Case Objectives

• Appreciate the incidence and consequences of PICC line breakage.
• Understand the risk factors for PICC line breakage.
• Understand the treatment options in case of PICC line breakage.
• Understand the measures to safely place a PICC line and prevent PICC line breakage.
• Appreciate the guidelines to reduce risk of complications from central venous catheters.

The Case

Born at 27 weeks' gestation, a premature infant had a standard, silastic, 1.9 F percutaneously inserted central venous catheter (PICC) placed on day two of life for parenteral nutrition. The PICC was inserted under sterile conditions with placement verified by X-ray. Initially, the infant was on ventilator support and NPO due to feeding intolerance and necrotizing enterocolitis surveillance. Several attempts were made to introduce feeds; however, the infant continued to have large residuals and increased abdominal girth.

After 40 days of parenteral therapy, the antecubital site and the upper arm became red, swollen, and tender to the touch. The neonatologist opted to remove the catheter. When the RN started to remove the PICC, it broke, leaving approximately 7 cm in the patient.

After several attempts to retrieve the remainder of the line, with X-rays to check placement, the infant was sent for surgical removal of the catheter. Cultures taken via blood and PICC reported moderate growth of Staphylococcus. The infant required an increased level of care that included ventilator support, infusion of blood products, and antibiotic treatment.

The Commentary

Venous access is of critical importance in sick neonates. Patients in neonatal intensive care units (NICUs) often require parenteral antibiotics for treatment of sepsis or other infections, total parenteral nutrition (TPN), and life support medications. In addition, neonates have large fluid losses because of their relatively large body surface area, which increases their need for reliable access to deliver hydration.(1)

Peripherally inserted central catheters (PICCs) were introduced in 1975 as an alternative to tunneled central catheters (Hickman lines) and ports (e.g., Portacaths).(2) These catheters, which are made of silicone, polyurethane, or polyethylene, are generally inserted in the antecubital fossa by interventional radiologists or members of a PICC team, often using ultrasonic or fluoroscopic guidance.

PICCs are being used with increasing frequency for several reasons, not only in the NICU setting but also in the general inpatient and outpatient pediatric population. First, the increasing use is related to the availability of these devices, and the increasing availability of specialized PICC teams to insert them. Second, PICCs have a lower risk of complications than tunneled central venous lines.(3,4) Third, the procedure is simpler to perform than insertion of tunneled catheters and can be done rapidly, relatively inexpensively, and with only mild sedation or pain relief.

Turning specifically to neonates, there are other reasons that PICCs have become increasingly attractive. The catheters are widely available in sizes as small as 1.2 F, facilitating insertion in micropremies weighing less than 500 g to 700 g.(5) Moreover, they have been shown to reduce the length of hospital stay and can reduce the stress and suffering associated with frequent venipuncture in pediatric inpatients during a prolonged hospital stay.(6)

Notwithstanding all these attractive features, PICCs can cause complications. These include injury to vessels or organs during insertion, catheter migration or malposition with extravasation, infection, thromboembolism, catheter breakage (fracture), and dysfunction.(5) Several retrospective studies have tracked these complications in pediatric populations. One study of 120 inpatients' records found that PICCs were generally placed to administer chemotherapy, blood transfusions, antibiotics, or parenteral nutrition. All inpatients received fluoroscopic guided PICC (4 F single-lumen silicone rubber catheter) insertions into distal superior vena cava via the antecubital region of the forearm. The study found that the most common complications were wound oozing, phlebitis, occlusion, infection, and leaking.(7)

A second study was a retrospective review of PICC-related complications in 53 pediatric patients with various types of malignancies.(8) In this population, PICCs were used to administer fluid, parenteral nutrition, anticancer agents, antibiotics, and blood products and also for the through-line blood sampling. PICCs were successfully placed in 109 of 112 attempts (97.3%) in 53 patients, and they were followed for a total of 11,797 catheter days. Fifty-five PICCs (50.5%) were removed as a result of PICC-related complications, yielding a complication rate of 4.66 per 1000 catheter days. The most common reasons for catheter removal were occlusion (n=18), breakage/leakage (n=15), and infection (n=10). Because more than 70% of such complications occurred more than 30 days after placement, the authors concluded that longer-term placement of PICCs may be related to an increased risk of complications.(8)

The case presented here describes a relatively rare PICC complication: breakage that occurs while the PICC is in the intravascular space.

Only one study in the literature examines the complication of PICC breakage in sufficient detail to analyze possible risk factors and review outcomes. A retrospective study examined the records of PICC insertions in a single tertiary care pediatric hospital over a 6-year period.(9) Among approximately 1650 PICCs, the most common complications were mechanical and accidental failures of the catheter (leaks, accidental removal, migration of the tip, fracture, and embolization), PICC-related infections, occlusion of the PICC (chemical, mechanical, or thrombotic), venous or right atrial perforation, arrhythmias, and venous stasis causing phlebitis. In this study, 11 children were identified with a fractured PICC line, an incidence of 6.7 per 1000 PICCS. All fractured lines were 3 F or 4 F in size and were inserted in the upper extremities; 75% of control patients had the same type of PICCs placed. Patient characteristics did not reveal any specific risk factors for intravascular PICC fracture, nor were catheter size, insertion site, and specific medications infused through the line significant predictors of fracture.(9)

On the other hand, catheter fractures were more common in older lines and when there was evidence of another complication with the line (blockage of the line, leaking at the insertion site, or history of difficulty flushing the line with heparin). The median time from insertion to discovery of the PICC fracture was 93 days, consistent with the hypothesis that catheter fatigue plays a role in breakage. Only two catheters fractured less than 2 months after insertion. All catheters were fractured at or near the entrance site. Together, these data support the hypothesis that catheter fatigue and stress play a role in breakage. The investigators speculate that mechanical manipulation (particularly rotational torque or twisting of the catheter) may be more likely to promote fatigue and breakage than linear bending, and that flushing blocked lines under high pressure (using too much manual force or using small syringes) may also contribute to breakage.

The complication of PICC breakage may be discovered in a variety of ways. In four cases each, the fracture was identified by chest roentgenography or on fluoroscopy before contrast injection. Two fractured lines were discovered at the time of line removal; the remaining case was identified during cardiac catheterization for myocardial biopsy.

In all cases, the embolized line fragment was successfully retrieved by percutaneously inserted catheters and snares. Although no major complications arose from the fractured catheters in the case series (9), the transvenous removal of a PICC fragment from the circulation may be challenging, especially in neonates born prematurely or with very low birth weight. The child described in the present case required surgery for removal of the PICC fragment.

The most commonly used nonsurgical method of PICC fragment removal is snaring the line and pulling it into a sheath that is then pulled out of the body. This is most often accomplished under direct visualization by an interventional radiologist. The migration of the embolized fragment usually does not lead to hemodynamic instability, even when it enters the heart or lungs. The size and weight of the child present several challenges to successful PICC fragment removal. The challenges with preterm interventions include those related to access, maintenance of homeostasis (hypothermia, hypoglycemia) during the procedure, and negotiating the curves within the vascular structures.(10,11)

What can we learn about this unusual complication from this case? When using PICCs in neonates, the small size of the line (1.9 F [0.64 mm] in this case) can make it difficult to prevent kinks and other damage. The fact that the site underwent repeated sterile dressings and had been in place for more than a month might have led to its fragility. The catheter's small size and intravascular location would also facilitate fibrin binding, keeping it secure in the vessel and making it more likely to break on removal. Another factor was the use of a small syringe for flushing. According to the case reporter, after this case was reviewed, the hospital mandated that a syringe with a volume greater than 5 mL be used when flushing the line. Chow and colleagues have hypothesized that the use of small syringes (5 mL or less) could lead to increased force on catheter walls and higher risk of fractures.(9)

Because PICC breakage is so unusual, it is difficult to formulate a set of evidence-based recommendations to prevent the complication. Nevertheless, based on the experience in the literature, some recommendations can be made (Table). It seems prudent to avoid flushing catheters under high pressure or using small syringes. Although PICC line duration is clearly a risk factor for breakage, routine removal and reinsertion also carry risks and costs and cannot be recommended at this time. Catheter tips should be in the superior vena cava (having the tip in a large-lumen vessel may decrease the risk of local complications); this position should be monitored frequently by radiographs or ultrasound.(12,13) PICCs should be removed as soon as the indication for them is no longer present. Some investigators have called for the development of a new material or surface coating on the PICC line to prevent fibrin adherence.(7)

Health care professionals and parents responsible for maintaining PICCs (since many patients go home with these lines, where they are cared for by patients and families) should be informed about the possibility of PICC breakage during the informed consent process, and should be educated about the phenomenon of PICC fracture and the signs to watch for: difficulty flushing or withdrawing from the line and leaking at the site of insertion. Such problems should be promptly investigated, because PICC complications are potentially life-threatening. A chest roentgenogram, including a view of the arm with the insertion site, should be performed initially, followed by fluoroscopy if the catheter appears intact. In addition, caregivers should be warned against flushing with small-volume syringes.(9)

Take-Home Points

• For a variety of reasons, use of PICCs has become increasingly prevalent, including in pediatric inpatients.
• PICC complications include injury to other vessels or organs during insertion, catheter migration or malposition with extravasation from the malpositioned catheter, infection, thromboembolism, catheter breakage, and dysfunction.
• Over the course of a case series of 1650 PICCs, fracture and embolization occurred at an incidence of 6.7 in 1000 PICCs.(9)
• Duration of placement and a line complication (blockage of the line or leaking at the insertion site) are associated with PICC fractures.
• Caregivers should be warned against flushing PICCs with small-volume syringes or with too much pressure.

Vesselin Dimov, MD Allergy and Immunology Fellow

Division of Allergy and Immunology

Creighton University

Omaha, Nebraska Former Clinical Assistant Professor of Medicine

Cleveland Clinic Lerner College of Medicine of Case Western Reserve University

Cleveland, Ohio

Faculty Disclosure: Dr. Dimov has declared that neither he, nor any immediate member of his family, has a financial arrangement or other relationship with the manufacturers of any commercial products discussed in this continuing medical education activity. In addition, the commentary does not include information regarding investigational or off-label use of pharmaceutical products or medical devices.

References

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8. Matsuzaki A, Suminoe A, Koga Y, Hatano M, Hattori S, Hara T. Long-term use of peripherally inserted central venous catheters for cancer chemotherapy in children. Support Care Cancer. 2006;14:153-160. [go to PubMed]

9. Chow LM, Friedman JN, Macarthur C, Restrepo R, Temple M, Chait PG, et al. Peripherally inserted central catheter (PICC) fracture and embolization in the pediatric population. J Pediatr. 2003;142:141-144. [go to PubMed]

10. Kohli V, Joshi R. Central line retrieval in a neonate. Indian J Pediatr. 2007;74:692-693. [go to PubMed]

11. Robbins AB, Patel H. Transvascular retrieval of a catheter remnant from the peripheral vein of a preterm neonate. J Vasc Access. 2008;9:299-300. [go to PubMed]

12. Coit AK, Kamitsuka MD; Pediatrix Medical Group. Peripherally inserted central catheter using the saphenous vein: importance of two-view radiographs to determine the tip location. J Perinatol. 2005;25:674-676. [go to PubMed]

13. Schwengel DA, McGready J, Berenholtz SM, Kozlowski LJ, Nichols DG, Yaster M. Peripherally inserted central catheters: a randomized, controlled, prospective trial in pediatric surgical patients. Anesth Analg. 2004;99:1038-1043. [go to PubMed]

Table

Table. Guidelines to reduce risk of complications from central venous catheters.(5)