Use of a Tunneled PICC for long term Venous Access
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The insertion of a long-term central venous catheter (CVC) for parenteral nutrition in neonates and small infants is problematic. Ideally, a cuffed CVC is used for this purpose. However, neonatal-sized cuffed CVCs are expensive and not readily available. In addition, such catheters require general anaesthesia and surgery for insertion and removal.

Therefore, a clear clinical indication and a thoughtful balance of risk and benefits should be considered in each case. Many patients require a CVC for more than two weeks, but the exact duration of therapy may be difficult to anticipate. In these cases, the insertion of a cuffed CVC may not be the best option.

A tunnelled PICC (Peripherally inserted central catheter) is used as an alternative to a cuffed CVC in a one month-old male infant with a weight of 2.9 kg and a medical history of DiGeorge syndrome, congenital heart defect, necrotizing enterocolitis (bearing an ileostomy) and severe malnutrition needing mid-term parenteral nutrition. The patient was admitted to the paediatric intensive care unit for the procedure. After induction of general anaesthesia and tracheal intubation, ultrasound (US)-guided supraclavicular cannulation of the left brachiocephalic vein (BCV) was performed at the bedside. A subcutaneous tunnel to the lateral chest wall was created using an 18 Gauge angiocatheter.

A 3 French one-lumen conventional PICC was advanced through the tunnel. After cutting the PICC to the desired length, it was inserted into the BCV using a 3.5 French-peel-away introducer sheath. The catheter was fixed using surgical glue at the exit site and a suture-less device. The catheter was used for 8 weeks without complications and was removed when it was no longer needed by simply pulling out the device.

The off-label use of tunnelled PICCs as long-term CVCs was first described as an alternative central access for neonates and infants in whom the insertion of a PICC through a peripheral vein is not feasible. Subcutaneous tunnel and sutureless fixation reduce the risk of infection. The main advantage of this technique is bedside insertion and explant without surgery, which is very important when the predicted duration of therapy is not clear.

In conclusion, this technique constitutes a cheap and widely available alternative to the surgical insertion of cuffed CVCs in neonates and small infants.