Unveiling Peripherally Inserted Central Catheter Fractures and Related Complications in the Neonatal Intensive Care Unit: A Concise Review

Peripherally inserted central catheters (PICCs) have become popular over tunneled catheters in neonatal intensive care units (NICUs) due to their ease of use and convenience. Although rare, a PICC fracture can be a severe and potentially fatal complication. This narrative review aims to identify factors predisposing neonates to PICC fracture and related complications, such as catheter jamming, and explore strategies for preventing and detecting this complication. A thorough search of PubMed and Google Scholar was conducted using relevant keywords to identify articles discussing PICC fracture in neonates. The review encompassed English-language literature on PICC fracture in neonates, with additional pertinent publications identified through citation searching. The incidence of PICC fracture in neonates varies from less than 1% to 10%, with a higher risk associated with prolonged catheterization, lower gestational age and lower birth weight, and the use of multi-lumen catheters. PICC fractures can occur during insertion, maintenance, or removal. Factors such as catheter duration, gestational age, birth weight, and catheter type increase the risk of PICC fracture. Excessive syringe pressure, securement failure, and excessive force during removal are contributing factors. Catheter fatigue and thin-walled catheter design are common causes of breakage. Preventive measures include proper training of healthcare providers, regular monitoring, early recognition, and prompt catheter removal upon fracture. Preventing and detecting PICC fractures is crucial for neonatal safety. Vigilance during insertion, maintenance, and removal, along with care to avoid excessive force during removal and high pressure during flushing, can help prevent catheter breakage. More research is required to improve prevention strategies for PICC fractures in neonates.


Introduction And Background
Peripherally inserted central catheters (PICCs) have replaced tunneled catheters since the 1970s.The utilization of PICCs in neonatal intensive care units (NICUs) has witnessed a remarkable surge, attributed to their reduced complication rates and less invasive insertion procedures in contrast to surgically placed nontunneled and tunneled catheters.The availability of smaller PICCs (1 Fr and 2 Fr) has grown over the last two decades.The most common complications are catheter-related bloodstream infections, occlusion, thrombosis, infiltration, unintentional removal, pleural effusion, pericardial effusion, catheter fracture, and embolization [1][2][3][4][5][6].The younger the gestational age and lower the birth weight, the higher the rates of PICC complications observed.A PICC fracture is the term used to describe the occurrence of a break or separation in the catheter tubing that has been inserted into an infant's vein.PICC fracture is uncommon but lifethreatening.This narrative review aims to identify and characterize potential predisposing factors for PICC fracture and related complications, such as catheter jamming in the neonatal population, and evaluate methods for preventing these issues.

Review Search methodology
A comprehensive search was done through PubMed and Google Scholar to identify publications about PICC fracture and catheter jamming in the neonatal population until April 2023.The keywords "PICC," "peripherally inserted central catheter," "central catheter," "fracture," "embolization," "catheter jamming," "difficult removal," "neonate," and "NICU" were used.Citation searching was also employed to evaluate more publications.Articles were included for the review if they discussed PICC fracture or catheter jamming in the NICU.Publications in languages other than English were excluded.Ethical clearance was unnecessary for this narrative review, as it involved consolidating and examining existing data from previous studies without direct engagement with human subjects or collecting new primary data.Figure 1 summarizes the search methods and the study selection process.

PICC complications in neonates
Despite the benefits of using a PICC instead of a traditional central vein catheter (CVC), the insertion and maintenance of PICCs can be challenging.Catheter fractures are more prevalent in PICCs than in traditional CVCs.PICCs are associated with multiple other complications, such as migration or dislodgement, air embolism, bleeding, extravasation, arrhythmia, cardiac tamponade, venous or right atrial perforation, pleural or pericardial effusion, hydrothorax, phrenic nerve injury or diaphragmatic paralysis, inadvertent arterial cannulation, venous thrombosis, mechanical or chemical phlebitis, and resistance to removal, also known as jamming [1][2][3][4][5][6].

PICC fracture
The incidence of PICC fractures is approximately 6.7 per 1,000 PICCs in pediatrics [4], and in neonates, it varies widely across studies, ranging from less than 1% to as high as 10% [2,[7][8][9][10][11].According to Pet et al., there was no statistically significant difference in the risk of PICC fracture between upper and lower extremity catheters [2].Catheter strength depends on size and material.Polyurethane has higher tensile strength than silicone, but both can fracture with improper care.Gomes de Souza et al. reported that the probability of PICC fracture is higher in silicone catheters than in polyurethane [13].
Factors associated with increased risk of PICC fracture include longer duration of catheterization, lower gestational age and birth weight, and stiff or multi-lumen catheters.Tsai et al. have documented that PICC insertion that takes longer than 60 minutes and PICC placement for more than 30 days are correlated with greater rates of catheter-related complications, including fractures of the PICC [11].
PICC fractures can occur during insertion, maintenance, or removal.During insertion, the catheter may fracture if it is withdrawn while the insertion needle is still in place or if the patient moves significantly [14][15][16].The risk of PICC fracture increases when excessive syringe pressure is applied, especially when using small-volume syringes for infusion or flushing against resistance [17,18].Another factor during maintenance associated with PICC fractures in the outer segment is the failure to secure the line or excessive force during dressing changes [19][20][21].Sharp objects such as clamps and adhesive tape on the catheter can cause PICC fractures.During removal or adjusting the depth, PICC fracture is possible if excessive force is applied [22][23][24].
Signs of a fractured catheter in neonates may include local site swelling, tenderness, redness, leakage, and resistance during insertion and removal [25].PICC fracture can be an incidental finding without symptoms and may be detected on routine imaging or removal [26][27][28][29].
Table 2 summarizes cases of PICC fractures in NICU settings from various journal reports.Notable findings include PICC fractures occurring within a few days to months after insertion, with the risk of embolizing catheter fragments into ventricles and critical arteries such as pulmonary arteries.Additionally, lower gestational age and birth weight seem to be associated with an elevated likelihood of PICC fractures.
Preceding events leading to PICC fractures exhibited diversity, encompassing symptoms such as catheter swelling and blood stains at insertion sites, and, in certain instances, catheter embolization into the pulmonary artery.The retrieval methods range from cardiac catheterization and endovascular techniques to more invasive procedures such as thoracotomies.These cases emphasize the critical importance of monitoring and adopting suitable retrieval strategies for PICC fractures among neonatal patients.

Risk factors associated with PICC fracture
A comprehensive analysis was conducted on the available data, stratifying the results into upper vs. lower extremity and central vs. non-central catheter insertion sites concerning PICC fracture.Comprehensive summary statistics and forest plots were generated for these variables using the NCSS 2023 Statistical Software (NCSS, LLC, Kaysville, Utah, USA), contributing to a robust understanding of outcomes associated with these distinctions.Figure 2 and Figure 3 forest plot images visually depict the outcomes, reinforcing the conclusion that there is no statistically significant difference in PICC fracture rates among central vs. noncentral and upper vs. lower extremity catheter insertions.It is noteworthy that variables such as gestational age, birth weight, catheter size, duration of catheterization, and catheter type posed challenges in the analysis due to limited literature on PICC fracture.Nonetheless, valuable insights into PICC fracture were extracted through a qualitative analysis of the existing case reports and case series, though a formal statistical synthesis was not performed.

PICC = peripherally inserted central catheter
There is a strong association between catheter fracture, the length of catheter placement, and line complications, such as blockage or leakage [4].The primary cause of catheter breakage is generally attributed to catheter fatigue.Thin-walled PICCs designed for premature infants are more prone to breakage than wider bore catheters.The use of antiseptic solutions before catheter insertion may weaken the catheter material.The catheter is susceptible to fracture at multiple points, including the catheter hub, internal catheter, and extension tubing.Fractures in PICCs typically occur at the junction between the thin polyurethane section and the wider microbore tubing.The external tubing and hubs are subject to wear and tear from repeated use.The catheter-hub junction is prone to fracture if excessive and sudden tension is applied while weighing the neonate or during skin-to-skin care [7].Mechanical manipulation, particularly rotational torque or twisting, is more likely to induce fatigue and lead to breakage than linear bending.
Additionally, flushing blocked lines under high pressure, using too much manual force, or small syringes (<5 mL) may contribute to catheter breakage.The risk of mechanical complications, including PICC fracture, is similar in the upper and lower extremities [36].However, Chang et al. reported a higher risk of catheter fracture in pediatric patients with catheters placed distally on the forearm [3].This finding was not confirmed in another study that demonstrated the same fracture tension of proximal and distal PICCs [37].
Although most pediatric studies have not found any difference in post-insertion complications between silicone and polyurethane PICCs, Gomes de Souza et al. reported a higher occurrence of non-elective removals, extravasations, and fractures among neonates with silicone catheters in contrast to polyurethane ones [13].Using larger PICCs can elevate the likelihood of venous occlusion and thrombosis, while smaller catheters may cause more mechanical issues, including luminal occlusion and fractures [38].It is recommended to prioritize single-lumen catheters as they may have a lower likelihood of causing complications than multi-lumen catheters [39].

Difficult PICC removal in the NICU
Among the mechanical complications of PICC, catheter jamming is a concern.The term "catheter jamming" refers to a situation where a catheter is pulled with considerable force close to its fracture tension but remains stuck and cannot be removed.Several reasons are associated with the difficulty of removing a catheter, such as venous spasms [40], venous thrombus with or without infection trapping the catheter within the vein wall [34], or phlebitis [35,40].Stimulation of the vessel wall during catheter removal can result in severe vasospasm, which can be felt as a cord.A fibrin sheath can occasionally explain a difficult removal after partial extraction [41].Coiling or knotting is also responsible for excessive resistance during catheter removal [33,42].Despite these challenges, most PICCs can be removed over time, as long as aggressive traction is avoided to prevent catheter fracture and venous damage.Preventive measures for PICC fracture in the NICU Specific measures can be taken during insertion, maintenance, and removal stages to prevent PICC fractures in the NICU.

Insertion Stage
Before PICC insertion, a thorough evaluation of the patient's need for analgesia or sedation to reduce agitation and promote a smoother procedure is essential.Furthermore, it is imperative to assess the catheter's length, insertion site, and the condition of the vein.Before inserting a PICC line, a comprehensive examination of the catheter for any signs of leaks or breakage should also be conducted.Retracting the catheter through the introducer needle should be avoided to prevent catheter shearing.One way to reduce tension on the catheter is to secure it under the dressing and use a T-connector.Additionally, fixing the catheter in a standardized manner, with the external part of the catheter in an "S" shape or a loop, can also be effective [31].To prevent the catheter from moving and developing kinks that may cause breakage, the catheter and the hub should be firmly secured using skin closure strips and a transparent occlusive dressing [7][8][9].Corzine et al. found that securing the extension tubing with a second layer of a sterile semi-permeable dressing reduced PICC fracture in a NICU from 3.5% to 1%.The technique for securing the PICC is illustrated in Figure 4 and Figure 5.

Maintenance Stage
High-pressure injections through PICC can damage the catheter wall and cause line fracture [4].Infusion pumps should be used strictly per manufacturer instructions to avoid excessive pressure.Providers and nurses should avoid forcefully infusing fluids using syringes, and if resistance is encountered, flushing should be avoided.If flushing is required, using a syringe with a capacity greater than 5 mL is recommended [43].Catheters should be removed as soon as they are no longer needed, as prolonged use of PICCs increases the risk of breakage.However, the routine removal and reinsertion of PICCs may pose risks and incur costs.
Monitoring the PICC tip position regularly through radiographs or ultrasound to ensure the optimal placement is crucial.Handling them as little as possible is recommended to minimize the fracture risk to the PICC and external tubing.In addition, a critical aspect of the maintenance phase involves frequent education of nurses and providers on proper PICC line usage and maintenance.According to the findings of Garduno-Crespo et al., the risk of breakage is higher when PICC care, including dressing change, is performed every seven days compared to a 10-day interval [44].If the fluid administered is total parenteral nutrition, lipids, or dextrose >10%, the intravenous (IV) tubing should be replaced every 24 hours; otherwise, every 96 hours is sufficient [8].To ensure the catheter remains patent, heparin should be added to the fluids at a ratio of 0.5 to 1 U/1 mL and administered continuously at a minimum rate of 1 mL/hour for preterm neonates and 2 mL/hour for term neonates [45].Extension tubing with a clamp is recommended to avoid clamping the actual catheter.PICC with a diameter of less than 2 Fr should not be used for blood administration or sampling.Additionally, tourniquets, IV boards, and blood pressure cuffs should be avoided on the extremities with a catheter.Enhancing catheter securing techniques and regularly employing X-rays to track the catheter's tip position helps prevent severe complications, including PICC fractures.

Approach to snapped PICC during removal
In the event of a snapped PICC during removal, the outer segment of the catheter should be grasped to prevent embolism.In the event of an embolism, it is crucial to take measures to prevent the catheter fragment from moving deeper into the central circulation.This can be achieved by applying digital pressure or a tourniquet to the affected extremity [50].However, it is crucial to ensure that the tourniquet is not excessively tight, which may obstruct arterial blood flow.The infant should be placed on the right side to trap the catheter within the right heart.The patient should be kept still and radiographic confirmation of the catheter fragment's location should be requested.Prompt removal of a fractured catheter fragment is critical to minimize the risk of complications such as arrhythmia, blood clot formation, and catheter embedding in the vessel walls [51].To remove catheters in the peripheral circulation, venotomy should be performed.However, if catheters have already embolized to the central circulation, their removal may require interventional radiology, interventional cardiology, or surgical procedures [30][31][32].

Conclusions
PICC fractures are an uncommon but life-threatening complication in neonates, and their prevention and early detection are crucial to ensure neonatal safety.More studies are needed to confirm the association between PICC fracture risk and factors such as extended catheterization periods, lower gestational age, lower birth weight, and the utilization of rigid or multi-lumen catheters.To prevent PICC fractures, healthcare providers should be vigilant during the insertion, maintenance, and removal of these lines and avoid excessive force and high-pressure flushing.Early detection and management of PICC fractures are essential to minimize morbidity and mortality.Further research is needed to understand the risk factors better and develop more effective prevention strategies for PICC fractures in neonates.

FIGURE 1 :
FIGURE 1: Flow diagram of the study selection process.

Table 1
summarizes the published data on the frequency of PICC fractures in the NICU.
23in the upper extremity and 39 in the lower extremity (odds ratio of 0.79 (0.47-1.34) was not statistically significant)

TABLE 2 : PICC fracture cases reported in various journals within the NICU setting.
PICC = peripherally inserted central catheter; NICU = neonatal intensive care unit

Table 3
provides an overview of cases where PICC removal posed challenges in the NICU.