The CCSG prospective study of venous access devices: an analysis of insertions and causes for removal

Tunnelled external versus implanted port central venous catheters in paediatric oncology: a systematic review and meta-analysis

OBJECTIVE

To evaluate and compare the complications associated with tunnelled external and implanted port (PORT) central venous catheters (CVCs) in children with cancer.

DESIGN

A systematic review in accordance with PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) guidelines was performed (pre-registered on PROSPERO: CRD42022300869). MEDLINE, Web of Science and the Cochrane Library databases were searched.

PATIENTS

Patients ≤18 years of age with haematological or solid malignancies.

INTERVENTIONS

Studies comparing tunnelled external and PORT CVCs.

MAIN OUTCOMES MEASURES

Infection, mechanical failure, thrombosis, bleeding, acceptability, quality of life (QoL), cost, premature removal, and days from insertion to removal for any reason.

RESULTS

Twenty-three observational studies met the inclusion criteria, representing 6644 devices and 6032 patients. Tunnelled external CVCs were associated with an increased risk for systemic infection (OR 2.10, 95% CI 1.59 to 2.77, p<0.001, 16 studies, 3425 devices). There was no significant difference in the risk of localised infection (OR 1.15, 95% CI 0.66 to 2.01, p=0.62, 5 studies, 979 devices). Tunnelled external CVCs were also associated with a significantly increased risk of mechanical complications (OR 2.47, 95% CI 1.21 to 5.05, p=0.01, 11 studies, 2187 devices) and premature device removal (OR 3.24, 95% CI 1.28 to 8.22, p=0.01, 6 studies, 1514 devices).

CONCLUSION

This study shows that PORTs associate with a reduced risk of infectious and mechanical complications, and a lower overall risk of removal, compared with tunnelled external CVCs in children with cancer. Further work is required to confirm these findings in a prospective randomised trial and to compare cost implications and acceptability to patients and caregivers.

Factors Affecting Cuff Extrusion of Tunneled Hemodialysis Catheters

PURPOSE

To identify patient and procedural factors associated with extrusion of the Dacron cuff from the subcutaneous tunnel of tunneled hemodialysis catheters (THDCs).

MATERIALS AND METHODS

Single center 5-year retrospective analysis of 625 catheters in 293 adult patients. Patient data included age, gender, body mass index (BMI), and common comorbidities. Procedural details included type of procedure (new insertion vs. exchange), operator seniority, side of insertion, catheter model and presence of catheter wings skin-sutures. Complications were reported as cumulative risk over time and Cox proportional hazards model was used to evaluate risk factors for cuff extrusion (CE).

RESULTS

Median patient follow-up was 503 days (188,913 catheter-days) and median catheter survival 163 days. CE occurred in 23.8% of catheters, at a rate of 0.79 per 1,000 catheter-days and a median time of 64 days. It was more common than infection (14.6%) and inadequate flow (15.5%). The 1-month and 12-month risk of CE was 5.9% and 21.3% respectively. A first episode of CE was a strong predictor of future CE episodes. The only patient factor that affected the risk of CE was BMI (Hazard Ratio 2.36 for obese patients). Procedural factors that affected the risk of CE, adjusted for BMI, were catheter model, type of procedure (lower risk for new insertions) and catheter wings skin-sutures; the latter reduced the 30-day CE risk by 76% without increasing catheter-related infections.

CONCLUSION

Cuff extrusion is common in long-term THDCs. The risk increases with obesity, history of previous cuff extrusion, certain catheter models and absence of wing-sutures.

Application of transesophageal echocardiography for localization in totally implantable venous access port implantation through subclavian approach in children

A totally implantable venous access port (TIVAP) is important in children who need intravenous infusion for a long time. A number of studies have shown methods for locating the tip of the TIVAP catheter. To explore whether transesophageal echocardiography (TEE) can be used to accurately locate the TIVAP catheter tip through a subclavian approach and to improve the rate of correct TIVAP catheter placement and reduce complications of TIVAP placement. In 36 children who needed TIVAP implantation surgery, we used real-time TEE guidance to place the catheter tip around the crista terminalis. In all children, chest X-rays were used to figure out whether the catheter tip as localized by TEE was within the T5-T7 segment. Then, we compared the length of the catheter calculated by the height formula and the actual catheter length applied under TEE guidance. The medical records, surgical details, nursing records, and recorded complications were collected during the follow-up. The success rate of TIVAP implantation was 100% in all enrolled patients and no hemopneumothorax or pinch-off syndrome occurred. Compared with TEE, chest X-ray showed a coincidence rate of 80.56% in correctly detecting the TIVAP catheter tip locate. The height-derived catheter length (11.0 [9.6, 11.8]) cm and the TEE-derived catheter length (10.0 [9.3, 10.8]) cm were significantly different (p < .001). TEE can be used to guide TIVAP catheter positioning through a left subclavian approach in children accurately and successfully and more accurate than chest X-ray and height calculation formula.

The effect of Absolute Neutrophil Count (ANC) on early surgical site infection in Implanted Central Venous Catheter (ICVC)

PURPOSE

The aim of this study was to evaluate surgical site infection (SSI) rates related to implanted central venous catheters (ICVC) in pediatric hematology and oncology patients with respect to absolute neutrophil count (ANC) levels.

PATIENTS AND METHODS

From January 2004 to December 2015, pediatric patients with ICVC insertion were investigated retrospectively. Patients were divided into four groups according to preoperative ANC levels and Granulocyte-colony stimulating factor (G-CSF) usage. Immediate and early surgical site infections were evaluated 7 and 30 days following surgery.

RESULTS

In total, 1143 patients were enrolled. Patients were placed into 4 groups: 930 patients in group 1 with an ANC≥500/μL without G-CSF, 149 in group 2 with an ANC≥500/μL after G-CSF usage, 36 in group 3 with an ANC<500/μL without G-CSF, and 28 in group 4 with an ANC<500/μL even after G-CSF administration. Rates of immediate and early SSIs were not statistically different between groups. In the two-group analysis (group 1 and 2 vs. 3 and 4), the number of immediate and early SSIs were not also different, respectively.

CONCLUSION

There was no correlation between ANC levels and immediate and early SSI occurrence after ICVC placement.

LEVEL OF EVIDENCE

III.

Neutropenia at the time of subcutaneous port insertion may not be a risk factor for early infectious complications in pediatric oncology patients

BACKGROUND

The risk of infection associated with subcutaneous port (SQP) placement in patients with neutropenia remains unclear. We reviewed the rate of early infectious complications (<30 days) following SQP placement in pediatric oncology patients with or without neutropenia [absolute neutrophil count (ANC) <500/mm³].

METHODS

Baseline characteristics and infectious complications were compared between groups using univariate and multivariate analyses.

RESULTS

A total of 614 SQP were placed in 542 patients. Compared to nonneutropenic patients, those with neutropenia were more likely to have leukemia (n = 74, 94% vs n = 268, 50%), preoperative fever (n = 17, 22% vs n = 25, 5%), recent documented infection (n = 15, 19% vs n = 47, 9%), and were younger (81 vs 109 months) (p values <0.01). After adjusting for fever and underlying-disease, there was a nonsignificant association between neutropenia and early postoperative infection (OR 2.42, 95% CI 0.82-7.18, p = 0.11). Only preoperative fever was a predictor of infection (OR 6.09, 95% CI 2.08-17.81, p = 0.001).

CONCLUSION

SQP placement appears safe in most neutropenic patients.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

Level III.

Open tunneled central line insertion in children - External or internal jugular vein?

BACKGROUND/PURPOSE

Tunneled central venous catheters (TCVCs) are commonly used to manage pediatric patients with chronic disease. The aim of this study is to compare the outcomes of external jugular vein (EJV) and internal jugular vein (IJV) tunneled catheters inserted using the open technique.

METHODS

This is a single institution retrospective analysis of patients requiring an IJV or EJV TCVC in the period between 2009 and 2014. Data collected included the following: patient demographics, site/side of insertion, catheter size, number of lumens, duration of catheter in situ, and complications.

RESULTS

A total of 942 TCVCs (690 IJV; 252 EJV) were inserted in 761 patients. No statistical difference was seen between the two groups for procedure indications, age, gender, duration of line in situ, side of insertion, catheter size, number of lumens, and rate of premature catheter removals owing to complications. Rates of infection, blockage, and breakage were similar, but dislodgement was higher in the IJV group. EJV access was successful in 91% of attempts.

CONCLUSIONS

Open EJV TCVC insertion is a safe, quick, and feasible alternative to IJV insertion. EJV access offers comparable outcomes, reduced surgical morbidity, and improved hemostasis especially in children with coagulopathy and/or reduced platelet counts.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

Level 3.

Adult 'PICC' Device May be Used as a Tunnelled Central Venous Catheter in Children

Purpose

Central venous access in children, in particular small children and infants, is challenging. We have developed a technique employing adult peripherally inserted central venous catheters (PICCs) as tunnelled central venous catheters (TCVCs) in children. The principal advantage of this novel technique is that the removal technique is less complex than that of conventional cuffed TCVCs. The catheter can be removed simply by being pulled out and does not require general anaesthesia. The purpose of this study is to determine the success, safety and utility of this technique and to identify the rate of late complications. We describe the 6-year experience in our unit.

Materials and Methods

Electronic and paper medical records were reviewed for consecutive paediatric patients who had a PICC device inserted as a TCVC over a 6-year period (September 2009 through July 2015). The following data were recorded—patient demographics, setting for PICC as TCVC insertion, use of ultrasound and fluoroscopy, PICC device type, early or late complications and date of and reason for removal.

Results

Twenty-one PICCs were inserted as TCVCs in 19 children, all aged less than 10 years. Mean patient age at the time of placement was 3.7 years. Average patient weight was 15.7 kg. All insertions were successful with no significant immediate complications recorded. The most common indication for insertion in our patient sample was pseudo-obstruction secondary to gastrointestinal dysmotility disorder (24%), with cystic fibrosis infective exacerbation being the second most frequent diagnosis (14%). Suspected catheter-related infection led to early device removal in one case (4.8%). Inadvertent dislodgement occurred in one case (4.8%). Nineteen of the 21 devices (90.4%) lasted for the total intended duration of use.

Conclusion

Using a PICC device as a TCVC in small children appears to be a safe technique, with an acceptable complication profile.

Antimicrobial nitric oxide releasing surfaces based on S-nitroso-N-acetylpenicillamine impregnated polymers combined with submicron-textured surface topography

A novel dual functioning antimicrobial CarboSil 20 80A polymer material that combines physical topographical surface modification and nitric oxide (NO) release is prepared and evaluated for its efficacy in reducing bacterial adhesion in vitro. The new biomaterial is created via a soft lithography two-stage replication process to induce submicron textures on its surface, followed by solvent impregnation with the NO donor, S-nitroso-N-acetylpenicillamine (SNAP), to obtain long-term (up to 38 d) NO release. The NO releasing textured polymer surface is evaluated against four bacteria commonly known to cause infections in hospital settings and the results demonstrate that the combined strategy enables a synergistic effect on reducing the bacterial adhesion of Staphylococcus epidermidis and Pseudomonas aeruginosa bacteria.

Brachiocephalic vein for percutaneous ultrasound-guided central line positioning in children: A 20-month preliminary experience with 109 procedures

BACKGROUND

Ultrasound-guided (USG) cannulation of the brachiocephalic vein (BCV) is gaining worldwide consensus for central venous access in children. This study reports a 20-month experience with this approach in children.

METHODS

All patients who underwent percutaneous USG central venous catheter (CVC) positioning in the BCV between August 2013 and March 2015 have been included. Devices inserted during this period were open-ended, either single or double-lumen tunneled CVC. Our series was divided into three consecutive study periods in order to determine the relative incidence of repositioning and complications.

RESULTS

During the study period, a total of 95 patients underwent 109 CVC insertions in the BCV. The median length of CVC duration was 230 days for a total of 23,212 catheter days. No major intraoperative complications occurred. Overall rate of CVC-related postoperative complications requiring repositioning or precocious removal was 0.90 per 1,000 catheter days and involved 21 CVC (19%, 95% confidence interval 13-28). These included 18 dislodgments, two infections, and one malfunction. Double-lumen CVCs represented the only significant risk factor for complications (52% complications-three per 1,000 catheter days).

CONCLUSION

USG supraclavicular cannulation of the BCV represents a safe approach for central line placement in children. It proved to be versatile, as it can be used in premature infants as well as in adolescents. Provided it is adopted by operators experienced in USG cannulation, we strongly suggest to resort to this approach as a first-line choice in children undergoing tunnelled central line placement for long-lasting therapy.

Risk factors for central line-associated bloodstream infection in pediatric oncology patients with a totally implantable venous access port: A cohort study

BACKGROUND

Totally implantable venous access ports (TIVAPs) are used for prolonged central venous access, allowing the infusion of chemotherapy and other fluids and improving the quality of life of children with cancer. TIVAPs were developed to reduce the infection rates associated with central venous catheters; however, infectious events remain common and have not been fully investigated in pediatric oncology patients.

PROCEDURE

A retrospective cohort was formed to investigate risk factors for central line-associated bloodstream infection (CLABSI) in pediatric cancer patients. Sociodemographic, clinical, and TIVAP insertion-related variables were evaluated, with the endpoint being the first CLABSI. A Kaplan-Meier analysis was performed to determine CLABSI-free catheter survival.

RESULTS

Overall, 188 children were evaluated over 77,541 catheter days, with 94 being diagnosed with CLABSI (50%). Although coagulase-negative staphylococci were the pathogens most commonly isolated, Gram-negative microorganisms (46.8%) were also prevalent. In the multivariate analysis, factors that increased the risk for CLABSI were TIVAP insertion prior to chemotherapy (risk ratio [RR] = 1.56; P < 0.01), white blood cell count less than 1,000 mm^-3 on the day of implantation (RR = 1.64; P < 0.01), and chronic malnutrition (RR = 1.41; P < 0.05). Median time without CLABSI following TIVAP insertion was 74.5 days.

CONCLUSIONS

Risk factors for CLABSI in pediatric cancer patients with a TIVAP may be related to the severity of the child's condition at catheter insertion. Insertion of the catheter before chemotherapy and unfavorable conditions such as malnutrition and bone marrow aplasia can increase the risk of CLABSI. Protocols must be revised and surveillance increased over the first 10 weeks of treatment.

Transhepatic Central Venous Catheters in Pediatric Patients With Congenital Heart Disease

OBJECTIVES

Patients with congenital heart disease may have limited venous access routes as a result of multiple central venous catheters, surgical interventions, and catheterization procedures. Unconventional venous access includes transhepatic central venous catheter. We evaluated transhepatic central venous catheter placed in patients with congenital heart disease and risk factors associated with complications and outcomes.

DESIGN

Demographic, procedural, and complication data were retrospectively collected on all patients who underwent transhepatic central venous catheter placement at our center over the past 10 years.

SETTING

This study was completed in a tertiary congenital heart center.

PATIENTS

A total of 92 transhepatic central venous catheters were placed in 54 patients (63% male patients). The median age and weight of the patient population was 5.7 months and 5.5 kg, respectively.

INTERVENTIONS

Placement of a transhepatic central venous catheter.

MEASUREMENTS AND MAIN RESULTS

Successful catheter placement occurred in 96% of cases with median procedure time of 54 minutes with a procedural complication rate of 14%. A total of 86 complications occurred in 54 catheters placed during 2,166 catheter-days (39.7 complications per 1,000 catheter-days). Individual complication rates per 1,000 catheter-days included catheter dysfunction (14.8), dislodgement (8.8), systemic infection (5.1), thrombosis (4.2), local infection (3.7), and bleeding (3.2). Two complications contributed to patient deaths. Factors associated with developing complications included polyurethane central venous catheters (p = 0.03) and catheter duration at least 21 days (p = 0.004). The overall mortality in this population was 50% with median length of hospitalization of 49 days (interquartile range, 33-97).

CONCLUSIONS

Transhepatic central venous catheters represent a viable option for patients with limited access. Polyurethane catheters and catheter duration at least 21 days are associated with increased transhepatic central venous catheter complications. Although complication rates are higher than more traditional forms of central venous catheters, the long duration of hospitalization and high mortality rates in this patient population attest to their risks for poor outcomes irrespective of venous access.

Guideline for Prevention of Intravascular-Device–Related Infections

The “Guideline for Prevention of Intravascular Device-Related Infections” is designed to reduce the incidence of intravascular device-related infections by providing an over view of the evidence for recommendations considered prudent by consensus of Hospital Infection Control Practices Advisor y Committee (HICPAC) members. This two-part document updates and replaces the previously published Centers for Disease Control's (CDC) Guideline for Intravascular Infections (Am J Infect Control1983;11:183-199). Part I, “Intravascular Device-Related Infections: An Over view” discusses many of the issues and controversies in intravascular-device use and maintenance. These issues include definitions and diagnosis of catheter-related infection, appropriate barrier precautions during catheter insertion, inter vals for replacement of catheters, intravenous (IV) fluids and administration sets, catheter-site care, the role of specialized IV personnel, and the use of prophylactic antimi-crobials, flush solutions, and anticoagulants. Part II, “Recommendations for Prevention of Intravascular Device-Related Infections” provides consensus recommendations of the HICPAC for the prevention and control of intravascular device-related infections. A working draft of this document also was reviewed by experts in hospital infection control, internal medicine, pediatrics, and intravenous therapy. However, all recommendations contained in the guideline may not reflect the opinion of all reviewers.

Reduction in Thrombosis and Bacterial Adhesion with 7 Day Implantation of S-Nitroso-N-acetylpenicillamine (SNAP)-Doped Elast-eon E2As Catheters in Sheep

Thrombosis and infection are two common problems associated with blood-contacting medical devices such as catheters. Nitric oxide (NO) is known to be a potent antimicrobial agent as well as an inhibitor of platelet activation and adhesion. Healthy endothelial cells that line the inner walls of all blood vessels exhibit a NO flux of 0.5~4×10^-10 mol cm^-2 min^-1 that helps prevent thrombosis. Materials with a NO flux that is equivalent to this level are expected to exhibit similar anti-thrombotic properties. In this study, NO-releasing catheters were fabricated by incorporating S-nitroso-N-acetylpenicillamine (SNAP) in the Elast-eon E2As polymer. The SNAP/E2As catheters release physiological levels of NO for up to 20 d, as measured by chemiluminescence. Furthermore, SNAP is stable in the E2As polymer, retaining 89% of the initial SNAP after ethylene oxide (EO) sterilization. The SNAP/E2As and E2As control catheters were implanted in sheep veins for 7 d to examine the effect on thrombosis and bacterial adhesion. The SNAP/E2As catheters reduced the thrombus area when compared to the control (1.56 ± 0.76 and 5.06 ± 1.44 cm², respectively). A 90% reduction in bacterial adhesion was also observed for the SNAP/E2As catheters as compared to the controls. The results suggest that the SNAP/E2As polymer has the potential to improve the hemocompatibility and bactericidal activity of intravascular catheters, as well as other blood-contacting medical devices (e.g., vascular grafts, extracorporeal circuits).

Thrombosis as a complication of central venous access in pediatric patients with malignancies: a 5-year single-center experience

Background

Reliable central venous access (CVC) is essential for hematology–oncology patients since frequent puncture of peripheral veins—e.g., for chemotherapy, antibiotic administration, repeated blood sampling, and monitoring—can cause unacceptable pain and psychological trauma, as well as severe side effects in cases of extravasation of chemotherapy drugs. However, CVC lines still carry major risk factors, including thrombosis, infection (e.g., entry site, tunnel, and luminal infections), and catheter dislocation, leakage, or breakage.

Methods

Here we performed a retrospective database analysis to determine the incidence of CVC-associated thrombosis in a single-center cohort of 448 pediatric oncologic patients, and to analyze whether any subgroup of patients was at increased risk and thus might benefit from prophylactic anticoagulation.

Results

Of the 448 patients, 269 consecutive patients received a CVC, and 55 of these 269 patients (20%) also had a thrombosis. Of these 55 patients, 43 had at least one CVC-associated thrombosis (total number of CVC-associated thrombosis: n = 52). Among all patients, the median duration of CVC exposure was 464 days. Regarding exposure time, no significant difference was found between patients with and without CVC-associated thrombosis. Subclavia catheters and advanced tumor stages seem to be the main risk factors for the development of CVC-associated thrombosis, whereas pharmacologic prophylaxis did not seem to have a relevant impact on the rate of thrombosis.

Conclusions

We conclude that pediatric surgeons and oncologists should pay close attention to ensuring optimal and accurate CVC placement, as this appears the most effective tool to minimize CVC-associated complications.

Cost and safety of pediatric intensive care physician-placed broviac catheters

OBJECTIVE

To compare the cost and safety of placement of Broviac catheters in children by pediatric intensivists in a sedation suite versus placement by pediatric surgeons in the operating room.

DESIGN

Single-center retrospective analysis.

SETTING

Pediatric sedation suite and operating rooms in a tertiary care children's hospital.

PATIENTS

All pediatric patients with Broviac catheters placed (n = 253) at this institution over a 3-year period from 2007 to 2009.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We reviewed the charts of all pediatric patients with Broviac catheters placed, either by intensivists or surgeons, and compared cost and outcomes. Procedure safety was assessed and categorized into immediate, short-term (within 2 wk of procedure), and long-term outcomes. Anesthetic safety and billing data for the procedure were also collected. Among similar patient populations, immediate complications, such as pneumothorax, procedure failure (p > 0.999), and anesthetic complications (p = 0.60), were not significantly different. Short-term outcomes, including infection (p = 0.27) and catheter malfunction (p > 0.999), were not different. Long-term outcomes, including mean indwelling catheter days (p = 0.60) and removal due to catheter infection (p = 0.09), were not different between the groups. Overall cost of the procedure was significantly different: $7,031 (± $784) when performed by surgeons and $3,565 (± $311) when performed by intensivists (p < 0.001).

CONCLUSIONS

Pediatric critical care physicians can place Broviac catheters as safely as pediatric surgeons and at a lower cost in a defined patient population.

A comparison of central lines in pediatric oncology patients: Early removal and patient centered outcomes

BACKGROUND

While there is increasing evidence supporting the choice of subcutaneous ports (SPs) over external venous catheters (EVCs) in pediatric oncology patients, prior conflicting studies exist and little data have been gathered as to which type of central line is preferred from the patient/family perspective.

PROCEDURE

We performed a single institution, 10 years, retrospective analysis of central lines in pediatric oncology patients (n = 878) to evaluate unplanned early removal and cause of removal while simultaneously obtaining a cross sectional survey of 143 of the primary caretakers/parents of these patients to evaluate their overall satisfaction with the line.

RESULTS

EVCs have significantly higher odds of unplanned early removal in comparison to SPs (6.7% of SPs vs. 27.3% of EVCs, odds ratio (OR) = 6.3, P < 0.0001 when controlling for age and diagnosis) secondary to increased infection, malfunction and patient preference. Patients with SPs felt like their central line was easier to care for, had less daily impact in their life, and were overall more satisfied with their central line compared to patients with EVCs, even when controlling for early removal (P < 0.0001 for all). SP patients were much more likely to state that they would choose the same type of line again (OR = 15, P < 0.0001) than EVC patients.

CONCLUSION

SPs demonstrated lower removal rates and greater patient satisfaction than EVCs. These data should be considered when choosing a central line for pediatric cancer patients.

Antibiotic and other lock treatments for tunnelled central venous catheter-related infections in children with cancer

BACKGROUND

The risk of developing a tunnelled central venous catheter (CVC)-related infection ranges between 0.1 and 2.3 per 1000 catheter days for children with cancer. These infections are difficult to treat with systemic antibiotics (salvage rate 24% - 66%) due to biofilm formation in the CVC. Lock treatments can achieve 100 - 1000 times higher concentrations locally without exposure to high systemic concentrations.

OBJECTIVES

Our objective was to investigate the efficacy of antibiotic and other lock treatments in the treatment of CVC-related infections in children with cancer compared to a control intervention. We also assessed adverse events of lock treatments.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, issue 3, 2011), MEDLINE/PubMed (1945 to August 2011) and EMBASE/Ovid (1980 to August 2011). In addition we searched reference lists from relevant articles and the conference proceedings of the International Society for Paediatric Oncology (SIOP) (from 2006 to 2010), American Society of Clinical Oncology (ASCO) (from 2006 to 2010), the Multinational Association of Supportive Care in Cancer (MASCC) (from 2006 to 2011), the American Society of Hematology (ASH) (from 2006 to 2010) and the International Society of Thrombosis and Haematology (ISTH) (from 2006 to 2011). We scanned the ISRCTN Register and the National Institute of Health Register for ongoing trials (www.controlled-trials.com) (August 2011).

SELECTION CRITERIA

Randomised controlled trials (RCTs) and controlled clinical trials (CCTs) comparing an antibiotic lock or other lock treatment (with or without concomitant systemic antibiotics) with a control intervention (other lock treatment with or without concomitant systemic antibiotics or systemic antibiotics alone) for the treatment of CVC-related infections in children with cancer. For the description of adverse events, cohort studies were also eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, extracted data and performed 'Risk of bias' assessments of included studies. Analyses were performed according to the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

Two RCTs evaluated urokinase lock treatment with concomitant systemic antibiotics (n = 56) versus systemic antibiotics alone (n = 48), and one CCT evaluated ethanol lock treatment with concomitant systemic antibiotics (n = 15) versus systemic antibiotics alone (n = 13). No RCTs or CCTs evaluating antibiotic lock treatments were identified. All studies had methodological limitations and clinical heterogeneity between studies was present. We found no evidence of significant difference between ethanol or urokinase lock treatments with concomitant systemic antibiotics and systemic antibiotics alone regarding the number of participants cured, the number of recurrent CVC-related infections, the number of days until the first negative blood culture, the number of CVCs prematurely removed, ICU admission and sepsis. Not all studies were included in all analyses. No adverse events occurred in the five publications of cohort studies (one cohort was included in two publications) assessing this outcome; CVC malfunctioning occurred in three out of five publications of cohort studies assessing this outcome.

AUTHORS' CONCLUSIONS

No significant effect of urokinase or ethanol lock in addition to systemic antibiotics was found. However, this could be due to low power or a too-short follow-up. The cohort studies identified no adverse events; some cohort studies reported CVC malfunctioning. No RCTs or CCTs were published on antibiotic lock treatment alone. More well-designed RCTs are needed to further explore the effect of antibiotic or other lock treatments in the treatment of CVC-related infections in children with cancer.

Thromboresistance characterization of extruded nitric oxide-releasing silicone catheters

Intravascular catheters used in clinical practice can activate platelets, leading to thrombus formation and stagnation of blood flow. Nitric oxide (NO)-releasing polymers have been shown previously to reduce clot formation on a number of blood contacting devices. In this work, trilaminar NO-releasing silicone catheters were fabricated and tested for their thrombogenicity. All catheters had specifications of L = 6 cm, inner diameter = 21 gauge (0.0723 cm), outer diameter = 12 gauge (0.2052 cm), and NO-releasing layer thickness = 200 ± 11 µm. Control and NO-releasing catheters were characterized in vitro for their NO flux and NO release duration by gas phase chemiluminescence measurements. The catheters were then implanted in the right and left internal jugular veins of (N = 6 and average weight = 3 kg) adult male rabbits for 4 hours thrombogenicity testing. Platelet counts and function, methemoglobin (metHb), hemoglobin (Hb), and white cell counts and functional time (defined as patency time of catheter) were monitored as measured outcomes. Nitric oxide-releasing catheters (N = 6) maintained an average flux above (2 ± 0.5) × 10(-10) mol/min/cm for more than 24 hours, whereas controls showed no NO release. Methemoglobin, Hb, white cell, and platelet counts and platelet function at 4 hours were not significantly different from baseline (α = 0.05). However, clots on controls were visibly larger and prevented blood draws at a significantly (p < 0.05) earlier time (2.3 ± 0.7 hours) into the experiment, whereas all NO-releasing catheters survived the entire 4 hours test period. Results indicate that catheter NO flux levels attenuated thrombus formation in a short-term animal model.

Early cuff anchorage for tunneled central venous catheters using a buried absorbable suture

PURPOSE

Long-term tunneled cuffed central venous catheters (CVC) are widely used for the administration of chemotherapy, parenteral nutrition, and fluids. External migration and displacement of catheters have been reported to occur in 2.4% to 24% of cases, prompting the development of various anchoring strategies. We report an adaptation of previous techniques, where the cuff of a tunneled catheter is prevented from moving outwards by inserting a buried absorbable purse string suture around the catheter. Its effectiveness in catheter fixation has been assessed in a prospective audit.

METHODS

The effectiveness of the anchoring suture was assessed in a cohort of 101 oncology chemotherapy patients using specific measurements of catheter movement (Dacron cuff to suture distance, Dacron cuff to exit site distance, and external catheter length), taken at catheter insertion and removal.

RESULTS

Catheters were placed in situ for a median of 16 weeks. Displacement was found in 19% to 36% of lines (depending on the specific measurement taken), with a median cuff to exit site movement of 7.5 mm (range 5 to 40 mm) and a median length of external line movement of 10 mm (range 5 to 70 mm). The suture had good cosmetic results.

CONCLUSIONS

This is, to our knowledge, the first study to attempt to quantify CVC movement. Our data suggest that this suture technique provides an effective and safe additional strategy for cuffed tunneled CVC fixation.

Calcified Thrombus in Right Atrium: Rare but Treatable Complication of Long-term Indwelling Central Venous Catheter

Catheter-related central thrombosis is a rare complication of long-term central line. We describe the case of an asymptomatic boy who was diagnosed a calcified thrombus in right atrium eight years after the removal of a long-term central venous device. Although the most appropriate therapeutic approach for managing floating right heart thrombi remains to be determined, surgical removal is an effective and safe procedure for calcified long-standing thrombus and it is to be preferred in elective conditions especially in young asymptomatic patients without hemodynamic involvement, that are at low risk of surgery-related morbidity and mortality.

Central venous catheter database: an important issue in quality assurance

BACKGROUND/PURPOSE

The purpose of this study was to analyze the factors that affect the longevity of central venous catheters.

METHODS

Comprehensive clinical data recorded during insertion and removal of totally implantable devices (TID) and tunneled lines (TL) from October 1988 to January 2009 were analyzed. Univariate and multivariate Cox proportional hazards regression models were used to identify clinical factors that predict catheter longevity.

RESULTS

Information was available for 1167 central venous catheter insertions in 858 patients, 648 TID and 509 TL. Univariate analysis detected longer device longevity in the following: TID longer than TL (P < .0001), catheter tip in the superior vena cava (SVC)/right atrial junction (P < .0001), and right side greater than left (P = .002). Shorter device longevity was observed in lines used for total parenteral nutrition (P < .0001) and young age (P < .0001). Multivariate model detected the following: hazard of removal for TID is 0.304 that of TL (P < .0001) and SVC is 0.525 that of other locations (P = .0005). Hazard decreases by 5.4% for every 1-year increase in patient age (P < .0004).

CONCLUSION

Multiple confounding factors were encountered. However, the single most important factor in catheter longevity that is influenced by the surgeon is tip location in the SVC/right atrial junction.

Exclusion of neutropenic children from implanted central venous catheter placement: impact on early catheter removal

BACKGROUND/PURPOSE

Based on the known risks of implanted central venous catheter (ICVC) placement in neutropenic children, we instituted a protocol whereby children with hematologic malignancies and an absolute neutrophil count less than 0.5 x 10(9)/L were excluded from an ICVC and had a percutaneously inserted central catheter placed until neutropenia resolved. The impact of this policy on the incidence of ICVC removal within 100 days of placement was evaluated.

METHODS

The records of all children with hematologic malignancies who underwent placement of an ICVC (port or cuffed catheter) from 1999 through 2008 were reviewed. The incidence of catheter removal within 100 days was compared between subjects who had ICVC placed before (preprotocol) and after (postprotocol) the absolute neutrophil count-based exclusion protocol.

RESULTS

Implanted central venous catheters were placed in 437 children, 311 in group 1 and 126 in group 2. The incidence of catheter removal within 100 days of placement for infection (4.1% [13/314] versus 0.8% [1/126], P = .07) and all causes combined (9.6% [30/314] versus 2.4% [3/126], P = .01) was substantially lower in the postprotocol group.

CONCLUSIONS

We have demonstrated that a protocol whereby neutropenic children were excluded from ICVC placement dramatically diminished complications that necessitated early catheter removal.

Complications and risk factors of infection in pediatric hemato-oncology patients with totally implantable access ports (TIAPs)

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.

Prolonged interval in prophylactic heparin flushing for maintenance of subcutaneous implanted port care in patients with cancer

The long-term use of subcutaneous implanted ports for chemotherapy in cancer patients has been associated with the occurrence of thrombosis and infection. In this study, we compared the safety and efficacy of administration of 1000 U of heparin flushes in prolonged interval (every 6 weeks) with standard dose and schedule (500 U every 4 weeks) for port-related infections and thrombosis during periods of non-use. Data were collected retrospectively from patients treated for various cancer types (matched as 2:1 for age, gender, stage of the disease). Patients who had diseases that could cause thrombosis or bleeding in their past medical history, or were taking oral anticoagulants, or had contraindications for heparin usage were excluded. After completing their chemotherapy, 59 patients received prolonged interval, while 30 patients received standard schedule. All patients were followed for at least 1 year. No clinically documented port-related infection or thrombosis has been found in both groups. Also, none of the devices was removed during this time. Prophylactic flushing of central venous ports with 1000 U of heparin in every 6 weeks might be a safe, easy, cheaper, comfortable and effective alternative to standard dose and schedule for preventing thrombosis and infections.

Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America

These updated guidelines replace the previous management guidelines published in 2001. The guidelines are intended for use by health care providers who care for patients who either have these infections or may be at risk for them.

Ultrasound-guided percutaneous insertion of Hickman lines in children. Prospective study of 500 consecutive procedures

AIM

The ultrasound-guided percutaneous technique of Hickman line insertion has not been widely adopted in pediatric surgical practice. We wished to review our own experience of using this technique for insertion into the internal jugular vein.

METHODS

Our vascular access team consists of a consultant surgeon and 2 consultant anesthetists. All procedures were prospectively recorded on a database and were either performed or directly supervised by our team.

RESULTS

Five hundred consecutive Hickman lines were inserted between June 2004 and October 2006. Patients' ages ranged from 14 days to 19 years (median, 44 months). Patients weighed between 600 g to more than 100 kg. Lines inserted were all tunneled silicone Hickman lines with a Dacron cuff (size 2.7F-10F, with 1-3 lumens), of which 60% were 7F double-lumen lines. Successful cannulation occurred in 99.8%. Perioperative complications (within 30 days) occurred in 12 patients (2.4%) and were all treated conservatively with no need for either blood transfusion or chest drain. Catheter-related sepsis rate was 3.16 per 1000 line days.

DISCUSSION

1. The technique of ultrasound-guided percutaneous insertion of Hickman line to the internal jugular vein is safe and is applicable to all children regardless of size, age, or diagnosis. 2. Pediatric surgeons and anesthetists can learn this technique without specific training in interventional radiology. 3. A learning curve does exist, and we recommend concentrating pediatric vascular access procedures to a specialist team.

Pain, distress, and adult-child interaction during venipuncture in pediatric oncology: an examination of three types of venous access

This study examined pain and distress from needles in children undergoing blood sampling as a function of adult-child interaction and type of venous access (i.e., central external venous lines, internalized ports, or peripheral access via venipuncture). Participants were 55 pediatric oncology patients, aged 3-18 years, who were undergoing routine blood work. Pain ratings were obtained using the Faces Pain Scale-Revised (FPS-R) and conversation during the procedure was audio taped for coding using the Child-Adult Medical Procedure Interaction Scale-Revised (CAMPIS-R). Children's ratings of pain using the FPS-R were similar in the port (M=2.57/10, standard deviation [SD]=3.46) and peripheral (M=2.56/10, SD=3.24) groups, despite the fact that most children with internal ports were given a topical anesthetic. Similarly, there were no differences between port and peripheral groups in rates of child coping or distress, or parent and nurse observations of child pain. As would be expected, external line access was not associated with pain or distress, even among very young children, suggesting that they appropriately understood the pain rating scale. Results of the transcribed CAMPIS-R data indicate that the influences in adult-child interaction are bidirectional. Support was found for the well-established positive relationship between child distress and adult reassurance and empathy. Implications for intervention and selection of central venous access devices are discussed.

Prevention and management of central venous catheter occlusion and thrombosis in children with cancer

BACKGROUND

The views and clinical practice of children's cancer units were surveyed regarding management of central venous catheter (CVC) occlusion (CVC-occlusion), CVC-related thrombosis (CVC-thrombosis) and thromboembolism (CVC-thromboembolism).

PROCEDURE

A questionnaire was sent to all 22 United Kingdom Children's Cancer Study Group centres, requesting information about their views of the importance of, and their practices regarding, prophylaxis, diagnosis and treatment of CVC-occlusion/thrombosis.

RESULTS

Twenty (91%) centres responded. Eighty percent, 80% and 70%, respectively, stated that CVC-occlusion, CVC-thrombosis and CVC-thromboembolism were clinically important concerns. All centres used heparinised saline flushes as prophylaxis against CVC-occlusion, with little variation (</=30% centres) in frequency, volume and heparin concentration. Symptoms or signs suggesting partial CVC-occlusion, total CVC-occlusion, or CVC-thrombosis/thromboembolism were always investigated in 20%, 55% and 85% of centres, respectively, but with considerable variability in the nature and sequence of investigations performed, which included (depending on the clinical scenario) chest X-ray, contrast linography or venography, ultrasonography, echocardiography and magnetic resonance venography. A fibrinolytic lock was administered before investigation of CVC-occlusion in 75% of centres. Although 45%, 60% and 80%, respectively, always treated partial CVC-occlusion, total CVC-occlusion or CVC-thrombosis/thromboembolism, the type and order of treatments differed greatly between centres, especially for CVC-thrombosis/thromboembolism, in which CVC removal, systemic anticoagulation (heparin or warfarin), local or systemic fibrinolysis, or thrombectomy were performed in at least some centres.

CONCLUSIONS

The clinical practice of UKCCSG centres regarding prevention, investigation and treatment of CVC-occlusion/thrombosis varies greatly. Additional trials should facilitate development of evidence-based guidelines.

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.

Complications of Implanted Central Venous Catheters in Neutropenic Children

Although neutropenia is recognized as a risk factor for infection and compromised wound healing, there are little data regarding the specific impact of neutropenia on morbidity and mortality after placement of implanted central venous catheters (CVC). We conducted a retrospective review of children with a diagnosis of acute lymphocytic leukemia or aplastic anemia who received a CVC over a 5-year period. The absolute neutrophil count immediately before catheter placement was recorded. Three hundred eight catheters were placed in 195 patients with acute lymphocytic leukemia and 15 with aplastic anemia. Absolute neutrophil count was less than 0.5 x 109/L in 105 cases (Group 1). The incidence of CVC removal for all causes and for infection within 100 days in Group 1 was 17.1 per cent and 11.4 per cent, respectively, compared with 7.9 per cent ( P = 0.01) and 1.5 per cent ( P < 0.0001) with absolute neutrophil count 0.5 x 109/L or greater (Group 2). Infections included two cases of mucormycosis with one death. Ports were more likely than Hickman catheters (C. R. Bard Inc., Murray Hill, NJ) to be removed for all causes ( P = 0.01) and for infection ( P = 0.04). The placement of implanted central venous catheters in neutropenic children was associated with substantial infectious morbidity and one death. When possible, CVC, particularly ports, should be avoided in the presence of neutropenia.

Complications of central venous catheterization in critically ill children

BACKGROUND

Placement of central venous catheter is essential in the management of critically ill children. The purpose of the present paper was to evaluate the success rate, mechanical and thrombotic complications and risk factors associated with these complications from different central venous access sites in critically ill children.

METHODS

A prospective study was undertaken from February 2000 to March 2005 of 369 central venous catheterizations in children in a pediatric intensive care unit.

RESULTS

The veins most frequently used were femoral vein (45%), subclavian vein (32.2%), and internal jugular vein (22.8%). Mean +/- SD duration of catheterization was 9.5 +/- 6.5 days. The procedure was performed under emergency conditions in 18% of patients with an overall success rate of 92.4%. The success rate was significantly lower in younger patients with subclavian catheterization. Insertion-related complications were noted, including 33 arterial punctures (8.9%), 27 cases of malposition (7.3%), 19 hematomas (5.2%), 12 cases of minor bleeding (3.3%), and three cases of pneumothorax (0.8%), and they were more common in the subclavian vein than in the internal jugular and femoral vein. Multiple attempts and failed attempts significantly correlated with higher incidence of complications. Maintenance-related complications included obstruction (n = 26; 7%), accidental removal (n = 14; 3.8%), central venous thrombosis (n = 8; 2.2%), subcutaneous extravasation (n = 14; 3.8%), dislodgment (n = 1; 0.25%), and extravascular infusion (n = 1; 0.25%). The frequency of catheter maintenance-related complications was significantly higher in femoral catheterizations and increased significantly with an increase in the duration of catheterization. A total of five serious complications were seen (pneumothorax in three, dislodgment in one and extravascular infusion in one) in the present series.

CONCLUSIONS

Central venous catheterization in critically ill children is a relatively safe procedure, with a 1.3% rate of serious complications and no mortality. It seems safer to choose initially the femoral or internal jugular vein instead of the subclavian vein because of high success rate without serious insertion-related complications.

Port-A-Cath Insertions in Acute Leukaemia and Childhood Malignancies

OBJECTIVE

This retrospective case series sought to determine the incidence and profile of catheter-related complications associated with Port-A-Cath insertions in paediatric cancer patients, as well as predictive factors for infection-related port removals.

METHODS

Between January 2002 and December 2004, 175 consecutive Port-A-Cath insertions were followed for a total of 75,000 days (median, 407; range, 6-1,074). Incidence of catheter-related bloodstream infections (CRBSIs), other complications and CRBSI-related port removals were analysed for cases with acute leukaemia versus other malignancies.

RESULTS

A total of 33 CRBSIs were encountered in 26 cases (18.9%), an infection rate of 0.44 episodes per 1,000 catheter days. While mean preoperative platelet count was 125.34 x 10(9)/L in children with acute leukaemia and 392.11 x 10(9)/L in those with other malignancies (p < 0.01), the incidence of all complications were similar between both subgroups. Staphylococcus epidermidis (23.1%) and Klebsiella spp. (19.2%) were most commonly isolated from infected ports. Median patient age and duration of implantation in CRBSI-related port removals was 1.5 years and 111 days respectively, and 10.0 years and 414 days respectively in CRBSIs without port removal.

CONCLUSION

Minimal complications are associated with Port-A-Cath insertions, even in thrombocytopaenic leukaemic patients. The dominance of Gram-negative organisms in CRBSIs parallels the changing trend of nosocomial infectious agents involved in catheter-related infections.

Transhepatic Broviac catheter placement for long-term central venous access in critically ill children with complex congenital heart disease

OBJECTIVE

Critically ill children with cardiac disease often require prolonged central venous access. Thrombosis of systemic veins or the need to preserve vessels for future cardiac procedures limits sites for placement of central venous catheters in these patients. This study evaluates the use of Broviac placement via the transhepatic approach for this patient population.

DESIGN

A retrospective review.

SETTING

A tertiary care center.

PATIENTS

All children with complex congenital heart disease who underwent transhepatic Broviac placement between May 2000 and April 2004.

INTERVENTIONS

Transhepatic Broviac placement.

MEASUREMENTS AND MAIN RESULTS

Thirty-two children with a median age of 5 months (20 days-5.3 yrs) and a median weight of 4.2 kg (2.2-24.9 kg) underwent 40 transhepatic Broviac placements. There were three (8.8%) procedural-related complications. One patient suffered an intra-abdominal bleed requiring an urgent laparotomy and removal of the Broviac, one patient required transfusion because of a mild self-contained intra-abdominal bleed, and one patient developed temporary complete heart block. There was one catheter infection. Thrombus was noted by echocardiography on the tip of two Broviacs; however, no intracardiac vegetations or embolic events occurred. There was no mortality related to the procedure. Broviacs remained in place for a median of 36 days (1 day-6 months). Five Broviacs were dislodged inadvertently (two during cardiac massage and three resulting from patient manipulation). The remaining Broviacs were electively removed safely without coil embolization. At a median follow-up of 3.5 months (10 days-3 yrs), there have been no long-term complications related to the Broviacs.

CONCLUSIONS

Transhepatic Broviac catheters can be used safely in critically ill children with cardiac disease and remain indwelling for adequate periods of time. This modality of prolonged vascular access should be considered for children whose veins are occluded or need to be preserved for future procedures.

Prevention of catheter-related bacteremia in pediatric intestinal transplantation/short gut syndrome children with long-term central venous catheters

Catheter-related bacteremia (CRB), along with liver failure is the leading cause of mortality and morbidity in parenteral nutrition dependent children. Immunosuppressant therapy following transplantation increases the risk of CRB. Previous reports in pediatric cancer patients have described the use of antibiotic lock solutions (ABL) for prophylaxis of CRB. In our institution, we evaluated five children (ages between one and four yr old), three with intestinal transplantation and two with short gut syndrome, who were high risk for recurrent CRB defined by their incidence of bacteremias in the observation period (>2 CRB/six months or life-threatening CRB). These children received the prophylactic ABL protocol with tobramycin-tissue plasminogen activator, four h per day, on alternating ports for six to eight months. Each patient was his/her own historical control. We observed decreased incidence of CRB's (p < 0.05), days of hospitalization due to CRB's (p < 0.0001), the days of intensive care admissions due to CRB (p < 0.0001), as well as the total days of systemic antibiotic exposure (p < 0.001). Catheter survival during the ABL era was longer but not reaching statistical significance. There was no advantage in removing and later replacing the catheter to wire-guided exchange while on systemic antibiotics. One patient presented with break-through bacteremia, septic shock and died. None of the catheters were lost to occlusion/malfunction. ABL did not induce an increased resistance to tobramycin. These preliminary findings suggest that ABL can be used safely and effectively in parenteral nutrition dependent children with long-term central venous catheters.

Central venous cannulation: are routine chest radiographs necessary after B-mode and colour Doppler sonography check?

BACKGROUND

After the insertion of a central venous catheter, a chest radiograph is usually obtained to ensure correct positioning of the catheter tip.

OBJECTIVE

To determine in a paediatric population whether B-mode and colour Doppler sonography after central venous access is useful to evaluate catheter position, thus obviating the need for a postprocedural radiograph.

MATERIALS AND METHODS

A prospective study of 107 consecutive central venous access procedures placed in a paediatric intensive care unit was performed. At the end of the procedure, B-mode and colour Doppler sonography were used to assess catheter position and check for complications. A postprocedural chest radiograph was obtained in all patients.

RESULTS

In 96 patients postprocedural B-mode and colour Doppler sonography showed colour Doppler signals within the vena cava. Among the 11 patients predicted to have a potential complication, there was one pneumothorax and ten malpositions. Chest radiography showed a total of 13 complications-1 pneumothorax and 12 malpositions. The concordance between colour Doppler sonography and chest radiography was 98.1% in the detection of catheter position; sonography had a sensitivity of 84.6% and a specificity of 100%.

CONCLUSIONS

The close concordance between B-mode and colour Doppler sonography and chest radiography justifies the more frequent use of sonography to evaluate catheter position because ionizing radiation is eliminated. Chest radiography may then be performed only when there is suspected inappropriate catheter tip position after sonography.

Central Venous Lines in Children With Lesser Risk Acute Lymphoblastic Leukemia: Optimal Type and Timing of Placement

Purpose

In pediatric patients with acute lymphoblastic leukemia (ALL), the optimal time for central venous line (CVL) insertion and the optimal type of CVL (internal v external) is unclear. This study was undertaken to compare complication rates between early versus late line insertion, and between internal versus external lines in children with lesser risk ALL.

Patients and Methods

We performed a retrospective analysis of patients enrolled onto Pediatric Oncology Group (POG) protocol 9201. Data regarding demographics, CVL types and insertion dates, blood counts, and complications were reviewed through week 25 of therapy.

Results

Of 697 patients enrolled onto POG protocol 9201, 362 patients had sufficient data for analysis. When compared to late line placement (> day 15 of induction), early CVL placement (≤ day 15 of induction) was associated with an increased risk of having a positive blood culture (odds ratio, 2.2; 95% CI, 1.0 to 5.0; P = .05). When compared with internal CVLs (“ports”), external CVLs were associated with a positive blood culture (odds ratio, 3.1; 95% CI, 1.3 to 7.5; P = .01), thrombosis (odds ratio, 3.9; 95% CI, 1.5 to 10.3; P = .006), and CVL removal (odds ratio, 5.6; 95% CI, 2.7 to 11.6; P < .001).

Conclusion

In pediatric patients with lesser risk ALL, internal lines (ports) should be the preferred CVL type due to a lower risk of infectious and thrombotic complications. In addition, CVLs placed early in induction are associated with a higher risk of positive blood culture than those placed later in induction.

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.

Central venous catheter-related complications in children with oncological/hematological diseases: an observational study of 418 devices

BACKGROUND

The use of indwelling central venous catheters (CVCs) has become commonplace in the management of children undergoing anticancer treatment. Several types of CVC are available, while information on complications observed in children is scarce. We describe the experience of two tertiary care centers in Italy that prospectively followed up three types of CVC used at both institutions over a 30-month period.

PATIENTS AND METHODS

Between January 2000 and May 2002, double-lumen (DL) or single-lumen (SL) Hickman-Broviac (HB) catheters, and single-lumen pressure-activated safety valve (PASV) catheters were used and prospectively evaluated. Four types of possible complication were defined a priori: mechanical, thrombotic, malfunctioning and infectious.

RESULTS

Four hundred and eighteen CVCs (180 SL-HB, 162 DL-HB and 76 PASV) were inserted in 368 children, for a total of 107 012 catheter days at risk of complication. At least one complication occurred while using 169 of the devices (40%): 46% of the DL-HB, 46% of the PASV and 33% of the SL-HB (P=0.02) catheters. Subjects with hematological malignancies or non-malignant diseases had significantly more complications than those with solid tumors (P <0.0001). Overall, 234 complications were documented: 93 infectious [complication rate per 1000 catheter days at risk (CR)=0.87], 84 malfunctioning (CR=0.78), 48 mechanical (CR=0.45) and nine thrombotic (CR=0.08). SL-HB had statistically fewer infectious complications, while PASV had more mechanical complications. In a multivariate regression model, the most significant risk factors for having a CVC complication were hematological disease [relative risk (RR)=3.0; 95% confidence interval (CI) 1.8-4.8] and age <6 years at CVC insertion (RR=2.5; 95% CI 1.5-4.1). As for the type of CVC, compared with SL-HB, the DL-HB catheter had a statistically significant two-fold increased risk of any complication (RR=2.1; 95% CI 1.2-3.6), while the PASV catheter had a borderline RR of 1.8 (95% CI 1.0-3.6). Analysis by tumor type showed a higher risk of any kind of complication in patients with solid malignancies who had received a DL-HB catheter as compared with an SL-HB catheter (RR=7.2; 95% CI 2.8-18.7).

CONCLUSIONS

CVCs may cause complications in up to 40% of patients, with type of CVC, underlying disease and patient age being the three main factors that affect the incidence of CVC-related complications. SL-HB catheters have the best performance.

Port-A-Cath infections in children with cancer

Implanted subcutaneous (s.c.) central venous port accesses including Port-A-Cath (PAC) facilitate the administration of chemotherapy or blood products and are frequently used in children with cancer. The incidence of PAC-related infections was determined in 155 consecutive paediatric cancer patients with PAC followed for a total of 134,773 days (median, 738; range, 25-2080). Overall, 48 bloodstream infections occurred in 26 patients. 12 (25%) of these infections and 3 local infections at the insertion site were treatment-resistant and demanded removal of the PAC. Coagulase-negative staphylococci were involved in 12 of these 15 episodes. The rate of clearly PAC-related infections in this so far largest reported series was 0.11 episodes per 1000 PAC days, one of the lowest in the literature. Although catheter-related infections demanded PAC removal in 8% of our patients, the long periods PAC were in use and their benefits argue for continued PAC use in the paediatric cancer population.

Antibiotic lock with vancomycin and urokinase can successfully treat colonized central venous catheters in pediatric cancer patients

We used an antibiotic lock technique with vancomycin in combination with urokinase in 10 consecutive eligible children with Gram-positive catheter-related bacteremia persisting after appropriate intravenous antibiotics. Treatment was successful in sterilizing all colonized central venous catheters, avoiding device removal and delay of further chemotherapy. The antibiotic lock technique may represent a safe and effective therapeutic option in patients with selected, uncomplicated catheter-related bacteremias resistant to systemic antimicrobial therapy, particularly when maintaining a venous access is mandatory.

Factors influencing early failure of central venous catheters in children with cancer

BACKGROUND

The authors report the results of a prospective, multicenter, multidisciplinary study of central venous catheters (CVCs) in pediatric oncology patients analyzing factors involved in early failure.

METHODS

Information was collected from parent-held records on the fate of 824 devices inserted over a 20-month period, 415 of which were no longer in situ.

RESULTS

Within the first 7 weeks after insertion, there were 66 failures, all occurring in external lines. Accidental dislodgement was the principal reason for CVC failure (44 of 66, 67%). Detailed analysis of the reason for failure of this large subgroup showed 11 factors individually associated with early dislodgement, of which, 4 were independently associated with failure by multivariate analysis. These 4 variables were the use of multilumen catheters, the absence of a skin exit site suture, platelet transfusion at the time of insertion, and patient age less than 2 years.

CONCLUSIONS

This study confirms the multiple influences on successful CVC usage. Our analysis supports the principle of only using multilumen lines when clinically essential. The findings also support the inception of randomized studies of fixation, particularly in infants.

Prophylactic urokinase in the management of long-term venous access devices in children: a Children's Oncology Group study

PURPOSE

Infection and thrombosis are serious complications of long-term vascular access devices in children undergoing chemotherapy. Since routine fibrinolytic therapy may decrease these complications, the purpose of this study was to compare the efficacy of an every-2-week administration of urokinase with standard heparin flushes in reducing the incidence of device-related infections and occlusions.

MATERIALS AND METHODS

This study was a prospective, randomized phase III multicenter trial conducted by the Children's Cancer Group, in which patients with implantable ports or tunneled catheters received either urokinase or heparin every 2 weeks for 12 months. Study end points were time to first occlusion or time to first device-related infection.

RESULTS

Five hundred seventy-seven patients from 29 institutions were enrolled, of whom 51% had external catheters and 49% had ports. Urokinase administration resulted in fewer occlusive events than heparin (23% v 31%; P =.02), a longer time to first occlusive event (log-rank analysis, P =.006), and a 1.6-fold difference in the rate of occlusive events (Poisson regression, P =.003). Similar results were noted when comparing ports and tunneled catheters. The urokinase group also had a 1.4-fold difference in the rate of infection (Poisson regression, P =.05) and longer time to first infection (log-rank, P =.07), but the difference was significant only in tunneled catheters.

CONCLUSION

Urokinase administration every 2 weeks significantly affects the rate of occlusive events in ports and tunneled catheters and of infectious events in external catheters compared with heparin administration.

A single institution observational study of early mechanical complications in central venous catheters (valved and open-ended) in children with cancer

The use of indwelling central venous catheters (CVCs) has become essential for managing children undergoing cancer treatment. Various types of CVCs are available, but reports on complications observed in pediatric series are scarce. We describe our experience concerning early mechanical complications at our institute by providing a prospective evaluation of three types of CVCs that were inserted over a 39-month period. Between January 1, 2000, and March 31, 2003, double-lumen (DL) or single-lumen (SL) Hickman-Broviac (HB) and single-lumen pressure-activated safety-valved (PASV) catheters were inserted and prospectively evaluated. Five groups of possible mechanical complications were defined a priori: dislodgement, migration, rupture, accidental removal, and blockage. We took into consideration complications occurring only within the first 30 days of insertion. A total of 272 CVCs (118 PASV, 57 DL-HB, and 97 SL-HB) were inserted in 232 children. A total of 29 early mechanical complications (10.7% of all CVCs) were diagnosed: 15.2% of the PASV, 10.5% of the DL-HB, and 4.1% of the SL-HB. Elective removal of the catheter due to complications was required in eight patients. SL-HB catheters had fewer complications, while the complication rate and the number of devices that were removed were significantly higher in patients with PASV catheters. We conclude that catheter type correlates with the risk of early mechanical complications and removal.

Candida infections in children treated with conventional chemotherapy for solid tumors (transplant recipients excluded): The Institut Gustave Roussy Pediatrics Department experience

INTRODUCTION

Advances in medical therapy have greatly improved the survival of children suffering from cancer. Although progress has been made in the eradication of malignant disease there is growing concern for the development of fungal infections in patients treated with chemotherapy.

MATERIALS AND METHODS

We reviewed all episodes of pediatric candidemia that occurred between January 1988 and December 2000. We analyzed the general characteristics of this population, risk factors, microbiology features, treatment, complications, and outcome.

RESULTS

Seventeen cases of candidemia were observed during the 12 years of the study at an estimated incidence of 0.4%. Neutropenia occurred at the onset of infection in 13/17 (76.5%) children. A central venous device was present in all cases. Seventy-seven percent of the infections were caused by Candida albicans and in 85% of patients, yeasts had colonized the gastrointestinal tract. In 9/17 patients visceral dissemination was documented. Overall, in 77% of the episodes the outcome was favorable.

CONCLUSIONS

Candidemia is a rare but severe complication in pediatric oncology. Even if the prognosis is better in children than in adults, Candida septicemia remains of great concern since a high percentage of these infections result in visceral dissemination and mortality is still elevated.

Comparison of delayed complications of central venous catheters placed surgically or radiologically in pediatric oncology patients

PURPOSE

Pediatric central venous catheters (CVCs) traditionally have been placed surgically, guided by anatomic landmarks. Increasingly, interventional radiology services are inserting CVCs using ultrasound image guidance. This study compares the frequency of delayed complications in CVCs placed surgically or radiologically in a pediatric oncology population.

METHODS

Data on CVCs placed in one academic institution over 10 years were collected and analyzed retrospectively. Main outcomes assessed were infectious complications, mechanical complications, and premature catheter removal.

RESULTS

Ninety-eight CVCs-comprising 52 external tunneled catheters (ETCs) and 46 subcutaneous ports-were assessed in 67 patients. Median patient age was 6.1 years for children with external catheters and 7.8 years for those with ports. Both infectious and mechanical complications were significantly more common among surgically placed ETCs than those placed radiologically (P <.05). Complications per 1,000 catheter days and premature removal showed a trend toward greater frequency among surgical ETCs, although this did not reach statistical significance. No consistent trends were seen in complications among ports.

CONCLUSIONS

Pediatric patients with CVCs, especially those with external catheters, experience frequent delayed complications. Patients with radiologically inserted ETCs may encounter fewer complications than those with surgically placed ones. This corroborates previous reports in the literature suggesting image-guided CVC placement as a preferable alternative to traditional techniques.