Seminars in Pediatric Surgery 30 (2021) 151119

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Seminars in Pediatric Surgery

journal homepage: www.elsevier.com/locate/sempedsurg

Peripherally inserted central venous access

Omar Nunez Lopez a, Jamie M Lorenc b, Brenton D Reading b, David Juang a, Pablo Aguayo a,∗
a
Department of Surgery, Children’s Mercy, Kansas City, Missouri, United States
b
Department of Radiology, Children’s Mercy, Kansas City, Missouri, United States

Introduction for the delivery of solutions and medications that otherwise would
cause damage to peripheral veins. Increased blood flow in the cen-
Central venous access is a common requirement in the acute tral venous circulation, compared to peripheral veins, allows for
and chronic care of pediatric patients. Peripherally inserted cen- hemodilution of infusates decreasing the risk of chemical phlebitis.
tral catheters (PICC) represent one of the most common modes of Central venous access is recommended for administration of medi-
central venous access used.1 A PICC is a vascular device inserted cation and solutions with an osmolality >600 mOsm/kg, pH <5 or
into a peripheral vein and advanced into the central venous circu- >9, or medications and solutions that are known chemical irritants
lation. PICCs are intermediate- and long-term vascular access de- that can cause vein damage promoting phlebitis and thrombosis,
vices that represent an alternative to temporary percutaneous cen- especially in the setting of inadequate hemodilution.2 Common in-
tral catheters.2 They are most commonly inserted through the arm dications include resuscitation, administration of total parenteral
veins (basilic, cephalic, or brachial veins). PICCs decrease the need nutrition, long-term medications (antibiotics, chemotherapy, coag-
of tunneled catheters and can be used for weeks or months in both ulation factors), frequent need for blood transfusion or blood sam-
the inpatient and outpatient setting. pling, and prolonged or frequent hospitalization.
Many specialized centers have vascular access teams who are An absolute contraindication is the absence of a suitable pe-
responsible for the placement of PICC. These teams usually consist ripheral vein for access. Most of the contraindications are relative.
of skilled nurses and/or advanced practitioners.3 , 4 Having a ded- Each patient should be evaluated individually to assess the risks
icated vascular access team improves outcomes, including a de- and benefits of the procedure. Some of the situations where spe-
crease in the number of attempts, lower infection rates, and is cial considerations must be taken include:
proven to be cost-effective.5 , 6 . Use of ultrasound guidance and con- -Bacteremia or fungemia. Practices vary across institutions;
firmation of tip position with radiography are standard. Depending whereas some recommend empiric treatment for 24-48 hours be-
on institutional practices, the procedure can also be performed by fore placement of an elective PICC, some institutions require ob-
an interventional radiologist and can be done, if the clinical condi- jective proof of clearance (negative blood cultures). However, the
tion of the patient allows it, with fluoroscopy assistance in an an- patient may indeed need a PICC for administration of antimicro-
giography suite. Most commonly, the procedure takes place at the bial therapy and thus immediate placement may be warranted in
bedside, is relatively expeditious, and does not require sedation or the presence of microbial infection.8
general anesthesia.
The use of PICC decreases the need for several peripheral in- -Coagulopathy. Although frequently central venous access is
travenous lines (PIV), reducing the pain and stress associated with needed in order to treat the coagulopathy or correct the un-
PIV placement. Compared to PIV, there is less risk of infiltration derlying cause.
around surrounding soft tissues at the insertion site. They also can -Long bone fracture along the course of vein used for peripheral
be used for collecting blood samples. For all the above-mentioned cannulation
reasons, PICCs have gained widespread use and have reduced the -Congenital cardiac anomalies requiring operative intervention.
need of surgically placed central venous catheters.7 In these cases, consultation with the cardiac surgeon regard-
ing the use of a PICC and tip position are recommended.2
Indications and contraindications
Anatomic considerations
In general, placement of a PICC should be considered when in-
travenous therapy for six days or more is anticipated.3 In addition, Upper extremity
not only the time but the type of intravenous therapy dictates the
need for a PICC. Access to the inferior or superior vena cava allows If present and size is adequate, the basilic vein is the preferred
initial access. The basilic vein tends to take a straight course and it
∗
Corresponding author at: Department of Surgery, Children’s Mercy Hospital. is usually the largest deep vein in the arm. The brachial artery is
2401 Gillham Rd, Kansas City, MO, 64108, United States. in proximity therefore there is a risk of inadvertent arterial punc-
E-mail address: [email protected] (P. Aguayo). ture.9

https://doi.org/10.1016/j.sempedsurg.2021.151119
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O.N. Lopez, J.M. Lorenc, B.D. Reading et al. Seminars in Pediatric Surgery 30 (2021) 151119

The cephalic vein tends to be more tortuous than the basilic Power-injectable PICC lines are recommended in children when
vein. It takes an acute angulation during its course through the ax- contrast for CT and/or MRI is needed to avoid the risk of
illa and is often small. This can make cannulation and threading catheter rupture and line failure. They are catheters FDA-approved
the catheter difficult. However, it can also be cannulated and in for power injection of contrast. They are typically made of
some infants the cephalic vein can be larger than the basilic. 9 polyurethane and come in different sizes (starting at 2.6 Fr). These
The axillary vein is larger in size, but it is located more prox- catheters can have either single, double or triple lumens (Table 1).
imal and deeper. Visualization can be difficult, especially in pa- The recommended injection rate and injector pressure varies de-
tients with a thick layer of subcutaneous fat. It is a vein suitable pending on size and manufacturer’s recommendations and it is
for double-lumen catheters given its size. However, it is in close clearly marked (typically on the clamp).1 , 14
proximity to the axillary artery with an associated risk of arterial Currently our facility uses mostly power injectable PICC lines,
puncture. few silicones, and no longer uses coated lines. An institutional in-
ternal prospective review showed that antimicrobial coated lines
Head and neck were not associated with decreased central line associated blood
stream infection (CLABSI).
The external jugular vein is superficial, large, and commonly It is recommended to use electrocardiogram (ECG) to provide
visible and palpable. The right side is preferred due to a straighter “real-time” monitoring and “tracking” of the tip location during
course into the superior vena cava, this applies to all vein cannu- PICC line insertion to increase accuracy of tip location, decrease the
lation sites in the head and neck. However, securing and stabiliz- time from insertion to initiation of infusion therapy, reduce costs,
ing the catheter can be challenging. There is an increased risk of and reduce radiation exposure.15–18
catheter migration or dislodgement. Similarly, use of an ultrasound is recommended during PICC
The temporal vein can be another site of cannulation. It is lo- line insertions for identification and visualization of the depth,
cated anterior to the ear and is commonly visible. Threading of the size, and trajectory of the vein. The use of ultrasound increases
catheter can be challenging. The temporal artery is in proximity success of the procedure, decrease complications, and can also
and tends to be superficial, caution must be taken to distinguish confirm catheter tip placement in neonates due to the ease of vi-
both vessels before attempting cannulation. The posterior auricular sualizing the catheter within the SVC in this age group.19–21
vein is located behind the ear, its size varies, and its course can be It is not recommended to use fluoroscopy for routine PICC in-
very tortuous. Threading the catheter can be challenging.2 sertions due to the increased exposure to ionizing radiation. This
is an acceptable alternative when the use of ECG is difficult or has
failed at the bedside.21 , 22
Lower extremity
Placement techniques
The femoral vein is a large vein that can easily be cannulated
and accommodate larger catheters. It can be easily cannulated in- There is a large amount of evidence promoting the standard-
ferior to the inguinal ligament and medial to the femoral artery. ization of PICC line insertion and the use of central line bundles,
However, it is not a first-choice vessel for PICC placement. Despite which includes the following interventions: hand hygiene, skin an-
its favorable access and size, femoral PICCs are associated with tisepsis using alcohol-based chlorhexidine, maximal sterile barrier
higher infection rates and lower extremity edema.2 , 10 Moreover, precautions, and preference for upper body insertion site to reduce
this vein may also be needed for percutaneous cardiac intervention risk of infection. 21 , 23
(PCI) or placement of extracorporeal life support (ECLS) cannulas.2 It is important to adhere to proper technique by using stan-
The greater saphenous vein is the longest vein in the body, it dardized checklists as well as empowering clinicians to stop the
is superficial and can be easily cannulated. Due to its long course, procedure for any breaches in aseptic technique. Completion of a
PICC placement implies traversing multiple valves. This can cause checklist should be done by someone other than the professional
edema of the leg although this is typically not clinically relevant inserting the PICC. The person completing the checklist can focus
as the venous drainage of the leg is preserved by the deep venous more on the aseptic integrity of the procedure while the provider
system. For patients requiring femoral vein cannulation for PCI or inserting the catheter is focused on placement. The two individuals
ECLS, the distal veins in the lower extremity are not an appropriate need to communicate clearly throughout the procedure to ensure
choice. aseptic technique is maintained. 24–27
The lesser saphenous and popliteal veins can also be cannu- Preferred veins for PICC line insertion include the basilic,
lated, but access is limited by the vein location and positioning. brachial, and cephalic veins in the upper arm, above the antecu-
Securing the catheter in place can also be challenging.11 bital fossa with a catheter to vein ratio less than 33-45% for re-
duced risk of catheter-related thrombosis. 21 , 24 , 28 Additional, but
Equipment and devices less preferred, sites include axillary, temporal, posterior auricular,
saphenous, and popliteal. It is recommended to avoid the use of
There are different types of PICCs available. Common variations lower extremity placement due to increased risk of infection re-
include different materials (silicone or polyurethane), presence of lated to stool, urine, food spills, and sweat. Areas adjacent or in-
coating with thrombolytic or antimicrobial agents, and suitability volving wounds, non-intact skin, bruising, venous stenosis should
for faster infusion rates (power injectable lines). be also voided when feasible.21 , 24
In relation to the material, polyurethane catheters provide After selecting the catheter and vein to be cannulated, the
higher flow rates, and lower risk of line migration. However, they length of the catheter needs to be measured. For upper body inser-
have been associated with increased risk for thrombophlebitis and tion, measurement goes from insertion site to the third intercostal
external kinking. Both catheters seem to have similar infection space at the level of the right sternal border. For lower body inser-
rates. Silicone catheters have higher incidence of fracture.12 , 13 tion, measurement goes from insertion site to the xiphoid. 2 , 29
PICCs coated with antimicrobial agents have shown a decrease All the equipment and supplies should be readily available
in colonization when used in high-risk patients. However, mixed (Figs. 1 and 2)). The sterile field is prepared and the procedural-
results have been reported and it is unclear if the use of coated ist should follow maximal sterile barrier precautions. The selected
catheters significantly decreases CLABSI.13 catheter is prepared by flushing it and trimming it to the measured

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O.N. Lopez, J.M. Lorenc, B.D. Reading et al. Seminars in Pediatric Surgery 30 (2021) 151119

Table 1
List of available PICC lines.

Catheter Name Manufacturer Valve or Clamp Size # lumen material

L-cath Argon clamp 1.9F single silicone

Vascu-PICC TLS Pediatric Angiodynamics/Medcomp clamp 2.6F double polyurethane
Bioflow Angiodynamics valve 3F single polyurethane
Provena BD/Bard valve 4F double polyurethane
Provena BD/Bard valve 5F triple polyurethane
Bioflow Angiodynamic valve 5F double polyurethane

Table 2
Catheter (rows) to vein (columns) ratios.

length. The patient is positioned and restrained as needed. The in- added and the catheter is then trimmed accordingly. When avail-
sertion site is prepped with chlorhexidine (preferred) or povidone able, we use the Arrow® VPS Rhythm Device with the Tip Tracker
iodine solutions based on local protocols, followed by a sterile Technology. This is a portable system that uses electromagnetic
drape. A tourniquet is used for extremity insertion. The introducer tracking of the stylet in the catheter and a T-piece placed exter-
is then inserted at a 15°-30°, under ultrasound guidance. Once the nally on the patient allowing for real-time graphic mapping of the
vessel is cannulated, the tourniquet is removed, and the catheter is catheter’s trajectory. A confirmatory X-ray to confirm placement is
threaded to the measured length. If not using a stylet, flushing the still performed when using this technology.
catheter while threading might facilitate this step. Then, the intro-
ducer is removed making sure that the catheter does not slip out Care and removal
and adjusting as necessary. If a stylet is present, it needs to be re-
moved. Then, blood return is checked by aspiration. An extension A daily assessment of the PICC should include dressing in-
might then be connected and considered part of the catheter. The tegrity, catheter integrity, extremity circumference measurement,
catheter is temporarily secured until tip position verification.2 functionality (ease of flushing and aspiration), signs and symp-
The catheter tip, for upper body insertion, should terminate toms of complications (swelling, drainage, redness, phlebitis)
within the lower one-third of the superior vena cava.15 , 21 For and line necessity. Sterile dressing change should be per-
lower body insertion, the catheter tip should be positioned in the formed every 7 days (or according to institution protocol) and
IVC above the level of the diaphragm near T9 through T11.21 , 30 , 31 as needed with integrity of the line or if the dressing is
Catheter tip location is determined radiographically prior to initia- compromised.34–39
tion of infusion therapy or when clinical signs and symptoms sug- It is recommended to use a needleless connector (Fig. 3) to de-
gest tip malposition.15 , 21 , 32 After position is verified, the catheter crease the risk of needlestick injury, reduce the risk of infection to
is secured to the skin preferably with semipermeable transparent the patient and to reduce the risk of caregiver exposure to blood-
dressings. The length of the catheter should be documented to en- borne pathogens. The needleless connector and connection surface
sure that it is completely removed when no longer indicated (see to the catheter should be disinfected prior to each access with 70%
below).33 isopropyl alcohol or chlorhexidine. Needleless connectors and any
In our institution, we use ultrasound guidance for every PICC add-on devices (extension sets, cannula caps, filters, stop cocks)
placement (GE Logiq E Portable, L10-22-RS Transducer). The di- used should be changed every 96 hours or when integrity is com-
ameter of the target vein is measured to determine the catheter’s promised.21 , 40–42
diameter aiming for a catheter to vein ratio less than 45%, opti- It is also recommended to use a securement device (integrated
mally less than 33% (Table 2). The length of the catheter is then securement device, subcutaneous anchor securement system, tis-
determined by measuring from the insertion site to the desired tip sue adhesive, or adhesive securement device). along with the pri-
position site by measuring the expected trajectory of the catheter. mary dressing to effectively secure the catheter, prevent dislodge-
For example, for basilic vein cannulation, measurements are taken ment, reduce the risk of infection and prevent malpositioning
from the mid arm to the axilla, from the axilla to the clavicular 21 , 37 , 43 , 44 At our institution,our standard securement is the Se-
head, and from the clavicular heat to the right edge of the sternum curePortIV Catheter Securement Adhesive (Adhezion Biomedical,
at the level of the third intercostal space. These measurements are Wyomissing, PA) (Fig. 4). Our second choice is SorbaView Shield

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O.N. Lopez, J.M. Lorenc, B.D. Reading et al. Seminars in Pediatric Surgery 30 (2021) 151119

Fig. 1. Sterile equipment needed for PICC line placement

Fig. 2. Sterile personal protective equipment for PICC line insertion

Removal of a PICC is completed by using a sterile petroleum-

based gauze to seal the insertion site after removal, suture removal
kits (if needed), and a transparent dressing. The securement de-
vice dressing should be removed with adhesive remover. While
applying light pressure over the insertion site with petroleum-
based gauze the catheter is gradually withdrawn. The petroleum-
based gauze is covered with plain gauze and pressure applied
for 3-5 minutes. This is thereafter secured with a transparent
dressing and left in place for 24 hours. It is imperative to mea-
Fig. 3. Needless connector. (McKesson Medical, Kansas City, MO) sure the PICC length removed (and compare it to the docu-
mented length recorded at the time of insertion) and obtain a
chest radiograph if there is concern for a retained portion of the
catheter.21
Dressing (Centurian Medical Products, Williamston, MI) that has
the securement device within the dressing and our third choice Complications
is the StatLock PICC Plus Stabilization Device (BD Corporation,
Franklin Lakes, NJ) (Fig. 5). Sutures are not an effective alterna- Malposition of the catheter
tive to the securement methods listed. Indeed, they are associated
with needlestick injury, growth of biofilm, and increased risk of A PICC is malpositioned when the tip of the catheter is not
CLABSI.37 , 45–47 located within the vena cava. The reported rate of tip malposi-
Prior to each infusion, each lumen of a PICC should be flushed tion varies enormously ranging from 10-70%.48 Malposition is sus-
with normal saline solution and aspirated with a minimum volume pected when the catheter is difficult to thread, the stylet used
equal to twice the internal volume of the catheter system, as spec- for placement is difficult to remove or is bent when removed,
ified by the manufacturer. A pulsatile flushing technique should there is resistance when flushing, or there is difficulty obtaining
help remove solid deposits like drug precipitate, fibrin, and bac- blood return. Radiographs are used to confirm positioning of the
teria. 21 catheter.

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O.N. Lopez, J.M. Lorenc, B.D. Reading et al. Seminars in Pediatric Surgery 30 (2021) 151119

Fig. 4. SecurePortIV Catheter Securement Adhesive (Adhezion Biomedical, Wyomissing, PA)

Fig. 5. StatLock PICC Plus Stabilization Device (BD Corporation, Franklin Lakes, NJ)

Malposition is addressed with different techniques including Bleeding at insertion site

partial withdrawal and reinsertion with or without patient repo-
sitioning maneuvers. Some examples include abduction of the arm It is common to observe oozing from the insertion site during
at the shoulder with extension of the elbow for basilic vein can- the first 24 hours. Pressure and hemostatic agents can be used and
nulations with tip positioned in the jugular vein or adduction typically address this issue. In our institution, we use StatSeal®.
of the arm and extension of the elbow for cephalic vein inser-
tions which withdraws the catheter into a more peripheral loca-
Central line-associated bloodstream infection (CLABSI)
tion when needed. Alternatively, the patient can also be reposi-
tioned to aid with tip placement by elevating the head of the
A CLABSI occurs when there is a laboratory-confirmed blood-
bed or placing the patient on the ipsilateral or contralateral de-
stream infection that originates from a central venous catheter that
cubitus position if the catheter has entered the contralateral side
has been in place for two or more days, and that is not secondary
or looped back, respectively. Catheter exchange, over a guidewire
to an infection at another body site.3 Microorganisms can access
or using an introducer, might be needed if these maneuvers fail.
the bloodstream via PICC in several ways. They can migrate along
Sometimes, more conservative steps can be used. For example,
the external surface of the catheter from the skin entry site. They
if the catheter is malpositioned in a large vein (jugular, sub-
can migrate along the internal surface of the catheter due to con-
clavian), fluid infusion can encourage the catheter to flip down
tamination of the catheter hub. They also can be introduced di-
into the superior vena cava. Gentle flushing can also help repo-
rectly if the infusate is contaminated. Reported CLABSI rates asso-
sitioning. Observation for less than 24 hours while using the
ciated with PICC in pediatric patients vary between 0.5-4%. 24 , 49 , 50
catheter with appropriate fluids/medications followed by repeat X
When compared to conventional CVC, PICC placement is associ-
rays to reassess tip position can be done. Ultimately, if the po-
ated with increased rate of CLABSI.49 , 51 , 52 Implementation of bun-
sition of the catheter is not appropriate the catheter should be
dle practices based on available evidence have proven to decrease
removed.48
CLABSI rates. These practices include both technical and social el-
ements as addressed above. Checklists and active surveillance are
used to prevent and early identify CLABSI.2 , 3

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O.N. Lopez, J.M. Lorenc, B.D. Reading et al. Seminars in Pediatric Surgery 30 (2021) 151119

Guidelines exist for the management of CLABSI. Empiric ther- ment entails drainage of the effusion and correction of tamponade
apy of gram-positive and gram-negative bacteria should follow lo- (pericardiocentesis), repositioning of the catheter and potentially
cal antimicrobial susceptibility data and disease severity. Empirical repair of the perforation in rare cases.58–60
therapy for suspected candidemia is recommended in the presence
of additional risk factors (hematologic malignancy, bone-marrow Pleural effusion
or solid organ transplantation, prolonged use of antibiotics, doc-
umented Candida colonization at multiple sites). The PICC should PICC-related pleural effusion is a rare complication (0.76% of
be removed when treating a complicated CLABSI. A CLABSI is con- neonatal PICCs)61 and occurs due to vessel injury during place-
sidered complicated when associated with severe sepsis, throm- ment, cannulation of the thoracic duct, vessel erosion due to con-
bophlebitis, endocarditis, ongoing bacteremia after more than 72 tact with the catheter, diffusion injury when hyperosmolar fluids
hours of adequate antibiotic treatment, or infection due to specific come in contact with the endothelium. Despite the appropriate ini-
pathogens known to be difficult to eradicate.2 , 8 tial position of the catheter tip, migration can occur. PICC-related
Catheter salvage may be attempted with both systemic and pleural effusion typically occurs as a late complication (∼16 days
antimicrobial lock therapy in uncomplicated CLABSI and/or in [7-75 days] after placement) and treatment typically includes re-
cases of limited vascular access. Consultation of an infectious dis- moval of the PICC and drainage.62 , 63
ease specialist is recommended to tailor treatment recommenda-
Catheter malfunction and fracture
tions.2 , 24 , 53

Catheter occlusion is a common occurrence with a reported rate

Catheter-related venous thrombosis
of 35%64 and is frequently due to low rates of flow, infusate char-
acteristics, compatibility of different infusates, fibrin sheath forma-
Catheter-related venous thrombosis is defined as venous throm-
tion, improper flushing or locking, or catheter tip position. The
boembolism associated with central venous catheters. Damage to
management depends of the cause of the obstruction and may
the vascular endothelial during venous cannulation is a thrombo-
include repositioning the patient and/or catheter, use of clearing
genic event. Therefore, venous thrombosis is a well-known compli-
agents or thrombolytics, or replacement for a new catheter.33 , 65 At
cation of PICC placement. The rates of PICC-related venous throm-
our institution, we use 2 mg of alteplase with a dwell time of 30
bosis are difficult to ascertain and range from 1-20%. However, the
minutes up to 2 hours. A second dose, same specifications, can be
asymptomatic thrombosis rate may be ∼60%.50 Enormous varia-
used if the line is not cleared.
tion exists in reported rates depending on the surveillance strat-
Catheter fracture can occur in the external or internal segment
egy, definitions used, diagnostic methods, and consideration of as-
of the PICC. Internal catheter fracture with subsequent emboliza-
sociated symptomatology. Known risk factors for the development
tion of a catheter fragment is a rare event. The location of the
of catheter-related venous thrombosis include age (peak incidences
catheter fragment should be determined by radiography. Retrieval
in infancy and adolescence), underlying conditions (cancer, cardiac
might include venotomy if located peripherally, or most commonly,
disease, infections, trauma, renal failure, surgery), and underlying
endovascular removal by a skilled interventional radiologist. If this
thrombophilia.50 , 54 , 55
is unsuccessful, surgical intervention may be required.2 , 66 , 67
Other catheter factors associated with thrombosis include
catheter size, catheter/vein ratio > 0.33, catheter tip location, left Other complications
sided placement, catheters with more than one lumen, catheter
material (polyurethane catheters seem to be associated with less Extremity edema can occur secondary to an associated throm-
rates of thrombosis)12 and dwell time of the catheter. The num- bus, extravasation of the infusate, positioning, decreased move-
ber of insertions attempts, and the use of ultrasound guidance ment, among other causes. Management depends on the cause,
might influence the development of catheter-related thrombosis, dressing changes and repositioning might prove useful. If catheter-
however conflicting findings have been reported.56 Compared to related thrombosis is suspected an ultrasound should be obtained.
conventional central venous catheters, PICCs are associated with Observation and close monitoring are appropriate for mild edema.
an increased risk of venous thrombosis.54 Symptoms are generally If the edema is worsening and there is concern for extremity com-
vague or nonexistent. When present, they can include local pain, promise, removal of the PICC should be considered.2
edema, or discoloration of the affected extremity, prominent su- Different neurological complications can occur varying from
perficial vessels, unexplained fever.57 neuropathic pain due to proximity of the cannulated vein to ad-
Management includes removal of the catheter if no longer func- jacent nerves to neurologic deficits when a lower extremity PICC
tional, after initiation of anticoagulation therapy. If the catheter is is placed and the catheter enters an ascending lumbar vein rather
functional and appropriate anticoagulation is administered, it can than the inferior vena cava. When this later scenario occurs, symp-
remain in place with low risk of thrombosis recurrence or exten- toms can be nonspecific (lethargy, respiratory distress, abnormal
sion. Optimal duration of anticoagulation therapy remains to be glucose and protein serum levels) or more indicative of spinal
elucidated. 56 cord insult such as neurologic deficits, quadriplegia, seizures. Ra-
diographic findings include posterior deviation at the low lumbar
Cardiac perforation level on a lateral view, curls or loops in the inguinal region, kinks
or bends on AP views at the low lumbar level, failure to cross the
Perforation of the myocardium and associated pericardial ef- midline to enter the inferior vena cava when the left lower ex-
fusion and tamponade can occur in rare cases. Myocardial dam- tremity has been accessed. A high index of suspicion is required
age occurs due to direct contact of the tip of the catheter with to identify this problem. If suspected, catheter infusions should
the cardiac tissue or due to diffusion injury when hyperosmolar be stopped, and radiographs obtained. If confirmed, the catheter
fluids come in direct contact with the myocardium. Alternatively, should be removed or repositioned if feasible.68–70
the catheter may erode through the superior vena cava and cause
blood extravasation into the pericardial space. The main risk factor Conclusions
for this feared complication is the position of the catheter tip. Pre-
vention includes regular surveillance for PICC line position – usu- PICCs are ubiquitous in modern pediatric care. Individualized
ally in the form of a weekly or bi-weekly chest radiograph. Treat- treatment goals expected prognosis and patient’s specifics factors

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O.N. Lopez, J.M. Lorenc, B.D. Reading et al. Seminars in Pediatric Surgery 30 (2021) 151119

(comorbid conditions, medical and surgical history, anatomic vari- ment in neonates. J Perinat Neonatal Nurs. 2019;33(1):89–95. doi:10.1097/jpn.
ations) need to be considered at every step of the decision mak- 0 0 0 0 0 0 0 0 0 0 0 0 0389.
23. Rowley S, Clare S. Standardizing the critical clinical competency of aseptic,
ing for PICC placement and care. A dedicated vascular access team, sterile, and clean techniques with a single international standard: aseptic non
procedural checklists, utilization of adjuncts (ultrasound, EKC trac- touch technique (ANTT®). J Assoc Vasc Access. 2019;24(4):12–17. doi:10.2309/j.
ing if available) and best practice bundles are associated with less java.2019.0 04.0 03.
24. Chopra V, O’Horo JC, Rogers MAM, Maki DG, Safdar N. The risk of bloodstream
unsuccessful placement attempts and less complications. However, infection associated with peripherally inserted central catheters compared with
clinicians must be familiar with potential complications and their central venous catheters in adults: a systematic review and meta-analysis. Infect
managements. When possible, standardized protocols should be Control Hosp Epidemiol. 2013;34(9):908–918. doi:10.1086/671737.
25. Lorente L. What is new for the prevention of catheter-related bloodstream in-
in place to manage common complications (infection, thrombosis,
fections? Ann Transl Med. 2016;4(6):119. doi:10.21037/atm.2016.03.10.
catheter malfunction due to obstruction). 26. Marschall J, Mermel LA, Fakih M, et al. Strategies to prevent central line–
associated bloodstream infections in acute care hospitals: 2014 update. Infect
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