Importance of choosing correct catheter placement in hospitalized children

Location, location, location. A new Johns Hopkins Children's Center study shows the real-estate mantra also holds true when it comes to choosing correct catheter placement in children.

The research findings, described online March 18 in JAMA Pediatrics, show that catheters in children inserted in a vessel in the arm or leg and not threaded into a large vein near the heart are nearly four times as likely to dislodge, cause vein inflammation or dangerous blood clots as are catheters advanced into major vessels near the heart.

A peripherally inserted central venous catheter, or PICC line, is a tube placed into a small blood vessel, usually in the arm, and threaded toward a major blood vessel near the lungs and heart to serve as a temporary portal for medications, nutrients or fluids. However, clinicians sometimes forego threading close to the heart and leave the PICC line in a peripheral vein in the arm or leg instead — a choice dictated by the ease and speed of placement or a child's overall condition or anatomy.

The study findings, however, suggest that leaving the device in a non-central vein should only be done as last resort, the researchers say.

"Clinicians should carefully weigh the ease and speed of non-central vein placement against the higher complication risk that our study found goes with it," says senior investigator and pediatric infectious disease specialist Aaron Milstone, M.D., M.H.S.

Non-central, smaller veins, especially those in the arm, are narrower, thinner and more prone to injury than major vessels near the heart, the researchers say. Thus, a catheter can easily damage the protective coating on the walls of such veins and encourage the formation of blood clots that, in the worst-case scenario, can dislodge and travel to the lungs or heart, causing a pulmonary embolism or heart damage.

Conducted among more than 1,800 pediatric patients hospitalized at Johns Hopkins over six years, the study found that such non-centrally positioned catheters accounted for a mere 16 percent of the central lines, but for 44 percent of all complications that led to catheter removal.

Children in the study cumulatively underwent more than 2,500 catheter insertions, of which more than 500 — one in five — had to be removed due to complications. Three-quarters of problems stemmed from mechanical malfunction such as device breakage or dislodgement, clot formation or blood vessel inflammation. The rest were due to infection, which traditionally has been the greatest worry with central lines. Vein location, however, played no role in infection risk, the research showed.

Despite the higher risks seen with non-centrally position catheters, overall complications rates dropped significantly over the six-year study period, a trend that should get a further boost by emerging technologies, the investigators say.

"We are already adopting new technologies that render PICC placement near the heart easier, safer and faster, and which will drive complications rates further down," says Leslie Gosey, R.N., M.S., leader of the pediatric catheter-insertion team at Johns Hopkins.