Errors in NICU related to central lines and catheters

Patients treated in intensive care units frequently require central line placement for long-term infusion of intravenous fluids and medications. 

Neonatologists often place central catheters in premature babies, those who need surgery or are treated on ventilators. Some extremely premature babies may need a central line for intravenous nutrition for many weeks. 

Since central line placement is an invasive procedure, it should not be surprising that various complications may be associated with it and its long-term use (source article). 

In my article, I will explain what types of central lines neonatologists use most commonly in the NICU. I will also discuss probable causes of medico-legal issues associated with the use of central catheters in neonates. Additionally, I will advise you on how to review a chart of a newborn with a central line placed during its hospitalization.

Another article I wrote discusses various causes of malpractice suits in neonatology, you will find it here.

The most common central lines used in neonates

Umbilical Venous Catheter (UVC)

We place it during the first week of life, but usually, it will be done during the first two days. Also, the UVC is a procedure of choice if the baby requires IV medications right after birth during resuscitation. 

We use UVC for infusions of drugs and fluids and blood drawings. It is debatable for how many days UVC can be safely used. Some say it should be used for only 2-3 days, but others will claim that seven or even 30 days is acceptable. 

If we expect the baby to need intravenous fluids for a long time, most neonatologists will attempt PICC line placement and remove UVC during the first week of life. UVC lines are known to have a higher rate of infections and may get displaced more quickly than other types of catheters.

Umbilical Arterial catheter (UAC)

We place a catheter in an umbilical artery to monitor the baby’s blood pressure and draw blood. Rarely, when we cannot insert UVC, we can use UAC to infuse certain fluids and medication. However, using UAC for infusions is not a recommended or standard practice. 

We put this type of catheter during the first week of life and, if needed, can keep using it for a few days. 

Peripherally Inserted Central Catheter – PICC

It is a long, thin tube made of plastic that we insert through the vein in the arm, leg, or on the head and advance until the tip reaches a larger vessel close to the heart. 

Ideally, the end of the catheter should not be placed too shallow (near the entry point) or too deep (in the heart). The PICC is used for intravenous infusions of fluids and medications. Using PICC for blood drawings is not recommended as it creates the risk of clotting, making such a line useless and risky for the patient.

Radial line

We place a radial catheter in very sick babies in whom we want to monitor blood pressure and who will require frequent blood draws for testing. This particular line may be associated with decreased blood flow to the hand and necrosis of fingers. Therefore, careful and continuous evaluations of skin color and the appearance of the fingers are a must.

Broviac line

A broviac line is a type of central line catheter placed by a surgeon through the entry point in the upper chest and tunneled under the skin before entering the vein. The tip of the catheter will be located in a large vessel very close to the heart. 

Medico-legal issues related to central line use in a neonate

If a baby develops any complications related to central line placement, I suggest performing a careful chart review focusing on the items described below (source article). 

Inappropriate consent for a procedure

Except for emergencies when a delay in care could cause significant harm to the patient, every invasive procedure performed in the NICU requires informed consent. For the consent to be valid, a person who inserts the catheter should provide all relevant information to the parent. The conversation should include a thorough review of indications, benefits, risks, and possible complications. 

Sometimes, a surgeon’s designee will talk to the family, but it should be a person familiar with the procedure and ideally licensed to perform it. 

When a nurse obtains consent, one can argue that she is not licensed to insert central catheters; therefore, she is not an appropriate person for the task. She would be unable to explain how the procedure is done or answer all questions related to possible complications. As a result, lawyers can later challenge nurses’ consents as invalid.  

Another consent issue is that a mother who gives consent is often under the influence of narcotics given for her pain management. She may not have the mental capacity to consent; therefore, such consent may be later challenged as invalid. 

Malfunctioning equipment or shortages of instruments

I have heard of many instances where low-volume hospitals and NICUs did not have appropriate instruments to perform specific procedures or equipment had expired usability dates. 

While reading procedure notes, a reviewer should pay attention to the description of the procedure and if there is any mention of equipment problems.

Lack of sterile technique

A rare complication associated with the insertion of central line catheters is post-procedure infection (an infection that occurs within 24-72 hours). One could argue that among the factors contributing to infections will be non-sterile technique during the procedure or inappropriate catheter maintenance after insertion (source article). 

It has been shown in the literature that many NICU teams could significantly decrease rates of their central line infections by introducing standardized protocols involving checklists and trained observers. 

Unsafe techniques of insertion

There are standard steps for each procedure or surgery described in the literature to ensure the safest outcomes for the patient. Ideally, doctors should follow standard techniques unless they have a good reason to modify that technique. 

Whenever modifying their technique, they need to explain the reasons for that in their note, and they should also explain that to the newborn’s parent or guardian. 

Following the standardized steps for each procedure will minimize the risks of bleeding, pain, infections, and many other complications. 

Untrained personnel performing procedure

In the NICU, a nurse will place peripheral IV catheters. A physician, a nurse practitioner, or a physician assistant will place most central catheters such as UVC, UAC, or PICC. 

Rarely a surgeon or interventional radiologist will be called to assist with more complicated cases or to place a broviac line (see my article describing the roles of different professionals in the NICU). 

Each hospital should ensure that doctors and nurses have adequate experience and case volumes to continue performing invasive procedures associated with risks and complications to their patients. 

In most hospitals, the Credentialing Committee, the Quality Committee, and the department chair decide whether a doctor or mid-level provider can perform invasive procedures. 

The tip of the catheter was left in the wrong location

Before securing the catheter for long-term use, we must ensure that the catheter’s tip is in the proper and safe location. In most cases, we have two quick ways of doing that. We can do an X-ray or an Ultrasound. Both techniques will provide information, and physicians will choose one based on their experience and equipment availability. 

Many severe complications after central line placement are due to misplacement of the catheter tip. Therefore, ordering a study to confirm a tip’s position is extremely important. In addition, a location needs to be documented in the chart and be known to all medical providers. 

Inappropriately secured central line

After the catheter insertion procedure is completed and its tip is in the desired place, we must secure it. This final step is to provide a sterile environment around the entry point to prevent infections. We will also avoid catheter movements by ensuring proper anchoring using sutures or special dressings. 

H3: Inappropriate evaluations while the catheter was in place and in use

Some catheters stay in newborns’ bodies for a month or even longer. During that time, we must ensure that continuing their use is safe. Depending on the type of catheter, such an evaluation should include:

• Assessment of the surrounding area for any signs of infection
• Checking the length of the catheter that is located above the entry point
• Making sure that the catheter is not leaking around the entry point or through the connectors
• Periodic evaluations of the catheter tip location using an X-ray

H3: Inadequate documentation regarding the procedure

After performing a procedure, the physician should write a detailed note. At a minimum, the note should include:

• Indications
• A consent statement
• A brief description of the procedure with attention to unexpected events or complications
• The exact location of the tip of the catheter
• Plans for future follow-up and maintenance of the central line

Inadequate documentation while the catheter was in the baby’s body

If the catheter is left in a newborn’s body for a long time, ideally, physicians and nurses should daily perform its evaluation. In those cases, a note should state how the dressing looks, at what length the catheter is still secured, and if there are any signs of skin infection. 

Problems related to the removal of the catheter

Various individuals can remove the catheters. The most common complications witnessed after the removal of central lines are listed below:

• Excessive bleeding
• Infection
• Injury to the surrounding skin or organs if a scalpel was used to cut the sutures
• Cutting the catheter by mistake and leaving a piece of it inside the body

If these complications occur, a doctor must notify parents immediately and implement an appropriate treatment or remedy. 

In Summary: 

Central lines are essential to provide the necessary treatments for neonates in the NICU. The procedures during which we insert a central catheter may be associated with immediate and later occurring complications. 

Attention to detail and standardizing techniques may minimize risks to the patient. I strongly recommend that all NICUs develop programs to reduce catheter-associated bloodstream infections. 

A neonatal chart reviewer must know all possible complications associated with central lines and look for certain red flags in the doctor’s or nurse’s charting (tips on how to review a neonatal chart). 

It may not be evident that the baby’s condition deteriorated due to central line placement unless you carefully analyze documentation and gather all facts and additional studies (images and lab results).