Prevention of complications related to peripherally inserted central catheter insertion techniques in newborns: systematic review and network meta-analysis

Beleza, Ludmylla de Oliveira; Brasil, Guilherme da Costa; Margatho, Amanda Salles; Vasques, Christiane Inocêncio; Silveira, Renata Cristina de Campos Pereira; Rocha, Priscilla Roberta Silva; Ribeiro, Laiane Medeiros

doi:10.1590/1518-8345.6905.4161

Ludmylla de Oliveira Beleza Corresponding author: Ludmylla de Oliveira Beleza E-mail: ludmyllab@hotmail.com https://orcid.org/0000-0001-9975-562x

Study concept and design

Obtaining data

Data analysis and interpretation

Statistical analysis

Drafting the manuscript

Critical review of the manuscript as to its relevant intellectual content

Others (Manuscript review)

Others: (Preparation of the review protocol)

Universidade de Brasília, Brasília, DF, Brazil.

Secretaria do Estado de Saúde, Hospital Materno Infantil de Brasília, UTI Neonatal, Brasília, DF, Brazil.

https://orcid.org/0000-0001-9975-562X

Guilherme da Costa Brasil

Obtaining data

Data analysis and interpretation

Drafting the manuscript

Others (Manuscript review)

Centro Universitário do Distrito Federal, Brasília, DF, Brazil.

https://orcid.org/0000-0001-6878-7098

Amanda Salles Margatho

Study concept and design

Data analysis and interpretation

Drafting the manuscript

Critical review of the manuscript as to its relevant intellectual content

Others (Manuscript review)

Others: (Preparation of the review protocol)

Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil.

https://orcid.org/0000-0002-1006-9357

Christiane Inocêncio Vasques

Study concept and design

Data analysis and interpretation

Drafting the manuscript

Critical review of the manuscript as to its relevant intellectual content

Others: (Preparation of the review protocol)

Universidade de Brasília, Faculdade de Ciências da Saúde, Brasília, DF, Brazil.

https://orcid.org/0000-0001-9586-9486

Renata Cristina de Campos Pereira Silveira

Study concept and design

Drafting the manuscript

Critical review of the manuscript as to its relevant intellectual content

Others: (Preparation of the review protocol)

Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil.

https://orcid.org/0000-0002-2883-3640

Priscilla Roberta Silva Rocha

Study concept and design

Drafting the manuscript

Critical review of the manuscript as to its relevant intellectual content

Others: (Preparation of the review protocol)

Universidade de Brasília, Faculdade de Ceilândia, Brasília, DF, Brazil.

https://orcid.org/0000-0002-2058-8548

Laiane Medeiros Ribeiro

Study concept and design

Data analysis and interpretation

Obtaining financing

Drafting the manuscript

Critical review of the manuscript as to its relevant intellectual content

Others: (Preparation of the review protocol)

Universidade de Brasília, Faculdade de Ceilândia, Brasília, DF, Brazil.

https://orcid.org/0000-0002-5041-8283

Corresponding author: Ludmylla de Oliveira Beleza E-mail: ludmyllab@hotmail.com https://orcid.org/0000-0001-9975-562x

Conflict of interest: the authors have declared that there is no conflict of interest.

Associate Editor:

Karina Dal Sasso Mendes

Study and sample characteristics					Results	Main Conclusions
Author; Year; Country	Interventions (Insertion and Control Technique)	Sample (n)	GAB ^* * GAB= Gestational Age at Birth; (s ^† † w = Weeks; ) and BW ^§ § BW = Birth Weight; (g ^\|\| \|\| g = Grams; )	CGA ^‡ ‡ CGA = Corrected Gestational Age; (s ^† † w = Weeks; ) or days old and/or weight (g ^\|\| \|\| g = Grams; )	Complications n (%) experimental x n (%) control	Main Conclusions
Katheria, et al.; 2013 ⁽ ³⁸38. Katheria AC, Fleming SE, Kim JH. A randomized controlled trial of ultrasound-guided peripherally inserted central catheters compared with standard radiograph in neonates. J Perinatol. 2013;33(10):791-4. https://doi.org/10.1038/jp.2013.58 https://doi.org/10.1038/jp.2013.58... ⁾ ; United States	Experimental Group: blind puncture, measurement by anatomical landmark, USGRT ^ USGRT = Real-Time Ultrasound; for tip verification	20		CGA ^‡ ‡ CGA = Corrected Gestational Age; : 31 ± 4 w ^† † w = Weeks; Weight: 1,185 ± 538 g ^\|\| \|\| g = Grams; 4 ±5 days	1 ^st¶ Malpositioning: 5(25%) x 16(57.1%) 2 ^nd†† Malpositioning (Cardiac tamponade): 1 (5%) x 0 (0%)	USGRT ^ USGRT = Real-Time Ultrasound; reduced the insertion procedure time by 40% ( p =0.034), as well as the need for x-ray ( p =0.001) and for manipulations ( p =0.034).
	Control Group: puncture guided by anatomical landmarks	28		CGA ^‡ ‡ CGA = Corrected Gestational Age; : 30 ± 4 w ^† † w = Weeks; Weight: 1.208 ± 481 g ^\|\| \|\| g = Grams; 5 ±5 days
Ling, et al.; 2019 ⁽ ¹⁴14. Ling Q, Chen H, Tang M, Qu Y, Tang B. Accuracy and safety study of intracavitary electrocardiographic guidance for peripherally inserted central catheter placement in neonates. J Perinat Neonatal Nurs. 2019;33(1):89-95. https://doi.org/10.1097/JPN.0000000000000389 https://doi.org/10.1097/JPN.000000000000... ⁾ ; China	Experimental Group: blind puncture, measurement by anatomical landmark, IC-ECG ^‡‡ ‡‡ IC-ECG = Intracavitary Electrocardiogram; to guide the tip	80	GAB ^* * GAB= Gestational Age at Birth; : 37.1± 1.4 w ^† † w = Weeks; (32-40)	3.4 ± 0.5 days (1-6)	General complications: 3(3.75%) x 19(23.75%), p =0.000 Arrhythmia: 0(0%) x 4(5%), p =0.043 Phlebitis: 1(1.25%) x 7(8.75%), p =0.03 Infection: 0(0%) x 1(1.25%), p =0.316 Skin lesion: 1(1.25%) x 1(1.25%), p =0.316 1 ^st¶ Malpositioning: 4(5%) x 17(21.25%), p =0.002 Occlusion: 1(1.25%) x 4(5%), p =0.173	IC-ECG ^‡‡ ‡‡ IC-ECG = Intracavitary Electrocardiogram; improved the rate of the first attempt to insert the PICC ^§§ §§ PICC = Peripherally Inserted Central Catheter; up to the central position; it also required less time and medical cost, less exposure to radiation and reduced complication rates.
	Control Group: puncture guided by anatomical landmarks	80	GAB ^* * GAB= Gestational Age at Birth; : 36.8± 1.3 w ^† † w = Weeks; (32-40)	3.2 ± 0.3 days (1-5)
Oleti, et al.; 2019 ⁽ ³⁹39. Oleti T, Jeeva Sankar M, Thukral A, Sreenivas V, Gupta AK, Agarwal R, et al. Does ultrasound guidance for peripherally inserted central catheter (PICC) insertion reduce the incidence of tip malposition? - a randomized trial. J Perinatol. 2019;39(1):95-101. https://doi.org/10.1038/s41372-018-0249-x https://doi.org/10.1038/s41372-018-0249-... ⁾ ; India	Experimental Group: blind puncture, measurement by anatomical landmark, USGRT ^ USGRT = Real-Time Ultrasound; for tip verification	40	GAB ^* * GAB= Gestational Age at Birth; : 31.1± 3.1 w ^† † w = Weeks; BW ^§ § BW = Birth Weight; : 1,286 g ^\|\| \|\| g = Grams; (926-1,662)	1.75 days (0.83-5.37)	Infection: 4(10.2%) x 1(2.5%) - RR ^\|\|\|\| \|\|\|\| RR = Relative Risk; 4.1; 95% CI ^¶¶ ¶¶ CI = Confidence Interval; : 0.47-35, p =0.24 Infiltration or occlusion: 4(10%) x 6(15%) 1 ^st¶ Malpositioning: 13(32.5%) x 27(67.5%) – RR ^\|\|\|\| \|\|\|\| RR = Relative Risk; 0.48; 95% CI ^¶¶ ¶¶ CI = Confidence Interval; : 0.29-0.79; p =0.002	The use of USGRT ^ USGRT = Real-Time Ultrasound; reduced the incidence of tip malpositioning by 52%, and can be recommended for PICC ^§§ §§ PICC = Peripherally Inserted Central Catheter; insertion.
	Control Group: puncture guided by anatomical landmarks	40	GAB ^* * GAB= Gestational Age at Birth; : 31.4 ± 3.6 w ^† † w = Weeks; BW ^§ § BW = Birth Weight; : 1,061 g ^\|\| \|\| g = Grams; (889-1,636)	1.04 days (0.77-4.87)
Tang, et al.; 2021 ⁽ ³⁵35. Tang BZ, Chen CH, Chen H, Ling QY. [RCT of reduction in catheter-related complications by using intracavitary electrocardiogram-assisted guidance in neonatal PICC placement]. Sichuan Da Xue Xue Bao Yi Xue Ban. 2021;52(3):497-502. https://doi.org/10.12182/20210560506 https://doi.org/10.12182/20210560506... ⁾ ; China	Experimental Group: blind puncture, measurement by anatomical landmark, IC-ECG ^‡‡ ‡‡ IC-ECG = Intracavitary Electrocardiogram; to guide the tip	105	GAB ^* * GAB= Gestational Age at Birth; : 36.9 ± 1.3 w ^† † w = Weeks; (33-40)		General complications: 4(3.8%) x 23(21.9%); p =0.000 Arrhythmia: 0(0%) x 6(5.7%); p =0.015 Phlebitis: 2(1.9%) x 9(8.6%); p =0.029 Infection: 0(0%) x 1(1%); p =1 Skin lesion: 1(1%) x 3(2.9%); p =0.311 Thrombosis: 1(1%) x 4(3.8%); p =0.184	The use of IC-ECG ^‡‡ ‡‡ IC-ECG = Intracavitary Electrocardiogram; helps to timely detect and correct ectopic tip and the resulting vascular injury, infection and arrhythmia, bringing greater safety than control.
	Control Group: puncture guided by anatomical landmarks	105	GAB ^* * GAB= Gestational Age at Birth; : 36.4 ± 1.3 w ^† † w = Weeks; (32-40)
Tomazoni, et al.; 2022 ⁽ ⁴⁰40. Tomazoni A, Rocha PK, Pedreira MLG, Rodrigues EC, Manzo BF, Santos LM. Methods for measuring venous peripherally inserted central catheters in newborns. Rev Bras Enferm. 2022;75(2):e20210045. https://doi.org/10.1590/0034-7167-2021-0045 https://doi.org/10.1590/0034-7167-2021-0... ⁾ ; Brazil	Experimental Group: blind puncture, measurement using a modified anatomical reference landmark (insertion site up to the right sternoclavicular junction), x-ray to check the tip	44	GAB ^* * GAB= Gestational Age at Birth; and BW ^§ § BW = Birth Weight; are stratified into bands		General complications: 17(38.6%) x 27(61.3%) Phlebitis: 1(2.3%) x 3(6.8%) Infiltration: 3(6.8%) x 6(13.6%) 1 ^st¶ Malpositioning: 23(52.27%) x 43(97.7%); p =0.000 2 ^nd†† Malpositioning: 1(2.3%) x 1(2.3%) Occlusion: 3(6.8%) x 4(9.1%) Rupture: 1(2.3%) x 1(2.3%) Suspected infection: 2(4.5%) x 1(2.3%)	Using the modified measurement method provided better results for adequate PICC ^§§ §§ PICC = Peripherally Inserted Central Catheter; tip positioning.
	Control Group: puncture guided by anatomical landmarks (insertion site up to the right sternoclavicular junction and up to the 3 ^rd intercostal space)	44
Wu, et al.; 2021 ⁽ ³⁶36. Wu J, Li J, Li H, Lei X, Liu H. Comparison of formula-based PICC catheterisation versus common method for the treatment of newborns. Int J Clin Pract. 2021;00:e14210. https://doi.org/10.1111/ijcp.14210 https://doi.org/10.1111/ijcp.14210... ⁾ ; China	Experimental Group: saphenous puncture after 15 minutes of warm compress, guided by formula, x-ray to check the tip Formula >1,500 g: L ^* *** L = Size of the PICC to be inserted; = M ^††† †††** M = Newborn weight; - 1.5 + 23 0.3 Formula >1,500 g: L ^* *** L = Size of the PICC to be inserted; = 23 – 1.5 - M ^††† ††† M = Newborn weight; 0.3 L ^* ***** L = Size of the PICC to be inserted; : Size of the PICC ^§§ §§ PICC = Peripherally Inserted Central Catheter; to be inserted M ^††† †††** M = Newborn weight; : Newborn weight Control Group: saphenous vein puncture guided by anatomical landmarks	65		16.52± 0.63 days (1.47-26.46) Weight: 2,510 ± 180 g ^\|\| \|\| g = Grams; (1,170-3,760)	General complications: 4(6.15%) x 23(35.38%); <0.001 Phlebitis: 1(1.53%) x 7(10.76%) Infection: 1(1.53%) x 6(9.23%) 2 ^nd†† Malpositioning: 1(1.53%) x 4(6.15%) Thrombosis: 1(1.53%) x 6(9.23%) Note: The 1 ^st st 1 Malpositioning = Primary tip malpositioning; malpositioning ^st st 1 Malpositioning = Primary tip malpositioning; was not checked per individual, but regarding the number of centimeters that had to be pulled: Formula with traction of 0.25 ± 0.08 centimeters x Control with traction of 2.87 ± 0.23 centimeters ( p <0.000)	Using the formula to determine the catheter length to be inserted reduced hospitalization time, pain scale and related complications, as well as it increased the success rate of the first puncture and the time the catheter remained in place.
		65		16.73 ± 0.84 days (8.4-26.81) Weight: 2,570 ± 210 g ^\|\| \|\| g = Grams; (1,190-3,890)
Xiao, et al.; 2019 ⁽ ²⁸28. Xiao AQ, Sun J, Zhu LH, Liao ZY, Shen P, Zhao LL, et al. Effectiveness of intracavitary electrocardiogram-guided peripherally inserted central catheter tip placement in premature infants: a multicentre pre-post intervention study. Eur J Pediatr. 2020;179(3):439-46. https://doi.org/10.1007/s00431-019-03524-3 https://doi.org/10.1007/s00431-019-03524... ⁾ ; China	Experimental Group: USG ^‡‡‡ ‡‡‡ USG = Ultrasound for vascular visualization and IC-ECG ^‡‡ ‡‡ IC-ECG = Intracavitary Electrocardiogram; to guide the tip	78	GAB ^* * GAB= Gestational Age at Birth; : 32.17 ± 2.63 w ^† † w = Weeks; (28-37) BW ^§ § BW = Birth Weight; : 1,520 ± 377.38 g ^\|\| \|\| g = Grams;	15.21 ±7.52 days Weight: 1,657.44 ± 307.22 g ^\|\| \|\| g = Grams;	General complications: 5(6.41%) x 14(16.86%); p =0.040 Phlebitis: 2(2.56%) x 7(10.84%); p =0.202 Infection: 1(1.28%) x 3(3.61%); p =0.657 1 ^st¶ Malpositioning: 5(6.41%) x 22(26.51%); p =0.001 Rupture: 2(2.56%) x 4(4.82%); p =0.735	IC-ECG ^‡‡ ‡‡ IC-ECG = Intracavitary Electrocardiogram; can contribute to reducing the rates of tip repositioning and complications, in addition to increasing the rates of adequate tip positioning on the first attempt.
	Control Group: puncture guided by anatomical landmarks	83	GAB ^* * GAB= Gestational Age at Birth; : 32.36 ± 2.63 w ^† † w = Weeks; (28-37) BW ^§ § BW = Birth Weight; : 1,508.13 ± 279.31 g ^\|\| \|\| g = Grams;	13.19 ±8.8 days Weight: 1,571.63 ± 266.16 g ^\|\| \|\| g = Grams;
Zhou et al.; 2017 ⁽ ³⁷37. Zhou L, Xu H, Liang J, Xu M, Yu J. Effectiveness of Intracavitary Electrocardiogram Guidance in Peripherally Inserted Central Catheter Tip Placement in Neonates. J Perinat Neonatal Nurs. 2017;31(4):326-31. https://doi.org/10.1097/JPN.0000000000000264 https://doi.org/10.1097/JPN.000000000000... ⁾ ; China	Experimental Group: USG ^‡‡‡ ‡‡‡ USG = Ultrasound for vascular visualization and IC-ECG ^‡‡ ‡‡ IC-ECG = Intracavitary Electrocardiogram; to guide the tip	49	GAB ^* * GAB= Gestational Age at Birth; : 35 ± 4 w ^† † w = Weeks; (28-41)	17 ± 16 days (1-28) BW: 2,700 ± 900 g ^\|\| \|\| g = Grams; (1,100-4,900)	1 ^st¶ Malpositioning: 3(6.12%) x 75(37.5%); p <0.001 2 ^nd nd 2 Malpositionging = Secondary intravascular or extravascular tip malpositioning; ^nd nd 2 Malpositionging = Secondary intravascular or extravascular tip malpositioning; : Malpositioning (Pleural effusion): 0(0%) x 1(0.5%)	IC-ECG ^‡‡ ‡‡ IC-ECG = Intracavitary Electrocardiogram; with saline column can be applied to neonates, guiding the catheter tip appropriately, thus reducing the risks, delays and costs of tip adjustments.
	Control Group: puncture guided by anatomical landmarks	200	GAB ^* * GAB= Gestational Age at Birth; : 36 ± 3 w ^† † w = Weeks; (28-41)	13 ± 12 days (1-28) BW: 2,700 ± 900 g ^\|\| \|\| g = Grams; (1,000-5,000)

Outcomes	Comparisons	Certainty of the evidence from direct estimates	Certainty of the evidence from direct estimates	Certainty of the evidence from network meta-analysis
Arrhythmia	IC-ECG ^* * IC-ECG = Intracavitary Electrocardiogram; x Control	Moderate	-	-
General complications	IC-ECG ^* * IC-ECG = Intracavitary Electrocardiogram; x Control Formula x Control Modified AL ^† † AL = Anatomical Landmark; x Control IC-ECG/USG ^‡ ‡ IC-ECG/USG = Intracavitary Electrocardiogram with Ultrasound for visualization; x Control USGRT ^§ § USGRT = Real-Time Ultrasound x Control IC-ECG ^* * IC-ECG = Intracavitary Electrocardiogram; x Formula IC-ECG ^* * IC-ECG = Intracavitary Electrocardiogram; x Modified AL ^† † AL = Anatomical Landmark; Formula x Modified AL ^† † AL = Anatomical Landmark;	Moderate Moderate Moderate Low Very low - - -	- - - - - Moderate Moderate Moderate	Moderate Low Low - - Low Moderate Low
Phlebitis	IC-ECG ^* * IC-ECG = Intracavitary Electrocardiogram; x Control Modified AL ^† † AL = Anatomical Landmark; x Control Formula x Control Formula x Modified AL ^† † AL = Anatomical Landmark; Formula x IC-ECG ^* * IC-ECG = Intracavitary Electrocardiogram; IC-ECG ^* * IC-ECG = Intracavitary Electrocardiogram; x Modified AL ^† † AL = Anatomical Landmark;	Moderate Moderate Moderate - - -	- - - Moderate Moderate Moderate	Moderate Very Low Low Very Low Very Low Very Low
Infection	IC-ECG ^* * IC-ECG = Intracavitary Electrocardiogram; x Control Modified AL ^† † AL = Anatomical Landmark; x Control Formula x Control USGRT ^§ § USGRT = Real-Time Ultrasound x Control Formula x Modified AL ^† † AL = Anatomical Landmark; Formula x IC-ECG ^* * IC-ECG = Intracavitary Electrocardiogram; IC-ECG ^* * IC-ECG = Intracavitary Electrocardiogram; x Modified AL ^† † AL = Anatomical Landmark; IC-ECG/USG ^‡ ‡ IC-ECG/USG = Intracavitary Electrocardiogram with Ultrasound for visualization; x Control	Moderate Low Moderate Very low - - - Very low	- - - - Low Moderate Low -	Very low Very low Low - Very low Very low Very low -
Skin lesion	IC-ECG ^* * IC-ECG = Intracavitary Electrocardiogram; x Control	Very low	-	-
Primary malpositioning	IC-ECG ^* * IC-ECG = Intracavitary Electrocardiogram; x Control Modified AL ^† † AL = Anatomical Landmark; x Control IC-ECG/USG ^‡ ‡ IC-ECG/USG = Intracavitary Electrocardiogram with Ultrasound for visualization; x Control USGRT ^§ § USGRT = Real-Time Ultrasound x Control IC-ECG/USG ^‡ ‡ IC-ECG/USG = Intracavitary Electrocardiogram with Ultrasound for visualization; x Modified AL ^† † AL = Anatomical Landmark; IC-ECG/USG ^‡ ‡ IC-ECG/USG = Intracavitary Electrocardiogram with Ultrasound for visualization; x IC-ECG ^* * IC-ECG = Intracavitary Electrocardiogram; IC-ECG ^* * IC-ECG = Intracavitary Electrocardiogram; x Modified AL ^† † AL = Anatomical Landmark;	Moderate Moderate Very low Moderate - - -	- - - - Low Low Moderate	Moderate Moderate Low - Low Very low Very low
Secondary malpositioning	Modified AL ^† † AL = Anatomical Landmark; x Control Formula x Control IC-ECG/USG ^‡ ‡ IC-ECG/USG = Intracavitary Electrocardiogram with Ultrasound for visualization; x Control USGRT ^§ § USGRT = Real-Time Ultrasound x Control Formula x IC-ECG/USG ^‡ ‡ IC-ECG/USG = Intracavitary Electrocardiogram with Ultrasound for visualization; Formula x Modified AL ^† † AL = Anatomical Landmark; Modified AL ^† † AL = Anatomical Landmark; x IC-ECG/USG ^‡ ‡ IC-ECG/USG = Intracavitary Electrocardiogram with Ultrasound for visualization;	Moderate Low Very low Very low - - -	- - - - Very low Low Very low	Very low Very low Very low - Very low Very low Very low
Occlusion	IC-ECG ^* * IC-ECG = Intracavitary Electrocardiogram; x Control Modified AL ^† † AL = Anatomical Landmark; x Control IC-ECG ^* * IC-ECG = Intracavitary Electrocardiogram; x Modified AL ^† † AL = Anatomical Landmark;	Moderate Moderate -	- - Moderate	Very low Very low Very low
Dwell time	IC-ECG ^* * IC-ECG = Intracavitary Electrocardiogram; x Control Formula x Control USGRT ^§ § USGRT = Real-Time Ultrasound x Control IC-ECG ^* * IC-ECG = Intracavitary Electrocardiogram; x Formula	Moderate Moderate Moderate -	- - - Moderate	Very low Moderate - Moderate
Thrombosis	IC-ECG ^* * IC-ECG = Intracavitary Electrocardiogram; x Control Formula x Control Formula x IC-ECG ^* * IC-ECG = Intracavitary Electrocardiogram;	High Moderate -	- - Moderate	Low Very low Very low
Overall Success Rate	Modified AL ^† † AL = Anatomical Landmark; x Control USGRT ^§ § USGRT = Real-Time Ultrasound x Control	Low Very low	- -	- -

[1] Corresponding author: Ludmylla de Oliveira Beleza E-mail: ludmyllab@hotmail.com https://orcid.org/0000-0001-9975-562x

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