The advantage of point-of-care ultrasound in central venous catheterization and related pericardial effusion in infants in the NICU

Abstract

BackgroundCentral venous catheterization (CVC) is broadly used in neonatal intensive care units (NICUs) for efficient vascular access; however, its establishment and maintenance are associated with numerous risks and complications. Here, we focus on investigating the value of point-of-care ultrasound (POCUS) in the early diagnosis and treatment of pericardial effusion associated with CVC and compare the differences in ultrasound and radiography in CVC localization and monitoring in the NICU.MethodsTwenty-five infants with CVC-associated pericardial effusion (PCE) who were hospitalized in the NICU of Peking University Third Hospital between January 2013 and March 2023 were retrospectively selected for the study. Data concerning their catheterization characteristics, CVC tip position, clinical and imaging manifestations of PCE, treatments, and prognoses were analyzed.ResultsThe mean gestational age of our cohort was 29.3 ± 3.1 weeks, and the mean birth weight was 1,211 ± 237 g. The incidence of CVC-associated PCE was 0.65%, and 80% of PCE cases occurred within 4 days of CVC. After PCE, the most common symptoms were tachypnea (44%) and tachycardia (64%). Chest radiographs revealed cardiothoracic enlargement, and only 2 cases (9.10%) showed a “flask heart”. Cardiac ultrasound showed that the catheter tip extended deep into the heart in 72% of infants with PCE. Cardiac insufficiency was observed in 12 cases (48%). Overall, 8 infants (32%) had pericardial tamponade, 7 (87.5%) of whom underwent pericardiocentesis. Overall, 2 (8%) infants died, and the remaining 23 (92%) were cured.ConclusionCVC-associated PCE mostly occurs in the early post-catheterization stages (within 4 days) in infants. Some cases may have critical clinical manifestations and progress rapidly, with some even developing pericardial tamponade. A CVC tip being deep into the heart cavity is an important cause of PCE. Compared with chest radiography, point-of-care ultrasound is more accurate for CVC tip positioning and can detect PCE more quickly. Furthermore, it is more advantageous for locating and monitoring CVC-associated PCE. Early identification and diagnosis can effectively reduce fatality rates and improve the prognosis of infants with CVC-associated PCE.

Peripherally inserted central catheter related pericardial effusion/cardiac tamponade in neonates: Analysis of two cases and literature review

“…[3] Therefore, maintaining arm adduction and elbow flexion during X-ray positioning can effectively reduce the risk of pericardial effusion caused by PICC displacement into the right atrium due to arm movement, [10] and the exposed end of the PICC should be securely affixed with adhesive tape to minimize catheter migration. [4,9] To ensure accurate positioning of the catheter tip, X-ray or cardiovascular ultrasonography should be performed at least twice a week. However, the sensitivity and specificity of X-ray localization are inferior to those of cardiovascular ultrasonography.…”

“…As shown in Table 1, from the beginning of the 21 st century, including our 2 cases reported herein, a total of 35 cases of PICC-related neonatal pericardial effusion/cardiac tamponade have been reported in China and abroad, [3,4,[6][7][8][9][10][11][12][13][14][15][16][17][18] with an average GA of (29.7 ± 3.7) weeks and an average BW of (1243.3 ± 517.3) g. Normally, there are about 5 ml of pericardial fluid in the pericardial cavity of newborns, and a small amount of fluid serves as lubrication to reduce friction during cardiac contraction. [8] However, when a significant accumulation of fluid occurs within the pericardium, the pressure within the pericardial cavity increases, thereby limiting cardiac diastolic function correspondingly.…”

“…3). The reasons are as follows: The current method for evaluating catheter length is inadequate in guiding the position of the PICC catheter tips in premature infants, [9,23] yet proper placement of the catheter tip is essential to ensure the safety of PICC; There are numerous risk factors associated with catheter tip malposition in premature infants, including weight loss, changes in abdominal circumference, umbilical cord shrinkage and contracture, limb movement, and shortness of the superior vena cava; [9,11,15] Premature neonates with immature cardiac tissue may exhibit myocardial weakness, which can be easily damaged by repeated friction between the catheter tip and heart wall during diastole and contraction. This damage can lead to endothelial cell injury, allowing fluid to diffuse into the pericardial cavity and form effusion.…”

“…[15] The perforation may result from repeated rubbing of the catheter tip against the inner wall of the pericardial vena cava with each heartbeat or continuous infusion of hypertonic PN, leading to transmural injury and necrosis that ultimately results in pericardial effusion. [9][10][11]19] Both cases in this study received PN infusion through PICC prior to the onset of pericardial effusion/cardiac tamponade. In case 1 and case 2, the highest concentration of (2.9%) located in the pulmonary artery, 1 case (2.9%) located in the left atrium, and 1 case (2.9%) located in the pericardial cavity, while exact location was not specified for the remaining 7 cases (20.0%).…”

“…Zhang et al suggested that conservative treatment such as fluid restriction and diuresis, may be appropriate for mild to moderate pericardial effusions with hemodynamic stability. [9] There were also reports of successful rescue by either repositioning the catheter tip away from the right atrium or direct drainage of the effusion via PICC. [10] However, once echocardiography reveals cardiac chamber compression and deformation, restricted diastole and systole, and reduced cardiac output, prompt pericardiocentesis is necessary.…”