Percutaneous central venous catheterization in a pediatric intensive care unit: a survival analysis of complications

Pathogenesis of sepsis with central venous catheter use: alternate locus-related versus central venous catheter-related sepsis

OBJECTIVE

To review literature identifying a central venous catheter (CVC) as either a primary or a secondary source of sepsis.

DATA SOURCES

Studies of CVC use in adults, children, and infants from 1968 to 1994.

STUDY SELECTION

Selection of 10 studies was based on documented distinction between CVC-related and alternate infectious locus-related sepsis.

DATA EXTRACTION

Abstracted from each study were either total sepsis or colonization rates, as well as the percentages of infection related to the CVC and to alternate infectious loci.

DATA SYNTHESIS

Percentages of alternate-locus-related sepsis can be two to four times greater than percentages of CVC-related sepsis.

CONCLUSIONS

The potential exists for the development of alternate-locus-related sepsis in patients with CVCs. Surveillance measures should reflect this potential.

Effect of airway pressure on inferior vena cava pressure as a measure of central venous pressure in children

We evaluated the effect of elevated airway pressure on the validity of intravascular pressure obtained in the distal inferior vena cava (IVC) as a measure of central venous pressure (CVP) in a group of children receiving mechanical ventilation. The IVC pressure correlated well with CVP in the patients without abdominal distention, but the disparity was wider in those with abdominal distention. Elevated mean airway pressure or positive end-expiratory pressure had no effect on the relationship of IVC to CVP.

Optimal interval for triple-lumen catheter changes: a decision analysis

A survey of 53 university and community hospitals revealed that 73% of the institutions had no standard policy for the replacement of triple-lumen catheters (TLCs). Since the maintenance of a TLC in place for a prolonged period may lead to infectious complications, it appeared warranted that standards of management be developed. A decision-tree model was constructed for evaluating the optimal time for changing a TLC that would minimize infection. Cost estimates and health effects at three-, five-, and ten-day change intervals were considered for catheter insertion and complications resulting from such insertion. The results suggested that prophylactic catheter changes should occur no later than every five days, provided that there are no signs of infection. However, sensitivity analysis of several variables suggested that individual institutions should establish policy timing changes based upon careful interpretation of their own data. A model was developed to assist in determining the optimal time to change a TLC based upon such data.

A cross-sectional study of catheter-related thrombosis in children receiving total parenteral nutrition at home

We performed a cross-sectional evaluation of deep vein thrombosis (DVT) related to the use of central venous lines (CVLs) in all pediatric patients receiving home total parenteral nutrition at our institution (N = 12). All children (5 months to 17 years of age) were examined with bilateral upper limb venography. All CVLs were flushed daily with heparin (200 units). At the time of evaluation, 49 CVLs had been placed in the 12 children. Of the 39 CVLs removed, 27 (66%) were blocked; venograms had not been previously obtained except of one child. Eight children had clinical evidence of superficial collateral circulation in the upper portion of the chest and the upper extremities; five had intermittent symptoms of superior vena cava obstruction. On venography, 8 of the 12 children had extensive evidence of DVT; two were unilateral and six bilateral. Five children were treated with warfarin (0.12 to 0.28 mg/kg per day) to achieve an international normalized ratio of 1.4 to 1.8. Neither bleeding nor further CVL-related DVT has occurred. We conclude that the risk of CVL-related DVT in children requiring home total parenteral nutrition is high, and that venography should be performed early in the event of CVL blockage. A multicenter, controlled trial assessing optimal warfarin therapy in this patient population is indicated.

Duration of intracranial pressure monitoring does not predict daily risk of infectious complications

A group of 205 patients (115 children and 90 adults) with a total of 212 intracranial pressure (ICP) monitors were retrospectively studied with attention to daily cerebrospinal fluid cultures, duration of monitoring, associated cranial injuries, and hospital site of the ICP monitor (intensive care unit or operating room). Only closed ICP monitoring systems without irrigation or compliance testing were used, and all patients received antibiotics as prophylaxis throughout the monitoring period. There were no complications associated with monitor placement. Incidence histograms and regression analysis were used to determine the daily risk of subsequent infections, in addition to evaluating the cumulative risk of infection, as has been previously described in the literature. No relation between the duration of ICP monitoring and the rate of daily infection through the period of maximal monitoring (1-2 weeks) was found in this series. The overall incidence of infection was 7.1% with a median duration of monitoring of 7.2 days. The age of the patient (adult vs. child), site of ICP monitor placement, and nature of the underlying disease (trauma vs. nontrauma) had no significant effect on the development of monitor-related infections in our study. These data indicate that the decision to continue ICP monitoring can be based solely on the clinical necessity for further monitoring rather than on concerns for monitor removal to prevent infection.

[Massive pulmonary embolism caused by thrombosis formed on a central catheter in a child]

A case is reported of a 9-year-old girl admitted with a subarachnoid haemorrhage. Her neurological recovery was favourable after the embolization of a cerebral arterio-venous malformation. She stayed in ICU with mechanical ventilation because of a bacterial pneumonia and a post-extubation laryngeal oedema. She required insertion of a polyurethane subclavian catheter, as a peripheral venous access was not available. Five days later, the child suffered a sudden respiratory distress without changes of the electrocardiogram and the chest X-ray. The diagnosis of pulmonary embolism was suspected because of the presence of the central venous catheter, a catheter dysfunction and a superior vena cava syndrome. A catheter tip thrombus was shown by angiography as well as a thrombus in the pulmonary artery, a 90% obstruction of the proximal valvular tree of the right lung, a 10 to 15% distal obstruction in the left lung, a complete obstruction of the superior vena cava (SCV). The thrombolytic therapy was contra-indicated in this case because of the neurological pathology. Heparin was given by continuous intravenous infusion. When heparin concentration was at an appropriate level, the catheter was removed. Its microbiological culture remained negative. The next day, another angiography showed a partial permeability of the SVC and a better right pulmonary perfusion. During this procedure, the haemodynamic assessment showed only moderate abnormalities. Therefore the surgical treatment was not indicated and the heparin continued. The child recovered gradually with a normalization of the lung scintigraphy.

A controlled trial of scheduled replacement of central venous and pulmonary-artery catheters

BACKGROUND

The incidence of infection increases with the prolonged use of central vascular catheters, but it is unclear whether changing catheters every three days, as some recommend, will reduce the rate of infection, It is also unclear whether it is safer to change a catheter over a guide wire or insert it at a new site.

METHODS

We conducted a controlled trial in adult patients in intensive care units who required central venous or pulmonary-artery catheters for more than three days. Patients were assigned randomly to undergo one of four methods of catheter exchange: replacement every three days either by insertion at a new site (group 1) or by exchange over a guide wire (group 2), or replacement when clinically indicated either by insertion at a new site (group 3) or by exchange over a guide wire (group 4).

RESULTS

Of the 160 patients, 5 percent had catheter-related bloodstream infections, 16 percent had catheters that became colonized, and 9 percent had major mechanical complications. The incidence rates (per 1000 days of catheter use) of bloodstream infection were 3 in group 1, 6 in group 2, 2 in group 3, and 3 in group 4; the incidence rates of mechanical complications were 14, 4, 8, and 3, respectively. Patients randomly assigned to guide-wire-assisted exchange were more likely to have bloodstream infection after the first three days of catheterization (6 percent vs. 0, P = 0.06). Insertions at new sites were associated with more mechanical complications (5 percent vs. 1 percent, P = 0.005).

CONCLUSIONS

Routine replacement of central vascular catheters every three days does not prevent infection. Exchanging catheters with the use of a guide wire increases the risk of bloodstream infection, but replacement involving insertion of catheters at new sites increases the risk of mechanical complications.

Subclavian vein catheterization in critically ill children: analysis of 322 cannulations

Complications in 322 percutaneous subclavian vein catheters placed in 272 children by the infraclavicular approach were investigated prospectively. Ages ranged from 4 days to 15 years. Incidents during catheter introduction occurred in 13 cases, and were more common when insertion was on the right side (p less than 0.01). Nine (2.8%) required urgent treatment: (6 pneumothorax, 1 hydrothorax, and 2 hemothorax). Anomalous lodging of the catheter tip was more common when insertion was on the right side (p less than 0.05). Complications during catheter maintenance were 3 venous thromboses, 3 catheter obstructions, and 7 migrations out of position. There was no significant difference in complications related to age. Catheter cultures were positive in 33 (17%) of 190 catheters cultured (27 through colonization and 6 through catheter-related sepsis). Staph. epidermidis was the organism most frequently isolated (19 cases; 58%). Catheterization time of more than 5 days and catheter-related sepsis were statistically associated (p less than 0.05). Staph. epidermidis isolation and duration of cannula use were statistically related (p less than 0.01). No catheter-related deaths occurred. We conclude that subclavian vein catheterization is a simple and useful procedure that entails relatively few serious complications when performed by experienced pediatricians.

Intravascular catheter colonization and related bloodstream infection in critically ill neonates

Intravascular catheter tip colonization was prospectively evaluated in critically ill neonates to determine its relationship to the type of device used, duration of catheterization, insertion site and nosocomial bloodstream infection. Sixty-one percent (376 of 621) of all intravascular catheter tips were retrieved from 91 infants. Thirteen percent (41 of 310) of peripheral intravenous, 14% (6 of 42) of umbilical, 21% (3 of 11) of central venous, 36% (4 of 11) of peripheral arterial and 100% (2 of 2) of femoral catheters were colonized. Duration of catheterization was significantly longer for colonized lines (p less than .001). Eight of 26 (30.8%) peripheral intravenous catheters remaining in place for more than three days were colonized, compared with 33 of 284 (11.6%) at three days or less (p = 0.012). Coagulase-negative staphylococcus was the organism most frequently isolated from catheter tips and bloodstream infections. Catheter colonization rates in this population were higher than those found in adults. Heavily manipulated devices and those in place for longer periods of time were the most frequently colonized.