intercorrências durante a punção em região central -pneumotórax, hemotórax, lesão do plexo braquial e embolia gasosa (1)(2)(3) . A experiência com o CCIP no Hospital de Clínicas de Porto Alegre (HCPA) iniciou em 1999, mas, somente em 2008, quando houve a introdução do CCIP valvulado (impede refluxo e não necessita de infusão contínua), que o cateter obteve ampla utilização no hospital.…”

Intravenous therapy and non-elective removal of epicutaneous catheters: a cohort study of neonates

“…The most common complications that lead to the non-elective removal of the PICC in neonates and children include the mechanics, such as obstruction, accidental pull, rupture and leakage of catheter, as well as infectious complications, phlebitis and thrombosis (8) . A cohort study conducted at a NICU in São Paulo analyzed 270 PICCs and reported an incidence of non-elective removal in 35.4% of cases, and an incidence rate of 34.8 / 1000 catheters--day, for the 1.9 Fr silicone catheter and the most frequent complications were external rupturing and obstruction (9) .…”

“…A cohort study conducted at a NICU in São Paulo analyzed 270 PICCs and reported an incidence of non-elective removal in 35.4% of cases, and an incidence rate of 34.8 / 1000 catheters--day, for the 1.9 Fr silicone catheter and the most frequent complications were external rupturing and obstruction (9) . The obstruction may be thrombotic or non-thrombotic; non--thrombotic blockages are caused by the precipitation of incompatible drugs and multiple infusions through the catheter lumen, and the thrombotic blockage by clots (8) .…”