Dear Editor,

We read with great interest the publication of the audit on the use of peripherally inserted central catheter (PICC) by D W Cartwright.

A 25-gauge polyurethane double-lumen PICC (PI catheter Kit® double-lumen, Nippon Sherwood, Tokyo) is used in the neonatal intensive care unit since July 2001. The advantages include an insertion approach similar to that for single-lumen PICC insertion, simultaneous administration of incompatible drugs, and a reduction in the required number of catheter insertions.

Double-lumen PICC was utilized in 163 infants with the mean birth weight of 1230 g (range: 373-3610 g), the mean gestational age of 28.9 weeks (range: 22-41 weeks), and the mean duration with the catheter in place of 15.8 days (range: 1-95 days). Complications included occlusions, mechanical and accidental failures of the catheter in 23 cases (14.1%), and septicemia in 5 cases (3.1%). Myocardial perforation, pericardial effusion and thrombosis did not occur in any infants. Double-lumen PICC was inserted at the initiation of treatment and no further insertion was required until infusion was complete in 79 cases (54.9% survivors).

These results suggest that the incidence of complications with double-lumen PICC is similar to or lower than that with single-lumen PICC.

In conclusion, the usefulness of double-lumen PICC is equivalent to that of single-lumen PICC and we suggest that double-lumen PICC can replace with single-lumen PICC in the near future.

Dear Editor,

Dr Asumang in her eletter, in response to my recently published audit of peripherally inserted central venous catheters (PICCs) in neonates, questions the details of the location of line tips, and the determination and recording of tip positions.

Tip positions were – right atrium (1282), SVC (239), subclavian vein (203), limb vein (100), IVC (98), jugular vein (71), innominate vein (61), neck vein (11), iliac vein (9), aorta (8 – removed on recognition), chest wall vein (7), cephalic vein (4), axillary vein (2), ascending lumbar vein (2), abdominal wall vein (1), pulmonary artery (1), not recorded (73) and unknown – record not traced (14).

As detailed in the methods section of the paper, line tip positions are recorded prospectively, initially in the medical chart notes. Since 1996, these have been recorded then into the computerised neonatal database. While preparing this paper, needing as described to retrieve some such details from medical charts in the 1991-1995 time period, I realised that the chart records of line insertions were not always as complete as I would desire, and unsuccessful attempts were virtually never recorded. Therefore in late 2001 we introduced a ‘procedure stamp’ to be placed into the chart and filled in for every attempted line insertion. For central venous lines, line tip positions recorded are those determined by the clinical medical staff who insert the line, not those in imaging department reports. I hold very strongly to the view that any imaging report of a vascular catheter or endotracheal tube that describes the tip position as ‘satisfactory’ is an unsatisfactory report. Imaging reports, and chart medical records, should record anatomical tip positions. It is the responsibility of clinical medical staff to decide whether the position is ‘satisfactory’ or not, and to clearly document this opinion and any action taken when it is deemed to be ‘unsatisfactory’.

As an addendum to my paper, I might now add that while that issue of your journal was being printed, in a recent one month period I twice saw the complication of pleural effusion, manifest as sudden onset of respiratory distress, in babies with central venous catheters in place. In my paper I stated correctly that I had not ever seen that complication. One catheter was a surgically inserted catheter, the other a ‘PICC’. The tips of both catheters were clearly demonstrated to be well outside the heart, in the region of the superior vena cava. Both complications were dealt with swiftly and effectively with no detriment to the baby. One required needle thoracocentesis and line removal, the other simply line removal. These observations do not alter the main conclusion of my paper – that central venous catheters ‘with their tips in the right atrium and not coiled do not cause pericardial effusion’. They do emphasise that catheters placed with their tips in and around the heart are inherently risky, we must know accurately where their tips are located, and we must be eternally vigilant while such catheters are in place and balance their continued presence against demonstrable positive need.

Dear Editor,

I read with interest the publication of the audit on the use of central venous lines(CVL) by DW Cartwright.

He reported that 58.6% of the catheters were postioned in the right atrium, but there was no breakdown of where the other 41.8% tips were located. Probably this was because he was interested in only catheters in the right atrium. I would have liked to know as well if this information was initially recorded or radiographs had to be reviewed to ascertain the anatomical position of these catheter tips.

In my experience, catheter tips have been reported as "satisfactory" without anatomical description of the position of the tip. Since most of the serious problems with CVL are related to the position of the catheter tip, this needs to be appropriately recorded. This will help with audits and subsequent formulation of guidelines on the insertion of CVLs.