Central venous catheter infections in pediatric patients--in a community hospital

Catéter Venoso Totalmente Implantável em 278 Pacientes Oncológicos

Os catéteres totalmente implantáveis proporcionam acesso vascular prolongado, baixo risco durante inserção e remoção, fácil manutenção, conforto e segurança para o paciente e baixo índice de complicações. Nosso objetivo é relatar a experiência com 278 catéteres implantados por um único cirurgião. Foram critérios para o implante: diagnóstico histopatológico, expectativa de vida maior que 3 meses, dificuldade de acesso venoso periférico e programa de quimioterapia. Entre março de 1990 e março 1998 foram implantados 278 catéteres em 272 pacientes. Tempo de permanência: 382 dias (5a 2897) totalizando 106.457 dias. Sexo feminino 64.8%. Idade média 50,2 anos. Via de acesso: jugular interna 67,9%, jugular externa 26,5%, safena 2,2%, cefálica 1,7% e subclávia 1.7%. Complicações: #1. Obstrução (0,26/1000 dias) #2. Hematoma 6,11% do total, todos em pacientes leucêmicos. #3. Extravasamento 0,2/1000 dias). #4. Trombose (0,03/1000 dias). #5. Infecção 20 episódios, 0,19/1000 dias), sendo 6 lúmen, 7 peri-port e 7 suspeita clínica de sepses. Foram retirados 34 catéteres, 26 por complicações e 8 ao término do tratamento. Permanecem vivos em uso do cateter 45,2%. Não apresentaram qualquer tipo de complicação 74,5% dos pacientes. Em nossa experiência o número de complicações é baixo. O manuseio é realizado exclusivamente por profissionais treinados. Atenção com pacientes leucêmicos para a formação de hematomas.

Transhepatic central venous catheter for long-term access in paediatric patients

Vascular access in paediatric patients with chronic and/or life-threatening illness is crucial to survival. Access is frequently lost in this group because of thrombosis, infection, or displacement, and vascular options can quickly be exhausted. The last resort access procedure is generally a direct atrial catheter inserted via a thoracotomy. A viable alternative is the percutaneous transhepatic Broviac catheter (Bard Access Systems, Salt Lake City, UT). We retrospectively reviewed the charts of 5 patients who underwent percutaneous transhepatic Broviac insertion for long-term access over a 4-year period in a single institution. Four of the patients (80%) had a significant cardiac abnormality, with 1 patient requiring long-term parenteral nutrition after complicated necrotizing enterocolitis. All patients had significant caval thrombosis, which precluded them having placement of a standard percutaneous or openly placed central catheter. Of the 5 patients, 2 (40%) died of cardiac-related illnesses. Of the 3 surviving patients, 2 had functioning catheters electively removed because they were no longer required. One catheter was removed at thoracotomy for right atrial perforation because of catheter erosion. Vascular access in paediatric patients with chronic and/or life-threatening illness is crucial to survival. Transhepatic central venous catheters are a feasible, reliable, and relatively easily placed form of central access in patients with multiple venous thromboses requiring long-term access. This route should be considered in paediatric patients requiring central access in preference to a thoracotomy.

Central venous access

Central venous access plays an important role in the management of an ever-increasing population of patients ranging from those that are critically ill to patients with difficult clinical access. Interventional radiologists are key in delivering this service and should be familiar with the wide range of techniques and catheters now available to them. A comprehensive description of these catheters with regard to indications, technical aspects of catheterization, success rates, and associated early and late complications, as well as a review of various published guidelines on central venous catheter insertion are given in this article.

Central venous catheter use in the pediatric patient: mechanical and infectious complications

OBJECTIVE

Following the introduction and widespread use of central venous catheters (CVCs) in adults, these devices are being used with increasing frequency in the pediatric population. This review will focus on differences between adults and children regarding CVC use and its potential complications. Both mechanical and infectious complications will be discussed.

DATA SOURCES

Systematic review of the literature.

CONCLUSIONS

CVC-related complications in pediatric patients are closely linked to age, body size, and age-related immune status. In older children, many complications are similar to those encountered in adult patients. Because of ongoing growth and body changes, a cutoff point beyond which children can be regarded as "young adults" is difficult to define; many of our recommendations are therefore age-related. More frequently than in adults, an implanted port may be the first choice in pediatric patients when long indwelling times are expected. The optimal site of insertion also depends on factors such as the patients' age as well as the need for sedation and analgesia during the insertion procedure. In contrast to guidelines in adult patients, we recommend that a radiograph always be made following CVC insertion to check the position of the catheter. Regarding prevention of infectious complications, we recommend full sterile barrier precautions during CVC insertion and strict protocols for catheter care. CVCs should be removed as soon as possible when they are no longer needed, but there is no place for elective CVC replacement on a routine basis. New developments such as the use of impregnated catheters might help reduce infection rates; however, additional research will be required to provide more evidence of benefit in the pediatric population.

Candidaemia: risk factors in patients with cystic fibrosis who have totally implantable venous access systems

Patients with cystic fibrosis who have totally implantable venous access devices often have other consequences of their multi-system disease which predispose them to catheter-associated systemic infection. We describe four episodes of fungaemia in three patients. Each case presented with persistent fever during an acute respiratory exacerbation. The four episodes were successfully treated, but removal of the venous access device was necessary in each case. Identified risk factors for systemic fungal injection were: combinations of a severe background respiratory deficiency; an acute respiratory exacerbation; malnutrition; repeated and frequent broad spectrum antibiotic therapy; parenteral nutrition; and diabetes mellitus. Unexplained fever in high risk patients with cystic fibrosis who have indwelling venous access systems should be treated empirically with antifungal agents while awaiting blood culture results. If fungaemia is confirmed the venous access device must be removed. Daily prophylactic fluconazole may prevent recurrences.

Prospective analysis of urokinase in the treatment of catheter sepsis in pediatric hematology-oncology patients

Use of right atrial catheters (RACs) in children with cancer improves the comfort and efficacy of therapy. However, catheter-related infections are responsible for significant morbidity leading to the removal of approximately 20% of implanted RACs. Sepsis has been linked to thrombus and fibrin sheath formation within the RAC. Gram-negative and fungal infections appear to be particularly resistant to antibiotic therapy alone and most of these infections have required catheter removal. Urokinase has been effectively used for reopening thrombus occluded RACs. Theoretically, thrombolytic agents could improve the treatment of catheter-related infections by removing luminal sites of bacterial/fungal colonization. We prospectively monitored the use of urokinase and antibiotics for catheter-related sepsis in our pediatric hematology/oncology population from 1985 to 1991. Sepsis episodes were treated with 2 doses of urokinase and antibiotics (10 to 42 days) infused through the RAC. One to 2 mL of urokinase (5,000 U/mL) was instilled in the RAC for 1 hour, then removed and repeated 24 hours later. During the study, 224 RACs were placed in 177 children. RACs were in place for a total of 71,134 days (median, 274 days). There were 67 blood culture-positive sepsis episodes occurring in 50 RACs. Fifty-nine sepsis episodes were treated with urokinase and antibiotics and all responded by clearance of organisms from the blood. Three patients (5.1% of urokinase treated) had recurrent sepsis with the same organism within 2 months, were considered treatment failures and had RACs removed. Only 1 of 16 episodes of multiple organism/Candida sepsis led to RAC removal due to inability to cure the infection.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous translumbar and transhepatic inferior vena caval catheters for prolonged vascular access in children

Central venous access for children with caval occlusion remains a major challenge to pediatric surgeons. Traditionally, children with superior and inferior vena cava (SVC, IVC) thrombosis have often required a thoracotomy to directly cannulate the azygos system or right atrium (RA). Recently, the possibility of placing tunneled RA catheters (RACs) by a percutaneous translumbar or transhepatic approach has become available. We report our experience of seven children with SVC and IVC obstruction who have received 11 transhepatic and 4 translumbar RACs from 1987 to 1991. All but one child was less than 2.5 years old and all were chronically dependent on parenteral nutrition. All catheters were placed in the angiography suite under general anesthesia using ultrasound guidance and Seldinger technique. This technique was successful in all seven children. Perioperative complications included accidental extubation in one patient and aspiration pneumonia in another. Mechanical complications requiring RAC replacement occurred 5 times in three infants (greater than 2,650 catheter days) and included catheter dislodgement (2) and thrombosis (3). In the patients with catheter thrombosis, the existing tract was successfully wired and the catheter exchanged on three occasions. Thrombolytic therapy was effective in restoring catheter patency on three other occassions. Nine episodes of catheter sepsis occurred in five children. Two late deaths occurred from infection. Of the five remaining children, four are dependent on total parenteral nutrition and have a translumbar or transhepatic catheter in situ and one child has adapted successfully to enteral feedings. Percutaneous translumbar or transhepatic IVC catheters provide excellent alternative routes for prolonged central venous access in those patients whose traditional vascular access sites are no longer available. Complications of the technique itself were minimal and although late catheter complications were not infrequent, they appear to be comparable to the standard approaches reported.

Central venous catheter infections

When used wisely, central venous catheters are capable of providing vital circulatory access in any patient with a remarkably low risk of infection or major complication. Tunneled silicone catheters are the route of choice for long-term or outpatient use, particularly for oncology or TPN patients; insertion of such a catheter should occur early in the hospitalization of a newly diagnosed patient on chemotherapy. The greatest experience has accrued with the cuffed silicone catheters (for example, Broviac), but the totally implantable devices (for instance, Port-a-cath) may become the device of choice in pediatric outpatients. For infants, small, percutaneously inserted noncuffed silicone catheters appear to offer the greatest safety. Among acute care patients, percutaneous plastic central venous catheters fulfill a vital role but represent an important source of infection. Scrupulous technique, the minimizing of manipulation, and a readiness to replace the catheter at any suggestion of trouble are important to achieving the best results. Within a given design, it is generally best to use the smallest diameter catheter capable of performing the desired tasks. However, on the basis of currently available data, there need be no hesitation to use a multilumen catheter if the care of the patient demands multiple access ports. The various silicone catheters can usually be left in place while infection is treated, although fungal and certain other infections are more likely to require catheter removal. Percutaneous plastic catheters should be removed or changed over a wire if infection is suspected; if tip culture of the removed catheter is positive, and the catheter was replaced over a wire, then the replacement catheter should be promptly removed.