Introduction Umbilical venous catheter (UVC) related extravasation is an under recognised yet potentially catastrophic complication which can result in death. Prompt recognition and catheter removal is associated with excellent outcomes but requires a high index of suspicion. A series of near fatal UVC extravasation (Figure 1) prompted a retrospective analysis of umbilical catheters placed between April 2011 and July 2013.
Image 1 TPN Extravasation via UVC
Method All extravasations diagnosed clinically or by ultrasound with an umbilical catheter underwent root cause analysis. Factors looked at were placement, imaging, documentation, symptomatology, biochemistry and outcome after treatment. A simulated access workshop was implemented in September 2012 and posters addressing measurement, radiology and best practice were put in place in April 2013 at point of care.
Results In 2012 a total of 161 UVC’s were placed, of which. 4.3% extravasated (n = 7). In 2013, 3 cases of extravasation occurred up until the end of June with no further cases to date. An analysis of 16 UVC extravasations reveals 100% were double lumen catheters. In all the babies, the UVC tip was found to be below the diaphragm at the time of extravasation. 87% of these babies had TPN running through the lines. The dextrose concentration in TPN varied between 12.1 to 18.6%. 25% babies had multiple attempts at UVC insertion. 69% babies had inotropes and/or sodium bicarbonate administered through UVC. In 81% babies, extravasation injury was symptomatic. The most common symptom was abdominal distension (83%) which is subtle and has many other differentials. Other symptoms include nonspecific symptoms like abdominal discoloration (33.3%), hypotension (25%), and hepatomegaly (16.7%). 2 episodes were near fatal.
Conclusion The majority of UVC extravasations were associated with hypertonic solutions running through catheters in a low position where blood flow is slower predisposing to this complication. The symptoms can be subtle necessitating a high index of suspicion. Early ultrasound is key in diagnosis. Prompt removal of the UVC results in spontaneous improvement in symptoms as the norm. A quality improvement exercise targeting trainees involving simulated umbilical access workshops and posters to highlight best practice and complications have helped reduce the incidence of extravasation since implementation.