Peripheral limb ischaemia from peripherally inserted central catheter (PICC) line insertion in an extreme preterm neonate – Case report

Abstract

Background: There is extensive literature on incorrect positioning of peripherally inserted central catheter (PICC) line tips, particularly concerning advancement into the right atrium causing cardiac tamponade. However, there is little literature concerning inadvertent arterial cannulation as a complication of PICC insertion and what steps could be taken to prevent it. 

Case presentation: An extreme preterm neonate had a PICC line inserted into the left arm to provide central venous access for parenteral nutrition. Following the insertion, an anteroposterior chest X-ray was used to confirm positioning and was deemed acceptable. It was reviewed by a consultant radiologist the next day. Fifteen hours after insertion, the nursing staff raised concerns that the fingertips on the neonate’s left hand appeared dusky and were getting progressively darker. Upon removal of the PICC line, an upper limb Doppler was performed, showing severe stenosis of the brachial artery with no flow distally in the radial or ulnar arteries. 

Conclusions: This case demonstrates that glyceryl trinitrate (GTN) patches can be used to reverse peripheral ischaemia in neonates with good effect. After reflecting on the case, we decided that monitoring distal limb colour and perfusion should be part of observations in neonates with central venous lines in situ and documentation should reflect this. Furthermore, when concerns are raised about distal perfusion in a limb with lines in situ, all lines should be removed immediately. We would like to emphasise that it is of vital importance to promote a culture of openness where all team members are empowered to raise concerns about patient safety.