1. Introduction
Massive pleural effusion is a rare but life-threatening condition
in newborns, often requiring the insertion of a chest
tube for pleural drainage, sometimes as an emergency
procedure [1]. One of the most frequent complications of
such a procedure is the early dislodgment of the tube due to
failure of the methods commonly used for securement
(adhesive skin systems/surgical stitches), resulting in an
ineffective drainage of the pleural cavity and thus worsening
of the patient’s clinical conditions, requiring the placement
of a novel chest tube. Every new placement of a chest tube is
obviously associated with additional and potential risks for
the patient, both inherent to the procedure itself and related
to sedation.
2. Case Reports
We report the clinical cases of three neonates, all of them
premature, requiring the placement of a chest tube for
drainage of idiopathic congenital pleural effusion. In all three patients,
chest tubes were secured using a new subcutaneously
anchored sutureless device (SAS) (SecurAcath,
Interrad).
2.1. Case 1. The first case was a male neonate born by urgent
caesarean section (gestational age 32.2 weeks). The pregnancy
had been complicated by polyamnios and massive
bilateral hydrothorax of the fetus: the left pleural cavity had
been drained by the gynecologists while the baby was still in
the mother’s womb. The weight at birth was 1970 g. The
Apgar score was 1 in the first minute. Soon after birth, a right
pleural effusion was evident at x-ray and ultrasound scan;
70 ml of pleural citrine liquid was drained from the right
pleural space via a 21G intravenous cannula inserted into the
second rib space at the midclavicular line. Because of severe
respiratory distress, the patient was transferred to our
Neonatal Intensive Care Unit (NICU); after that, tracheal
intubation and mechanical ventilation with 100% oxygen
was started. A chest X-ray showed a tension pneumothorax
with almost complete atelectasis of the right lung and a left
shift of the mediastinum, with compression of the left lung.

Figure 1: (a) Case 1: 8Fr pigtail catheter secured by SAS; the exit site is sealed with cyanoacrylate glue; a small piece of gauze is placed under
the SAS device; the whole area is covered with transparent semipermeable membrane. (b) Case 2: same securement as in (a). (c) Case 3: 8Fr
trocar catheter secured by SAS; the exit site is sealed with cyanoacrylate glue and covered with transparent membrane

Therefore, few hours after birth, an 8Fr pigtail catheter (Safe-
T-Centesis Drainage System, BD) was placed into the right
pleural cavity and secured with sterile strips (Steri-Strips,
3M): the mediastinum shifted back to its median line, with
full expansion of the left lung. That same day, because of a
massive pleural effusion, another pigtail catheter was also
placed on the left side and secured with sterile strips; after
only 36 hours, it was accidentally dislodged. On day 5, the
right-side chest tube was still in place, but there was copious
leakage from the insertion site; suspecting a misplacement, it
was secured with surgical stitches; though, on day 7, we had
to remove it because of malfunction.
Two days later, on day 9, ultrasound scan showed a
massive bilateral pleural effusion, so that 8Fr pigtail catheters
were inserted again on both sides and secured with sterile
strips. On day 21, the left-side catheter was completely
dislodged; the right-side catheter was progressively dislodged
in the following days, so that on day 23 half of the
length of the catheter was out of the thorax. In order to avoid
complete dislodgement, we decided to remove the sterile
strips and anchor the catheter with an 8Fr SAS; the exit site
of the catheter was sealed with sterile cyanoacrylate glue and
covered with transparent semipermeable dressing
(Figure 1(a)). The device was well tolerated; no sign of
discomfort and/or pain was detected, and no manifestation
of skin irritation or inflammation was noticed.The right-side
chest tube stayed in place, well-functioning for ten days, and
was eventually removed on day 33, since pleural drainage
was not necessary any longer. After appropriate medical
treatment (parenteral nutrition, milk formula enriched with
medium chain triglycerides, intravenous infusion of octreotide,
and a somatostatin analog), the patient was
eventually discharged on day 72 in good general condition
with regular weight increase, feeding on mother’s milk.
2.2. Case 2. This female neonate was born at 34.2 weeks of
gestational age by urgent caesarean section, due to complicated
biamniotic-bicorial twin pregnancy with ascites
effusion detected by intrauterine ultrasound scan at week 33.
Before the delivery, a fetal thoracentesis had been performed
on the left hemithorax. The weight at birth was 2,330 g. The
Apgar score was 6 on the first minute of life. In the delivery
room, 20 ml of citrine fluid was drained from the left
hemithorax inserting directly a 21G butterfly needle under
ultrasound guidance, using a wireless linear probe (Linear
L14BG ATL), Immediately after birth, the
baby was intubated and admitted to our NICU on mechanical
ventilation. An ultrasound scan revealed a hydrothorax
also on the right side (that same side that had been
drained while inside the womb): an 8Fr pigtail catheter was
placed for pleural drainage under ultrasound guidance using
the wireless linear probe and anchored with an 8Fr SAS. The
exit site was sealed with sterile cyanoacrylate glue and
covered with transparent semipermeable dressing
(Figure 1(b)). On day 33, because of failure of medical
treatment (total parenteral nutrition and intravenous infusion
of octreotide), a thoracoscopy was performed so to
ligate the thoracic duct. During the procedure, the 8Fr
catheter, which had stayed in place anchored with the SAS
for 32 days without complications, was removed and
replaced with a 10Fr tube (Trocar Thoracic Catheter, Redax)
that was secured by surgical stitches. Due to the worsening of
the baby’s condition, a CT scan revealed an abundant
persistent pouch of pleural fluid on the right side, causing
the dislocation of the mediastinum and compression of the
right inferior lung lobe. On day 37, a new 8Fr pigtail catheter
was placed to drain the major anteroposterior pouch of fluid,
secured with sterile strips, and covered with transparent
semipermeable dressing. On day 38, a pleurodesis was
performed on the right side, by introducing 4% iodinepovidone
through the chest tube. This had a positive effect,
so that on day 45 both thoracic catheters were removed. The
patient’s conditions improved, and the patient was eventually
discharged on day 76.
2.3. Case 3. The third case was a male neonate born by
urgent caesarean section (gestational age 32 weeks) with a
prenatal history of polyamnios and fetal massive bilateral
hydrothorax. Two thoracenteses had been performed in
uterus; chylothorax diagnosis had been confirmed by the
analysis of the pleural fluid. At delivery, because of persistent
respiratory distress, the child was intubated and transferred
to our Neonatal Intensive Care Unit. The Apgar score at 1
and 5 minutes was 7–9 and the birth weight was 1970 g. An
ultrasound scan showed a massive pleural effusion in the left
pleural space. A 21G intravenous cannula was inserted into
the fifth rib space just behind the anterior axillary line, and
110 ml of citrine fluid was drained, with immediate clinical
improvement. Afterward, chest ultrasound was daily
performed to verify the magnitude of the effusion. At day 15,
a relevant pleural effusion was detected in the left pleural
space. At day 17, the clinical conditions worsened, and an
8Fr catheter (Trocar) was placed into the pleural space under
ultrasound guidance, anchored with an 8Fr SAS; the exit site
of the catheter was sealed with sterile cyanoacrylate glue and
covered with transparent semipermeable dressing
(Figure 1(c)). This chest tube remained in place for 12 days,
always well-functioning. It was removed on day 29. Chylothorax
was progressively reduced by medical treatment
(octreotide and medium chain triglycerides formula). The
infant was eventually discharged in good health on day 50.
3. Discussion
The placement of a pleural drainage is an invasive procedure,
since it implies piercing the chest wall and introducing a
large bore catheter into the pleural cavity [1]. The maneuver
is associated with both immediate complications such as
local hemorrhage, pneumothorax, or hemothorax—which
may be minimized by the adoption of ultrasound guidance—
and late complications such as local infection or
dislodgment of the catheter. The latter is particularly frequent;
incomplete dislodgment often yields malfunction of
the drainage, while complete dislodgment implies the need
of repositioning the catheter, with relevant impact on
morbidity and health costs.
Current strategies of securement of chest tubes in neonates
are far to be satisfactory. Securement by cutaneous
suture is traumatic, potentially associated with local skin
infection, and ultimately ineffective. In this case report, we
used securement by stitches in the first neonate, trying to
save a partially dislodged pigtail catheter, but this type of
securement was ineffective: the catheter was completely
dislodged after 2 days.
Chest tubes with pigtail end are now widely used, also in
our NICUs: their peculiar shape is designed to reduce the
risk of accidental dislocation of the catheter (Figure 2(a)).
Though they should not strictly require external securement,
we often secure them by adhesive sterile tapes and transparent
semipermeable dressing. In our first case, four pigtails
secured with sterile strips were not particularly effective: one
catheter was lost after 36 hours, another required securement
by suture after 5 days because of partial dislodgment,
another one dislodged completely after 12 days, and a fourth
was partially dislodged after 14 days.
As reported by these three cases, we are currently testing
an innovative approach to chest tube securement, using a
new subcutaneously anchored sutureless device (SAS)
(SecurAcath, Interrad) initially marketed for the securement
of central venous catheters. Its safety, efficacy, and cost
effectiveness are well acknowledged in the world of vascular
access [2–5]. SAS has also been used for other purposes: for
instance, as securement of cerebral-spinal catheters [6],
biliary tube drainage, and nephrostomy tubes [7]. To our
best knowledge, there are no published reports about the use
of SAS to anchor thoracic catheter for pleural drainage and
no reports at all about its use for securement of chest tubes in
neonates. In our first experience, reported in this paper, SAS
was highly effective and safe. In the first case, a pigtail
catheter was kept in place by SAS for 10 days without any
undesired effect: the catheter was removed electively and not
because of malfunction or dislodgment. In the second neonate,
a pigtail catheter was secured with SAS and stayed in
place for 32 days without any complication: the catheter was
eventually removed because it was not necessary anymore.
In the third neonate, an 8Fr trocar thoracic tube—secured
with SAS—stayed in place without any complication for 12
days

Figure 2: (a) 8Fr pigtail catheter (Safe-T-Centesis Drainage System, BD), used in cases 1 and 2. (b) Subcutaneously anchored system
(SecurAcath, Interrad). Before use, the system consists of two components: the anchor base and the cover.

Some considerations about insertion and management
of the SAS may be interesting.
First, we must consider that different SAS are available
for different size of catheters. In fact, the design of SAS is
such that, while the anchor blocks the device under the skin,
the catheter itself is blocked by the two portions of the device
(Figure 2(b)), inside a special groove that must be of appropriate
size. In other words, 8Fr tubes require 8Fr SAS,
10Fr tubes require 10Fr SAS, and so on.
Also, we noticed that insertion of SAS by anchoring it in
the subcutaneous tissue was extremely easy. As suggested by
our previous experience with SAS for securement of central
venous catheters in neonates, we placed a small piece of
sterile gauze under the base of the device so to avoid the risk
of an excessive pressure of the device over the delicate skin
[2].
Furthermore, the entrance of the SAS and of the chest
tube through the skin was sealed by a few drops of cyanoacrylate
glue; though this strategy may add little or
nothing in terms of securement, our experience with venous
catheters suggest that it is very effective in blocking any
oozing or bleeding from the breech.
As regards the maintenance, the securement with SAS
allowed an optimal periodic disinfection of the skin around
the chest tube, which is difficult or impossible when using
stitches or sterile strips. As already described, no skin abnormalities
of any kind were observed: no inflammation, no
irritation, and no bleeding. Also, no sign of local pain or
discomfort was evident in any of the three neonates whose
chest tube was secured by SAS.
In conclusion, we recommend SAS as a safe and effective
alternative option for securing chest tubes in neonate: it is
easy to insert and easy to remove; it is not associated with
any undesired effect, not even in premature newborns; most
of all, it minimizes and virtually eliminates the risk of accidental
dislodgment of the chest tube, an event associated
with increased morbidity and increased health cost.
Though we report a very initial clinical experience, we
think that our clinical results suggest the interest to conduct
further studies about the use of SAS in this clinical situation.
Ethical Approval
The parents gave their written informed consent (including
for images) to publish each one of these cases.
Conflicts of Interest
The authors declare that there are no conflicts of interest
regarding the publication of this case report.
Authors’ Contributions
CRP and VDA collected the data and wrote the first draft of
the manuscript; MGR, EP, and LP assisted in reviewing and
editing the manuscript. MP supervised the project and
prepared the final version of the manuscript.
References
[1] M. A. Attar and S. M. Donn, “Congenital chylothorax,”
Seminars in Fetal and Neonatal Medicine, vol. 22, no. 4,
pp. 234–239, August 2017.
[2] M. Pittiruti, G. Scoppettuolo, L. Dolcetti et al., “Clinical experience
of a subcutaneously anchored sutureless system for
securing central venous catheters,” British Journal of Nursing,
vol. 28, no. 2, pp. S4–S14, 2019.
[3] T. Macmillan, M. Pennington, J. A. Summers et al., “Secur-
Acath for securing peripherally inserted central catheters: a
NICE medical technology guidance,” Applied Health Economics
and Health Policy, vol. 16, no. 6, pp. 779–791, 2018.
[4] P. A. Zerla, A. Canelli, L. Cerne et al., “Evaluating safety, efficacy,
and cost-effectiveness of picc securement by subcutaneously
anchored stabilization device,” The Journal of Vascular
Access, vol. 18, no. 3, pp. 238–242, 2017.
[5] M. Pittiruti and D. Celentano, “Our experience with subcutaneously
anchored sutureless devices in pediatric patients,”
Journal of the Association for Vascular Access, vol. 21, no. 4,
p. 255, 2016.
[6] P. Frassanito, L. Massimi, G. Tamburrini et al., “A new subcutaneously
anchored device for securing external cerebrospinal
fluid catheters: our preliminary experience,” World
Neurosurgery, vol. 93, pp. 1–5, 2016.
[7] P. Hughes, M. O’Reilly, C. Farrelly, T. Geoghegan, and
L. Lawler, “Assessment of the SecurAcath® device in reducing
migration of drainage catheters in biliary and renal intervention,”
2017.

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