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Christison-Lagay ER, Brown EG, Bruny J, Funaro M, Glick RD, Dasgupta R, Grant CN, Engwall-Gill AJ, Lautz TB, Rothstein D, Walther A, Ehrlich PF, Aldrink JH, Rodeberg D, Baertschiger RM. Central Venous Catheter Consideration in Pediatric Oncology: A Systematic Review and Meta-analysis From the American Pediatric Surgical Association Cancer Committee. J Pediatr Surg 2024; 59:1427-1443. [PMID: 38637207 DOI: 10.1016/j.jpedsurg.2024.03.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 02/08/2024] [Accepted: 03/20/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Tunneled central venous catheters (CVCs) are the cornerstone of modern oncologic practice. Establishing best practices for catheter management in children with cancer is essential to optimize care, but few guidelines exist to guide placement and management. OBJECTIVES To address four questions: 1) Does catheter composition influence the incidence of complications; 2) Is there a platelet count below which catheter placement poses an increased risk of complications; 3) Is there an absolute neutrophil count (ANC) below which catheter placement poses an increased risk of complications; and 4) Are there best practices for the management of a central line associated bloodstream infection (CLABSI)? METHODS Data Sources: English language articles in Ovid Medline, PubMed, Embase, Web of Science, and Cochrane Databases. STUDY SELECTION Independently performed by 2 reviewers, disagreements resolved by a third reviewer. DATA EXTRACTION Performed by 4 reviewers on forms designed by consensus, quality assessed by GRADE methodology. RESULTS Data were extracted from 110 manuscripts. There was no significant difference in fracture rate, venous thrombosis, catheter occlusion or infection by catheter composition. Thrombocytopenia with minimum thresholds of 30,000-50,000 platelets/mcl was not associated with major hematoma. Limited evidence suggests a platelet count <30,000/mcL was associated with small increased risk of hematoma. While few studies found a significant increase in CLABSI in CVCs placed in neutropenic patients with ANC<500Kcells/dl, meta-analysis suggests a small increase in this population. Catheter removal remains recommended in complicated or persistent infections. Limited evidence supports antibiotic, ethanol, or hydrochloric lock therapy in definitive catheter salvage. No high-quality data were available to answer any of the proposed questions. CONCLUSIONS Although over 15,000 tunneled catheters are placed annually in North America into children with cancer, there is a paucity of evidence to guide practice, suggesting multiple opportunities to improve care. LEVEL OF EVIDENCE III. This study was registered as PROSPERO 2019 CRD42019124077.
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Affiliation(s)
- Emily R Christison-Lagay
- Department of Surgery, Yale New Haven Children's Hospital, Yale School of Medicine, New Haven, CT, USA
| | - Erin G Brown
- Department of Surgery, University of California Davis Children's Hospital, University of California Davis, Sacramento, CA, USA
| | - Jennifer Bruny
- Alaska Pediatric Surgery, Alaska Regional Hospital, Anchorage, AK, USA
| | - Melissa Funaro
- Harvey Cushing/John Hay Whitney Medical Library, Yale University, New Haven, CT, USA
| | - Richard D Glick
- Department of Surgery, Cohen Children's Medical Center, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
| | - Roshni Dasgupta
- Department of Surgery, Cincinnati Children's Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Christa N Grant
- Department of Surgery, Maria Fareri Children's Hospital, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | | | - Timothy B Lautz
- Department of Surgery, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University, Chicago IL, USA
| | - David Rothstein
- Department of Surgery, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Ashley Walther
- Department of Surgery, Children's Hospital of Los Angeles, Keck School of Medicine at University of Southern California, Los Angeles, CA, USA
| | - Peter F Ehrlich
- Department of Surgery, Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Jennifer H Aldrink
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - David Rodeberg
- Department of Surgery, Kentucky Children's Hospital, University of Kentucky, Lexington, KY, USA
| | - Reto M Baertschiger
- Department of Surgery, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada; Division of Pediatirc Surgery, Children's Hospital at Dartmouth, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebaon, NH, USA.
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Li H, Shan J. Risk Factors of the Totally Implantable Venous Access Device-Related Infection in Patients With Brain Tumors Undergoing Chemotherapy After Surgery. Surg Infect (Larchmt) 2024; 25:133-139. [PMID: 38265425 DOI: 10.1089/sur.2023.266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024] Open
Abstract
Background: The complication of totally implantable venous access device (TIVAD) is an infection, which causes the death of patients. Therefore, it is critical to identify risk factors for TIVAD infection to prevent death. Patients and Methods: The enrolled patients were divided into two groups and subsequently divided into subgroups according to various factors in which the correlation between infection and risk factors was analyzed. Multivariable logistic analysis of odds ratios (ORs) for seven risk factors was performed, meanwhile, the receiver operating characteristic (ROC) curve analysis of neutrophil and serum albumin was conducted for the prediction of TIVAD infection occurrence. Results: Catheter-related blood stream infection was the common infection type, which was dominantly caused by Staphylococcus aureus. Removal of TIVAD and antibiotic therapy were the preferred approaches for the treatment of infection. Seven risk factors were closely associated with the TIVAD infection, however, two risk factors, including age and outpatient, were excluded according to the multivariate logistic analysis of ORs. Receiver operating characteristic curve analysis revealed neutrophil count and serum albumin could predict the occurrence of TIVAD infection. Conclusions: Five risk factors were positively related to TIVAD infection; neutrophil and serum albumin could be used to predict the occurrence of TIVAD infection.
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Affiliation(s)
- Haihong Li
- Department of Neurosurgery 1, Cangzhou Central Hospital, Cangzhou, Hebei, China
| | - Jing Shan
- Department of Orthopaedics, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
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Vernamonti J, Kartal T, Overman E, Speck KE. Tunneled Central Venous Catheters in Young Children: Complication Profile Can Guide Choice of Line. J Surg Res 2023; 283:19-23. [PMID: 36356380 DOI: 10.1016/j.jss.2022.08.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 08/15/2022] [Accepted: 08/22/2022] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Placement of tunneled central venous catheters (CVCs) is one of the most common procedures performed in children and can either be externally accessed or internally accessed. However, there are no data-driven guidelines on when to offer each line type, particularly in small children aged less than 5 y. Our hypothesis is that the two types of lines have different complication profiles and indications that can guide providers and families in this decision. METHODS A single-institution retrospective chart review was performed for patients aged less than 5 y who underwent initial placement of a tunneled CVC between 2014 and 2016. Patients were included if they underwent initial tunneled CVC placement within the study period and were excluded if line was emergently placed for hemodynamic instability or was a replacement catheter. Data were compared by type of CVC, weight more than or less than 10 kg, indications for CVC, complications, and duration of catheter. RESULTS We identified 148 patients who underwent initial tunneled CVC during study period. Seventy one patients (48%) received an externally accessed type and 77 (52%) received internally accessed type. The indications for line placement were TPN in 24 patients (16%), chemotherapy in 67 (45%), vascular access in 45 (31%), and nonchemotherapy infusions in 12 (8%). Externally accessed catheters had higher late complications (> 30 d) in patients > 10 kg compared to internally accessed catheters (63% versus 21%, P < 0.01). CONCLUSIONS While some diagnoses determine line type, there are other indications that may qualify patients for either line. Our data demonstrate a lower long-term complication rate with internally accessed catheters and suggest they be considered over externally accessed lines in appropriate patients.
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Affiliation(s)
- Jack Vernamonti
- University of Michigan Department of Pediatric Surgery, Ann Arbor, Michigan.
| | - Tanvi Kartal
- University of Michigan Department of Pediatric Surgery, Ann Arbor, Michigan
| | - Elliott Overman
- University of Michigan Department of Pediatric Surgery, Ann Arbor, Michigan; East Carolina University, Brody School of Medicine Department of Surgery, Greenville, North Carolina
| | - K Elizabeth Speck
- University of Michigan Department of Pediatric Surgery, Ann Arbor, Michigan
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Ross AB, Rouanet E, Murphy AJ, Weldon CB, Weil BR. Complications associated with totally implantable access ports in children less than 1 year of age. J Pediatr Surg 2022; 57:463-468. [PMID: 34991865 DOI: 10.1016/j.jpedsurg.2021.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 11/24/2021] [Accepted: 12/01/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Long term central venous access is necessary for the treatment of several conditions affecting young children. Totally implantable access ports (ports) offer the advantage of containing no external components, thus simplifying their care and maintenance. However, there is no consensus on the safety of port placement in infants (birth to 1-year of age). The aim of this study was to describe complications associated with port placement in infants, including which specific factors may be associated with risk for developing complications among these patients, and thereby assess the safety of port placement in this young population. METHODS A two-institution, retrospective cohort study identified patients under 1-year old who underwent port placement. Intraoperative, early postoperative (within 30 days), and late postoperative (greater than 30 days) complications were recorded. Multivariate logistic regression models were employed to assess factors associated with port-related complications. RESULTS Among 121 patients who received a port, 36 (30%) experienced a complication with a median time to complication of 299.5 days [IQR 67.5-440.75]. Of those, 26 required unplanned port removal. Only 3 patients (2.5%) experienced an intraoperative complication, and 3 patients (2.5%) experienced a complication within 30 days of port placement. A diagnosis of cancer was found to be protective against early catheter malfunction (OR=0.31, p = 0.03). A non-statistically significant trend associated with increased complications for large caliber devices (>6.0Fr) and weight <7-kg (OR 2.20, p = 0.06 and OR=2.26, p = 0.11 respectively) was observed. CONCLUSIONS Port placement appears to be safe for most infants with low or acceptable rates of intra- or post-operative complications. Smaller patient size (< 7 kg) and larger-sized catheters (> 6.0Fr) may be associated with an increased risk for complications among this population. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Aaron B Ross
- College of Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, United States.
| | - Eva Rouanet
- Department of Surgery, Boston Children's Hospital/Harvard Medical School, Boston, MA 02115, United States; Department of Surgery, Brigham & Women's Hospital/Harvard Medical School, Boston, MA 02115, United States
| | - Andrew J Murphy
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN 38105, United States
| | - Christopher B Weldon
- Department of Surgery, Boston Children's Hospital/Harvard Medical School, Boston, MA 02115, United States; Department of Pediatric Oncology, Dana-Farber Cancer Institute/Harvard Medical School, Boston, MA 02115, United States; Department of Anesthesiology, Critical Care & Pain Medicine, Children's Hospital/Harvard Medical School, Boston, MA 02115, United States
| | - Brent R Weil
- Department of Surgery, Boston Children's Hospital/Harvard Medical School, Boston, MA 02115, United States; Department of Pediatric Oncology, Dana-Farber Cancer Institute/Harvard Medical School, Boston, MA 02115, United States
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Overman RE, Casar Berazaluce AM, Van Arendonk K, Wagner ML, Kartal T, Witte A, Rymeski B, Speck KE. Risk profile of subcutaneous port placement in small children. J Pediatr Surg 2021; 56:183-186. [PMID: 33131779 DOI: 10.1016/j.jpedsurg.2020.09.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 09/23/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND/PURPOSE Long-term central venous access is a safe and common procedure in children. However, complications with devices are a reality. Smaller children are thought to have a higher rate of complication after port placement, and some surgeons avoid placing ports with an arbitrary weight cutoff out of concern for surgical site morbidity. METHODS We performed a multi-institutional retrospective review of 500 patients less than 5 years of age undergoing port placement at three large volume children's hospitals from 2014 to 2018. Patients were divided by weight greater than or less than 10 kg at the time of insertion. Statistical analysis was performed to evaluate for differences in outcomes between the two groups. RESULTS The majority of ports were placed for chemotherapy access (71.8%). Other indications included long-term infusions (18.8%) and difficult chronic IV access (9.4%). Of the 500 charts reviewed, 110 (22%) experienced some documented complication (28.9% <10 kg, 20.6% >10 kg, p = 0.096). There were no differences between the two groups in terms of the type or timing of complications. Overall, 16.3% of ports required removal prior to the end of therapy owing to a complication. Complication rate per day with the port in place was not different between the two groups (<10 kg: 0.68 complications/1000 port-days vs >10 kg 0.44 complications/1000 port-days, p = 0.068). CONCLUSION Weight less than 10 kg was not associated with a significantly higher incidence of any type of port complication in our cohort. This suggests that concern for complications should not exclude children less than 10 kg from port placement. TYPE OF STUDY Multi-institutional retrospective review. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Richard E Overman
- Division of Pediatric Surgery, Department of Surgery, CS Mott Children's Hospital, University of Michigan, Ann Arbor, MI.
| | - Alejandra M Casar Berazaluce
- Division of Pediatric General and Thoracic Surgery, Department of Surgical Services, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Kyle Van Arendonk
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital of Wisconsin, Milwaukee, WI
| | - Monica L Wagner
- Division of Pediatric General and Thoracic Surgery, Department of Surgical Services, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Tanvi Kartal
- Division of Pediatric Surgery, Department of Surgery, CS Mott Children's Hospital, University of Michigan, Ann Arbor, MI
| | - Amanda Witte
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital of Wisconsin, Milwaukee, WI
| | - Beth Rymeski
- Division of Pediatric General and Thoracic Surgery, Department of Surgical Services, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - K Elizabeth Speck
- Division of Pediatric Surgery, Department of Surgery, CS Mott Children's Hospital, University of Michigan, Ann Arbor, MI
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Milford K, von Delft D, Majola N, Cox S. Long-term vascular access in differently resourced settings: a review of indications, devices, techniques, and complications. Pediatr Surg Int 2020; 36:551-562. [PMID: 32200406 DOI: 10.1007/s00383-020-04640-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2020] [Indexed: 11/26/2022]
Abstract
Central venous access is frequently essential for the management of many acute and chronic conditions in children. Millions of central venous access devices (CVADs) are placed each year. In this review article, we discuss the indications for long-term vascular access, the types of devices available, the state of the art of central venous cannulation and device placement, and the complications of long-term central venous access. We pay a special attention to the challenges of, and options for long-term central venous access, also those in developing countries, with limited financial, human, and material resources.
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Affiliation(s)
- Karen Milford
- The Division of Urology, The Hospital for Sick Children, The University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
| | - Dirk von Delft
- Division of Paediatric Surgery, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Nkululeko Majola
- Department of Paediatric Surgery, Frere Hospital, Walter Sisulu University, East London, South Africa
| | - Sharon Cox
- Division of Paediatric Surgery, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
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Nam SH, Kim DY, Kim SC, Kim IK. Complications and risk factors of infection in pediatric hemato-oncology patients with totally implantable access ports (TIAPs). Pediatr Blood Cancer 2010; 54:546-51. [PMID: 19967773 DOI: 10.1002/pbc.22286] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Totally implantable access ports (TIAPs) are widely used in pediatric hematology-oncology patients. We investigated the incidence of complications, causes of TIAP removal, and risk factors for infection. PROCEDURE We retrospectively analyzed the clinical, demographic, and surgical characteristics in 225 pediatric hematology-oncology patients implanted with 238 TIAPs between January 2004 and December 2005. RESULTS Except for 20 patients lost to follow-up, the mean maintenance period was 724.8 +/- 500.6 days (range: 17-2,124). Mechanical complications occurred in seven patients (2.9%). The causes of TIAP removal were termination of use in 130 patients (59.6%), death from primary disease with TIAP in situ in 35 (14.7%), infection in 35 (14.7%), and obstruction in 4 (1.8%). Early infections occurred in nine patients at mean 37.77 +/- 16.44 days (range: 17-56). Late infections occurred in 26 patients at mean 334.5 +/- 257.82 days (range: 68-997). Univariate analysis showed that the risk factors of early infection were re-implantation (P = 0.022) and long operation time (P = 0.045). The risk factors of late infection were ANC <500/mm(3) (P = 0.011) and platelet count <50,000/mm(3) (P < 0.001). In multivariate analysis, re-implantation was a significant risk factor of early infection (P = 0.033, OR 4.528) and low platelet count (<50,000/mm(3)) was the independent risk factor for late infection (P = 0.005, OR 4.24). CONCLUSIONS Correct procedure and careful use decreases the incidence of early infection and leads to the prevention of re-implantation. Initial thrombocytopenia was attributable to bone marrow suppression caused by hematologic malignancies or severe infection. Thus, this condition is of value in predicting late infection.
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Affiliation(s)
- So-Hyun Nam
- Department of Pediatric Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Sarper N, Zengin E, Corapçioglu F, Tugay M. Totally implantable central venous access devices in children with hemato-oncologic malignancies: evaluation of complications and comparison of incidence of febrile episodes with similar patients without central venous access devices. Pediatr Hematol Oncol 2006; 23:459-70. [PMID: 16849276 DOI: 10.1080/08880010600712514] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The incidence of mechanical and infectious complications of totally implantable central venous access devices (TIDs) must be related to underlying disease, intensity of the chemotherapy, and frequency of manipulations. Records of the patients hospitalized from January 2002 to May 2005 were evaluated. Patients with TIDs were matched with patients without TIDs having the same malignancy and the same anti-neoplastic chemotherapy. Catheter-related complications were documented and corresponding phases of the chemotherapy in matched pairs were compared with regard to infections. TIDs were inserted in 31 patients with a median age of 4.3 years (22 acute leukemia, 1 NHL, and 8 solid tumors). Total number of catheter days was 5268, with a median catheter life of 174 days (range 9-493 days). Nine catheters (29%) were removed due to mechanical and infectious complications. There was 13 catheter-related infections with a rate of 2.46/1000 catheter days. Total number of mechanical complications was 5 and overall rate of complications was 3.41/1000 catheter days. The rate of febrile episodes was 54 and 41 in the TID and no TID group, respectively (p: .11). Duration of neutropenia was 9.6 and 7.4 days and duration of fever per febrile attack was 5.6 and 4.4 days in the TID and no TID group, respectively (p: .047 and .56). Although most of the patients in this study had hematological malignancy and required frequent manipulation, the results were similar to those in developed countries. TIDs are essential for management of chemotherapy in pediatric malignancies with acceptable complications.
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Affiliation(s)
- Nazan Sarper
- Department of Pediatric Hematology, Kocaeli University, Kocaeli, Turkey.
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Munro FD, Gillett PM, Wratten JC, Shaw MP, Thomas A, MacKinlay GA, Wallace WH. Totally implantable central venous access devices for paediatric oncology patients. MEDICAL AND PEDIATRIC ONCOLOGY 1999; 33:377-81. [PMID: 10491546 DOI: 10.1002/(sici)1096-911x(199910)33:4<377::aid-mpo6>3.0.co;2-x] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Totally implantable central venous access devices (ports) have been available for over 10 years but have not achieved widespread use in paediatric oncology patients. We reviewed our experience with these devices over 9 years to assess their safety and acceptability. PROCEDURE We conducted a retrospective review of insertion technique and reasons for removal of all ports placed in paediatric oncology patients in this hospital between 1989 and 1996, with follow-up until 1998. Acceptability of both ports and external catheters was assessed by a questionnaire in a subgroup of families attending the oncology clinic. RESULTS One hundred forty-nine ports were inserted during the study period. The median catheter life was 399 days (4-1,406), with a total of 69,342 catheter days. Sixty-nine percent of ports were removed electively at the end of treatment; 8% required removal because of infection and 5% because of blockage. No ports were accidentally dislodged or damaged. Children experienced significantly less restriction of activity with a port compared to an external catheter and greatly preferred the cosmetic appearance. The need for needle insertion to access the port was not seen as a disadvantage by most families. CONCLUSIONS Ports can provide satisfactory central venous access for the majority of paediatric oncology patients, with a low risk of line-related complications and a high degree of acceptability to children and their parents.
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Affiliation(s)
- F D Munro
- Department of Paediatric Surgery, Royal Hospital for Sick Children, Edinburgh, Scotland
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