title: Changes in upper extremity position cause migration of peripherally inserted central catheters in neonates.
abstract: OBJECTIVE
  The migration of peripherally inserted central catheters (PICCs) from the superior or inferior vena cava into the right atrium can pose a significant risk of lethal pericardial effusion and tamponade secondary to myocardial perforation. Arm movement has been reported to cause displacement of the catheter tip toward the heart and lead to ventricular tachycardia in adults. The objective of this study was to investigate whether adduction or abduction at the shoulder and flexion or extension at the elbow affect the position of PICCs placed via upper limb veins. We also hypothesized that arm movements can be used to reposition malpositioned catheters.
  
  
  METHODS
  A total of 280 radiographs of 60 neonates with PICCs inserted via upper limb veins from July 2000 through June 2001 were reviewed. Differences in catheter tip position as a result of abduction versus adduction at the shoulder, flexion versus extension at the elbow, and combination changes in arm posture were determined by measurements in paired radiographs. Correction of malpositioned catheters was attempted in 10 patients by using arm movements without any alterations at the site of insertion.
  
  
  RESULTS
  Arm movements were associated with significant displacement of catheters. Catheters that were placed via the basilic or axillary vein migrated toward the heart with adduction of the arm, whereas those that were placed via the cephalic vein moved away from the heart with adduction. Flexion of the elbow displaced catheters that were placed in the basilic or cephalic vein below the elbow toward the heart but did not have any effect on catheters that were placed via the axillary vein. For catheters that were placed in the basilic vein, simultaneous shoulder adduction and elbow flexion caused the greatest movement toward the heart (15.11 +/- 1.22 mm). We were able to reposition correctly inappropriately placed catheters in 9 of 10 patients by using arm movements.
  
  
  CONCLUSIONS
  Arm movements significantly affect the position of the tip of the PICCs. Prevention of catheter migration into the right atrium requires radiographic determination of vein of insertion and monitoring of catheter tip position with upper extremity in position of maximum inward movement of catheter for that vein. Arm movements can be used to correct the malpositioned catheters.
authors.affiliation: Department of Pediatrics, Division of Newborn Medicine, Mount Sinai School of Medicine, New York, New York 10029, USA. anadroo@yahoo.com
authors.forename: Ali M
authors.initials: AM
authors.lastname: Nadroo
authors.forename: Ronald B
authors.initials: RB
authors.lastname: Glass
authors.forename: Jing
authors.initials: J
authors.lastname: Lin
authors.forename: Robert S
authors.initials: RS
authors.lastname: Green
authors.forename: Ian R
authors.initials: IR
authors.lastname: Holzman
mesh_terms: D001132:Arm / Q000098:blood supply / Q000000981:diagnostic imaging / Q000502:physiology*; D002405:Catheterization, Central Venous / Q000009:adverse effects*; D004551:Elbow Joint / Q000502:physiology; D005548:Foreign-Body Migration / Q000150:complications / Q000000981:diagnostic imaging / Q000209:etiology*; D006335:Heart Injuries / Q000209:etiology / Q000517:prevention & control; D006801:Humans; D007231:Infant, Newborn; D009068:Movement / Q000502:physiology*; D010690:Phlebography / Q000706:statistics & numerical data; D011187:Posture / Q000502:physiology*; D012785:Shoulder Joint / Q000502:physiology