Use umbilical venous catheters in neonates with caution, says study

Complication rates related to the use of umbilical venous catheters (UVCs) in Singapore are comparable to international norms, but UVCs may lead to serious complications and must be used with caution in neonates, according to a study.

“UVC-associated extravasation was more common than previously thought and was associated with both malpositioned and low-lying UVCs,” the researchers said. “Judicious use of UVCs is required to reduce the complication rates associated with them in neonates.”

A total of 108 patients (mean gestational age, 30.4±4.0 weeks; mean birth weight, 1,536.2±788.9 g) underwent UVC insertion from January 2016 to July 2017 in a tertiary neonatal unit in Singapore. Mean UVC duration was 6.6 days.

UVC position was ideal in 27 neonates (25.0 percent), deep in 13 (12.0 percent) and short in 35 (32.4 percent), and a third (n=33) was malpositioned. [Singapore Med J 2019;doi:10.11622/smedj.2019140]

Of the neonates, 16 (14.8 percent) had catheter-related sepsis, with five (4.6 percent) having catheter-associated bloodstream infection (CABSI). The most common organism was coagulase-negative Staphylococcus (CONS). Other complications included peritoneal extravasation in three (2.8 percent) patients, two of whom required surgical intervention.

In addition, two neonates had venous thrombosis, which was managed conservatively.

“The CABSI rate in our study was comparable with other international studies,” the researchers said.

A 2002 Canadian Neonatal Network study showed a rate of 7.2 per 1,000 umbilical catheter days, while another study from China in 2012 yielded a rate of 13.6 per 1,000 catheter days. [Pediatr Infect Dis J 2002;21:505-511; Am J Perinatol 2012;29:107-114]

In another review published in 2015, the Canadian Neonatal Network UVC-associated CABSI rate appeared to have remained stable at 7.8–8.2 per 1,000 catheter days, “as part of a comparison with the peripherally inserted central catheter line.” [Pediatrics 2015;136:1073-1079]

Furthermore, there were varied and nonspecific clinical presentations of CABSI in neonates, which might include fever, respiratory symptoms, erythema or purulent discharge at the insertion site, and feed intolerance. [J Pediatr Surg 1998;33:1383-1387]

“Clinicians will generally remove the UVC in the context of symptomatic bacteraemia,” according to the researchers.

In a cohort study that evaluated how often neonate with CONS bacteraemia can be treated successfully without removing the central venous catheter, results showed that retention of catheters was successful in nearly half (46 percent) of neonates with CONS bacteraemia but was a failure if the bacteraemia lasted for >4 days. [Pediatr Infect Dis J 2002;21:22-27]

“However, our practice still would more commonly be to remove a central catheter if there is definite bacteraemia in a neonate,” the researchers said.

The current single-centre retrospective study reviewed UVC-related complications in neonates over 19 months. Ideal UVC position was defined as catheter tip within 0.5 cm above or below the diaphragm. Catheter-related sepsis was defined as clinical or biochemical abnormalities suggesting any new-onset of worsening sepsis 72 hours before and after UVC removal, with or without positive culture.

CABSI referred to the positive microbiological growth in one or more blood cultures obtained from a symptomatic infant up to 2 days after UVC placement or within 48 hours of catheter removal.

“The presentation of CABSI or neonatal venous thrombosis is heterogeneous and may be subtle,” the researchers said. “A high index of suspicion is required for the further evaluation and management of neonates with UVCs.”