**2. Complications of centrally placed venous catheters**

Any venous catheters tip placed in the lower half or lower one-third of SVC/at or above the level of the diaphragm in IVC is called as centrally placed venous catheters, which commonly includes PICC line/umbilical venous catheter.

Above are the X-rays showing PICC line in an accepted position (**Figure 1**), PICC line in the right atrium (**Figure 2**), and PICC line looping within the cardiac chamber (**Figure 3**).

Although it is a common procedure in the neonatal critical care unit, it is not uncommon to have complications related to it. Due to the smaller size of the heart in neonates and premature infants, the usual anatomic landmark and distance from the insertion site may not be accurate. As they are commonly performed at bedside, fluoroscopic guidance would not be possible.

There are only a few randomized control clinical trials for PICC line use in neonates. The precise rate of complications of central venous catheters in neonates is unclear due to underreporting [5]. The reported incidence of PICC line induced complications from a compilation of various case reports varies from 0 to 33% [3]. Complications can be due to mechanical, vascular, cardiac and/or miscellaneous reasons. The most common mechanical complications are occlusion (reported as 30%), which can be minimized by inserting the smallest catheters into the larger veins. Vascular complications include phlebitis, bleeding from the insertion site, extravasation, and catheter-related venous thrombosis. It can be reduced through the atraumatic catheter insertion technique (slow and controlled technique), good compression immediately after insertion and accurate placement of the catheter in the vena cava [3, 5]. Migration of a properly placed catheter is not unusual to encounter and it may precipitate significant arrhythmias. A prospective study of 100 PICCs where catheter tip was evaluated at 24 h of post insertion revealed that 32.6% of catheters are migrated toward the heart and migration is more common in upper extremity PICC lines (47%) [4]. Peripheral dislodgement of catheters, catheter damage, catheter leakage/breakage and catheter fractures can occur. The above complications can be decreased with proper, transparent fixation of catheter end and more importantly fixation of its extension set [3]. Cardiac tamponade, myocardial perforation, and valve injury are commonly associated with curved or kinked intracardiac placement of centrally placed catheters. These complications can be minimized by making sure that the catheter tip is straight before insertion and most importantly adjusting the catheter position outside the

access for parenteral nutrition, the ability to transfuse hyperosmolar fluids, the opportunity to inject important drugs with PH less than 6 (e.g., vancomycin) or more than 8 (e.g., phenytoin) and continuous infusions like prostaglandins, irritants (calcium gluconate) and extended antibiotic therapy [1, 2, 11, 12]. These PICC lines are made of silicone or polyurethane. The preferred site of insertion is from the antecubital vein, cephalic vein, basilic vein or the long saphenous vein. The goal is to place the catheter tip at the level of superior vena cava (SVC) or inferior vena cava (IVC). The optimal placement of PICC lines in SVC should be 0.5–1 cm away from the cardiac silhouette in preterm and 1–2 cm away from the cardiac silhouette in term neonates [1]. This could help us in reducing the dreadful cardiac complications induced by PICC lines. All neonatal intensivists involved in taking decisions for insertion of central venous catheterization such as PICC or umbilical venous catheterization (UVC) should be aware of potential risk factors for

The aim of the chapter is to describe the common complications of central venous catheter with focus on arrhythmic complications. The timing and proposed mechanisms of malpositioned intracardiac catheter-induced arrhythmias are also explained. Common types of arrhythmias (atrial flutter and supraventricular tachycardia) secondary to the intracardiac catheters are explained with an outline of its basic management. Finally, practical tips are

Any venous catheters tip placed in the lower half or lower one-third of SVC/at or above the level of the diaphragm in IVC is called as centrally placed venous catheters, which commonly

Above are the X-rays showing PICC line in an accepted position (**Figure 1**), PICC line in the

Although it is a common procedure in the neonatal critical care unit, it is not uncommon to have complications related to it. Due to the smaller size of the heart in neonates and premature infants, the usual anatomic landmark and distance from the insertion site may not be accurate. As they are commonly performed at bedside, fluoroscopic guidance would not be possible. There are only a few randomized control clinical trials for PICC line use in neonates. The precise rate of complications of central venous catheters in neonates is unclear due to underreporting [5]. The reported incidence of PICC line induced complications from a compilation of various case reports varies from 0 to 33% [3]. Complications can be due to mechanical, vascular, cardiac and/or miscellaneous reasons. The most common mechanical complications are occlusion (reported as 30%), which can be minimized by inserting the smallest catheters into the larger veins. Vascular complications include phlebitis, bleeding from the insertion site, extravasation, and catheter-related venous thrombosis. It can be reduced through the atraumatic catheter insertion technique (slow and controlled technique), good compression immediately after insertion and accurate placement of the catheter in the vena cava [3, 5]. Migration

right atrium (**Figure 2**), and PICC line looping within the cardiac chamber (**Figure 3**).

complications. This helps to prevent or minimize the complication rate.

**2. Complications of centrally placed venous catheters**

includes PICC line/umbilical venous catheter.

162 Cardiac Arrhythmias

discussed to minimize the arrhythmic complications of central venous catheters.

**Figure 1.** PICC line—optimal position. Chest X-ray showing right PICC line in SVC—0.5 cm away from the cardiac silhouette an optimal position.

**Figure 2.** PICC line in the right atrium. Chest X-ray showing right PICC line in the right atrium.

**3.** Anytime at the indwelling phase due to migration/dislodgement of central venous

Central Venous Catheter-Induced Cardiac Arrhythmias in Neonates

http://dx.doi.org/10.5772/intechopen.74559

165

Cases were documented from within few minutes after insertion till 47 days post insertion of

Typically the etiology lies on inappropriately placed intracardiac catheters in all the cases.

**1. Direct contact of the catheter with SA node/atrial musculature**: direct contact may induce a triggered activity or increased automaticity. For example, direct contact with the endocardium may induce few premature atrial beats, which in the presence of an accessory

**2. Mechanical irritation of intracardiac chambers (especially atria) during the passage:** this

**3. Subsequent edema and inflammation**—would prolong the duration of arrhythmia which may explain the presence of arrhythmia for few days even after withdrawal of catheter

Malpositioned, migrated or inappropriately placed central venous catheter can cause a wide range of arrhythmias ranging from tachyarrhythmias to bradyarrhythmias as mentioned in **Figure 4**.

Tachyarrhythmias are abnormal fast rhythms originating from atria or from ventricles of the heart. With intracardiac indwelling catheters, tachyarrhythmias are more common than bradyarrhythmias. Recognition of tachyarrhythmia is crucial for any intensivist. If not identified in time, it may end up with congestive cardiac failure due to significantly compromised cardiac output due to incessant tachycardia. Cardiogenic shock may happen due to

will predispose to the development of an accessory or re-entrant pathway [6].

**3.3. Types of cardiac arrhythmias induced by intracardiac central venous catheter**

**2.**Willful over advancement 2 Secure phase Migration of catheters can happen due to handling at the time of fixation

catheters.

central venous catheter (CVC) [16, 17].

The possible mechanisms are

away from the heart.

*3.3.1. Tachyarrhythmia*

**Serial number**

**3.2. Proposed mechanism of arrhythmia induction**

pathway or dual AV node pathway may trigger a SVT.

**Time phase Possible reason**

1 Procedural phase **1.**Improper measurement

3 Indwelling phase Migration and dislodgement

**Table 1.** Timing of development of arrhythmias with central line.

**Figure 3.** PICC line with intracardiac looping. Chest X-ray shows left PICC line passed superior vena cava, got looped in right atrium.

cardiac shadow immediately after taking X-ray. After adjustment of the catheter tip, confirmatory X-ray is mandatory. Massive pleural effusion and pericardial effusion has been reported following an inappropriately placed PICC lines [1, 14].
