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Re: Neonatal long lines- Are they safe?

Dear Editor

Neonatal long lines are essential part in the management of extremely low birth babies and very sick babies. Technically to insert a longline is not that difficult especially if attempted in the first few days but often we have to accept suboptimal positions. Definitely use of long lines have improved the outcome of babies weighing less than 1000grams and postoperative cases.

More than safety we regard the venous access very important in premies. Our unit had incidences of cardiac tamponade and abdominal perforation in babies with longlines. Interestingly the total parenteral fluid extravasated into the peritoneal cavity following perforation of the iliac vein had resulted in progressive abdominal distension and erythema for nearly eight days. Interestingly, baby had never experienced hypoglycemia. Abdominal distension was thought to be the result of necrotizing enterocolitis for which the long line was inserted. On the 8th day a necrotic area pointed over the abodomen near the umbilicus and on removal of the eschar, lipid and nutriflex started oozing from the ulcer. A diagnostic purge has confirmed the tip of the long line in the anterior abdominal wall. Removal of the long line wasn’t difficult at all and the anterior wall erythema and induration disappeared in 48 hours and ulcer healed well in 5 days. The point I would like to make from the above incident is that all these 8 days baby could maintain the blood sugar and it showed that the parenteral nutrients were absorbed adequately through peritoneum. This observation is well supported with the dealyed presentation of the abdominal distension. It wont be surprising if researchers come out in future with nutrients which can be given intraperitoneal.

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Re: Neonatal long lines and pericardial effusions: a differance between silicone and polyurethane?

Dear Editor

We read with interest the articles of Menon and Beardsall et al.[1,2] especially as we recently experienced in a very low birth weight baby a pericardial effusion case related to a neonatal long line. This percutaneous long line was a polyurethane one and it was not surprising for us as the Agence Francaise de Sécurité Sanitaire des Produits de Santé (AFSSPS) (“French Agency for Health Products and Medical Safety”) made special advice about this type of percutaneous long line. After an unusual outbreak of pericardial effusions and cardiac tamponnades that seemed linked with recent use of new polyurethane long lines in some NICU, AFSSPS performed a retrospective study. The main result of this investigation about 3599 peripherally inserted central catheters (2916 silicone ones and 683 made with polyurethane) was a dramatic difference in the frequency of serious accidents between polyurethane and silicone catheters:
1 accident recorded for 972 silicone catheters inserted (0.1%) vs 1 accident for 115 polyurethane catheter inserted (0.9%) or 1 accident recorded for 16039 silicone catheter days vs 1 accident for 1879 polyurethane catheter days.

This quite significant difference led AFSSPS to recommend using silicone neonatal long lines and keep those 27 G polyurethane catheters for very low birth weight premature babies (lower than 800g) or for the cases in which inserting other catheters failed.[3]

In our case, as we knew it, and we could not insert another catheter, we were particularly careful to practice serial echographic and radiographic controls which showed pericardial effusion before any clinical sign and we could just reposition the catheter tip without any invasive treatment. So we think this AFSSPS advice is important to be known.

References

(1) Menon G. Neonatal long lines. Arch Dis Child Fetal Neonatal Ed. 2003; 88:F260-F262.

(2) Beardsall K, White DK, Pinto EM, et al. Pericardial effusions and cardiac tamponade as complications of neonatal long lines: are they really a problem? Arch Dis Child Fetal Neonatal Ed 2003;88:292–5.

(3) AFSSPS Recommandations d'utilisation des cathéters veineux centraux chez les prématurés. http://agmed.sante.gouv.fr/htm/alertes/filalert/dm020204.htm

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Re: Catheter material

Dear Editor

It is interesting to hear of the French experience of long lines reported by Bedu et al.[1]

It is difficult to come to conclusions about real differences in incidence of pericardial effusion (PCE) with different catheter types with just one adverse event in each group in the AFSSPS survey.[2] The results of this survey may hide other factors, including type of unit (amount of experience with use of long lines) and case-mix (smaller babies may be more likely to develop some complications), which confound the difference in outcome with the two types of catheter.

It is conceivable that there is a real difference in risk of PCE with catheters made of different materials. This could be related to differences in thrombogenic potential (thus the likelihood of catheter adhesion to a vascular wall, creating the circumstances for vascular erosion) or elasticity (thus the risk of direct perforation or looping of redundant catheter within a cardiac chamber). The published literature about the effect of catheter material is not clear-cut, being based on retrospective surveys, one of which suggested that technical problems were more frequent with silicone then polyurethane catheters, although there were no cases of PCE in this small study.[3]

There is no mention of catheter tip position in the French survey. The observations of Dr Bedu and colleagues serves to stress the complicated nature of the interaction between catheter and baby which results in PCE, a complication which cannot be abolished by a simple change in practice. There is the need for constant vigilance both with individual babies and at unit level in the use of long lines in neonatal care in order to ensure that there is a careful balancing of risks.

References

(1) Bedu A et al. Neonatal long lines and pericardial effusions: a difference between silicone and polyurethane [ electronic response to G Menon, Neonatal long lines] archdischild 2003 http://adc.bmjjournals.com/cgi/eletters/fetalneonatal;88/4/F260#231

(2) AFSSPS Recommandations d'utilisation des cathéters veineux centraux chez les prématurés. http://agmed.sante.gouv.fr/htm/alertes/filalert/dm020204.htm

(3) Rudin C,.Nars PW. A comparative study of two different percutaneous venous catheters in newborn infants. Eur J Pediatr 1990;150:119-24.

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Re: Neonatal long lines and the risk of pericardial effusion

Dear Editor

Whilst the leading article by Menon [1] provides an excellent overview of the use and complications of different types of neonatal venous lines. We must point out that in our retrospective study,[2] we demonstrated that pericardial effusions (PCE) were extremely rare with an incidence of 1.8/1000 (0.18%) lines inserted not 1.8%. as stated by Dr Menon.

We agree with Menon1 and the Associate Editor [3] that a prospective study would provide more accurate information about the many potential complications, including PCE associated with percutaneous long lines (PLL). An audit of parenteral nutrition and central venous line use in neonatal units was proposed by the National Institute for Clinical Excellence (NICE) in 2001 following publication of the Department of Health review of neonatal deaths due to cardiac tamponade.[4]

The National Collaborating Centre for Women and Childrens Health approached us for guidance on drafting their study proposal that was sent to the British Association of Perinatal Medicine in 2002 for consultation. Since then clinical practice and the priorities of NICE have changed. Could a national survey be conducted and would it be worthwhile? The manufacturers of PLLs have indicated a willingness to include a survey form with each line that could be used to provide denominator data in a national survey. However our experience of conducting a 12 month prospective audit of PLL use in neonatal units across the Eastern Region has proved challenging. We have obtained accurate information on more than 500 lines but this has required careful liaison with consultants, specialist registrars and named nurses in the participating units to ensure that audit forms were properly completed.

We are concerned that considerable motivation would be required for a national prospective study to obtain accurate data. Incomplete data collection runs the risk of producing more misinformation and recommendations that do not necessarily positively influence medical care. We believe that paediatricians are much more aware of the risks and benefits of PLLs, and take more care in siting and using lines. Even though PCE is a rare complication the signs of presentation are being recognised earlier by neonatal staff leading to potentially life saving interventions.

We submitted a phase one application to the British Paediatric Surveillance Unit (BPSU) in early 2002 to prospectively determine the incidence and outcome of neonatal PCE associated with PLL. The BPSU executive recognised the importance of the problem but rejected the study proposal because of the difficulties in determining an accurate denominator figure for number of lines inserted. However, we believe it would be important in defining the number of cases per year and potential risk factors. May be we should send them your recommendation.

References

(1) G Menon. Neonatal long lines. Arch Dis Child Fetal Neonatal Ed 2003;88:F260-F262.

(2) K Beardsall, D K White, E M Pinto, and A W R Kelsall. Pericardial effusion and cardiac tamponade as complications of neonatal long lines: are they really a problem? Arch Dis Child Fetal Neonatal Ed 2003; 88:F292-F295.

(3) Martin Ward Platt. Fantoms. Arch Dis Child Fetal Neonatal Ed 2003;88:F260.

(4) Department of Health. Review of the deaths of four babies due to cardiac tamponade associated with the presence of central venous.