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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 9  |  Issue : 3  |  Page : 211-213

Entrapment of peripherally inserted central catheter due to fibrin sheath required surgical removal


1 Department of Neonatal Intensive Care Unit, Nice Children Hospital, Bhavnagar, Gujarat, India
2 Department of Neonatology, Nice Children Hospital, Bhavnagar, Gujarat, India

Date of Submission18-Sep-2019
Date of Decision15-Oct-2019
Date of Acceptance01-Jun-2020
Date of Web Publication07-Aug-2020

Correspondence Address:
Dr. Prakash C Vaghela
Nice Children Hospital, 1st Floor, Sammep Comlex, Opp. Kalubha, Bhavnagar, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcn.JCN_100_19

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  Abstract 


Entrapment of the percutaneous inserted central catheter (PICC) is a rare complication in NICU, but when it occurs, it becomes very stressful for neonatologist and the health-care provider team. Peripherally inserted central catheters are simple procedures if done by experienced and skillful hand in the level 3 NICU for long-term TPN. We reported a challenging complication in a premature neonate with entrapment of the PICC line due to fibrin sheath and surgical removal of the same. In our situation, if we had not been successful in the removal of the catheter, the patient would have faced transfer to the higher center supported by cardiovascular surgeons.

Keywords: Peripherally inserted central catheter, surgical intervention, venospasm


How to cite this article:
Vaghela PC, Gabani C, Mangukiya H, Dankhara D. Entrapment of peripherally inserted central catheter due to fibrin sheath required surgical removal. J Clin Neonatol 2020;9:211-3

How to cite this URL:
Vaghela PC, Gabani C, Mangukiya H, Dankhara D. Entrapment of peripherally inserted central catheter due to fibrin sheath required surgical removal. J Clin Neonatol [serial online] 2020 [cited 2020 Sep 27];9:211-3. Available from: http://www.jcnonweb.com/text.asp?2020/9/3/211/291638




  Introduction Top


Percutaneously inserted central catheter is commonly used for long term TPN in premature neonates and may sometimes associated with some rare complication like entrapment due to fibrin sheath or difficulty removal due to catheter breakage and require surgical intervatnion. Surgical intervention is used as last resort when all the other non-invasive modalities failed. Accurate position of catheter tip is mandatory to prevent such sort complications. Team approach & surgical intervention when dealing with the difficult removal of a stuck PICC in a tiny patient is easily available in level II care. This treatment modality reduce the morbidity and mortality.


  Case Report Top


A 31-week-old preterm male neonate was admitted in NICU for RDS and early-onset sepsis. The baby had septic shock, so for inotrope infusion percutaneous inserted central catheter (PICC) was placed into the left saphenous vein. Insertion was smooth and without undue complications. The position was confirmed by X-ray. PICC was used for 6 days for inotropes and TPN administration without any complication. The baby was tolerating full feed and inotrope was gradually tapered off, so PICC removal was planned. During line removal, the catheter has come out smoothly up to 10 cm, then after resistance was felt during further removal of the catheter. We tried reposition of leg, leg massage, heat application, tourniquet application, gentle traction, heparin infusion, and reinsertion of guidewire for catheter removal.

Entrapment of peripherally inserted central catheter due to fibrin sheath

Catheter X-ray of that limb was done for exact location and to rule out any knot in catheter-ray showed its catheter tip location 3–4 cm below the knee joint [Figure 1]. During removal, high resistance was encountered, so attempts were discontinued due to risk of catheter breakage. The parents were counseled in detail about this difficulty in removal. After all, noninvasive attempt was failed; we discussed this case with a pediatric surgeon and planned surgical intervention.
Figure 1: X-ray of the patient showing catheter tip

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The baby was shifted to the operation theater; the expert team approach was made with the help of a neonatologist, pediatric surgeon, and pediatric anesthetics. With short anesthetic agent, the baby was sedated, and with small incisions, the leg muscle was dissected and the catheter was identified with to and fro movement of the catheter with a guidewire. The catheter was encircled with tissue-like fibrous sheath that was obscuring the vessel passage and making its removal difficult [Figure 2].[1] Fibrous sheath was cleaned with gauze peace and the catheter was removed through insertion site without any breakage. Hemostasis was achieved and the stitches were taken. The baby was hemodynamically stable and shifted back to the NICU for further care and management.
Figure 2: Surgical removal showing fibrin sheath

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  Discussion Top


Why doesn't PICC come out?

  1. Vasospasm
  2. Thrombotic changes
  3. Entrapment
  4. Knotted PICC
  5. Fractured catheter.


Management key:

  1. Diagnose the exact cause and manage accordingly
  2. Handle patiently
  3. Don't get panic
  4. Counsel the parents
  5. Take well informed verbal and written consent
  6. First take noninvasive measures to remove PICC
  7. Invasive surgical intervention as last resort.


    1. Use a soft-tipped wire if possible
    2. Surgical dissection
    3. Endoluminal balloon dilation.


The use of PICCs is now routinely used method for prolonged TPN.[2] Most of the noninvasive methods for PICC removal in the neonates were tried in our CASE. Repositioning of the arm, the application of warm pack, limb massage, a tourniquet, and heparin infusion were all used without any benefits.[3],[4] Invasive measures such as surgical blunt dissection, venesection, or venotomy (surgical “cutdown”) can be used as a last resort; noninvasive things are not helpful. The big problems are catheter puncture or breakage that can become an embolism. Venospasm is the most common cause for catheters that are retained; thus, warm pack application helps.[1] Gentle traction over time can be used as a trial for PICC, which does not come out.[1],[5] This case demonstrates the value of a team approach, and in particular, that interventional cardiovascular surgeon can have a key role if available in the center. More significantly, surgical intervention when dealing with the difficult removal of a stuck PICC in a tiny patient is easily available in level II care.


  Conclusion Top


This report explains the role of surgical intervention. Surgical intervention is a last resort when classical management failed. This treatment modality reduces morbidity and mortality. The use of adequate analgesia is must. We noticed that low-lying catheter tip position is one of the risk factors for entrapment. Therefore, the ideal tip position of the catheter is to be confirmed.

Precautionary measures

  1. Accurate tip position and preferable site is upper limb
  2. Heparinized TPN
  3. CLABSI protocol-based line maintenance
  4. Polyurethane-based material.


Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Marx M. The management of the difficult peripherally inserted central venous catheter line removal. J Intraven Nurs 1995;18:246-9.  Back to cited text no. 1
    
2.
Serrano M, García-Alix A, López JC, Pérez J, Quero J. Retained central venous lines in the newborn: Report of one case and systematic review of the literature. Neonatal Netw 2007;26:105-10.  Back to cited text no. 2
    
3.
Miall LS, Das A, Brownlee KG, Conway SP. Peripherally inserted central catheters inchildren with cystic fibrosis. Eight cases of difficult removal. J Infus Nurs 2001;24:297-300.  Back to cited text no. 3
    
4.
Wall JL, Kierstead VL. Peripherally inserted central catheters: Resistance to removal: A rare complication. J Intraven Nurs 1995;18:251-4.  Back to cited text no. 4
    
5.
MacDonald G, Ramasethu J. Atlas of Procedures in Neonatology. 4th ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins; 2007. p. 4.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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Abstract
Introduction
Case Report
Discussion
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