Accidental arterial PICC placement in neonatal patients: a case series

There is a paucity of literature relating to accidental arterial peripherally inserted central catheter (PICC) placement in neonatal patients. We present a series of nine cases from a single centre. A database of point-of-care ultrasound (POCUS) assessments of PICC lines was recorded at a single tertiary neonatal intensive care unit over a 5-year period (2020-25). This database was reviewed and cases of arterial PICC line placement were identified. Of 265 POCUS assessments, intra-arterial PICC placement was identified in 3% (n = 9). High-risk insertion sites include the area posterior to the medial malleolus (n = 3, 33%) and the median cubital fossa (n = 3, 33%). A third of cases (n = 3, 33%) developed no complications. Complications included oozing from the site (n = 3, 33%), high pressure on infusion pumps (n = 2, 22%) and digital ischaemia (n = 3, 33%). All cases of ischemia occurred in lower limb PICCs and the majority (n = 2, 66%) in the contralateral limb to the insertion site, leading to a delay in identification of the arterial placement by 5 to 17 days.

This series supports the use of routine immediate POCUS for all neonatal PICC lines and consideration of real-time ultrasound-guided PICC placement. Warning signs of intra-arterial placement include abnormal line trajectory on radiographs, insertion site oozing, high pump pressures and limb ischaemia (including contralateral limb involvement). Particularly high-risk neonates include those with congenital diaphragmatic hernia whereby mediastinal shift renders radiographic confirmation of PICC position unreliable.

• Neonatal PICC position is usually confirmed by radiography, and accidental arterial cannulation (AAC) is considered rare.

• AAC occurred more frequently than previously reported and was often not detected clinically or on radiographs. • Point-of-care ultrasound improved identification of AAC and may improve neonatal PICC safety.