Contrast Enhanced Radiography for Peripherally Inserted Central Venous Catheter (PICC) Tip localization- Is it really needed for all infants?
Introduction: Contrast enhanced radiography (CER) was the standard procedure for localizing PICC tip at our NICU.It was observed that despite doing multiple catheter readjustments and imaging, tip location was sub-optimal many a times, raising the question whether to use contrast routinely for all infants or not ?
Methods: The intention of this quality improvement project was to adopt the use of plain radiography (PR) as the first modality for PICC tip localization and use CER only if localization was unsuccessful in the first instance. The objective was to examine the effect this change of clinical practice on the a) number of radio-graphs taken for PICC insertions b) the frequency of intravenous contrast use in PICC insertion.
After education of all care providers who insert PICC, ,PR was adopted as the first modality for PICC tip visualization from June 1, 2019. We collected the information on infants who had PICC insertion in the NICU before and after the implementation of the initiative for a given period
Results: Of the 113 PICC inserted, 39 PICCs were inserted during routine CER period, and 74 PICCs were inserted during PR period. Catheter was visualized on first PR in 56/74 (75%) in the PR period. Overall, the CER was performed in 30/74 (40%), of which 18 were for non-visualization of tip on first PR and 11 for non-visualization after subsequent manipulation. There was no difference in the median (IQR) number of radio-graphs between CER period and PR period [2 (2-3) vs 2 (1-3), p =NS].
Conclusion: The use of plain radiography as the initial imaging modality is a safe alternative, without increasing radiation exposure and minimizes the use of intravenous contrast in neonates undergoing PICC insertions. In spite of being superior for tip visualization, CER does not reduce the number of X-rays taken for the same purpose.