Part 5 of the series: Neonatal Vascular Access: A Practical Guide to PICCs and Midlines
Introduction
Peripherally inserted central catheters (PICCs) and Midlines are essential tools in neonatal care, supporting the delivery of medications, parenteral nutrition, fluids and blood products when short peripheral cannulas are no longer appropriate.
While these devices offer numerous benefits, complications remain a recognised challenge. Catheter failure can result in treatment interruption, additional procedures, loss of valuable vascular access sites and increased stress for patients, families and clinical teams.
Importantly, many complications do not occur suddenly. They often develop gradually, with subtle warning signs appearing before significant clinical deterioration. For this reason, complication prevention should be considered a continuous process rather than a response to problems once they occur.
This article provides a practical guide to the most common complications associated with neonatal PICCs and Midlines, including risk factors, early warning signs and preventative strategies that can support safer vascular access practice.
A Practical Approach to Complication Prevention
Successful complication prevention begins with a simple principle:
The best complication is the one that never occurs.
Clinicians can reduce risk by focusing on:
- Appropriate device selection
- Careful vein assessment
- Optimal insertion technique
- Effective securement
- Routine maintenance
- Vigilant monitoring
- Timely removal when devices are no longer required
Risk Factors → Early Warning Signs → Prevention Strategies → Escalation Considerations
Complication 1: Catheter Occlusion
Why It Matters
Occlusion is one of the most common causes of catheter dysfunction and unplanned device removal in vascular access practice.
Occlusions may be:
- Partial
- Intermittent
- Complete
Reduced catheter function can delay therapy, increase manipulation of the device and ultimately necessitate replacement.
| Risk Factors | Early Warning Signs | Prevention Strategies | Escalate If |
| -Inadequate flushing practices -Blood reflux into the catheter -Medication residue -Prolonged interruption of infusions -Catheter malposition -Thrombotic complications | -Increased resistance during flushing -Sluggish infusion rates -Difficulty aspirating blood where previously possible -Recurrent infusion pump alarms -Intermittent device performance | -Assess catheter function during every access -Promptly investigate changes in flow -Minimise unnecessary line manipulation -Review catheter position if dysfunction develops | -Resistance increases significantly -The catheter becomes impossible to flush -Occlusion persists despite troubleshooting |
Follow local flushing protocols.
Complication 2: Catheter Migration
Why It Matters
Migration occurs when the catheter position changes after insertion.
Even relatively small changes in external catheter length may alter catheter tip location and affect device performance.
| Risk Factors | Early Warning Signs | Prevention Strategies | Escalate If |
| -Inadequate securement -Limb movement -Patient growth -Frequent repositioning -Dressing disruption | -Change in external catheter length -New infusion difficulties -Increased pump alarms -Unexpected dressing tension -Visible movement of the catheter | -Assess external catheter length daily -Standardise documentation -Maintain dressing integrity -Ensure securement devices remain intact -Investigate changes promptly | -Catheter length changes unexpectedly -Migration is suspected clinically -Device function deteriorates following positional change |
Complication 3: Accidental Dislodgement
Why It Matters
Accidental dislodgement remains a major cause of unplanned catheter removal within neonatal units.
Each unplanned removal may expose the infant to additional vascular access procedures and further vessel trauma.
| Risk Factors | Early Warning Signs | Prevention Strategies | Escalate If |
| -Poor securement -Loose dressings -Frequent handling -Transfer procedures -Unsecured tubing | -Lifting dressings -Loose stabilisation devices -Excessive catheter movement -External catheter length changes | -Regularly inspect securement systems -Minimise tension on extension tubing -Assess device stability during every care episode -Reinforce safe handling practices across the multidisciplinary team | -Significant movement is observed -Securement becomes compromised -Partial dislodgement is suspected |
Complication 4: Phlebitis
Why It Matters
Phlebitis refers to inflammation of the vessel wall and may occur with vascular access devices.
Although often mild initially, untreated phlebitis can compromise catheter function and patient comfort.
| Risk Factors | Early Warning Signs | Prevention Strategies | Escalate If |
| -Mechanical irritation -Repeated catheter movement -Poor catheter-to-vessel ratio -Certain medications and infusates | -Erythema Swelling -Localised warmth -Tenderness -Discomfort during infusion | -Select an appropriate vessel -Optimise catheter-to-vessel ratio -Maintain catheter stability -Monitor insertion sites routinely -Address migration promptly | -Symptoms worsen -Swelling increases -Catheter performance changes |
Complication 5: Infiltration and Extravasation
Why It Matters
Infiltration occurs when non-vesicant solutions enter surrounding tissue, while extravasation involves the leakage of vesicant or potentially harmful substances into tissue.
Although less common with well-functioning PICCs and Midlines, these complications can result in significant tissue injury.
| Risk Factors | Early Warning Signs | Prevention Strategies | Escalate If |
| -Catheter migration -Vessel injury -Mechanical damage -Inappropriate device function | -Swelling -Leakage -Skin blanching -Reduced infusion flow -Changes around the insertion site | -Assess the insertion site regularly -Investigate any unexpected swelling immediately -Confirm catheter function before infusions -Monitor high-risk therapies closely | -Extravasation is suspected -Rapid tissue swelling develops -Skin integrity begins to deteriorate |
Complication 6: Catheter-Associated Infection
Why It Matters
Catheter-associated infections remain among the most significant vascular access complications encountered in neonatal care. They have the potential to lead to a Catheter Related Blood Stream Infection (CRBSI) and in severe cases Sepsis.
Prevention requires attention throughout the catheter’s lifespan rather than focusing solely on insertion.
| Risk Factors | Early Warning Signs | Prevention Strategies | Escalate If |
| -Poor hand hygiene -Dressing disruption -Frequent catheter manipulation -Breaches in aseptic technique -Prolonged catheter dwell times | -Temperature instability -Unexplained clinical deterioration -Local redness -Drainage at the insertion site -Increased respiratory support needs Reduced feeding tolerance | -Adhere to hand hygiene protocols -Use Aseptic Non-Touch Technique (ANTT®) -Maintain dressing integrity -Minimise unnecessary access -Perform routine site assessment | -Infection is suspected -Systemic signs emerge -Local site changes worsen |
Complication 7: Thrombosis
Why It Matters
Thrombosis may affect both catheter performance and long-term vessel health.
Although some cases are asymptomatic, others may compromise vascular access and increase clinical complexity.
| Risk Factors | Early Warning Signs | Prevention Strategies | Escalate If |
| -Vessel trauma -Large catheter-to-vessel ratio -Catheter movement -Prolonged dwell time -Reduced blood flow around the catheter | -Unexplained catheter dysfunction -Limb swelling -Changes in catheter performance -Recurrent occlusion events | -Prioritise vessel assessment -Select appropriately sized catheters -Optimise securement -Monitor performance trends -Investigate recurrent dysfunction promptly | -Thrombosis is suspected -Limb swelling develops -Persistent performance issues occur |
Red Flags Requiring Immediate Escalation
The following findings should trigger urgent review according to local policy:
🔴 Rapid or unexplained swelling
🔴 Suspected extravasation
🔴 Significant catheter migration
🔴 Catheter-related infection concerns
🔴 Loss of catheter function
🔴 Catheter damage or rupture
🔴 Unexplained limb swelling
Clinical Scenario
Recognising a Developing Complication
A 30-week infant has a Midline that has been functioning well for seven days.
During a routine assessment:
- Infusions remain running.
- The dressing is intact.
- Mild resistance is noted during flushing.
- Two infusion pump alarms have occurred during the previous shift.
Although therapy continues successfully, these findings may represent early catheter dysfunction.
Recommended action: Further assessment should occur before complete occlusion develops. Waiting until the catheter becomes non-functional may result in avoidable device loss.
Key Practice Points
✅ Assess every catheter at every interaction.
✅ Monitor trends, not just individual observations.
✅ Investigate subtle changes early.
✅ Standardise escalation pathways.
✅ Protect vessel health through proactive intervention.
✅ Consider complications before they occur, not after.
✅ Treat every unplanned removal as a learning opportunity.
Conclusion
Complications associated with neonatal PICCs and Midlines cannot always be prevented, but many can be anticipated, recognised early and managed before they result in device failure.
A structured approach that combines careful assessment, routine monitoring, effective maintenance and prompt escalation can help preserve vascular access, minimise treatment interruption and improve patient outcomes. Ultimately, successful complication prevention is a key component of vessel preservation and should be embedded within every stage of the neonatal vascular access pathway.
Next Article:
Neonatal PICC and Midline Removal: When Is the Right Time?
Supporting Materials
- Sharpe EL, Wyckoff MM, Pettit J, et al. Peripherally Inserted Central Catheters: Guideline for Practice. 4th ed. Chicago (IL): National Association of Neonatal Nurses; 2024.
- Sharpe EL, Pettit J. NANN neonatal peripherally inserted central catheters: clinical practice update. Adv Neonatal Care. 2024;24(4):e95-e107.
- Infusion Nurses Society. Infusion Therapy Standards of Practice. 9th ed. Norwood (MA): Infusion Nurses Society; 2024.
- Chen JW. Neonatal Vascular Access: Pearls, Proficiency and Innovation in Practice. Academy of Neonatal Nursing Annual Conference; 2018.
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