Comparing conventional and modified Seldinger techniques using a micro-insertion kit for PICC placement in neonates: a retrospective cohort study.

Objective: This study aims to assess the comparative effectiveness of a conventional splitting needle or a peelable cannula vs. the modified Seldinger technique (MST) by utilizing a dedicated micro-insertion kit across various clinically significant metrics, including insertion success, complications, and catheter-related infections. Methods: We conducted a retrospective observational cohort study using an anonymized data set spanning 3 years (2017-2019) in a large tertiary-level neonatal intensive care unit in Qatar. Results: A total of 1,445 peripherally inserted central catheter (PICC) insertion procedures were included in the analysis, of which 1,285 (89%) were successful. The primary indication for insertion was mainly determined by the planned therapy duration, with the saphenous vein being the most frequently selected blood vessel. The patients exposed to MST were generally younger (7 ± 15 days vs. 11 ± 26 days), but exhibited similar mean weights and gestational ages. Although not statistically significant, the MST demonstrated slightly higher overall and first-attempt insertion success rates compared to conventional methods (91 vs. 88%). However, patients undergoing conventional insertion techniques experienced a greater incidence of catheter-related complications (p < 0.001). There were 39 cases of catheter-related bloodstream infections (CLABSI) in the conventional group (3.45/1,000 catheter days) and eight cases in the MST group (1.06/1,000 catheter days), indicating a statistically significant difference (p < 0.001). Throughout the study period, there was a noticeable shift toward the utilization of the MST kit for PICC insertions. Conclusion: The study underscores the viability of MST facilitated by an all-in-one micro kit for neonatal PICC insertion. Utilized by adept and trained inserters, this approach is associated with improved first-attempt success rates, decreased catheter-related complications, and fewer incidences of CLABSI. However, while these findings are promising, it is imperative to recognize potential confounding factors. Therefore, additional prospective multicenter studies are recommended to substantiate these results and ascertain the comprehensive benefits of employing the all-in-one kit.

Safe and effective removal of cyanoacrylate vascular access catheter securement adhesive in neonates.

Neonatal vascular access continues to pose challenges. Recent times have seen considerable innovations in practice and the design and manufacture of materials used to provide infusion-based therapies with the intent of reducing the incidence and severity of vascular access-related complications. However, despite these efforts, vascular access-related complication rates remain high in this patient group and research evidence remains incomplete. In neonates, a medical-grade formulation of cyanoacrylate adhesive is widely used to secure percutaneously inserted central venous catheters and is beginning to establish a role in supporting the effective securement of other devices, such as umbilical and peripheral intravenous catheters. This Perspective article considers issues specific to the removal of cyanoacrylate used to secure vascular access devices from neonatal skin before its bonding releases due to natural skin exfoliation processes. The aim of this information is to ensure the safe and effective removal of octyl-cyanoacrylate adhesive-secured vascular access catheters from neonatal skin and stimulate professional discussion.

Peripheral intravenous therapy infiltration/extravasation (PIVIE) risks and the potential for earlier notification of events using a novel sensor technology in a neonatal population.

BACKGROUND: Intravenous (IV) therapy using short peripheral IV catheters (PIVC) is commonplace with neonatal patients. However, this therapy is associated with high complication rates including the leakage of infused fluids from the vasculature into the surrounding tissues; a condition referred to as, peripheral IV infiltration/extravasation (PIVIE). OBJECTIVE: The quality improvement project aimed to identify the prevalence of known risk factors for PIVIE in the neonatal intensive care unit (NICU) and explore the feasibility of using novel optical sensor technology to aid in earlier detection of PIVIE events. METHODS: The plan, do, study, act (PDSA) model of quality improvement (QI) was used to provide a systematic framework to identify PIVIE risks and evaluate the potential utility of continuous PIVC monitoring using the ivWatch model 400® system. The site was provided with eight monitoring systems and consumables. Hospital staff were supported with theoretical education and bedside training about the system operations and best use practices. RESULTS: In total 113 PIVIE's (graded II-IV) were recorded from 3476 PIVCs, representing an incidence of 3.25%. Lower birth weight and gestational age were statistically significant factors for increased risk of PIVIE (p = 0.004); all other known risk factors did not reach statistical significance. Piloting the ivWatch with 21 PIVCs using high-risk vesicant solutions over a total of 523.9 h (21.83 days) detected 11 PIVIEs (graded I-II). System sensitivity reached 100%; 11 out of 11 PIVIEs were detected by the ivWatch before clinician confirmation. CONCLUSIONS: Prevailing risk factors for PIVIE in the unit were comparable to those published. Continuous infusion site monitoring using the ivWatch suggests this technology offers the potential to detect PIVIE events earlier than relying on intermittent observation alone (i.e. the current standard of care). However, large-scale study with neonatal populations is required to ensure the technology is optimally configured to meet their needs.

Clotted blood samples in the neonatal intensive care unit: A retrospective, observational study to evaluate interventions to reduce blood sample clotting.

BACKGROUND: Blood draws for laboratory investigations are essential for patient management in neonatal intensive care units (NICU). When blood samples clot before analysis, they are rejected, which delays treatment decisions and necessitates repeated sampling. AIMS: To decrease the incidence of rejected blood samples taken for laboratory investigation as a result of clotted sample. STUDY DESIGN: This retrospective observational study used routine data on blood draws from preterm infants collected between January 2017 and June 2019 in a 112-cot NICU in Qatar. Quality improvement interventions to reduce the rate of clotted blood samples included: awareness raising and safe sampling workshops with NICU staff, involvement of the neonatal vascular access team, development of a complete blood count (CBC) sample collection pathway, review of sample collection equipment, introducing the Tenderfoot® heel lance, establishment of benchmarks and provision of dedicated blood extraction equipment. RESULTS: First attempt blood draw occurred in 10 706 cases, representing a 96.2% success rate. In 427 (3.8%) cases, the samples were clotted requiring repeat collection. The overall rate of clotted specimens decreased from 4.8% in 2017 and 2018 to 2.4% in 2019, with odds ratios of 1.42 (95% confidence interval [CI] 1.13-1.78, p = .002), 1.46 (95% CI 1.17-1.81, p < .001) and 0.49 (95% CI 0.39-0.63, p < .001), respectively. The majority (87%-95%) of blood samples were by venepuncture using an intravenous (IV) catheter or the NeoSafe™ blood sampling device. Heel prick sampling was the second (2%-9%) most common method. Clotted samples were most frequently associated with needle use, 228 of 427 (53%), and IV cannula, 162 of 427 (38%), with odds ratios of 4.14 (95% CI 3.34-5.13, p < .001) and 3.11 (95% CI 2.51-3.86, p < .001), respectively. CONCLUSIONS: Our interventions over 3 years were associated with reduced rates of sample rejection due to clotting, and this led to improved patient experience through fewer repeated samplings. RELEVANCE TO CLINICAL PRACTICE: The insights gained from this project can help to improve patient care. Interventions that reduce the rate of blood sample rejection by clinical laboratories can lead to economic savings, timelier diagnostic and treatment decisions, and contribute to an improved quality care experience for all critical care patients, irrespective of age, by reducing the need for repeated phlebotomy and the risk of related complications.

Octyl-butyl-cyanoacrylate glue for securement of peripheral intravenous catheters: A retrospective, observational study in the neonatal population.

BACKGROUND: Evidence-based insertion and maintenance strategies for neonatal vascular access devices (VAD) exist to reduce the causes of VAD failure and complications in neonates. Peripheral intravenous catheter failure and complications including, infiltration, extravasation, phlebitis, dislodgement with/without removal, and infection are majorly influenced by catheter securement methods. METHODS: A retrospective, observational study using routinely collected data on intravenous device use in a large neonatal intensive care unit in Qatar. A 6-month historical cohort was compared with a 6-month cohort after the introduction of an octyl-butyl-cyanoacrylate glue (CG). In the historical cohort, the catheter was secured using a semi-permeable transparent membrane dressing while in the CG cohort, CG was applied at the insertion site on initial insertion and after any dressing change. This was the only variable intervention between both groups. RESULTS: A total of 8330 peripheral catheters were inserted. All catheters were inserted and monitored by members of the NeoVAT team. 4457 (53.5%) were secured with just a semi-permeable transparent dressing and 3873 (46.5%) secured a semi-permeable transparent dressing with the addition of CG. The odds ratio for premature failure after securement with CG was 0.59 (0.54-0.65) when compared to the catheters secured with a semi-permeable transparent dressing, which was statistically significant (p < 0.001). The correlation between the occurrence of a complication and the use of CG for device securement was significant (p < 0.001). CONCLUSIONS: The risk of developing device-related phlebitis and premature device removal, increased significantly if CG was not used for adjunct catheter securement. In parallel with the currently published literature, this study's findings support the use of CG for vascular device securement. When device securement and stabilization concerns are most pertinent CG is a safe and effective adjunct to reducing therapy failures in the neonatal patient population.

Effect of peripheral intravenous catheter type and material on therapy failure in a neonatal population.

BACKGROUND: In neonatal settings vascular access devices are essential for treatment. However, their use is not without risks. The design and materials of peripheral vascular access devices have been evaluated amongst adult populations, but contemporary studies in neonatal settings are scant. PURPOSE/OUTCOME MEASURES: This research describes the prevalence of peripheral intravenous catheter failure related to three different catheter types with the intent to identify modifiable risks that might be used to evaluate device efficacy, innovate neonatal practice, and support future policy developments. METHOD AND SETTING: This was a retrospective observational analysis of routinely collected anonymized intravenous therapy related data. The study was carried out at the tertiary neonatal intensive care unit (112 beds) of the Women's Wellness and Research Center of Hamad Medical Corporation, Doha, Qatar. PARTICIPANTS: Neonates who were admitted to the unit requiring intravenous treatment wherefore peripheral intravenous cannulation was indicated, were included in this study. RESULTS: The use of different type of catheters resulted in significantly less therapy failures as phlebitis and increased dwell time, compared with the control groups. This remains significant after adjusting for age at insertion, gestational age, birth weight, and catheter type. CONCLUSIONS: The study's findings are in accord with international literature concerning adult and pediatric patients concerning the superiority of PUR over PTFE catheters with respect to the risk of phlebitis and longer dwell times. However, the risk of failure of therapy did not differ between catheters. This finding is reassuring and supports practitioner judgment when selecting peripheral catheter devices.

Closed intravenous systems for central vascular access: A difference maker for CLABSI rates in neonates?

BACKGROUND: Infants in neonatal units are susceptible to numerous potential iatrogenic risks. One key concern is central line-associated blood stream infection (CLABSI). To ensure patient safety and reduce the incidence of CLABSI toward zero, numerous evidence-based clinical interventions and product innovations have been implemented. Nevertheless, sustaining zero CLABSI for sustained periods remains challenging. AIM: The purpose of this study was to evaluate the impact on CLABSI rates of introducing a preassembled closed intravenous (IV) administration set in a neonatal intensive care unit (NICU). METHODS: This was a retrospective observational analysis of routinely collected anonymized IV therapy infection data in a NICU. The study period was from January 2019 through June 2020. RESULTS: Nine-hundred eighty five patients with a Epicutaneo-Caval Catheter (ECC) were included (456 legacy IV set, 529 closed IV set). Patient demographics were comparable between the two groups. ECC dwell time was the only IV characteristic associated (p = 0.04) with CLABSI. Mann-Whitney U-test demonstrated significant differences between the two sets for CLABSI complication events (p = 0.031). Prior to using the closed IV administration sets (January 2019-September 2019) the mean monthly CLABSI rate was 2.87 (/1000 device days). This figure declined to 0.22 (/1000 device days) afterwards (October 2019-June 2020). Zero CLABSIs were observed during January to June 2020. CONCLUSIONS: Utilization of a pre-assembled closed IV administration set was associated with a reduction in CLABSI rates. The study results suggest that using a pre-assembled closed IV set concurrently with evidence-based central line infection control interventions can help attain extended periods of zero CLABSI.

Does the antimicrobial-impregnated peripherally inserted central catheter decrease the CLABSI rate in neonates? Results from a retrospective cohort study.

Background: The use of antimicrobial-impregnated peripherally inserted central catheters (PICCs) has been introduced in the last few years to neonatal units aiming to reduce central line-associated bloodstream infection (CLABSI). Methods: This retrospective observational study aimed to compare the CLABSI rates and other catheter-related parameters including the insertion success rates and catheter-related complications in the antimicrobial-impregnated and conventional (ordinary) PICCs in NICU between 2017 and 2020. Results: Our dedicated PICC team including physicians and nurses inserted 1,242 conventional (PremiCath and NutriLine) and 791 antimicrobial-impregnated PICCs (PremiStar) over the study period from 2017 to 2020. Of those 1,242 conventional PICCs, 1,171 (94.3%) were 1 Fr single lumen and only 71 (5.7%) were 2 Fr double lumen. The mean ± SD [median (IQR)] for the birth weight in all babies who had a PICC line was 1,343.3 ± 686.75 [1,200 (900, 1,500)] g, while the mean ± SD for the gestational age was 29.6 ± 4.03 [29 (27, 31)] weeks. The mean ± SD [median (IQR)] age at the time of insertion for all catheters was 9.3 ± 21.47 [2 (1, 9)] days, while the mean ± SD [median (IQR)] dwell time was 15.7 ± 14.03 [12 (8, 17)] days. The overall success rate of the PICC insertion is 1,815/2,033 (89.3%), while the first attempt success rate is 1,290/2,033 (63.5%). The mean ± SD [median (IQR)] gestational age, birth weight, age at catheter insertion, and catheter dwell time were 28.8 ± 3.24 [29, (26, 31)] weeks, 1,192.1 ± 410.3 [1,150, (900, 1,450)] g, 6.3 ± 10.85 [2, (1, 8)] days, and 17.73 ± 17.532 [13, (9, 18)] days in the antimicrobial-impregnated catheter compared with 30.1 ± 4.39 [29, (27, 32)] weeks (P < 0.001), 1,439.5 ± 800.8 [1,240, (920, 1,520)] g (P < 0.001), 11.1 ± 25.9 [1, (1, 9)] days (P < 0.001), and 14.30 ± 10.964 [12, (8, 17)] days (P < 0.001), respectively, in the conventional PICCs. The use of the antimicrobial-impregnated catheter was not associated with any significant reduction in the CLABSI rate (per 1,000 days dwell time), either the overall [P = 0.11, risk ratio (RR) (95% CI): 0.60 (0.32, 1.13)] or the yearly CLABSI rates. Conclusions: The use of miconazole and rifampicin-impregnated PICCs did not reduce the CLABSI rate in neonates compared with conventional PICCs. However, it has a higher overall rate of elective removal after completion of therapy and less extravasation/infiltration, occlusion, and phlebitis compared with the conventional PICCs. Further large RCTs are recommended to enrich the current paucity of evidence and to reduce the risk of bias. Neonatal PICCs impregnation by other antimicrobials is a recommendation for vascular access device manufacturers.

The ABBA project (Assess Better Before Access): A retrospective cohort study of neonatal intravascular device outcomes.

Background: Venous access devices (VADs) play a vital role within the neonatal intensive care unit. However, there are significant risks associated with the use of VADs, with complications such as infection, thrombosis, device occlusion, and infiltration/extravasation frequently contributing to device-related failures and increasing the risk of significant patient harm or injury. This study aimed to explore the relationships between risk factors and different venous access device complications in the neonatal setting, and then use that evidence to develop an algorithm based on observational data. Methods: This is a retrospective, single-center cohort study that was conducted in a large 112-bed neonatal intensive care unit in Qatar. We examined venous access device data from January 2016 to December 2018 for all term and preterm neonates. Descriptive statistics were used to summarize the outcomes, which included a mean and its standard deviation or median and an interquartile range for continuous variables regarding normal distribution, and absolute numbers with percentages for discrete variables. Results: The authors recorded a total of 23,858 VADs inserted during the study period. Of these, 21,313 (89%) were peripheral intravenous catheters, 689 (3%) were extended dwell-peripheral intravenous catheters, 1,335 (6%) were epicutaneo-caval catheters, and 521 (2%) were umbilical venous catheters. In total, 51,179 catheter days were registered, with 2.17 catheter days reported per patient. Peripheral device dwell times were significantly shorter when compared with central venous catheter devices (P < 0.001), with mean dwell times of 22 days ± 23 h and 236 days ± 183 h, respectively. After insertion, a complication occurred in 11,177 (51%) of peripheral VADs and 221 (12%) of central VADs. The type of device inserted [P < 0.001, hazard ratio (HR) = 0.52, 95% confidence interval (CI): 0.50-0.54], reason/indication for intravenous therapy (P < 0.001, HR = 0.85, 95% CI: 0.82-0.87), and the side of insertion of the device (P < 0.001, HR = 1.25, 95% CI: 1.24-1.27) had a significant relationship with outcomes. Conclusions: Four subgroups of VADs were identified (peripheral intravenous catheters, extended dwell-peripheral intravenous devices, epicutaneo-caval catheters, and umbilical venous catheters) with outcome-related differences. Central venous access devices (epicutaneo-caval catheters and umbilical venous catheters) had lower complications compared with peripheral VADs. Proper venous access device selection, early insertion, and early removal approaches remain crucial to preventing venous access device complications. Peripheral intravenous devices should be used carefully and closely watched for early detection of complications.

Treatment of a neonatal peripheral intravenous infiltration/extravasation (PIVIE) injury with hyaluronidase: a case report.

INTRODUCTION: Intravenous therapy-related injury, its prevention, and treatment are ubiquitous topics of interest among neonatal clinicians and practitioners. This is due to the economic costs, reputational censure, and patents' wellbeing concerns coupled with the possibility of potentially avoidable serious and life-long harm occurring in this vulnerable patient population. CASE DESCRIPTION: A term infant receiving a hypertonic dextrose infusion for the management of hypoglycemia developed a fulminating extravasation shortly after commencement of the infusion. This complication developed without notification of infusion pump pressure changes pertaining to a change in blood vessel compliance or early warning of infiltration by the optical sensor site monitoring technology (ivWatch®) in use. The injury was extensive and treated with a hyaluronidase/saline mix subcutaneously injected into the extravasation site using established techniques. Over a period of 2 weeks, the initially deep wound healed successfully without further incident, and the infant was discharged home without evident cosmetic scarring or functional effects. CONCLUSION: This article reports on a case of a term baby who postroutine insertion of a peripherally intravenous catheter showed an extreme reaction to extravasation of the administered intravenous fluids. We discuss the condition, our successful management with hyaluronidase, and the need to remain observationally vigilant of intravenous infusions despite the advances in infusion monitoring technology. HIGHLIGHTS: In a neonatal population peripheral infusion therapy-related complication rates have been reported to be as high as 75% Peripheral IV infiltration and extravasation (PIVIE) is implicated in up to 65% of IV-related complications PIVIE injury has the potential to cause serious harm Prompt recognition and timely appropriate intervention can mitigate many of these risks Adhering to the 5Rs for vascular access optimizes infusion therapy and potentially reduces complications.

Neonatal Simulation Program: A 5 Years Educational Journey From Qatar.

We describe the process of implementation, adaptation, expansion and some related clinical intuitional impacts of the neonatal simulation program since its launch in 2016 in a non-simulation neonatal unit. The team has developed 6 types of curricula: 1 full-day course and 5 half-day workshops. A total of 35 free of charge simulation courses/workshops were conducted, 32 in Qatar and 3 abroad with a total of 799 diverse participants. There was a steady increase in the overall success rate of PICC insertion from 81.7% (309/378) to 97.6% (439/450) across 3 years (P < 0.0001). The first attempt PICC insertion success rate has been also increased from 57.7% (218/378) to 66.9% (301/450) across 3 years. The mean duration of PICC insertion has been improved from 39.7 ± 25 to 34.9 ± 12.4 min after implementing the program (P = 0.33). The mean duration of the LISA catheter insertion at the beginning of the workshop was 23.5 ± 15.9 compared to 12.1 ± 8.5 s at the end of the workshop (P = 0.001). When it came to clinical practise in real patients by the same participants, the overall LISA catheter insertion success rate was 100% and the first attempt success rate was 80.4%. The mean duration of LISA catheter insertion in real patients was 26.9 ± 13.9 s compared to the end of the workshop (P = 0.001). The mean duration of the endotracheal intubation at the beginning of the workshop was 12.5 ± 9.2 compared to 4.2 ± 3.8 s at the end of the workshop (P = 0.001). In real patients, the first-attempt intubation success rate has been improved from 37/139 (26.6%) in the first year to 141/187 (75.5%) in the second year after the program implementation (P = 0.001). The mean duration of successful endotracheal intubation attempts has been improved from 39.1 ± 52.4 to 20.1 ± 9.9 s (P = 0.78). As per the participants, the skills learned in the program sessions help in protecting neonates from potential harm and improve the overall neonatal outcome. Implementing a neonatal simulation program is a promising and feasible idea. Our experience can be generalised and replicated in other neonatal care institutions.

Evaluation of a diluted lipid emulsion solution as a lubricant for improved peripherally inserted central catheter guidewire removal in a neonatal population.

BACKGROUND: Medical management of neonates is often established upon safe and reliable vascular access, frequently utilized to provide physiological monitoring, parenteral and supportive treatments, and diagnostic and/or procedural purposes. For this, peripherally inserted central catheters (PICCs) are often used to provide safe vascular access and infusion-related therapies in the neonatal intensive care (NICU) setting. PURPOSE: Difficult PICC guidewire removal is understood to cause catheter damage, causing luminal rupture or possible breakage of the catheter or guidewire itself. The aim of this study was to assess and compare the incidence of therapy failures with use of a preflush fluid using normal saline (NSS) versus a diluted lipid solution (DLS) prior to device insertion, to assist with guidewire removal and prevent unnecessary catheter damage. METHOD AND SETTING: A retrospective, observational study was performed in the Neonatal Intensive Care Unit (NICU) of the Women's Wellness and Research Centre, Hamad Medical Corporation, Qatar. This single site study included 507 neonates who required intravenous therapy administered via a PICC during the study period. RESULTS: Results demonstrated the use of a diluted lipid solution preflush (DLS) resulted in significantly lesser failures, when compared with the control group (NSS). This highlights a clinical significance after adjusting for day of insertion, gestational age, birth weight and catheter type. CONCLUSION: DLS preflush demonstrated a benefit over the use of a NSS preflush to enhance PICC guidewire removal in neonatal patients in the NICU. The risk for development of maintenance-related complications leading to premature device removal decreased significantly if the DLS preflush was used. During the study period, no complications related to the use of a lipid preflush solution were identified. IMPLICATIONS FOR PRACTICE AND RESEARCH: This may be the first study published investigating and supporting guidewire removal enhancement by using a diluted lipid/saline preflush solution. When the requirement for vascular access is most pertinent in the neonate, using a diluted lipid preflush may provide an effective method to assist in guidewire removal to prevent malposition and vascular device complications in the neonatal population.

Cyanoacrylate Securement in Neonatal PICC Use: A 4-Year Observational Study.

BACKGROUND: Within every neonatal clinical setting, vascular access devices are considered essential for administration of fluids, nutrition, and medications. However, use of vascular access devices is not without danger of failure. Catheter securement adhesives are being evaluated among adult populations, but to date, studies in neonatal settings are scant. PURPOSE: This research describes the prevalence of peripherally inserted central catheter failure related to catheter securement before and after the introduction of tissue adhesive for catheter securement. The identified modifiable risks might be used to evaluate efficacy, to innovate neonatal practice and support future policy developments. METHOD AND SETTING: This was a retrospective observational analysis of routinely collected anonymized intravenous therapy-related data. The study was carried out at the tertiary neonatal intensive care unit (112 beds) of the Women's Wellness and Research Center of Hamad Medical Corporation, Doha, Qatar. RESULTS: The results showed that the use of an approved medical grade adhesive for catheter securement resulted in significantly less therapy failures, compared with the control group. This remains significant after adjusting for day of insertion, gestational age, birth weight, and catheter type. IMPLICATIONS FOR PRACTICE AND RESEARCH: In parallel with currently published international literature, this study's findings support catheter securement with an octyl-based tissue adhesive in use with central venous catheters. When device stabilization is most pertinent, securement with tissue adhesive is a safe and effective method for long-term vascular access among the neonatal population.

Evaluation of unmodifiable and potentially modifiable factors affecting peripheral intravenous device-related complications in neonates: a retrospective observational study.

OBJECTIVES: Infants in neonatal units benefit from dependable peripheral intravenous access. However, peripheral intravenous access exposes infants to high rates of clinically minor and serious complications. Despite this, little is known about the interplay of risk factors. The aim of this study was to assess the incidence and evaluate the interactions of risk factors on the occurrence of peripheral intravenous complications in a neonatal population. DESIGN: This was a retrospective observational study. SETTING: The study was performed on the neonatal intensive care unit of the Women's Wellness and Research Center, Hamad Medical Corporation, Qatar, as a single-site study. PARTICIPANTS: This study included 12 978 neonates who required intravenous therapy. OUTCOME MEASUREMENTS: The main outcome was the occurrence of any peripheral intravenous cannulation failure, leading to unplanned removal of the device before completion of the intended intravenous therapy. RESULTS: A mean dwell time of 36±28 hours was recorded in participants with no complications, whereas the mean dwell time was 31±23 hours in participants with an indication for premature removal of the peripheral intravenous catheter (PIVC) (p<0.001, t=11.35). Unplanned removal occurred in 59% of cases; the overall complication rate was 18 per 1000 catheter days. Unmodifiable factors affecting PIVC dwell time include lower birth (HR=0.23, 0.20 to 0.28, p<0.001) and current body weight (HR=1.06, 1.03 to 1.10, p=0.018). Cannulation site (HR=1.23, 1.16 to 1.30, p<0.001), the inserted device (HR=0.89, 0.84 to 0.94, p<0.001) and the indication for intravenous treatment (HR=0.76, 0.73 to 0.79, p<0.001) were modifiable factors. CONCLUSION: Most infants experienced a vascular access-related complication. Given the high complication rate, PIVCs should be used judiciously and thought given prior to their use as to whether alternate means of intravenous access might be more appropriate.

Effect of implementing an Epicutaneo-Caval Catheter team in Neonatal Intensive Care Unit.

BACKGROUND: Until the 1980s, central vascular access in the Neonatal Intensive Care Unit was predominantly delivered by umbilical catheters and only and if needed by surgical cutdowns or subclavian vein catheterization through blind percutaneous venipuncture. In the early 1980s, epicutaneo-caval catheters were successfully introduced. METHODS: In our Neonatal Intensive Care Unit, a dedicated team to insert epicutaneo-caval catheters was formally established in January 2017, including 12 neonatologists and 1 neonatal nurse practitioner. A before- versus after-intervention study was designed to determine whether the establishment of the epicutaneo-caval catheter insertion team is associated with increased success rates and a decreased risk of catheter-related complications. Success rates and other catheter-related parameters were traced from 2016 onward. Collected data were analyzed for three consecutive years: 2016, 2017, and 2018. RESULTS: The epicutaneo-caval catheter team inserted 1336 catheters over 3 years. Both first prick (from 57.7% to 66.9%; p = 0.023) and overall success (from 81.7% to 97.6%; p < 0.0001) rates significantly improved. In 2018, the number of tunneled or surgically inserted central venous catheters came down to zero (p < 0.0001). Overall catheter-related complications were significantly lower following the epicutaneo-caval catheter team's establishment (p < 0.0001) while there was no significant decrease noted (p = 0.978) in central line-associated bacterial stream infection rates. CONCLUSION: A dedicated epicutaneo-caval catheter team is a promising intervention to increase success rates and significantly decrease catheter-related complications in Neonatal Intensive Care Unit. Standardizing epicutaneo-caval catheter placement is important; however, standardizing catheter maintenance seems essential to the improvement of central line-associated bacterial stream infection rates.

Inserting central lines via the peripheral circulation in neonates.

Peripherally inserted central catheters (PICCs) are extensively used in neonatal intensive and high-dependency care settings. These intravenous catheters provide medium to longer-term access to the circulatory system for the delivery of medications, parenteral nutrition and the like. Catheters are available in a variety of bespoke designs and materials, each with their unique characteristics, benefits and limitations. PICCs are frequently inserted in a sterile zone cot-side procedure, one that requires an advanced knowledge base, technical skill and training. This article relates some important practical advice around managing minor complications that can be encountered while using the modified Seldinger technique (MST) to insert neonatal PICCs, which can make this procedure a less stressful experience for both infants and health professionals.