Central Venous Silicone Elastomer Catheter Placement by Basilic Vein Cutdown in Neonates

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Central

Venous

Silicone

Elastomer

Catheter

Placement

by Basilic

Vein

Cutdown

in

Neonates

Joseph

Gilhooly,

MD, Jeffrey

Lindenberg,

MD,

and John

W. Reynolds,

MD

From the Department of Pediatrics, Oregon Health Sciences University, Portland

ABSTRACT. There is a need for central venous access in

small premature infants and other neonates when enteral

feeding is not tolerated or is contraindicated. We placed

83 small (0.635-mm od) silicone elastomer catheters by

basilic vein cutdown through a subcutaneous tunnel in

79 patients during a 12-month period. Thirty-five

pa-tients (44%) weighed <1,000 g. Each patient on whom

the procedure was attempted had successful placement of a catheter, and they remained in place a mean of 20 days (range three to 82). Patients had a mean weight gain of 15 g per day ofcatheter use. Sixty-two catheters (75%) were removed electively, 13 (16%) secondary to

compli-cations, six (7%) because ofpatient deaths (none catheter

related), and two (2%) were accidentally dislodged. Two episodes of catheter-related sepsis (0.12 episodes per 100 days of catheter use) caused by Candida albicans and

Staphylococcus epidermidis were encountered. Other

complications included one subclavian vein thrombosis,

eight catheter occlusions, and two local arm

inflamma-tions. This technique proved to be a safe, easy, and inexpensive method to administer parenteral nutrition to neonates, especially those weighing <1,000 g. Pediatrics

1986;78:636-639; central venous catheter, silicone elasto-mer catheter, hyperalimentation, neonate.

Vascular access in neonates is a problem,

espe-cially

in those weighing <1,000 g and when more than 3 weeks of vascular access are needed. Meth-ods currently used include umbilical artery and vein catheters, peripheral venous catheters, and central venous catheters placed percutaneously or sur-gically into the subclavian or internal jugular veins.

Each of these procedures has limitations and

com-plications.’13

Received for publication Nov 8, 1985; accepted Feb 14, 1986. Reprint requests to (J.G.) Department of Pediatrics, Oregon Health Sciences University, 3181 SW Sam Jackson Park Rd,

Portland, OR 97201.

Central placement of silicone elastomer catheters placed percutaneously through peripheral veins has

been described by Shaw,’4 Riordan,15 Dolcourt and Bose,’6 and Loeff et al.’3 We found this method

technically difficult in infants <1,000 g. Placement of these catheters by basilic vein cutdown was de-scribed by Sherman et al,’7 with good success. We prospectively evaluated the technique of Sherman et al,’7 modified by exiting the catheter through a

subcutaneous tunnel.

MATERIALS AND METHODS

Catheter placement was performed in the new-born intensive care center and intermediate

neo-natal care nursery at Doernbecher Memorial Hos-pital for Children between September 1, 1984, and

August 31, 1985. Indications for placement varied depending on the attending staff and included (1) lack of peripheral intravenous sites, (2) anticipated vascular access need for >2 to 3 weeks, (3) infants weighing <1,000 g with an umbilical artery catheter,

allowing us to maintain the umbilical catheter solely for blood gas analysis. The procedure was

performed by pediatric residents under the super-vision of neonatal fellows and attendings.

We used 0.635-mm od (23-gauge, 1.9-Fr) radio-paque silicone elastomer catheters from

PER-Q-CATH trays prepared by Gesco International, Inc

(San Antonio, TX). The trays contain a 20-gauge

breakpart introducer needle (used to make the

sub-cutaneous tunnel) and a transparent occlusive

dressing. An infant venous cutdown tray was also needed. The procedure was done in an open warmer under radiant heat in the intensive or intermediate

care nursery. The arm on which the cutdown was

performed was secured with an arm board and the infant’s head was turned to face the cutdown site

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TABLE 1. Patient Characteristics

ARTICLES 637

The skin was cleaned with povidone-iodine solu-tion. Lidocaine (1%) was used for a local anesthetic. A No. 15 scalpel blade was used to make a 3-mm

incision along a crease in the antecubital fossa, and

the basilic vein was isolated using blunt dissection with a curved hemostat. A 4-0 silk tie was placed around the vein for control during catheter inser-tion. The breakapart introducer needle was inserted 2-cm distal to the incision and was brought out through the incision site. The catheter was pre-pared by removing the stylet, flushing it with hep-arinized saline, and cutting a 45 degree bevel in the tip with scissors. (Gesco currently manufactures the catheter without a stylet and a precut 45-degree bevel.) The catheter was then placed through the breakapart needle, and the needle was removed, broken apart, and discarded, leaving the catheter in a subcutaneous tunnel. A small nick was made in the vein using a No. 11 scalpel blade, and the catheter was inserted in the vein using a curved iris forcep and advanced to an estimated central posi-tion. The vein did not need to be tied off distally. The skin was closed with one stitch of 5-0 nylon. The catheter was temporarily secured, and correct catheter placement was verified radiographically. The catheter was pulled back if necessary to posi-tion the tip close to the superior vena cava-right atrium junction. The transparent dressing, included in the tray, was placed over the exit site to secure the catheter to the forearm and was not changed

unless it became loose. The incision site was left uncovered. Because no arm board was used, the infant had mobility of the elbow and wrist.

An Extension Set with “T” (Abbott Hospitals, Inc) was inserted at the hub for delivery of medi-cations. The catheter was not used for blood draw-ing (except when blood cultures were indicated) or administration of blood products. Dextrose concen-trations were not limited, and we infused parenteral nutrition solutions containing up to 35 g/dL of dextrose. Heparin, 20 units, was added per 100 mL of dextrose-containing solutions. Intralipid (10% fat emulsion) was infused continuously at rates up to 30 mL/kg/d. Tubings were changed with every bottle change.

If occlusion of the catheter occurred, we often found the obstruction to be in the metallic portion of the hub. We salvaged the catheter by cutting the hub from the catheter and inserting a 25-gauge blunt butterfly needle (Abbott Hospitals, mc) into the catheter.

RESULTS

In 79 patients, 83 catheters were placed. Patient characteristics are listed in Table 1. All patients were successfully catheterized, although six

pa-No. of patients 79

No. of catheters 83

Mean gestational age (wk [range]) 31 (23-41) Mean birth wt (g [range]) 1,654 (400-4,250) No. of infants <1,000 g birth wt 35

Mean postnatal age at insertion (d 17 (1-127) [range])

Mean wt at insertion (g [range]) 1,740 (360-4,520) Mean catheter duration (d [range]) 20 (3-82) Mean wt gain/day of catheter use 15

(g)

TABLE 2. Complications From 83 Catheterizations

No. (%)

Related to catheter insertion

Brachial artery nicked 1 (1.2)

Premature ventricular contractions 1 (1.2) Leading to catheter removal

Mechanical

Occluded catheter 8 (9.6)

Accidental dislodgement 2 (2.4)

Major

Sepsis 2 (2.4)

Subclavian vein thrombosis 1 (1.2)

Minor: local arm inflammation 2 (2.4)

tients (7%) required two cutdowns to place a cath-eter. A central position was not achieved in four patients (5%); three catheters went into neck veins,

but all flipped to an appropriate central position after withdrawing the catheter a small distance.

Catheters

remained

in place a mean of 20 days (range three to 82) for a total experience of 1,695 catheter days. Sixty-two catheters (75%) were re-moved electively, 13 (16%) because of complica-tions, six (7%) because of patient deaths, and two

(2%) because of accidental dislodgement. The mean duration of catheterization for these four groups was 21, 23, 15, and 15 days, respectively.

Sixteen patients experienced 17 catheter compli-cations (Table 2). Two complications occurred dur-ing catheter placement. In one patient, the brachial

artery was nicked when it was confused with the

basilic vein during cathether placement. The nick in the artery required one stitch of 6-0 proline and

a normal pulse remained after the artery repair. Premature ventricular contractions occurred in a second patient in whom the catheter was advanced

into the heart, and these resolved when the catheter was withdrawn to the proper location.

There were two episodes of catheter-related

sep-sis (0.12 episodes per 100 days of catheter use). Catheter sepsis was defined as growth of the same

organism in samples obtained from both a periph-eral vein and the catheter. Cultures were obtained when there was clinical suspicion for sepsis in the infant. The first episode was caused by Candida

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albicans after the catheter had been in place 53 days in an 840-g infant, and the second was caused by

Staphylococcus epidermidis after seven days of cath-eter use in a 4,000-g infant. The latter episode was associated with dehiscence of the cutdown site. Both episodes were treated with a regimen of anti-biotics through a second catheter, and the infec-tions resolved without sequelae.

Bilateral subclavian vein thrombosis was diag-nosed at autopsy in a 540-g infant who died at 61 days of age. The diagnosis had been suspected prior to the autopsy when the catheter, which had been in place for 35 days, was removed because of

bilat-eral upper arm and chest swelling. The patient died eight days later of respiratory and renal failure.

Two episodes of local arm inflammation occurred at eight and 29 days. The first episode was associ-ated with a noncentral catheter. Blood culture

re-sults were negative, and the inflammation resolved within 24 hours of catheter removal in both cases.

Eight catheters were removed because of occlu-sion (seven from clots and one from a drug precip-itate). Two of these catheters were removed without an attempt to replace the blunt needle. Two

cath-eters were pulled out by inexperienced personnel while changing the transparent occlusive dressing.

DISCUSSION

There is a need for safe long-term venous access in very low birth weight infants. Placement of small

silicone elastomer catheters by basilic vein cutdown offers advantages over currently available methods.

The use of peripheral intravenous catheters is

limited by the concentration of dextrose that can

be infused (s13%), the short time of patency, and

often the lack of accessible veins. Frequent catheter

replacement requires the removal of the infant from

the incubator and interruption of intravenous in-fusions. Associated complications include local and

systemic infections, phlebitis, and subcutaneous

fluid extravasation.13 Frequent catheter

replace-ment can be costly, not only in terms of materials ($8 for each Teflon catheter) but in terms of nursing time required for replacement of catheters.

Umbilical vessel catheters are associated with a

high incidence of infectious, thromboembolic, and

mechanical complications.4’5 Our own experience

shows a marked increase in infectious complica-tions after umbilical catheters are in place for more than seven days, which makes them unsuitable for

long-term parenteral nutrition administration. To reduce potential catheter-associated complications,

many neonatal units have policies not to administer parenteral nutrition via umbilical catheters or feed infants with umbilical catheters in place.

Percutaneously placed polyvinyl chloride

subcla-vian and internal jugular central venous catheters are associated with a significant number of inser-tion complications, occasionally causing death of the infant, which has limited their use in infants weighing <1,000 g. These complications include

arterial puncture, hydrothorax, pneumothorax and pneumomediastinum, hemothorax, tracheal

punc-ture, and Homer syndrome.’#{176} Other complications reported include catheter-related sepsis (up to

30%), superior vena cava syndrome, and frequent

mechanical and occlusion problems.6’#{176}

Broviac catheters placed under direct

visualiza-tion reduce complications associated with

place-ment but continue to be associated with a high

incidence of infectious and thrombotic

complica-tions despite a silicone elastomer composition and

a subcutaneous tunnel. Sepsis rates as high as 31%,

deaths related to superior vena cava thrombosis, right atrial thrombosis, and frequent mechanical

problems (27%) are reported.”’3 Another

consid-eration of the Broviac catheter is the cost of

place-ment. Broviac catheters at our institution are

placed in the operating room and cost about $1800

for a premature infant. Our technique, on the other

hand, cost $300, which includes physician,

radiol-ogy, and material costs.

The use of small gauge (0.635-mm od) silicone elastomer catheters to deliver parenteral nutrition

to premature infants was first described by Shaw14

in 1973 and has consistently been associated with few complications. Catheters were introduced

per-cutaneously, usually through a scalp vein, and

ad-vanced to a central position. In 24 patients, Shaw encountered one case of coagulase-negative staph-ylococci septicemia (4%) and two cases of

throm-bosis (8%). Riordan’5 used the same technique and encountered no complications, except accidental dislodgement, but he failed to report the number of

patients catheterized. Tanswell’8 modified Shaw’s

technique by not placing catheters in a central

position. These lasted a mean of only nine days,

but in 250 catheterizations he encountered no

in-fectious or embolic complications. Dolcourt and

Bose’6 reported their experience with Shaw’s tech-nique in 18 patients. No thrombotic or septic com-plications were reported (two catheters were

re-moved because of suspected sepsis but culture

re-sults were negative). Loeff et al’3 compared

compli-cations of 53 small (0.635-mm od) diameter

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ARTICLES

639

(8%) in the large-catheter group. Sherman et a117

compared percutaneous placement of small silicone catheters with placement by venous cutdown (usu-ally the basilic vein). There were no significant

differences in complications between the two

groups. Only one case of catheter-associated septi-cemia was encountered in 49 patients. Sherman et

al’7 described cutdown placement to be a safe alter-native to the percutaneous technique of Shaw.’4

We found that catheter placement by cutdown is

much better suited for infants weighing <1,000 g,

and we had a 100% success rate in the initial

catheter placement in this group. Almost one half of our patients weighed <1,000 g, and one patient

weighed only 360 g at the time of insertion. Reports of percutaneous insertion of catheters, where data are complete, have included only nine patients weighing <1,000 g.’6”7 Success rates for percuta-neous placement in all infants ranges between 88%

and 90%, occasionally requiring up to four attempts

for successful placement.’6’8

The basilic vein offers easy access, the site is easily kept clean, and the catheter can be easily secured to the forearm. A central position is more frequently obtained when catheterizing the basilic

vein than when using cephalic and saphenous

veins.17 The distal vein is not ligated during the

procedure; therefore, it can be reused after catheter

removal. The 3- to 4-mm incision required for the cutdown is along a natural skin fold, and only one stitch is needed for closure.

Mechanical problems accounted for 59% of our

complications (eight occluded, two dislodged). Our

frequency of mechanical complications (12%) is less

than that reported by others (Loeff et al’3 22%,

Dolcourt and Bose’6 17%, Sherman et al’7 22%). We obtained a reduced number of mechanical com-plications by replacing the hub of the catheter when occlusion occurred. Gesco, Inc has since redesigned

the hub of the catheter, eliminating all metal and

non-Silastic materials, in order to reduce occlusions

from this cause. Tunnelling the catheter subcuta-neously allows for better stabilization, and thus a

decrease in accidental dislodgements, and may help

to minimize septic complications.

REFERENCES

1. Batton DG, Maisels MJ, Appelbaum P: Use of peripheral

intravenous cannulas in premature infants: A controlled study. Pediatrics 1982;70:487-490

2. Tully JL, Friedland GH, Baldini LM, et al: Complications of intravenous therapy with steel needles and Teflon cath-eters. Am J Med 1981;70:702-706

3. Peter G, Lloyd-Still JD, Lovejoy FH: Local infection and

bacteremia from scalp vein needles and polyethylene

cath-eters in children. J Pediatr 1972;80:78-83

4. Caeton AJ, Goetzman BW: Risky business: Umbilical arte-nat catheterization. Am J Dis Child 1985;139:120-121 5. Thompson TR, Tilleli J, Johnson DE, et al: Umbilical artery

catheterization complicated by mycotic aortic aneurysm in

neonates. Adu Pediatr 1980;27:275-318

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7. Filston HC, Grant JP: A safer system for percutaneous

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infant.J Pediatr Surg 1974;9:171-174

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cannulation of the internal jugular vein in infants and

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10. Prince SR, Sullivan RL, Hacket A: Percutaneous catheteri-zation of the internal jugular vein in infants and children.

Anesthesiology 1976;44:170-174

11. Sadiq F, Devaskar 5, Weber T, et al: Life threatening complications ofbroviac catheterization, abstracted. Pediatr Res 1985;19361A

12. Mulvihill SJ, Fonkalsrud EW: Complications of superior versus inferior vena cava occlusion in infants receiving central total parenteral nutrition. J Pediatr Surg 1984;19: 752-757

13. Loeff DS, Matlak ME, Black RE, et at: Insertion of a small central venous catheter in neonates and young infants. J Pediatr Surg 1982;17:944-949

14. Shaw JCL: Parenteral nutrition in the management of sick low birthweight infants. Pediatr Clin NorthAm 1973;20:333-358

15. Riordan TP: Placement of central venous tines in the pre-mature infant. JPEN 1979;3:381-382

16. Dolcourt JL, Bose CL: Percutaneous insertion of Silastic

central venous catheters in newborn infants. Pediatrics 1982;70:484-486

17. Sherman MP, Vitale DE, McLaughlin GW, et at:

Percuta-neous and surgical placement of fine silicone elastomer central catheters in high-risk newborns. JPEN 1983;7:75-78

18. Tanswell AK: Long-term peripheral intravenous access in the neonate. J Pediatr 1979;94:480

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1986;78;636

Pediatrics

Joseph Gilhooly, Jeffrey Lindenberg and John W. Reynolds

Neonates