P95

P95

AN EVALUATION OF ANAESTHETIC TECHNIQUE AND OUTCOMES FOLLOWING NEONATAL AND INFANT PERIPHERALLY INSERTED CENTRAL CATHETER (PICC) LINE INSERTIONS

D. Vadivel¹, Z. A. Burton²

¹Sheffield Teaching Hospitals NHS Foundation Trust, UK

²Sheffield Children's NHS Foundation Trust, UK

Background

Peripherally Inserted Central Catheter (PICC) line insertion is performed regularly in hospitalised neonates and infants for venous access, nutrition, drug administration and blood sampling. Multiple venous access attempts owing to difficult venous anatomy can cause significant distress to children and their carers. PICC line insertions may be performed under general anaesthesia (GA), awake with local anaesthesia (LA) or under sedation. Dexmedetomidine is a potent alpha-2 agonist commonly used for procedural sedation and has been successfully used as a sole sedative for paediatric radiological procedures such as MRI scans (1).

Problem

GA provides the best conditions for PICC line insertions in neonates and infants but may be complicated by comorbidity, subglottic stenosis, pneumonia, risk of hypotension, hypothermia and long-term neurological deficits or neurotoxicity (2). In our institution, neonatal and infant PICC line insertions performed awake did not always involve anaesthetic presence, potentially leading to suboptimal procedural conditions, repeated theatre visits, unplanned general anaesthesia, hypothermia and hypoglycaemia.

 Strategy for change

We hypothesised that the increased use of dexmedetomidine for PICC line insertions in spontaneously ventilating neonates and infants may improve procedural conditions with improved likelihood of success, negating the need for GA and its potential associated complications (3).  At Sheffield Children’s Hospital, we conducted a retrospective analysis of data collected over a 3-year period from patients <1 year of age undergoing PICC insertions. Mechanically ventilated patients were excluded from the analysis.

Measure of improvement

We used success rate (%) of PICC line insertion as our primary measure to compare three procedural subgroups; dexmedetomidine sedation, insertion awake with LA or under GA. Possible outcomes included successful PICC, conversion to GA, re-booking of procedure under GA, abandonment, or insertion of alternative peripheral or Broviac lines.

 Lessons Learnt

148 patients underwent PICC line insertions between October 2019 and October 2022. Three infants were excluded due to unavailable data. Mean age and weight were 10.4 weeks 4.2kg (range 1.6-11.2 kg) respectively. Indications for PICC line insertions included long term antibiotics (n=70), total parenteral nutrition (n=50), long-term IV access (n=25). As hypothesised, PICC insertions using dexmedetomidine sedation showed a higher success rate (92.5%) than insertions awake with LA (87.5%; Table 1). In the GA group, PICC success rates appeared lower (83.8%) due to this being a more complex cohort who may have had multiple previous venous access attempts and hence much higher rates of conversion to Broviac lines (n=13).

 Message for others

In our institution, dexmedetomidine sedation provides a good balance of optimal cannulation conditions and maintenance of spontaneous ventilation. This is a potential means of reducing exposure to GA risks amongst a vulnerable cohort of neonates and infants. Anaesthetic presence helps to ensure adequate vigilance during procedures, with particular attention to normothermia and normoglycaemia.

References:

1. Mason KP, Zurakowski D, Zgleszewski SE, Robson CD, Carrier M, Hickey PR, et al. High dose dexmedetomidine as the sole sedative for paediatric MRI. Pediatric Anesthesia. 2008 May;18(5):403–11
2. Ing C, Jackson WM, Zaccariello MJ, Goldberg TE, McCann ME, Grobler A, et al. Prospectively assessed neurodevelopmental outcomes in studies of anaesthetic neurotoxicity in children: a systematic review and meta-analysis. British Journal of Anaesthesia. 2021 Feb;126(2):433–44.
3. Lu Y, Peng C, Xie L, Wu Y, Gu L, Li S. Nasal drip of dexmedetomidine for optimal sedation during PICC insertion in paediatric burn care. Medicine [Internet]. 2023 Feb 10 [cited 2024 Feb 8];102(6):e32831.