Elective removal of cuffed central venous catheters in children

Incidence and risk factors of complications during central venous access devices removal in children

PURPOSE

To quantify the rates and identify risk factors for the complications of central venous access devices (CVADs) removal in children.

METHOD

Retrospective (2018-2023) review of children undergoing CVADs removal at a single institution. Data are reported as frequency, percentages and median. Logistic regression analysis was used to identify risk factors associated with difficult removal. Receiver Operating Characteristic Curve (ROC) analysis was conducted to identify the age cut-off and positive likelihood ratio (+LH) for the indwelling time associated with complicated removal. p-Value <0.05 were considered statistically significant.

RESULTS

We identified 208 CVAD removals with a median age of 7.2 (0.2-18.4) years including 116 (55.8%) males. The median CVAD placement duration was 1.26 years (0.4-5.7) years. Indications for insertion included acute lymphoblastic leukaemia (ALL; 78/208, 37.5%), lymphomas (31/208, 14.9%), other malignancies (58/208, 27.9%). Removal indications included completion of treatment (144/208, 69.2%), infection (22/208, 10.6%), malfunction (7/208, 3.4%) and other reasons (35/208, 16.8%). There were 20 (9.6%) complications characterised by difficulty removing the CVAD. Complicated removals were more likely to occur in children with ALL as the primary diagnosis (p = 0.001); independently of the indication for insertion, longer indwelling time was associated with higher risk of complicated removal (p < 0.001). Indwelling time >2.09 years was associated with a 2.87 increased risk of difficult removal.

CONCLUSION

In our experience, almost 10% of CVAD removals in children result in complications. These findings are associated with an indwelling time >2 years; strategies to prevent complicated removals should be considered in children requiring long-term central venous access.

Vascular Access in Pediatric Oncology and Hematology: State of the Art

Management and successful use of vascular access are critical issues in pediatric patients affected by malignancies. Prolonged course of disease, complex and various treatment protocols require long-lasting vascular access providing adequate tools to administrate those therapies and to collect routine blood sampling without painful and repeated venipuncture. For these reasons, central venous catheters are currently an important component in pediatric onco-hematological care, with a direct influence on outcome. Indeed, there are peculiar issues (techniques of insertion, management, complications etc.) which must be well-known in order to improve the outcome and the quality of life of children with cancer.

Removal and insertion of central venous catheters in cancer patients is associated with high symptom burden

OBJECTIVES

To assess the symptom burden associated with CVC removal and insertion in cancer patients.

METHODS

We collected patient-reported symptom-burden outcomes for 60 consecutive cancer patients: 30 undergoing CVC removal and 30 undergoing CVC insertion. Cancer patients self-administered the MD Anderson Symptom Inventory to rate the severity of 21 different symptoms immediately after the procedure Results: Symptoms were present in up to 57% to 67% of patients undergoing CVC insertion and removal respectively. Nineteen patients (32%) were moderately symptomatic with a symptom burden of four or more: ten insertion and nine removal patients. Symptoms with a score of 4 or more clustered around physical symptoms (pain, pressure or burning) or more generalized symptoms (fatigue, sleep, distress, dry mouth, and drowsiness). Nine (15%) patients rated at least one symptom as eight or more, five (17%) being insertion patients.

CONCLUSIONS

CVCs are essential for the management of cancer patients. However, they can become infected and may need to be removed. Catheter removal and insertion produced moderate to severe symptom burden in cancer patients. Safe interventions that would salvage the vascular access without worsening the infectious outcome should be explored to alleviate morbidity associated with the symptom burden of removal and re-insertion.

Complications of indwelling central venous catheters in pediatric liver transplant recipients

In pLT recipients, the advantages of ICVCs need to be weighed against the risk of complications. This single-center retrospective study aimed to review ICVC complications in our cohort of pLT recipients. We performed chart reviews of pLT patients having undergone transplant between 01/2000 and 03/2014 and who underwent ICVC placement either before or after LT. We identified 100 ICVC in 85 patients. Overall observation time was 90 470 catheter-days. There was no difference in catheter lifespan between those inserted pre- or post-transplant; 46% of ICVC presented a complication. Most frequent complications were MD and infection. The infection rate was 0.09 per 1000 catheter-days, and MD rate was 0.36 per 1000 catheter-days. Patients having received technical variant grafts were more at risk of complications. To the best of our knowledge, this is the first study examining ICVC complications in pLT recipients. We conclude that ICVC have a high rate of MD. Children receiving technical variants may be more at risk of complications. By removing ICVC in a select number of patients at six months post-insertion, we might avoid as much as 60% of complications.

Mechanics of a stuck central venous catheter removal

Although a surgical removal of tunneled central venous catheter is usually simple, it can become complicated when the catheter is found to be stuck because of its adherence within a central vein. If a catheter is pulled too hard, it may fracture within a central vein in two pieces. In this report, we describe the mechanics of central venous catheter breakage and provide a solution that minimizes the possibility of catheter from breaking as it is pulled out from its stuck position within a central vein.

Central venous access devices in pediatric malignancies: a position paper of Italian Association of Pediatric Hematology and Oncology

INTRODUCTION

Treatment of pediatric malignancies is becoming progressively more complex, implying the adoption of multimodal therapies. A reliable, long-lasting venous access represents one of the critical requirements for the success of those treatments. Recent technical innovations-such as minimally invasive procedures for placement, new devices and novel materials-have rapidly spread for clinical use in adult patients, but are still not consistently used in the pediatric population.

METHODS

The Supportive Therapy Working Group of Italian Association of Hematology and Oncology (AIEOP) reviewed medical literature focusing on new aspects of central venous access devices (VADs) in pediatric patients affected by oncohematological diseases.

RESULTS

Appropriate recommendations for clinical use in these patients have been discussed and formulated.

CONCLUSIONS

The importance of the correct choice, management and use of VADs in pediatric oncohematological patients is a necessary prerequisite for an adequate standard of care, also considering the increased chances of cure and the longer life expectancy of those patients with modern therapies.

A Dedicated Protocol and Environment for central venous Catheter removal in Pediatric Patients Affected by Onco-Hematological Diseases

Purpose

The removal of long-term central venous catheters (CVCs) is not performed according to evidence-based guidelines, thus conveying the message that it is a procedure of secondary importance. Our study aims at comparing the experience at Bambino Gesù Pediatric Hospital before and after the implementation of a dedicated protocol and the identification of a specific area to perform such a procedure under the so-called nonoperating room anesthesia (NORA).

Methods

Starting on January 1, 2010, an appropriate protocol regarding long-term CVC removal was applied. Then, data from all patients who underwent CVC removal under NORA regimen were compared with patients who have undergone the same procedure before the beginning of such protocol in terms of complication rate, duration of procedure, and costs.

Results

Between January 2010 and December 2012, 266 patients were evaluated for long-term CVC removal under a NORA regimen. Of these, 194 underwent the procedure. In the period from January 2007 to December 2009, 60 out of 82 patients scheduled for elective removal of long-term CVC in the operating theatre were eligible for this study. Median procedure time was 7 min for removal in NORA and 10 min for the operating theatre (p=0.016); no complications occurred.

Conclusion

Long-term CVC removal is an often-neglected procedure, carrying a small, but definite rate of complications. Our study shows that CVC removal performed in NORA regimen is safe and feasible, also allowing multiple procedures in the same session with prompt management of possible complications and reduction of the anxiety and pain associated with the procedure.

Clinical guidelines on central venous catheterisation. Swedish Society of Anaesthesiology and Intensive Care Medicine

Safe and reliable venous access is mandatory in modern health care, but central venous catheters (CVCs) are associated with significant morbidity and mortality, This paper describes current Swedish guidelines for clinical management of CVCs The guidelines supply updated recommendations that may be useful in other countries as well. Literature retrieval in the Cochrane and Pubmed databases, of papers written in English or Swedish and pertaining to CVC management, was done by members of a task force of the Swedish Society of Anaesthesiology and Intensive Care Medicine. Consensus meetings were held throughout the review process to allow all parts of the guidelines to be embraced by all contributors. All of the content was carefully scored according to criteria by the Oxford Centre for Evidence-Based Medicine. We aimed at producing useful and reliable guidelines on bleeding diathesis, vascular approach, ultrasonic guidance, catheter tip positioning, prevention and management of associated trauma and infection, and specific training and follow-up. A structured patient history focused on bleeding should be taken prior to insertion of a CVCs. The right internal jugular vein should primarily be chosen for insertion of a wide-bore CVC. Catheter tip positioning in the right atrium or lower third of the superior caval vein should be verified for long-term use. Ultrasonic guidance should be used for catheterisation by the internal jugular or femoral veins and may also be used for insertion via the subclavian veins or the veins of the upper limb. The operator inserting a CVC should wear cap, mask, and sterile gown and gloves. For long-term intravenous access, tunnelled CVC or subcutaneous venous ports are preferred. Intravenous position of the catheter tip should be verified by clinical or radiological methods after insertion and before each use. Simulator-assisted training of CVC insertion should precede bedside training in patients. Units inserting and managing CVC should have quality assertion programmes for implementation and follow-up of routines, teaching, training and clinical outcome. Clinical guidelines on a wide range of relevant topics have been introduced, based on extensive literature retrieval, to facilitate effective and safe management of CVCs.

Difficult extraction of long-term central venous catheters in children--case report

Although many publications address the complications associated with insertion of long-term, indwelling central venous catheters, there are only scattered reports of problems related to their removal. We report 4 cases of pediatric patients in whom the lines could not be pulled from the vein by standard methods, requiring 2 intraperiosteal clavicle resections with venorrhaphy, 1 femoral vein exploration and reconstruction, and 1 jugular venorrhaphy. Despite their relative biocompatibility, long-term silicone lines may become fixed in the vein. The rare and unpredictable occurrence of this problem may present the surgeon with unexpected intraoperative dilemmas. Before attempting localized extraction, surgeons should consider what venue, equipment, and anesthesia support may be required to successfully remove these catheters.