Survival and complication rate of central venous catheters in newborns

The microorganisms most frequently isolated in blood were Klebsiella pneumoniae with 36.4% and coagulase-negative Staphylococcus (CNS) with 27.3%; in isolates from the CVC tip, SCN predominated with 28.6% (Table III).

Table IV shows the frequency of complications and some features related to the CVC and its installation.

Table V shows the frequency and type of complications according to the installation technique, i.e., percutaneous, subclavian puncture and venesection; Table VI shows the frequency and type of complications according to the vein used.

The duration of the CVC in place was a median of 9 days (range 1-60). The probability of CVC duration free of complications was 0.93 after 10 days and 0.91 after 17 days (Figure 1).

Figure 1 Kaplan-Meier survival analysis, showing that the longer the duration of the catheter, the less likely it is to be free of complications

Figure 2 shows the probability of CVC survival according to insertion technique. The probability of duration of CVC inserted by venesection was 0.93 after 10 days and 0.89 at 21 days; when inserted through the subclavian puncture it was 0.88 at 8 days and 0.80 at 21 days; and percutaneous 0.78 at five days and 0.56 at 11 days.

Figure 2 Kaplan-Meier survival analysis, showing that percutaneous CVC had lesser probability of duration, and that those inserted by venesection lasted the most, although the difference was not statistically significant

The probability of duration according to location of the CVC tip, that is, whether central or not, is shown in Figure 3. The probability of five days duration with non-central CVC was 0.61 and 0.15 at 12 days; for those with central location, the probability of five days duration was 0.96 and 0.94 at 12 days, with a statistically significant difference (p = 0.0001).

Figure 3 Kaplan-Meier survival analysis, showing that CVC with the tip in a non-central location had a lower probability of duration in the short term, with a statistically significant difference

Discussion

Preterm infants and critically ill newborns require prolonged vascular access, which is achieved in modern medical practice with a central venous catheter. The most important indications for CVC installation are administering parenteral nutrition and prolonged administration of intravenous medications. However, central vascular access in infants has been associated with increased risk of mechanical, infectious, and thrombotic complications.³

This study reported the results of 152 catheters in newborns hospitalized in a tertiary neonatal intensive care, whose main diagnoses were diseases of surgical resolution such as malformations of the digestive tract and congenital heart disease, which requires prolonged fasting and administration of parenteral nutrition also for a long time, and administering medications as amines, antibiotics, blood, and blood products. A high frequency of complications (48.7%) was found, similar to that reported by Colacchio et al.³⁴ of 44% and 47% by Jain et al. in percutaneous catheters³² as well as in non-central percutaneous CVC. Other authors have reported lower figures in recent studies with mainly percutaneous CVC.4,9 In the nineties, Hruszkewycz³⁵ reported a complication rate of 88% and Pandit³⁶ 57% in CVC installed by venesection.

Percutaneous channeling through a peripheral vein catheter that progresses to a central position has become increasingly important, sometimes displacing the surgical technique for installing CVC; today it may be the most commonly used form of central channeling in NICUs.^30,32 In the present study percutaneous CVC, that is those inserted in the upper or lower extremities, were less frequent, only 9.8% of total CVC. This is because the facility is a concentration hospital where patients come from other hospitals, and most of them have multiple punctures, making central venous access through the periphery difficult. However, nearly half (46.7%) of CVC were inserted by infraclavicular subclavian puncture. This technique is not often used in newborns, or at least not considered first choice for installing a CVC, as this technique is reported to have serious complications. In 1979, Filston³⁷ reported using this technique even in tiny infants with low frequency of serious complications. Moon et al.³⁸ recently reported using the subclavian vein for CVC insertion at three different times in a premature NB of 1280 g, without complications. In this report, the frequency of complications of CVC by subclavian puncture was similar to that of CVC inserted by venesection (21 and 24.3%, subclavian and venesection, respectively). However, with insertion in the subclavian vein serious complications were presented; two patients had pneumothorax and hemothorax, which resolved properly with immediate treatment. Hemothorax occurred in preterm infants, weighing 1300 to 1650 g. The two with pneumothorax were larger than 2000 g but with strong mechanical ventilatory support. It is noteworthy that of the 71 CVC installed by subclavian puncture, only 13 (18.3%) were in infants less than 2000 g. Based on these serious, life-threatening complications, CVC is only installed in the subclavian vein in patients > 2 kg without mechanical ventilation or when this has minimal variables, especially peak inspiratory pressure to avoid lung overdistension, and the procedure should be performed by personnel appropriately trained in this technique.

Central catheters are a potential source of nosocomial infection. Catheter-related sepsis is the most common nosocomial infection in NICUs.³⁹ CVC-associated infection rates have been reported ranging from 1.7 to 49/1000 catheter days.^{13,15,18-20,22,23,32,36,40-42} This was one of the most frequent complications found in this report, at 9.9/1000 catheter days, similar to that reported in the literature, and most frequently observed in CVC installed by venesection.

Unlike Tsai,¹⁵ who reported a significantly higher incidence of BRCCVC in CVC installed in the femoral vein (10.9 and 6.8 episodes per 1000 catheter days in femoral and non-femoral, respectively), the present study did not find that infectious complications were more frequent in CVC inserted in the femoral or saphenous veins.

Newborns are particularly susceptible to thromboembolism, due to factors such as the small size of their blood vessels, immaturity of the thrombolytic system, and hemostatic disorders caused by asphyxia or perinatal complications such as congenital heart disease. Furthermore, CVC use is the most common cause of thrombosis in neonates. Intravascular catheters can cause thromboembolism by damage to the endothelium, as a foreign body is introduced with thrombotic properties, and the administration of parenteral nutrition for a long time can aggravate the endothelial damage.^8,10,43 

A frequency of central line-related thrombosis in neonates has been reported with 1% when only symptomatic cases are included, about 44% when intentionally looking for thrombi, and 65% in autopsy studies.⁴⁴ The frequency of thrombotic complications in this study was low, at 5.4% (similar to the 6.8% reported by Saleem¹⁶), and these were cases in which echocardiography was done to intentionally search for thrombi. There was no difference between the CVC inserted by venesection or subclavian puncture, and no cases of thrombosis occurred in percutaneous CVC.

Regarding CVC survival, defined as duration free of complications, it was found that the probability of general CVC duration at 10 days was 93% and for the third week, 90%; this probability decreased over time. The main complications in the first week were non-infectious, although five of the 20 BRCCVC occurred in the first week.

Survival was lower in CVC inserted percutaneously, mainly due to mechanical complications. There was no statistically significant difference between the duration of CVC by subclavian puncture and venesection.

With respect to the location of CVC tip, it ​​was found that non-central location had a lower probability of duration in the short term; at five days it was only 61%, compared with central CVC whose probability of duration at that time was 96.4%. These findings are similar to those reported by Jain et al.,³² although they found that the probability of duration was similar in both groups in the first four days, after which time a marked difference between central and non-central CVC was observed. Other authors^4,17,31,34 have reported that non-central CVC have a higher frequency of complications; we found that of the 13 CVC whose location was not central, 10 had complications.

Conclusion

The frequency of CVC complications in newborns in a third level NICU is high but similar to that reported in other studies, and the complications are most frequently of infectious type, such as BRCCV. Potentially lethal complications were presented in the CVC inserted by subclavian puncture, although at low frequency. The probability of CVC duration in the first week is high and decreases over time. The CVC whose location is not central have less likely duration in the short term, i.e., the probability that they will have complications in the short term is greater than those with central location, so it is recommended that when installing a CVC in a NB, one should do everything possible so that it is well located to prevent further morbidity to the patient.

Furthermore, based on experience with CVC inserted by subclavian puncture, we recommend evaluating the risks and benefits of using this venous access, which should be done by well-trained staff and preferably in children weighing > 2000 g without or with only minimal mechanical ventilatory support and with adequate sedation and analgesia.

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