Primary malposition of peripherally inserted central catheter in the inferior vena cava among neonates: a case series

Lower-extremity insertion of peripherally inserted central catheters (PICCs) is recommended in neonates to reduce tip malposition risk, yet primary malposition into the inferior vena cava (IVC) remains underreported. This study examined the incidence, contributing factors, and management outcomes of this complication in a neonatal intensive care unit (NICU).

We conducted a retrospective case series in a tertiary Chinese hospital NICU (February 2022-March 2024). Among 18 neonates with confirmed IVC malposition after lower-extremity PICC placement, we assessed tip location by post-insertion x-ray, collected clinical and catheterization data, and analyzed associations between treatment strategies and final tip position.

18 of 723 lower-extremity PICC insertions (2.5%) showed primary IVC malposition. Concurrent umbilical venous catheter, respiratory support, and patient positioning were associated factors. We classified malpositions as high (T9-T12, n = 11) or low (L2-S2, n = 7). External manual repositioning corrected 90.9% of high malpositions. Catheter withdrawal by 4-8 cm with re-advancement succeeded in 85.7% of low-level cases. All catheters were retained throughout therapy.

Primary IVC malposition is linked to positioning, elevated intra-abdominal pressure, and umbilical catheter presence. Elevating the infant's hips during insertion can promote proper catheter ascent. If resistance occurs, removing an indwelling umbilical catheter often resolves malposition. Ultrasound-guided assessment supports successful correction in most cases, emphasizing preventive measures and tailored management.