Abstract
Background With the advance in technology and medical expertise, it has been increasingly common for clinicians to establish a secured vascular access in the hospitalized neonates. As the veins in preterm neonates are notoriously difficult to catheterize, clinicians are often left with limited options when a secured vascular access is clinically indicated for medications, fluids or intravenous nutrition.
Objectives Peripherally inserted central catheter (PICC) has the advantage of being easily available in most SCBU and NICU, does not require the input of anaesthetist or radiologist and they are often quite durable, lasting up to 3 to 4 weeks in a neonate with meticulous flushing and nursing care. While blood stream related infection, clot formation, malposition, occlusion and extravasation are commonly quoted PICC related complications in the literature, we report a case of tight knot formation of PICC during insertion in a neonate, subsequently requiring venotomy for retrieval.
Methods We report a case of a pre-term neonate with difficult PICC insertion and retrieval. Tight complex knotting of the PICC was confirmed by XRay, and the catheter was subsequently retrieved via cut down method in an emergency operation.
Results A 28-week-gestational age male infant presented with intestinal perforation requiring emergency laparotomy and ileostomy formation. At 3 months of age (corrected age 40 weeks), he required intravenous nutrition due to high output stoma and suboptimal weight gain. Insertion of a vygon Premicath 1French catheter via the left cephalic vein at the forearm was attempted. X ray showed complex coiling of the catheter within the vein (figure 1), therefore it was decided to remove the catheter at the bedside, however, resistance was encountered when withdrawing the catheter. Xray confirmed knotting of the catheter at about 6 cm away from the percutaneous puncture site (figure 2).
Emergency operation under general anesthesia was arranged, and venotomy was made directly over the knot after controlling the left cephalic vein. The catheter was retrieved and the cephalic vein was ligated afterwards. Post op recovery was uneventful. Subsequently a tunneled central catheter (Broviac catheter) was inserted at an elective operation into the right internal jugular vein
Conclusions PICC have been used extensively in children where vascular access can often be challenging for medium term infusion therapy. These are non-tunneled vascular devices that can be inserted at the bedside (1). Knot formation during PICC insertion in a 5-month old infant had been reported (2) and the author suggested a trial of knot dissolution by repeated flushing with saline solution. Another paper suggested using 0.008’ hydrophilic guidewire to unloop the PICC knot, however it was not actually performed as the case described did not have any real knot (3). Our case illustrated the potential complication of PICC insertion in a small neonate.
