The research, published in Nursing Open, followed 1,877 adults who received PICCs at a single comprehensive hospital between June 2022 and September 2023. Trained investigators assessed the skin around each catheter insertion site every week until the catheter was removed or six months had passed, whichever came first. The team defined CASI according to the Infusion Therapy Standards of Practice, which describe it as any abnormality such as erythema, vesicles, bullae, erosion or tearing observed in the area covered by the dressing or securement device for thirty minutes or longer after removal. Suspected lesions were photographed, coded and archived, and uncertain cases were jointly reviewed by the principal investigator and a dermatologist to reach a final diagnosis.

Overall, 156 patients, or 8.31 percent of the cohort, developed PICC-related CASI. The incidence was 8.86 percent in the development cohort of 1,309 patients and 7.04 percent in a temporal validation cohort of 568 patients enrolled later in the study period. Most injuries were mild, accounting for roughly 82 percent of cases in both groups, while moderate and severe injuries made up the remainder. The average catheter dwell time at the moment of injury was around 65 to 66 days, suggesting that the risk accumulates gradually over the weeks a catheter remains in place. These rates are lower than figures reported in earlier studies, which the authors attribute partly to their inclusion of both cancer and non-cancer patients and partly to the hospital’s specialist intravenous therapy team, which managed every catheter insertion and maintenance session with standardized procedures.

To build the prediction model, the researchers assembled 38 candidate predictors spanning six domains: demographic characteristics, disease-related information, nutritional status, treatment-related factors, catheter-insertion characteristics and catheter-maintenance practices. Rather than screening variables one by one, they entered all 38 candidates directly into a least absolute shrinkage and selection operator, or LASSO, logistic regression with ten-fold cross-validation. This machine-learning technique penalizes weak predictors, shrinking their coefficients toward zero and effectively discarding them, which helps guard against overfitting when the number of events is limited. The penalty parameter was chosen using the conservative one-standard-error criterion, yielding a parsimonious set of seven variables with non-zero coefficients.

Those seven candidates were then refitted in an ordinary multivariable logistic regression, and one of them, catheter diameter, was dropped because its rarest category contained only six participants and no injury events, producing unstable estimates. The final model settled on six predictors: a primary tumour diagnosis, a history of previous catheterization, use of iodophor disinfectant, use of a functional dressing, cytotoxic drug exposure and hormonal drug exposure. Three of these factors raised risk while two appeared protective. A history of catheterization was the strongest predictor, multiplying the odds of skin injury by just over five. Cytotoxic chemotherapy more than quadrupled the odds, and a cancer diagnosis nearly quadrupled them. Hormonal therapy, which included corticosteroids and sex hormones, roughly doubled the odds. In contrast, iodophor disinfectant reduced the odds by nearly 90 percent, and functional dressings such as thin foam or hydrocolloid materials reduced them by about 84 percent.

The biological logic behind these associations is plausible. Repeated catheter placements leave patients with fewer suitable veins and expose the skin to cycles of adhesive application and removal, which mechanically strips the protective barrier. Cytotoxic agents are notorious for causing erythema, dryness and blistering, and they can also weaken immunity and nutrition, compounding vulnerability. Corticosteroids thin the skin, impair collagen synthesis and delay repair. Cancer itself, along with radiotherapy and nutritional impairment, undermines skin integrity from multiple directions. On the protective side, povidone-iodine may spare the skin the irritant effects of alcohol-based chlorhexidine preparations, a pattern consistent with the CLEAN trial, which found more severe skin reactions with chlorhexidine-alcohol in patients with short-term central venous catheters. Foam and hydrocolloid dressings, meanwhile, manage local moisture, reduce friction and shear, and cushion fragile skin better than standard transparent polyurethane films.

Performance testing revealed a sobering story about transportability. In the development cohort, bootstrap internal validation with 1,000 resamples produced an optimism-corrected area under the receiver operating characteristic curve of 0.811, a level generally considered acceptable discrimination, and the calibration slope of 0.943 sat close to the ideal value of one. But when the model was applied unchanged to the temporal validation cohort of 568 later-enrolled patients, discrimination fell to 0.681. The calibration intercept of minus 0.668 and slope of 0.447 indicated systematic overprediction: the model tended to overestimate risk, particularly at the higher end of the predicted-probability range, where relatively few events supported the estimates. Decision-curve analysis suggested potential net benefit over treating everyone or no one, but only in parts of the threshold range and only convincingly in the development data.

The authors are candid about why performance degraded and what it means. Seasonal differences in recruitment, shifts in case mix, variation in treatment exposure and local antiseptic and dressing practices may all have contributed, since temperature and humidity are known to influence skin-barrier function and adhesive irritation. They also acknowledge methodological limitations: no formal sample-size calculation was performed before recruitment, the LASSO selection step was not repeated inside the bootstrap loop, and the subsequent unpenalized refit introduces additional selection uncertainty. The study was conducted at a single centre with convenience sampling, and several potentially relevant factors, including dressing-change frequency, product type, baseline skin condition and cumulative medication exposure, were not captured. For these reasons, the team classifies the tool as a development-stage model that requires recalibration and independent multicentre validation before any routine clinical use.

Even so, the findings offer nurses and clinicians a structured way of thinking about who needs the closest surveillance. Patients with cancer, previous catheterizations and intensive anticancer regimens emerge as the clear high-risk group, and the study highlights that two modifiable elements of catheter care, the choice of antiseptic and the choice of dressing, may meaningfully shift the odds. The authors suggest that povidone-iodine and functional dressings could be considered for patients at elevated risk of skin injury, while stressing that these observational associations need prospective confirmation before practice changes. Future work should define clinically meaningful risk thresholds, link them to specific preventive actions such as enhanced skin assessment or alternative antiseptic selection, and test whether embedding the model into nursing pathways actually reduces the burden of catheter-associated skin injury. Until then, the study stands as a careful, transparently reported reminder that the skin around a lifesaving catheter deserves the same vigilance as the device itself.

Subject of Research: Development and temporal validation of a clinical risk prediction model for PICC-related catheter-associated skin injury

Article Title: Development and Temporal Validation of a Prediction Model for PICC‐Related Catheter‐Associated Skin Injury

Article References: Development and Temporal Validation of a Prediction Model for PICC‐Related Catheter‐Associated Skin Injury. (n.d.). https://doi.org/10.1002/nop2.70895

Image Credits: AI Generated

DOI: 10.1002/nop2.70895

Keywords: PICC, catheter-associated skin injury, risk prediction model, LASSO regression, nursing, vascular access devices, chemotherapy, iodophor disinfectant, functional dressings, temporal validation, calibration, oncology

The recommendation comes from the Pediatric and Neonatal Vascular Access Special Interest Group of the ESPR, working alongside NEVAT, a European network dedicated to vascular access care. The author group, led by Matheus van Rens and Robin van der Lee of Radboudumc Amalia Children’s Hospital in Nijmegen, the Netherlands, includes neonatologists, nurses and vascular access experts from institutions across the Netherlands, Belgium, Italy, Austria, the United Kingdom, France, Portugal, Spain, Bulgaria and beyond, with international contributors such as Yogen Singh of the University of California Davis Children’s Hospital. Their stated goal is deceptively simple: ensure that the right vascular access device is chosen from the very start of therapy, rather than discovered through a process of trial and error at the patient’s bedside.

The clinical problem the VAMP addresses is well documented in the authors’ own prior work. In the ABBA project, short for Assess Better before Access, a retrospective cohort study of neonatal intravascular device outcomes published in Frontiers in Pediatrics in 2022, the group catalogued how frequently neonatal vascular access devices fail before therapy is complete. Peripheral intravenous catheters in newborns are notoriously short-lived, and repeated replacement attempts mean repeated needle sticks, repeated pain and repeated exposure to complications. Research cited by the group, including a 2023 study in the Journal of Vascular Access examining how catheter type and material affect therapy failure in neonates, underscores that even the physical properties of the device matter in this population, whose veins may be smaller than a millimeter in diameter.

The stakes extend beyond immediate mechanical failure. Neonatal sepsis, which can be triggered by catheter-associated bloodstream infections, has been linked in a 2024 systematic review and meta-analysis in BMC Pediatrics to adverse neurocognitive outcomes later in life. Pain experienced in the first days and weeks of life is likewise not a transient concern; a 2020 review in Frontiers in Pediatrics by Williams and Lascelles summarized clinical and experimental evidence that early neonatal pain can have lasting implications for painful conditions later in life. In other words, every unnecessary needle stick and every preventable catheter infection is not merely an acute event but a potential contributor to long-term developmental burden. This is why the VAMP authors frame vascular access decision-making as a neuroprotective issue, a theme they developed further in a 2025 patient-centered framework based on the 7-Rights concept published in Pediatric Research.

Technically, the VAMP functions as a structured, patient-centered decision pathway, presented by the authors as a flow diagram that guides clinicians through the assessment of an individual newborn’s veins, the expected duration and type of therapy, and the characteristics of available devices before any needle is inserted. The approach draws on a growing body of standardized pre-procedural assessment protocols. Among these is the Rapid Superficial Vein Assessment, or RaSuVa, described by D’Andrea and colleagues in 2024 as a systematic pre-procedural evaluation of superficial veins to optimize venous catheterization in neonates. Similar systematic ultrasound protocols exist for deeper vessels: the Rapid Central Vein Assessment, or RaCeVa, published by Spencer and Pittiruti in 2019, and the Rapid Femoral Vein Assessment, or RaFeVa, described by Brescia and colleagues in 2021, both of which standardize ultrasound evaluation before central catheterization. The VAMP embeds this assessment-first philosophy into routine neonatal practice.

The framework also builds on and harmonizes existing consensus documents rather than replacing them. The authors position VAMP alongside the neonatal DAV-expert algorithm, a GAVeCeLT/GAVePed consensus published in the European Journal of Pediatrics in 2023 for choosing the most appropriate venous access in newborns, and the ERPIUP consensus on the proper indication and use of peripheral venous access devices, a WoCoVA project published in the Journal of Vascular Access. Other reference points include the UK Vessel Health and Preservation framework updated in 2020, the miniMAGIC appropriateness guide for intravenous catheters in pediatrics published in Pediatrics in 2020, the Infusion Therapy Standards of Practice ninth edition from 2024, and the NANN neonatal peripherally inserted central catheter guideline for practice in its fourth edition. By synthesizing these sources into a single European recommendation, the ESPR group aims to reduce the fragmentation that currently produces wide variation in practice between units and countries.

Insertion technique and device maintenance form a second pillar of the plan. The recommendation references novel insertion bundles developed by Italian collaborators, including the SIUVeC protocol for safe insertion of umbilical venous catheters and the SIECC protocol for epicutaneo-cava catheters, both designed to minimize placement and management complications, as well as the SIC seven-step strategy for centrally inserted central catheters. Once a device is in place, the plan emphasizes evidence-based securement and site care, drawing on trials of cyanoacrylate glue as part of bundles to decrease neonatal PICC-related complications and to secure umbilical venous catheters, and on experience with dialkylcarbamoylchloride dressings at catheter exit sites in pediatric and neonatal populations. Care bundles of this kind have already been shown in a 2018 systematic review and meta-analysis in Archives of Disease in Childhood to reduce central line-associated bloodstream infections in neonatal units, and the SHEA NICU white paper series from 2023 offers practical approaches to the same goal.

Two technological themes run through the recommendation with particular force. The first is point-of-care ultrasound, which the authors describe as central to modern neonatal vascular access, from pre-procedural vein mapping to real-time guidance during insertion. A 2024 review in the European Journal of Pediatrics by Pittiruti, Annetta and D’Andrea summarized the role of ultrasound for vascular access in neonates and children, and a 2023 systematic review and meta-analysis in Diagnostics examined the role of ultrasound specifically in epicutaneo-caval catheter insertion. A related narrative review from 2025 weighs intracavitary electrocardiography against real-time ultrasound for tip navigation and tip location of central venous access devices in the neonate, a question also addressed in a 2025 Italian expert consensus on tip location methods. The second theme is standardization itself: the VAMP’s authors contend that a uniform, reproducible method, applied by every clinician on every shift, is what converts scattered best practices into reliable outcomes.

Notably, the recommendation also extends beyond the technical to the human. The framework incorporates family-centered principles, citing recent work on family integrated care in Acta Paediatrica, a 2024 study in Advances in Neonatal Care on family management skills reported by parents of preterm infants, and a 2025 nonrandomized clinical trial in JAMA Network Open on outcomes following close collaboration with parents interventions in neonatal intensive care units. Pain assessment and management in preterm infants, summarized in a 2022 practice update in Children, are likewise woven into the plan, reflecting the view that vascular access decisions should minimize discomfort as well as complications. The involvement of the European Foundation for the Care of Newborn Infants and the Global Foundation for the Care of Newborn Infants, acknowledged by the authors for contributions and critical readings of earlier drafts, signals that parent perspectives were part of the drafting process itself.

The authors state that proper use of the VAMP ensures choosing the right vascular access device from the start of therapy, that the method offers a structured and patient-centered approach, that its implementation ensures more uniform practice regarding vascular access in neonates, and that it has the potential to greatly decrease the number of vascular access-related complications in this population. As the first in what the group describes as a ten-recommendation project, VAMP represents the opening move of a coordinated European effort to professionalize neonatal vascular access in the way that adult vascular access care has been professionalized over the past two decades. If the framework achieves its stated aims, the routine insertion of a cannula in a premature newborn could shift from an improvised procedure, repeated until something works, into a planned, ultrasound-informed, family-aware intervention with fewer sticks, fewer infections and fewer of the long-term consequences that follow them. For the smallest patients in intensive care, that shift could matter for a lifetime.

Subject of Research: A structured European recommendation for vascular access device selection and management in neonatal intensive care

Article Title: Vascular access management plan (VAMP): neonatal European vascular access team—ESPR Recommendation 1

Article References: van Rens, M., Hugill, K., Piersigilli, F., Schwaberger, B., Mader, S., Geiger, I., Singh, Y., Ouwehand, T., van den Hoogen, A., Van Eenoo, S., van der Lee, R., on behalf of the Pediatric and Neonatal Vascular Access Special Interest Group (SIG) of the ESPR and NEVAT, van Rens, M., Van Der Lee, R., van den Hoogen, A., Rodriguez-Perez, C., Barone, G., van Eenoo, S., Hugill, K., … Tuna, M. L. (2026). Vascular access management plan (VAMP): neonatal European vascular access team—ESPR Recommendation 1. Pediatric Research. https://doi.org/10.1038/s41390-026-05467-6

Image Credits: AI Generated

DOI: 10.1038/s41390-026-05467-6

Keywords: neonatology, vascular access, VAMP, ESPR, central venous catheters, PICC, ultrasound, neonatal sepsis, care bundles, point-of-care ultrasound, umbilical venous catheter, family integrated care

The research, conducted at Adana City Training and Research Hospital and published in BMC Pediatrics, analyzed 58 preterm infants who underwent a total of 63 catheterization episodes. The cohort was extraordinarily premature, with a median gestational age of 27 weeks and a median birth weight of just 900 grams. These are babies whose skin is translucent, whose lungs are still maturing, and whose veins are fragile enough that every invasive procedure carries disproportionate risk. For this population, the authors argue, the question of catheter tip location is not a technical nicety but a matter of immediate clinical safety, because a malpositioned catheter can cause vessel perforation, cardiac arrhythmia, pleural effusion, or the inadvertent infusion of hypertonic solutions into surrounding tissue.

The technique the team evaluated is conceptually simple. Instead of relying on a plain radiograph, in which the radiopaque catheter may be indistinguishable from overlapping bones and soft tissues, clinicians instill a small bolus of iohexol—a non-ionic, low-osmolar iodinated contrast agent available at concentrations of 300 or 350 milligrams of iodine per milliliter—directly through the catheter lumen. The contrast fills the catheter and briefly opacifies its full course, so the subsequent X-ray captures not just a faint line but a sharply defined trajectory from the insertion site all the way to the tip. The authors describe a characteristic radiographic appearance they call the butterfly sign, produced when adequate opacification of the catheter creates a winged pattern at the point where the device enters the vessel. When radiographs showed superposition of structures or the absence of this butterfly sign, the team considered the image suboptimal and repeated the procedure with additional contrast.

Defining success required an anatomical standard. For catheters inserted through the upper extremities, the target tip position was set between the second and fifth thoracic vertebral levels, corresponding to the lower superior vena cava or the cavoatrial junction. For lower extremity insertions, the acceptable range was between the ninth and tenth thoracic vertebral levels, where the catheter tip should rest within the inferior vena cava. These landmarks matter because the ideal tip location balances two competing hazards: a tip that is too peripheral increases the risk of phlebitis and thrombosis, while a tip that advances too far toward or into the heart can provoke arrhythmias or cardiac perforation. In adults, tip verification is routine; in infants weighing under a kilogram, the margin of error shrinks to a few millimeters, and the bony landmarks themselves are tiny and difficult to interpret.

The results revealed how far current practice falls short of that ideal. Only 20 percent of the catheters in the study were positioned at the predefined target level on initial placement. In other words, four out of five catheters required some form of correction or repositioning before they could be considered safely located. This striking figure underscores the central argument of the paper: without a reliable visualization method, clinicians may be unknowingly operating with malpositioned devices, and the true rate of malposition in ultrathin PICCs has likely been underestimated simply because plain radiography could not detect it. Contrast-enhanced imaging, by making the catheter’s path explicit, converts a guess into a measurement.

Efficiency of the technique also emerged as a key finding. Across the 63 catheterization episodes, the team performed 71 contrast administrations in total, meaning that a single dose was sufficient in 84 percent of cases. The remaining episodes required a second administration, typically because the initial radiograph failed to demonstrate adequate opacification or because the butterfly sign was absent. For a population in which every handling event carries stress, heat loss, and infection risk, the ability to confirm tip position with one dose and one image represents a meaningful advantage over repeated plain films or blind repositioning attempts.

Safety was, understandably, the most scrutinized dimension of the study. Iodinated contrast agents are well tolerated in adults, but preterm infants have immature renal function, small circulating blood volumes, and a thyroid gland that avidly takes up iodine, raising theoretical concerns about contrast-induced nephropathy and iodine-induced thyroid dysfunction. The researchers therefore monitored serum creatinine at three time points—baseline, 48 to 72 hours after contrast administration, and again at 3 to 7 days—and evaluated kidney injury using the KDIGO classification. Among the 45 catheterization episodes that could be fully evaluated for renal outcomes, stage 1 acute kidney injury occurred in five cases, an incidence of 11.1 percent. Importantly, the authors report no allergic reactions, no catheter occlusions attributable to the contrast, and no clinically significant contrast-related thyroid dysfunction during the observation period.

It is worth interpreting the renal findings with appropriate caution, as the authors themselves do. Stage 1 acute kidney injury is common in extremely preterm infants for many reasons unrelated to contrast exposure, including hypotension, respiratory distress syndrome, patent ductus arteriosus, necrotizing enterocolitis, and exposure to nephrotoxic medications. Without a matched control group of infants who received ultrathin PICCs without contrast, the 11.1 percent figure cannot be attributed to iohexol itself. The study’s retrospective, single-center design limits causal inference, and the authors are explicit that no evident short-term safety signal emerged in this cohort rather than claiming definitive safety. Larger, ideally prospective, comparative studies would be needed to quantify any true renal or thyroid risk attributable to the procedure.

Even with those caveats, the clinical implications are substantial. Ultrathin 1 French PICCs have become increasingly popular in neonatology precisely because they suit the smallest veins of micro-preemies, allowing parenteral nutrition and long-term intravenous therapy without the complications of repeated peripheral cannulation. But their adoption has outpaced the availability of reliable verification methods, and many units still rely on plain radiographs that may simply fail to show the device. The contrast-enhanced protocol described in this study offers a low-cost, widely accessible alternative that requires no special equipment beyond the contrast agent and standard radiography already present in any neonatal intensive care unit. The butterfly sign, in particular, gives clinicians a simple visual quality check: if the sign is absent, the image is not trustworthy, and the study should be repeated rather than acted upon.

The broader lesson of the study extends beyond one catheter type or one hospital. In modern medicine, devices are often miniaturized faster than the diagnostic tools needed to monitor them, and the gap is filled by improvisation. This research demonstrates that a deliberate, protocolized approach—defining anatomical targets, standardizing contrast doses, setting explicit criteria for image adequacy, and prospectively tracking renal function—can close that gap even in the most fragile patients. For the 900-gram infant whose catheter tip sits a few millimeters from the heart, the difference between an invisible line on an X-ray and a clearly opacified trajectory may be the difference between uneventful therapy and a catastrophic complication. As neonatal intensive care continues to push the boundaries of viability at ever lower gestational ages, techniques like contrast-enhanced radiography remind us that sometimes the most impactful innovations are not new devices at all, but better ways of seeing the ones already in place.

Subject of Research: Contrast-enhanced radiography for localizing ultrathin PICC tips in preterm infants

Article Title: Contrast-enhanced radiography for localization of ultrathin (1 F) PICCs in preterm infants: a retrospective observational study

Article References: Çeki̇nmez, E. K., Gülaşı, S., Demi̇r, O., Coşkun, H., & Bulut, H. Ç. (2026). Contrast-enhanced radiography for localization of ultrathin (1 F) PICCs in preterm infants: a retrospective observational study. BMC Pediatrics. https://doi.org/10.1186/s12887-026-07573-0

Image Credits: AI Generated

DOI: 10.1186/s12887-026-07573-0

Keywords: preterm infants, PICC, contrast-enhanced radiography, iohexol, catheter malposition, neonatology, NICU, acute kidney injury, butterfly sign, radiography, very low birth weight, catheter tip localization

The review, led by Rajendra Prasad Anne of Kasturba Medical College at Manipal Academy of Higher Education in India, together with colleagues from the United Arab Emirates and India, set out to answer a deceptively simple question: when a newborn needs central venous access on the first day of life, which device is safer? The team searched PubMed, Embase, Web of Science and the Cochrane Central Register of Controlled Trials up to November 2025, capturing both randomised controlled trials and non-randomised studies of interventions. Their primary endpoints were the outcomes that matter most at the bedside: central line-associated bloodstream infection, known as CLABSI, mortality, late-onset sepsis and catheter-related complications such as thrombosis, occlusion, bleeding and tip malposition.

After screening the literature, the researchers pooled seven studies, five randomised trials and two non-randomised studies, encompassing 1,522 neonates. That may sound modest against the scale of neonatal medicine, but in a field where individual trials are small and fragmented, a meta-analysis of this kind carries real weight. The reviewers applied the GRADE framework to rate the certainty of the evidence and used random-effects models to combine results, acknowledging from the outset that the underlying studies differed in populations, protocols and catheter-management practices.

The headline finding is, in one sense, a null result. When the randomised trials were pooled, there was no statistically significant difference between PICCs and UVCs in the risk of central line-associated bloodstream infection. The pooled risk ratio was 0.75, with a 95 percent confidence interval of 0.50 to 1.11, a range that crosses the threshold of no effect. Mortality told a similar story, with a risk ratio of 1.05 and a confidence interval of 0.58 to 1.90. In plain terms, the evidence does not demonstrate that choosing a PICC over an umbilical line in the first day of life reduces bloodstream infections or saves lives, a conclusion that challenges the intuition of teams who have favoured PICCs on infection-prevention grounds.

Beneath that null result, however, the analysis surfaced signals that neonatologists will not be able to ignore. Babies who received PICCs showed a trend toward higher rates of late-onset sepsis, with a risk ratio of 1.36 and a confidence interval of 0.97 to 1.91, hovering just at the edge of statistical significance. Hospital stays also tended to be longer in the PICC groups, by a mean difference of 3.2 days, though the confidence interval of minus 0.2 to 6.6 days included the possibility of no difference. Neither finding is definitive on its own, but both point in the same direction, and both carry clinical consequences if they are real.

The mechanical performance of the two devices diverged more sharply. PICCs were significantly less likely to become malpositioned, meaning their tips wandered from the intended central position less often than umbilical catheters, with a risk ratio of 0.65 and a confidence interval of 0.49 to 0.86. Yet the same fine-bore lines paid a price elsewhere: they were nearly three times as likely to occlude, with a risk ratio of 2.84 and a confidence interval of 1.23 to 6.57. Anyone who has watched a nurse struggle to flush a clotted neonatal PICC will recognise the practical reality behind that number. The review also found that PICC insertion took significantly longer than umbilical catheterisation, a meaningful consideration in the delivery room, where minutes can matter and where the umbilical vein offers an immediate, anatomically obvious route.

One of the most intellectually honest parts of the analysis concerns catheter dwell time. The reviewers noted that PICCs tended to remain in place longer than umbilical catheters in the included studies, and they flagged this as an important unresolved confounder. The logic is straightforward: the longer any central line stays in the body, the greater the cumulative opportunity for microorganisms to colonise it and for bloodstream infection to develop. If PICCs dwell longer, any apparent excess of late-onset sepsis could partly reflect exposure time rather than intrinsic device risk, and conversely, the absence of an infection advantage for PICCs becomes even more striking given their longer residence. Disentangling device effects from dwell-time effects will require trials that standardise catheter duration, something the existing literature has not done.

Why does this matter beyond the neonatal unit? Central line-associated bloodstream infections are among the most feared complications in intensive care, driving antibiotic use, prolonging hospitalisation and, in vulnerable preterm infants whose immune systems are immature, contributing to mortality and long-term neurodevelopmental harm. Late-onset sepsis, which typically strikes after the first seventy-two hours of life, is a leading cause of death and disability in very low birth weight infants. If the choice of access device on day one influences these outcomes, then a simple procedural decision could ripple through an entire lifetime. Conversely, if the devices are truly equivalent on infection outcomes, units can base their choices on other grounds: insertion speed, malposition risk, occlusion rates, staff training and the anticipated duration of therapy.

The practical implications cut in different directions. For teams that need immediate central access at resuscitation, the umbilical venous catheter remains the fastest and most familiar option, and the new analysis gives no reason to abandon it. For infants expected to need weeks of parenteral nutrition or prolonged antibiotic courses, the PICC’s lower malposition rate and longer usable lifespan may still justify its placement, provided teams are prepared for occlusions and for the longer insertion procedure. What the review does not support is the assumption that switching early from an umbilical line to a PICC will, by itself, lower infection rates. The authors conclude plainly that current evidence does not demonstrate a reduction in CLABSI, mortality or late-onset sepsis when neonatal PICCs are used instead of UVCs for early central venous access.

Like all meta-analyses, this one inherits the limitations of its ingredients. Seven studies and roughly fifteen hundred infants is a small evidence base for a question of this importance, and the two non-randomised studies included are inherently vulnerable to selection bias, since clinicians may choose one device over the other based on how sick a baby appears. The GRADE assessment reflects that uncertainty. Still, the work exemplifies a quiet revolution in neonatology: the systematic aggregation of small trials to extract answers that no single centre could deliver alone. The review was registered prospectively on PROSPERO under number CRD42024604746 and received no external funding, and the authors declare no competing interests. For the parents of the roughly 1,500 infants whose data underpin this analysis, and for the millions more who will pass through neonatal units, the message is a call for better trials, not a final answer. Until those arrive, the humble umbilical catheter, inserted in the first minutes of life, remains a formidable and entirely defensible first choice.

Subject of Research: Comparative safety of peripherally inserted central catheters versus umbilical venous catheters for central venous access in newborns

Article Title: Peripherally inserted central catheter versus umbilical venous catheter for central venous access in neonates on the first day of life: a systematic review and meta-analysis of central line-associated bloodstream infections and clinical outcomes

Article References: Anne, R. P., Vardhelli, V., RD, R., & Murki, S. (2026). Peripherally inserted central catheter versus umbilical venous catheter for central venous access in neonates on the first day of life: a systematic review and meta-analysis of central line-associated bloodstream infections and clinical outcomes. BMC Pediatrics. https://doi.org/10.1186/s12887-026-07761-y

Image Credits: AI Generated

DOI: 10.1186/s12887-026-07761-y

Keywords: neonatology, central venous access, PICC, umbilical venous catheter, CLABSI, late-onset sepsis, meta-analysis, systematic review, premature infants, catheter complications, neonatal intensive care, bloodstream infection

The research team, led by Yuanyuan Song of the Key Laboratory of Cardiovascular Nursing in Zhengzhou and Qiaofang Yang of Fuwai Central China Cardiovascular Hospital, surveyed hospitals across all 31 provinces, autonomous regions, and municipalities of mainland China in November 2023. In total, 1,945 hospitals participated, each answering an institutional questionnaire completed by a nursing administrator or an intravenous therapy lead. Because the survey captured anonymized, hospital-level data rather than individual patient records, the Ethics Committee of Beijing Hospital waived the requirement for individual informed consent, and participation was entirely voluntary. The scale of the effort is what sets it apart: few studies anywhere in the world have examined intravenous therapy organization across an entire national health system, spanning everything from small community hospitals to massive tertiary centers.

The headline result is striking. Of the 1,945 hospitals surveyed, 1,689, or 86.8 percent, reported having an established intravenous therapy team. These teams are typically composed of nurses with specialized training in vascular access who take responsibility for difficult catheter insertions, maintenance protocols, complication surveillance, and staff education. The idea behind them is straightforward: concentrating expertise in a dedicated group should reduce practice variation, standardize care, and ultimately protect patients from the complications that arise when intravenous procedures are performed inconsistently by general staff with widely differing levels of experience.

To measure technology adoption, the researchers constructed an eleven-item score covering the range of vascular-access devices and supportive technologies a hospital had available, and the mean score across all hospitals was 6.1 with a standard deviation of 2.2. To capture quality management, they defined a demanding composite outcome called full measured quality implementation, which required a hospital to perform regular quality inspections, carry out systematic data collection and analysis, and maintain a functioning complication-reporting system. Only 73.6 percent of hospitals, 1,431 in total, met all three criteria simultaneously, which underscores that even in a health system with a strong tradition of nursing quality initiatives, the complete quality-management package is far from universal.

The statistical analysis was designed to be conservative. Using multivariable ordinary least squares regression with HC3 robust standard errors for the technology score and logistic regression for the quality outcome, and restricting both models to a common complete-case sample of 1,943 hospitals, the team adjusted for hospital characteristics that might otherwise explain the apparent associations. Even after these adjustments, hospitals with an intravenous therapy team scored substantially higher on technology adoption, with a beta coefficient of 1.57 points on the eleven-item scale, a difference that is large relative to the observed mean. The 95 percent confidence interval ran from 1.29 to 1.85, and the p value was below 0.001, indicating that a result this extreme would be extremely unlikely if the true association were zero.

The quality-management association was even more dramatic. Hospitals with a dedicated intravenous therapy team had roughly four and a half times the odds of achieving full measured quality implementation compared with hospitals without one, with an odds ratio of 4.46 and a confidence interval of 3.29 to 6.06. Perhaps most tellingly, team establishment was associated with more than a sevenfold increase in the odds that a hospital had formal intravenous therapy quality evaluation standards in place, with an odds ratio of 7.16 and a confidence interval spanning 5.01 to 10.23. Formal standards are the backbone of safe vascular access practice, because they translate national guidelines into concrete local protocols covering device selection, insertion technique, dressing changes, and removal criteria.

Why should an organizational structure be so tightly linked to technology and quality metrics? The authors frame intravenous therapy teams as an organizational marker and a potential target for strengthening quality management, and the mechanistic logic is plausible on several levels. A specialized team creates a critical mass of practitioners who understand new devices well enough to advocate for acquiring them, from ultrasound-guided peripheral insertion to midline catheters and advanced securement products. Concentrated expertise also lowers the threshold for adopting technologies safely, since a device that would be risky in untrained hands becomes routine for a team that inserts hundreds of catheters a year. On the quality side, a standing team provides a natural institutional home for inspections, data systems, and complication reporting, all of which require someone with both authority and technical knowledge to maintain them.

The study’s methods deserve attention because they reflect growing sophistication in observational health-services research. The use of HC3 robust standard errors, a technique that guards against inflated statistical confidence when residual variance is heterogeneous, suggests the authors were careful about uncertainty in a dataset this large and diverse. The supplementary analyses, which include province-level coverage checks, unadjusted comparisons, domain-level technology breakdowns, organizational-resource sensitivity analyses, and sensitivity analyses around the quality-implementation thresholds, indicate that the team stress-tested its findings rather than relying on a single model specification. Reporting followed the STROBE guidelines for cross-sectional studies, and the work was funded by the Henan Medical Science and Technology Research Program Joint Construction Project, with the funder having no role in the design, analysis, or manuscript.

Still, the authors are appropriately cautious about causality. This was a cross-sectional survey, a snapshot taken at a single point in time, which means it can establish association but not temporal direction. It is possible that hospitals already committed to quality improvement are simply more likely to create intravenous therapy teams, rather than teams driving the improvement. Hospitals with teams may also differ in resources, scale, or leadership culture in ways the adjusted models could not fully capture. The researchers explicitly call for longitudinal and implementation studies to determine whether establishing teams actually precedes gains in technology adoption and quality processes, and whether these organizational changes translate into measurable differences in patient outcomes such as bloodstream infections, catheter-related thrombosis, and device dwell times.

For health systems far beyond China, the message is nonetheless compelling. Vascular access is a high-volume, high-risk activity where small improvements in organization can scale into enormous reductions in harm, and dedicated intravenous therapy teams appear to be a low-cost structural intervention associated with both modernized practice and more complete quality infrastructure. With nearly 87 percent of Chinese hospitals already adopting the model, the question facing administrators elsewhere is less whether such teams can work and more how to replicate the conditions under which they do. If future longitudinal research confirms that team establishment drives the improvements seen here, this quiet organizational reform could become one of the most cost-effective patient-safety strategies available to hospitals worldwide.

Subject of Research: Association of hospital intravenous therapy teams with technology adoption and quality management in China

Article Title: Intravenous therapy teams and their association with technology adoption and quality management: a national cross-sectional study of 1,945 hospitals in China

Article References: Song, Y., Dong, F., Jia, X., Wang, Y., Wang, L., Li, C., Yang, Q., & Liu, H. (2026). Intravenous therapy teams and their association with technology adoption and quality management: a national cross-sectional study of 1,945 hospitals in China. BMC Nursing. https://doi.org/10.1186/s12912-026-05411-3

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05411-3

Keywords: intravenous therapy, vascular access, nursing teams, quality management, technology adoption, cross-sectional study, China, patient safety, hospital management, PICC, central venous catheter, health services research