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Paediatrics
Original research
Central venous catheter insertion profile and complications among neonates in Saudi Arabia: a cross-sectional study
  1. Ahmed Elabbasy1,
  2. Haifa Abdullah Alkorbi1,
  3. Ilene Padua1,
  4. Abdullah Ibrahim Abuharb2,
  5. Amjad Ahmad Alshedookhi2,
  6. Hassan Al-Shehri3
  1. 1 Division of Neonatology, Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
  2. 2 College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
  3. 3 Department of Pediatrics, College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
  1. Correspondence to Dr Hassan Al-Shehri; haalshehri{at}imamu.edu.sa

Abstract

Objectives To compare complications in neonates who had umbilical venous catheter (UVC) versus peripherally inserted central catheter (PICC), percentage of non-elective removal of central catheters, and to compare complications of PICC in the upper limb compared with the lower limb.

Design A prospective cross-sectional cohort study.

Setting Neonatal intensive care unit (NICU) in Prince Sultan Military Medical City in Riyadh, Saudi Arabia.

Participants All infants who are admitted to the unit requiring central catheter insertion were included in the study.

Primary outcome measure Complications of central catheters in infants admitted to the NICU.

Results A total of 415 central catheters were involved in this study (206 UVCs and 209 PICCs (85 in the lower limb, 99 in the upper limb and 25 in the head and neck). The median birth weight of the neonates was 1470 grams (1000–2215). Low birth weight was the most common reason for central catheter insertion, which accounted for 59.8%. Neonatologists were the main insertor for the majority of the cases. The median dwell days for the study sample were 11.00 (7.00–16.50) days. Complications were more common across PICC cases compared with UVC cases (p=0.001). There was non-elective removal of PICC (32.1%) compared with UVC (22.8%) (p=0.035). Phlebitis, occlusion, local infiltrate and leakage were more common in PICC compared with UVC (p<0.05). However, malposition was more commonly associated with the use of UVC (mainly to the liver) (p<0.01). Central line-associated bloodstream infection (CLABSI) rate in 1000.00 dwell days was higher in the upper limb 4.6 compared with the lower limb 2.72 but was not statistically significant (p=0.63), and there was no statistically significant difference in the proportion of other complications between the upper limb and the lower limb (p>0.05).

Conclusion Close monitoring during extended dwell times is crucial. Our findings underscore the importance of raising awareness of CLABSI risk factors and adhering to best practices for central catheter maintenance. Healthcare professionals should be vigilant about the differences in complication rates between PICC and UVC, tailoring their approach accordingly.

  • Paediatric intensive & critical care
  • Neonatology
  • Neonatal intensive & critical care

Data availability statement

Data are available upon reasonable request.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi-org.ezproxy.u-pec.fr/10.1136/bmjopen-2024-089554

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    STRENGTHS AND LIMITATIONS OF THIS STUDY

    • This is a single-centre study, which might have affected the generalisability of our study findings.

    • The use of cross-sectional study design restricted the ability to examine causality among the study variables.

    • Excluding neonates with no follow-up might lead to selection bias as they might have different outcomes profile.

    Introduction

    Central venous access refers to the insertion of a catheter into a large vein for different medical purposes.1 Central catheter insertion should be recommended in neonatal intensive care units (NICU) based on patient characteristics, fluid characteristics or the duration of the required therapy.2

    Central catheters encompass several types of catheters. First is the umbilical venous catheter (UVC), where the tip is located at the junction between the inferior vena cava (IVC) and right atrium (RA). Second is the epicutaneo-caval catheter (ECC) or neonatal-peripherally inserted central catheter (n-PICC). For ECC/n-PICC coming through the superior vena cava (SVC), the tip may be located (a) in the lower third of the SVC, (b) at the junction between the SVC and RA or (c) in the upper third of the RA. For ECC/n-PICC coming through the IVC, the tip may be located (a) in the subdiaphragmatic IVC (below the hepatic vein but above the renal vein) or (b) at the junction between IVC and RA. Third is the centrally inserted central catheter which is inserted by an ultrasound-guided venipuncture of deep veins of the supra-clavicular area (mainly the internal jugular vein or the brachiocephalic vein). The tip is located (a) at the junction between SVC and RA or (b) in the upper third of the RA. Last is the femorally inserted central catheter which is inserted by an ultrasound-guided venipuncture of deep veins of the groin (common femoral vein). The tip may be located (a) in the subdiaphragmatic IVC (below the hepatic vein but above the renal veins) or (b) at the junction between IVC and RA.3–6 Complications associated with central catheter insertion are frequently encountered, and although certain complications are fewer compared with peripheral catheters, they possess the potential to be life-threatening, such as cardiac tamponade and pleural effusion.7–10 A previous study by van Rens et al reported that for patients who received a peripheral catheter, the complication rate was significantly higher when compared with infants receiving a central venous access devices (CVAD) (407.00/1000.00 and 13.00/1000.00 catheter days, respectively).10

    Clinicians such as neonatologists typically insert the majority of central catheters in the NICU. The interventional radiologist employs either fluoroscopy or ultrasound guidance ‘as an insertion methods’ to guide the placement of the catheter and to facilitate the positioning.11 Additionally, there are instances where an anaesthetist may also provide assistance.

    Prior research has elucidated various risk factors associated with problems arising from PICCs in neonates.10 12 These factors encompass young age, severity of disease, duration of catheter stay, placement of catheter tip and site of catheter insertion.10 12–14 The identification of modifiable risk factors for complications holds significant importance in the efforts of the healthcare providers to prevent catheter-related challenges. Prior research examining modifiable risk variables, including the duration of catheter dwell time, the site of catheter insertion and the position of the catheter tip, has yielded inconclusive findings.9 15 16 The objectives of this study are to compare complications in neonates who had UVC versus PICC, percentage of non-elective removal of PICC catheters, and to compare complications of PICC in the upper limb compared with the lower limb.

    Methods

    Study design

    This is a prospective cross-sectional cohort study that examined the complications of central catheters in infants admitted to the NICU in Prince Sultan Military Medical City in Riyadh, Saudi Arabia from July 2022 to July 2023.

    Study population

    All infants who are admitted to the unit requiring central catheter insertion were included in the study. Neonates who lost the follow-up or transferred to other centre before removal of the central catheter were excluded.

    Data collection

    Data were collected from the neonates’ electronic medical records for demographic information, details of the central catheter and date and age at insertion. Other recorded data were the indication for its insertion, total dwell days, type of removal (elective or non-elective), reason for non-elective removal and any complication developed, such as malposition, phlebitis (any sign of inflammation at the course of the vein where the catheter is inserted may be chemical, mechanical or infectious and in UVC is diagnosed based on the presence of redness at the site of insertion of UVC), leakage, local infiltrate ‘any collection of fluid either superficial or deep, related to the catheter and is diagnosed in case the UVC is in the liver and there is abnormal translucency in the liver’, central line-associated bloodstream infection (CLABSI), occlusion, accidental pulling, migration, pleural effusion and mortality. The length of stay in the hospital was also recorded.

    Statistical analysis

    The Statistical Package for Social Science software V.28 was used to analyse the data for this study. Continuous variables were presented as median (IQR) as the data were non-normally distributed. The normality of the data was checked using skewness and kurtosis measures and the histogram. Categorical data were presented as frequencies and percentages. The χ2 was applied to compare the outcomes between PICC group and the UVC group. Binary logistic regression analysis was used to identify the OR of developing complications comparing UVC to PICC and the upper limb to the lower limb. The significance level was assigned as a p-value of less than 0.05.

    Patient and public involvement

    None.

    Results

    Neonates’ baseline characteristics

    Table 1 presents neonates’ baseline characteristics. Around 53.5% of the neonates were females. The median birth weight of the neonates was 1470 grams (1000–2215). The median insertion age of the neonates was 2.00 (1.00–8.00) days. Patient characteristic such as low birth weight was the most common reason for central catheter insertion, which accounted for 59.8%.

    View this table:
    Table 1

    Neonates’ baseline characteristics

    Table 2 presents central catheters‘ baseline characteristics. A total of 415 catheters were involved in this study. Peripherally inserted central catheter and UVC accounted for 50.4% and 49.6%, respectively (figure 1). Single lumen catheters contributed for the vast majority (96.9%). Neonatologists (dedicated and non-dedicated) were the main insertors for the majority of the cases. The median dwell days for the catheters were 11.00 (7.00–16.50) days.

    View this table:
    Table 2

    Central catheters’ baseline characteristics

    Figure 1
    Figure 1

    Flow chart for the study cohort. PICCs, peripherally inserted central catheters; UVCs, umbilical venous catheters.

    Characteristics of umbilical venous catheters compared with peripherally inserted catheters

    Table 3 presents the characteristics of neonates received UVCs compared with peripherally inserted catheters. There was a statistically significant difference in the median gestational age, birth weight, age of insertion, dwell days, length of stay, number of lumens, reason of insertion and insertor between neonates who received UVCs compared with peripherally inserted catheters (p<0.01).

    View this table:
    Table 3

    Characteristics of neonates received umbilical venous catheters compared with peripherally inserted catheters

    Complications of peripherally inserted central catheter compared with umbilical venous catheter

    Complications were more common across PICC cases (37.8%) compared with UVC cases (23.3%) (p value =0.001). The non-elective removal type for PICC (32.1%) and UVC (22.8%). Phlebitis, occlusion and local infiltrate were more commonly associated with PICC compared with UVC (p<0.05). However, malposition (mainly to the liver) was more commonly associated with the use of UVC compared with PICC (p value =0.002). There is no significant difference in CLABSI rate between both groups (table 4). In our practice, catheter tip migration typically occurs after the initial insertion and securement of the catheter, whereas tip malposition is the result of suboptimal positioning during the initial placement. To confirm precise tip location, we use both anteroposterior and lateral abdominal X-rays.

    View this table:
    Table 4

    Complications of peripherally inserted central catheters (PICCs) compared with umbilical vein catheters (UVCs)

    Characteristics of the upper limb versus lower limb peripherally inserted central catheter

    Online supplemental table 1 presents the characteristics of neonates received in the upper limb versus lower limb PICC. There was a statistically significant difference in the median gestational age, dwell days, single number of lumens and assistant between neonates received in the upper limb versus lower limb PICC (p<0.05).

    Supplemental material

    Complications of the upper limb versus lower limb peripherally inserted central catheters

    Online supplemental table 2 presents the complications of the upper limb versus lower limb PICC. The study found a higher rate of CLABSI in upper limb catheters (4.6) compared with lower limb catheters (2.72); however, this difference did not reach statistical significance (p=0.63). There was no statistically significant difference in the proportion of other complications between the upper limb and the lower limb (p>0.05).

    Predictors of complications

    Table 5 presents the findings of binary logistic regression analysis. The likelihood of non-elective removal was lower among users of UVC compared with PICC (OR 0.60; 95% CI 0.39 to 0.91) (p<0.05). On the other hand, the likelihood of malposition was three-fold higher among UVC users compared with PICC (OR 3.00; 95% CI 1.61 to 5.56) (p<0.001). The OR of malposition was 72% lower in the upper limb compared with the lower limb PICC (OR 0.28; 95% CI 0.11 to 0.73) (p<0.01). The likelihood of developing laboratory-confirmed bloodstream infection was higher among neonates with non-elective removal (OR 4.17; 95% CI 2.38 to 7.31), those who developed any complications (OR 5.30; 95% CI 3.00 to 9.38) and those who developed breakage (OR 4.12; 95% CI 1.44 to 11.80) (p<0.01).

    View this table:
    Table 5

    Predictors of complications comparing umbilical vein catheter (UVC) to peripherally inserted central catheter (PICC) and the upper limb to the lower limb

    Discussion

    Central catheters are commonly employed in NICUs, playing a crucial role in the care of premature infants and neonates with critical cardiac, respiratory and gastrointestinal diseases requiring surgical intervention by providing secure intravascular access for the administration of fluids, medications and parenteral nutrition, ensuring the safe delivery of substantial volumes and hypertonic solutions.17–22 Therefore, this study aimed to compare the complications between UVC and PICC, determining the percentage of non-elective PICC catheter removal and its causes and assessing complications in PICC placements in the upper limb versus the lower limb.

    In neonates who require long-term or complex therapy, central vascular access devices are generally regarded as more reliable and safer than peripheral devices. Central catheters offer secure and enduring access for the administration of parenteral nutrition, medications and hydration. Short peripheral catheters are frequently unable to facilitate the safe infusion of hypertonic solutions and larger volumes due to a higher risk of complications, including extravasation, phlebitis and catheter dislodgment, which these devices enable. In their retrospective study, van Rens et al found that central vascular access was associated with superior outcomes in neonatal populations when contrasted with peripheral devices.10 The significance of selecting the most suitable device for a patient’s requirements and treatment duration is underscored by the study, which emphasises the elevated risks of complications associated with short peripheral catheters. In critically ill neonates, reliable administration of life-saving therapies is of the utmost importance, and central vascular access devices, despite the fact that they necessitate more expertise for insertion, provide a higher level of safety and stability.10

    PICC and UVC are both considered the most common types of central catheters used in NICU.7 23 24 Its use differs in regards to the function and the need for each type, where UVCs are often used initially to provide a quick and convenient access in neonate during their early days of life.19 24 However, when there is a continued need for continuous intravenous therapy or total parenteral nutrition, it is advisable to replace the UVC with PICC.7 23

    The study results found that central catheter insertion was predominantly performed in two primary sites, with the umbilical vein and saphenous vein being the most prevalent, accounting for 46.7% and 17.9%, respectively. Notably, the umbilical site was the most frequently used insertion location, representing 46.7% of the cases, where these findings are similar to other studies where the most commonly used site for insertion was the umbilical location.25 26

    In our study, the median age for neonatal central catheter insertion was 2.00 days (with a range of 1.00–8.00 days). Median age for neonatal central catheter insertion may vary in relation to the reason, where the median age for percutaneous central venous cannulation in neonates was found to be 21.00 days27 and a median age of 7.00 days for PICC placement in neonates with congenital cardiac disease.28 The primary reason for insertion was low birth weight, constituting 59.8% of cases, where low birth weight infants had a high perinatal mortality rate.29 In addition, low birth weight contributes to a range of poor health outcomes.30 Additionally, in our study, the median dwell days for the study sample was 11.00 (7.00–16.50) days, and it was found similarly that a mean dwell day for neonates in the NICU is 8.70 days.31 However, the increased length of stay may increase the risk of central catheter-associated bloodstream infections during the first 2 weeks after PICC insertion.32

    Removal of central catheters may be non-elective where our study result revealed that 32.1% of PICCs were removed due to complications (non-elective removal). This was consistent with the findings of Costa et al who found that 39.3% of PICCs were removed non-electively.33 However, this was different from the findings of a previous study in Qatar, which reported lower non-removal rate.10 Previous literature reported the effectiveness of the use of an approved medical grade adhesive for catheter securement and demonstrated that it is significantly associated with lower rate therapy failures.34 Cyanoacrylate glue was found to be safe and effective for securement of UVCs and particularly effective in decreasing early catheter dislodgments.35

    In our study, approximately 37.8% of PICCs encountered complications, where these findings are higher than other studies findings where complications accounted for 31.7% of the catheters.36 Malposition may lead to a serious course of events and grave consequences like extravasations and sepsis.37 Besides, malposition found to have an increased incidence in the upper extremities with an increased risk of complications associated to it.38 Our study results did not show difference between upper and lower limb rate of malposition and migration complications related to PICC. A meta-analysis study revealed that lower limb insertion did not lead to poorer outcomes compared with upper limb insertion, and in certain aspects, it was linked to even improved outcomes.38 Meanwhile, insertion operators tend to use the upper limb, and this is due to that it easy to the operator to use the upper limb for peripheral cannulation as well as PICC.39 On the other hand, CLABSIs have multiple risk factors with an increased incidence rate, where the number of central venous catheter lumens and place of catheter insertion were significant risk factors among neonates in a tertiary NICU.40 Also, CLABSI in other studies was considered the most frequent healthcare-associated infection reported in NICU,41 where multi-drug resistance coagulase-negative staphylococci cause CLABSIs in neonates with very low birth weight.42 Therefore, understanding the microbiology and risk factors of CLABSI in neonates is crucial for developing targeted prevention strategies in NICUs,41 and attention to the insertion and maintenance of central catheters can minimise CLABSI rates.43

    Additionally, this study result found that complications were more common across PICC (37.8%) cases compared with UVC (23.3%) cases. This was comparable to a previous study by van Rens et al who reported that for patients who received a peripheral catheter, the complication rate was significantly higher when compared with infants receiving a CVAD (407.00/1000.00 and 13.00/1000.00 catheter days, respectively).10 Besides, the incidence rate of peripheral line-associated bloodstream infection was 1.19/1000.00 catheter days observed for all peripheral intravenous access devices (Peripheral Intravenous Catheter (PIVC) and Emergency Department Peripheral Intravenous Catheter (ED-PIVC)), whereas a CLABSI incidence rate of 0.34/1000.00 catheter days was observed after CVAD insertion (p<0.001).

    Similarly, PICC catheters have been found to have a greater number of complications and are statistically significant when compared with UVCs.44 While our study findings reveal that the removal type for the majority of PICC (67.9%) and UVC (77.2%) was elective type, the non-elective type of removal comes with complications that affect neonatal well-being, where phlebitis, occlusion and local infiltrate were reasons more commonly associated with PICC compared with UVC. It was found that phlebitis incidence is more related to PICC than to UVC,45 and factors such as site selection and maintenance measures play a vital role in preventing phlebitis and infection associated with PICC use in premature and low birth weight infants.46 However, in our study, malposition (mainly to the liver) was more commonly associated with the use of UVC compared with PICC. In fact, while UVC is a common procedure for intravenous access in NICU and associated with major complications,47 the non-elective removal type of UVCs is the malposition of UVCs, and it was found to have a significant complication including hepatic lesions and suboptimal positioning.48

    A previous study by Bayoumi et al assessed the effectiveness of implementing an ECC team in NICU and found that it is a promising intervention to increase success rates and significantly decrease catheter-related complications in NICU.49 Besides, it emphasised on standardising catheter maintenance in order to improve CLABSI rates.49 Another initiative that demonstrated its effectiveness is the application of neonatal simulation programme which proved its effectiveness in protecting neonates from potential harm and improving the overall neonatal outcome including insertion success rate and mean duration of insertion.50

    The results of this study underlined some of the modifiable factors that can enhance the outcomes of neonatal central venous catheter (CVC) insertions, mainly regarding the reduction of complications and optimisation of care. One of the important features is the use of Point of Care Ultrasound (POCUS) and intracavitary ECG for real-time tip navigation and placement verification. According to Natile et al, these technologies enhance CVC placement precision through the capability for real-time visualisation that would result in reduced risks of malposition, especially in neonates, where liver malposition might occur in UVCs due to improper placement and may lead to serious complications.51 The integration of such tools in routine practice could significantly reduce the occurrence rates of malposition and related complications. Another modifiable factor is the use of cyanoacrylate glue for catheter securement. Van Rens et al also noted that cyanoacrylate glue reduces dislodgement and increases the stability of the catheter.52 This prevents complications such as phlebitis and occlusion of peripheral intravenous catheters. In neonates, this may reduce the number of replacements required and thus reduce overall infection rates.52 Another advancement in improving outcomes has been the development of dedicated vascular access teams. Bayoumi et al indicated that an ECC team instituted in a NICU was associated with the advancement of catheter care and a reduction in complications.49 This is explained to mean that well-trained vascular access teams in neonatal catheter placement and maintenance can give the necessary expertise needed in reducing mechanical complications while ensuring that optimum care is accorded to the catheters.49 Taken together, all these modifiable factors—POCUS, intracavitary ECG, cyanoacrylate glue and vascular access teams—represent the key areas for improvement regarding catheter care and decreasing complications in neonates. These interventions can significantly impact healthcare providers’ ability to improve short- and long-term outcomes for neonates requiring central venous access.49 51 52

    Based on the study findings, it is recommended that healthcare professionals in NICUs carefully assess the specific needs of each infant when choosing between PICC and UVC for central catheter insertion. Additionally, careful consideration should be given to the selection of insertion sites, with a focus on reducing complications and infection risk. And to minimise complications, particularly in the case of non-elective removal, healthcare providers should prioritise proper central catheter positioning and infection control measures.

    Implications for practice

    This study outlines various suboptimal practices regarding CVC insertion among neonates that demand attention. First, complications were significantly higher in PICC compared with UVC, notably phlebitis, occlusion and local infiltrate, suggesting potential problems with the conditions of insertion and maintenance. This will require advanced training in insertion techniques and post-insertion care for neonatologists, along with a dedicated PICC team to ensure higher levels of competence. It was associated with an increased risk of infection of the bloodstream—likely related to a lack of structured protocols concerning removal of the catheter. Standardised protocols for the timely and elective removal of catheters serve to minimise infection risk. Malposition, particularly migration to the liver, was more frequent with the UVC, indicating poor confirmation of appropriate positioning. The verification of precise catheter placement should be coupled with routine imaging. Checklists related to post-insertion surveillance should also be developed. The significant differences in gestational age, birth weight and dwell days among the groups reflected the fragility of premature neonates and the prolonged use of the catheters. Wherever possible, the type of catheter and insertion site should be individualised based on clinical condition, with dwell times minimised. Further, complications were fewer for the upper limb PICC insertions compared with those of the lower limbs, indicating also that the site of insertion adds to catheter-related complications. Guidelines on upper limb insertion sites where appropriate and criteria for the best site selection may mitigate such risks. Lastly, the high phlebitis rate, occlusion and local infiltrate point towards vascular trauma with long dwell times in PICCs or poor technique. Therefore, monitoring for early signs of phlebitis and occlusion should be enhanced to prevent further complications.

    This study has limitations. This is a single-centre study, which might have affected the generalisability of our study findings as other institutions might have different clinical practices. Besides, the use of cross-sectional study design restricted the ability to examine causality among the study variables. Therefore, this type of studies has limited ability to examine cause-and-effect relationships among the study variables. Longitudinal study designs (such as cohort studies) are recommended to address this point in order to assess changes over time. Excluding neonates with no follow-up might lead to selection bias as they might have different outcomes profile.

    Conclusion

    Our study showed that complications and non-elective removal were less in UVCs compared with PICCs; however, the rate of malposition (mainly to the liver) in UVCs was higher. There is no significant difference between the upper limb and lower limb PICCs in terms of non-elective removal and complications; however, the implementation of rigorous surveillance for prolonged periods of residence is of utmost importance. The results of our study emphasise the significance of increasing awareness regarding risk factors associated with CLABSI and adhering to optimal practices for the maintenance of central catheters. Healthcare providers should exercise vigilance in recognising and addressing the variations in complication rates associated with PICC and UVC, adapting their strategies accordingly. Moreover, optimised catheter selection, insertion site and management practices are all necessary to help reduce risks and thus improve neonatal outcomes.

    Data availability statement

    Data are available upon reasonable request.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study involves human participants and was approved by the Institutional Review Board (IRB) at Prince Sultan Military Medical City, Riyadh, Saudi Arabia (IRB approval number 1623). Participants gave informed consent to participate in the study before taking part.

    References

    1. ↵
      2. Lockwood J ,
      3. Desai N
      . Central venous access. Br J Hosp Med 2019;80:C114–9. doi:10.12968/hmed.2019.80.8.C114
      OpenUrl
    2. ↵
      2. Aly H ,
      3. Mohamed M ,
      4. Ejaz S , et al
      . The accessibility and safety of inserting proximal basilic and axillary veins central lines in neonates. SAGE Open Med 2023;11:20503121231197150. doi:10.1177/20503121231197150
    3. ↵
      2. O’Grady NP ,
      3. Alexander M ,
      4. Burns LA , et al
      . Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis 2011;52:e162–93. doi:10.1093/cid/cir257
      OpenUrlCrossRefPubMed
    4. ↵
      2. Nickel B ,
      3. Gorski L ,
      4. Kleidon T , et al
      . Infusion Therapy Standards of Practice, 9th Edition. J Infus Nurs 2024;47:S1–285. doi:10.1097/NAN.0000000000000532
      OpenUrl
    5. ↵
      1. Infusion Nurses Society
      . Infusion Therapy Standards of Practice, 2024. Available: https://www.ins1.org/publications/infusion-therapy-standards-of-practice
    6. ↵
      1. National Association of Neonatal Nurses
      . Clinical Practice Products 2024. 2024. Available: https://nann.org/education/educational-products/clinical-practice-products
    7. ↵
      2. Arnts IJJ ,
      3. Bullens LM ,
      4. Groenewoud JMM , et al
      . Comparison of complication rates between umbilical and peripherally inserted central venous catheters in newborns. J Obstet Gynecol Neonatal Nurs 2014;43:205–15. doi:10.1111/1552-6909.12278
      OpenUrlCrossRefPubMed
    8. ↵
      2. Baker J ,
      3. Imong S
      . A rare complication of neonatal central venous access. Arch Dis Child Fetal Neonatal Ed 2002;86:F61–2. doi:10.1136/fn.86.1.f61
      OpenUrlAbstract/FREE Full Text
    9. ↵
      2. Barrier A ,
      3. Williams DJ ,
      4. Connelly M , et al
      . Frequency of peripherally inserted central catheter complications in children. Pediatr Infect Dis J 2012;31:519–21. doi:10.1097/INF.0b013e31824571b0
      OpenUrlCrossRefPubMed
    10. ↵
      2. van Rens MFPT ,
      3. Bayoumi MAA ,
      4. van de Hoogen A , et al
      . The ABBA project (Assess Better Before Access): A retrospective cohort study of neonatal intravascular device outcomes. Front Pediatr 2022;10:980725. doi:10.3389/fped.2022.980725
    11. ↵
      2. Hosseinpour M ,
      3. Mashadi MR ,
      4. Behdad S , et al
      . Central venous catheterization in neonates: Comparison of complications with percutaneous and open surgical methods. J Indian Assoc Pediatr Surg 2011;16:99–101. doi:10.4103/0971-9261.83487
      OpenUrlPubMed
    12. ↵
      2. Chenoweth KB ,
      3. Guo JW ,
      4. Chan B
      . The Extended Dwell Peripheral Intravenous Catheter Is an Alternative Method of NICU Intravenous Access. Adv Neonatal Care 2018;18:295–301. doi:10.1097/ANC.0000000000000515
      OpenUrl
    13. ↵
      2. Bahoush G ,
      3. Salajegheh P ,
      4. Anari AM , et al
      . A review of peripherally inserted central catheters and various types of vascular access in very small children and pediatric patients and their potential complications. J Med Life 2021;14:298–309. doi:10.25122/jml-2020-0011
      OpenUrl
    14. ↵
      2. Ozkiraz S ,
      3. Gokmen Z ,
      4. Anuk Ince D , et al
      . Peripherally inserted central venous catheters in critically ill premature neonates. J Vasc Access 2013;14:320–4. doi:10.5301/jva.5000157
      OpenUrlCrossRefPubMedWeb of Science
    15. ↵
      2. Advani S ,
      3. Reich NG ,
      4. Sengupta A , et al
      . Central line-associated bloodstream infection in hospitalized children with peripherally inserted central venous catheters: extending risk analyses outside the intensive care unit. Clin Infect Dis 2011;52:1108–15. doi:10.1093/cid/cir145
      OpenUrlCrossRefPubMed
    16. ↵
      2. Bonventre EV ,
      3. Lally KP ,
      4. Chwals WJ , et al
      . Percutaneous insertion of subclavian venous catheters in infants and children. Surg Gynecol Obstet 1989;169:203–5.
      OpenUrlPubMedWeb of Science
    17. ↵
      2. Haddad H ,
      3. Lee K-S ,
      4. Higgins A , et al
      . Routine surveillance ultrasound for the management of central venous catheters in neonates. J Pediatr 2014;164:118–22. doi:10.1016/j.jpeds.2013.08.048
      OpenUrlCrossRefPubMed
    18. ↵
      2. Piazza AJ ,
      3. Brozanski B ,
      4. Provost L , et al
      . SLUG Bug: Quality Improvement With Orchestrated Testing Leads to NICU CLABSI Reduction. Pediatrics 2016;137. doi:10.1542/peds.2014-3642
    19. ↵
      2. Taylor JE ,
      3. Tan K ,
      4. Lai NM , et al
      . Antibiotic lock for the prevention of catheter-related infection in neonates. Cochrane Database Syst Rev 2015;2015:CD010336. doi:10.1002/14651858.CD010336.pub2
    20. ↵
      2. Cardoso B ,
      3. Almeida HN ,
      4. França I , et al
      . Utilização de Cateteres Venosos Centrais numa Unidade de Cuidados Intensivos Pediátricos [Use of Central Venous Catheters in a Pediatric Intensive Care Unit]. Acta Pediatr Port 2004;35:7–12.
      OpenUrl
    21. ↵
      2. Jain A ,
      3. Deshpande P ,
      4. Shah P
      . Peripherally inserted central catheter tip position and risk of associated complications in neonates. J Perinatol 2013;33:307–12. doi:10.1038/jp.2012.112
      OpenUrlCrossRefPubMedWeb of Science
    22. ↵
      2. Nguyen J
      . Ultrasonography for Central Catheter Placement in the Neonatal Intensive Care Unit-A Review of Utility and Practicality. Am J Perinatol 2016;33:525–30. doi:10.1055/s-0035-1569987
      OpenUrl
    23. ↵
      2. Greenberg RG ,
      3. Cochran KM ,
      4. Smith PB , et al
      . Effect of Catheter Dwell Time on Risk of Central Line-Associated Bloodstream Infection in Infants. Pediatrics 2015;136:1080–6. doi:10.1542/peds.2015-0573
      OpenUrlCrossRefPubMed
    24. ↵
      2. Shalabi M ,
      3. Adel M ,
      4. Yoon E , et al
      . Risk of Infection Using Peripherally Inserted Central and Umbilical Catheters in Preterm Neonates. Pediatrics 2015;136:1073–9. doi:10.1542/peds.2015-2710
      OpenUrlCrossRefPubMed
    25. ↵
      2. Lateef RH
      . Morphological and histological study of umbilical cord at delivery. Kufa Jour Nurs Sci 2011;1:64–71. doi:10.36321/kjns.vi20111.2391
      OpenUrl
    26. ↵
      2. Thandaveshwara D
      . Central lines in a tertiary NICU its Indication & outcome– A descriptive study. 2018.
    27. ↵
      2. Jadhav V ,
      3. Shankar G ,
      4. Deepak J , et al
      . Percutaneous cannulation of central veins in neonates: Its safety and feasibility: Audit of 75 neonatal insertions. Indian J Child Health 2016;3:49–53. doi:10.32677/IJCH.2016.v03.i01.011
      OpenUrl
    28. ↵
      2. King DS ,
      3. da Cruz E ,
      4. Kaufman J
      . A model for a nurse-led programme of bedside placement of peripherally inserted central catheters in neonates and infants with congenital cardiac disease. Cardiol Young 2010;20:302–7. doi:10.1017/S1047951110000090
      OpenUrlPubMed
    29. ↵
      2. Ramsewak S ,
      3. Roopnarinesingh S ,
      4. The T
      . Obstetric factors affecting outcome in low birthweight infants. West Indian Med J 1986;35:166–9.
      OpenUrlPubMed
    30. ↵
      2. K C A ,
      3. Basel PL ,
      4. Singh S
      . Low birth weight and its associated risk factors: Health facility-based case-control study. PLoS ONE 2020;15:e0234907. doi:10.1371/journal.pone.0234907
    31. ↵
      2. Leick-Rude MK ,
      3. Haney B
      . Midline catheter use in the intensive care nursery. Neonatal Netw 2006;25:189–99. doi:10.1891/0730-0832.25.3.189
      OpenUrlAbstract/FREE Full Text
    32. ↵
      2. Milstone AM ,
      3. Reich NG ,
      4. Advani S , et al
      . Catheter dwell time and CLABSIs in neonates with PICCs: a multicenter cohort study. Pediatrics 2013;132:e1609–15. doi:10.1542/peds.2013-1645
      OpenUrlCrossRefPubMed
    33. ↵
      2. Costa P ,
      3. Kimura AF ,
      4. de Vizzotto MPS , et al
      . Prevalence and reasons for non-elective removal of peripherally inserted central catheter in neonates. Rev Gaucha Enferm 2012;33:126–33. doi:10.1590/s1983-14472012000300017
      OpenUrl
    34. ↵
      2. van Rens M ,
      3. Nimeri AMA ,
      4. Spencer TR , et al
      . Cyanoacrylate Securement in Neonatal PICC Use: A 4-Year Observational Study. Adv Neonatal Care 2022;22:270–9. doi:10.1097/ANC.0000000000000963
      OpenUrl
    35. ↵
      2. D’Andrea V ,
      3. Prontera G ,
      4. Pinna G , et al
      . Securement of Umbilical Venous Catheter Using Cyanoacrylate Glue: A Randomized Controlled Trial. J Pediatr 2023;260:S0022-3476(23)00365-7. doi:10.1016/j.jpeds.2023.113517
    36. ↵
      2. Liu H ,
      3. Han T ,
      4. Zheng Y , et al
      . Analysis of complication rates and reasons for nonelective removal of PICCs in neonatal intensive care unit preterm infants. J Infus Nurs 2009;32:336–40. doi:10.1097/NAN.0b013e3181bd5668
      OpenUrlPubMed
    37. ↵
      2. Garg M ,
      3. Rajan N ,
      4. Dhua A , et al
      . Malpositioned Central Line in A Neonate Presenting as Superficial Abdominal Abscess. J Neonatal Surg 2017;6:24. doi:10.21699/jns.v6i1.406
    38. ↵
      2. Chen H ,
      3. Zhang X ,
      4. Wang H , et al
      . Complications of upper extremity versus lower extremity placed peripherally inserted central catheters in neonatal intensive care units: A meta-analysis. Intensive Crit Care Nurs 2020;56:102753. doi:10.1016/j.iccn.2019.08.003
      OpenUrl
    39. ↵
      2. Paulson PR ,
      3. Miller KM
      . Neonatal peripherally inserted central catheters: recommendations for prevention of insertion and postinsertion complications. Neonatal Netw 2008;27:245–57. doi:10.1891/0730-0832.27.4.245
      OpenUrlAbstract/FREE Full Text
    40. ↵
      2. Khieosanuk K ,
      3. Fupinwong S ,
      4. Tosilakul A , et al
      . Incidence rate and risk factors of central line-associated bloodstream infections among neonates and children admitted to a tertiary care university hospital. Am J Infect Control 2022;50:105–7. doi:10.1016/j.ajic.2021.07.016
      OpenUrl
    41. ↵
      2. Moros C ,
      3. Navarrete MJ ,
      4. Flores T , et al
      . P244: Rates, microbiology and risk factors of central line associated bloodstream infection in a neonatal intensive care unit from 2003 to 2012. Antimicrob Resist Infect Control 2013;2:244. doi:10.1186/2047-2994-2-S1-P244
      OpenUrl
    42. ↵
      2. Brzychczy-Wloch M ,
      3. Wojkowska-Mach J ,
      4. Borszewska-Kornacka M , et al
      . Central line associated blood stream infectious cause by multi drug resistance coagulaso-negative Staphylococci in newborns from neonatial intensive care units in Poland. BMC Proc 2011;5:205. doi:10.1186/1753-6561-5-S6-P205
      OpenUrl
    43. ↵
      2. Cantey JB ,
      3. Milstone AM
      . Bloodstream infections: epidemiology and resistance. Clin Perinatol 2015;42:1–16. doi:10.1016/j.clp.2014.10.002
      OpenUrlCrossRefPubMed
    44. ↵
      2. Rajendran DK
      . A Prospective Study on Complications of Central Venous Access in Neonates in a Tertiary Care Hospital. J Med Sci Clin Res 2021;09. doi:10.18535/jmscr/v9i2.35
    45. ↵
      2. Patil K ,
      3. Dhaded SM ,
      4. Bhandankar M
      . A 1-Year Study on Association between Peripherally Inserted Central Catheter Tip Position and Complications in Neonates. J Indian Assoc Pediatr Surg 2020;25:276–9. doi:10.4103/jiaps.JIAPS_87_19
      OpenUrl
    46. ↵
      2. Baorong Z
      . Influencing factors of PICC infection among premture infants and low birth weight infants. Chin J Mod Nurs 2011;17:3747–8.
      OpenUrl
    47. ↵
      2. Pratap A ,
      3. Tiwari A ,
      4. Agrawal CS , et al
      . Gastric outlet obstruction: an unusual complication of umbilical vein catheterization. J Pediatr Gastroenterol Nutr 2006;43:113–5. doi:10.1097/01.mpg.0000221886.90758.08
      OpenUrlPubMed
    48. ↵
      2. Hartley M ,
      3. Ruppa Mohanram G ,
      4. Ahmed I
      . TPNoma: an unusual complication of umbilical venous catheter malposition. Arch Dis Child Fetal Neonatal Ed 2019;104:F326. doi:10.1136/archdischild-2018-315960
    49. ↵
      2. Bayoumi MAA ,
      3. Van Rens MFP ,
      4. Chandra P , et al
      . Effect of implementing an Epicutaneo-Caval Catheter team in Neonatal Intensive Care Unit. J Vasc Access 2021;22:243–53. doi:10.1177/1129729820928182
      OpenUrlCrossRef
    50. ↵
      2. Bayoumi MAA ,
      3. Elmalik EE ,
      4. Ali H , et al
      . Neonatal Simulation Program: A 5 Years Educational Journey From Qatar. Front Pediatr 2022;10:843147. doi:10.3389/fped.2022.843147
    51. ↵
      2. Natile M ,
      3. Ancora G ,
      4. D’Andrea V , et al
      . A narrative review on tip navigation and tip location of central venous access devices in the neonate: Intracavitary ECG or real time ultrasound? J Vasc Access 2024;2024:11297298241259247. doi:10.1177/11297298241259247
    52. ↵
      2. van Rens MF ,
      3. Spencer TR ,
      4. Hugill K , et al
      . Octyl-butyl-cyanoacrylate glue for securement of peripheral intravenous catheters: A retrospective, observational study in the neonatal population. J Vasc Access 2024;25:1229–37. doi:10.1177/11297298231154629
      OpenUrl

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    • Contributors AE, HAA, IP, AIA, AAA and HA-S made a significant contribution to the work reported, whether that is in the conception; study design; execution; acquisition of data; analysis and interpretation; and drafting, revising or critically reviewing the article, and gave the final approval of the version to be published. AE and HA supervised this research. All researchers have agreed on the journal to which the article has been submitted and agreed to be accountable for all aspects of the work. HA-S is responsible for the overall content as guarantor.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

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