Pediatric arterial catheters: Complications and associated risk factors

Epidemiology of Acute Respiratory Failure in US Children: Outcomes and Resource Use

OBJECTIVE

Acute respiratory failure recalcitrant to conventional management often requires specialized organ-supportive technologies to optimize outcomes. Variation in the availability of these technologies prompted testing of the hypothesis that outcomes and resource use will vary by not only patient characteristics but also hospital characteristics and receipt of organ-supportive technology.

METHODS

Retrospective study of children 0 to 20 years old hospitalized for acute respiratory failure using the 2019 Kids' Inpatient Database. Multivariable regression models identified factors associated with mortality, length of hospitalization, and costs.

RESULTS

Of an estimated 75 365 hospitalizations nationally, 97% were to urban teaching hospitals, 57% were of children < 6 years, and 58% were of males. Complex chronic conditions (CCC) existed in 62%, multiorgan dysfunction in 35%, and extreme illness severity in 54%. Mortality was 7%, length of stay 15 days, and hospital costs $77 168. Elevated mortality was associated with cumulative organ dysfunction (odds ratio [OR]:2.31, 95% confidence interval [CI]: 2.22-2.42), CCC (OR: 5.49, 95% CI: 4.73-6.37), transfer, higher illness severity, and cardiopulmonary resuscitation. Lower mortality was associated with extracorporeal membrane oxygenation (OR: 0.36, 95% CI: 0.28-0.47) and new tracheostomy (OR: 0.30, 95% CI: 0.25-0.35). Longer hospitalization was associated with transfer, infancy, CCC, higher illness severity, cumulative organ dysfunction, and urban hospitals. Higher costs accrued with noninfants, cumulative organ dysfunction, private insurance, and urban teaching hospitals.

CONCLUSIONS

Hospitalizations for pediatric acute respiratory failure incurred substantial mortality and resource consumption. Efforts to reduce mortality and resource consumption should address interhospital transfer, access to organ-supportive technology, and drivers of higher severity-adjusted resource consumption at urban hospitals.

Comparison of invasive blood pressure monitoring vs. non-invasive blood pressure monitoring in critically ill children receiving vasoactive agents-a prospective observational study

Objective

The primary aim of this study was to compare non-invasive blood pressure (NIBP) measurement using the automated oscillometric method with invasive blood pressure (IBP) measurement using peripheral arterial line insertion in critically ill children receiving vasoactive agents.

Design

Single-centre, prospective cohort study.

Setting

Tertiary care 15 bedded Pediatric ICU in Urban Indian city.

Subjects

All critically ill children between the ages of 1 month to 16 years with shock on vasoactive medications and with IBP monitoring.

Results

Forty children with 1,072 paired BP measurements were incorporated in the final analysis. Among all normotensive children (Total number of paired measurements = 623) receiving vasoactive agents, Bland-Altman analysis revealed an acceptable agreement between Invasive mean blood pressure (MBP) and non-invasive MBP with a bias of -2.10 mmHg (SD 11.35). The 95% limits of agreement were from -24.34 to 20.14 mmHg. In children with hypotension (Total number of paired measurements = 449), Bland-Altman analysis showed disagreement between Invasive MBP and non-invasive MBP i.e., a bias of -8.44 mmHg (SD 9.62). The 95% limits of agreement were from -27.29 to 10.41 mmHg.

Conclusion

A limited agreement exists between invasive blood pressure (IBP) and non-invasive blood pressure (NIBP) measurements in critically ill children requiring vasoactive agents. This discrepancy can lead to either an underestimation or an overestimation of blood pressure. While NIBP can serve as a screening tool for hemodynamically stable children, those who are hemodynamically unstable and necessitate the initiation of vasoactive agents should undergo IBP monitoring.

Peripheral arterial catheter securement and catheter survival in the pediatric intensive care unit

BACKGROUND

Peripheral arterial catheters (PACs), and their associated complications, are common in the pediatric intensive care unit (PICU). Accidental catheter displacement and non-functional PACs are the most common complications, and this may be related to inadequate catheter securement. There is mixed guidance on the best way to secure PACs to prevent complications. The authors hypothesized that sutures would not be associated with a decreased risk of malfunction or accidental removal.

METHODS

This was a single center retrospective cohort study at a quaternary-care PICU. PICU patients with a peripheral arterial catheter placed in the PICU from 7/2020 to 1/2023 were included. The primary outcome was unplanned PAC removal. A univariate and multivariate Cox proportional hazards regression analysis was performed, using patient weight, sedation, paralytic, and role of the proceduralist as covariates. The secondary outcome was survival probability. A log-rank test was used to compare survival curves.

RESULTS

Of 761 PACs that met inclusion criteria in 437 unique patients, 599 were sutured (78.7%) and 162 were un-sutured (21.3%). In 257 cases (33.8%), the PAC had an unplanned removal. Among all PACs, the median duration of PAC placement was 5.3 days (IQR 2.1-10.5 days). There was an unplanned removal rate of 42.2% (68) in the un-sutured group and 31.4% (188) in the sutured group (p < 0.001). In multivariable analysis, sutured PACs were also associated with a lower rate of unplanned removal (hazard ratio, 0.59; 95% CI, 0.44-0.78). Use of continuous sedation was also associated with an increased risk of unplanned removal of PACs (hazard ratio, 1.54; 95% CI, 1.10-2.16). There was a 50% survival probability at 13.3 days for un-sutured PACs and 23.7 days for sutured PACs.

CONCLUSIONS

Suturing is associated with fewer unplanned removals and longer catheter survival, compared to un-sutured PACs in pediatric patients.

Device Related Thrombosis and Bleeding in Pediatric Health Care: A Meta-analysis

CONTEXT

The risk of invasive device-related thrombosis and bleeding contributes to morbidity and mortality, yet their prevalence by device-types is poorly understood.

OBJECTIVES

This study aimed to estimate pooled proportions and rates of thrombotic and bleeding complications associated with invasive devices in pediatric health care.

DATA SOURCES

Medline, CINAHL, Embase, Web of Science, Scopus, Cochrane CENTRAL, clinical trial registries, and unpublished study databases were searched.

STUDY SELECTION

Cohort studies and trials published from January 2011 to June 2022, including (1) indwelling invasive devices, (2) pediatric participants admitted to a hospital, (3) reporting thrombotic and bleeding complications, and (4) published in English, were included.

DATA EXTRACTION

Meta-analysis of observational studies in epidemiology guidelines for abstracting and assessing data quality and validity were used.

MAIN OUTCOMES AND MEASURES

Device-specific pooled thromboses (symptomatic, asymptomatic, unspecified) and bleeding (major, minor).

RESULTS

Of the 107 studies, 71 (66%) focused on central venous access devices. Symptomatic venous thromboembolism in central venous access devices was 4% (95% confidence interval [CI], 3-5; incidence rate 0.03 per 1000 device-days, 95% CI, 0.00-0.07), whereas asymptomatic was 10% (95% CI, 7-13; incidence rate 0.25 per 1000 device-days, 95% CI, 0.14-0.36). Both ventricular assist devices (28%; 95% CI, 19-39) and extracorporeal membrane oxygenation (67%; 95% CI, 52-81) were often associated with major bleeding complications.

CONCLUSIONS

This comprehensive estimate of the incidence and prevalence of device-related thrombosis and bleeding complications in children can inform clinical decision-making, guide risk assessment, and surveillance.

Patient and Technical Factors Associated with Difficult Arterial Access and Ultrasound Use in the Operating Room

Arterial catheterization enables continuous hemodynamic monitoring but has been shown to cause severe complications, especially when multiple attempts are required. The aim of this study was to explore what factors were associated with multiple attempts and ultrasound use in the operating room. We performed a retrospective analysis of patients who had arterial catheters inserted at a tertiary care children's hospital from January 2018 to March 2022, identifying clinical factors that were associated with both outcomes. A total of 3946 successful arterial catheter insertions were included. Multivariable analysis showed multiple attempts were associated with noncardiac surgery: pediatric (OR: 1.79, 95% CI: 1.30-2.51), neurologic (OR: 2.63, 95% CI: 1.89-3.57), orthopedic (OR: 3.23, 95% CI: 2.27-4.55), and non-radial artery placement (OR: 5.00, 95% CI: 3.33-7.14) (all p < 0.001). Multivariable analysis showed ultrasound use was associated with neonates (OR: 9.6, 95% CI: 4.1-22.5), infants (OR: 6.98, 95% CI: 4.67-10.42), toddlers (OR: 6.10, 95% CI: 3.8-9.8), and children (OR: 2.0, 95% CI: 1.7-2.5) compared to teenagers, with cardiac surgery being relative to other specialties-pediatric (OR: 0.48, 95% CI: 0.3-0.7), neurologic (OR: 0.27, 95% CI: 0.18-0.40), and orthopedic (OR: 0.38, 95% CI: 0.25-0.58) (all p < 0.001). In our exploratory analysis, increased odds of first-attempt arterial catheter insertion success were associated with cardiac surgery, palpation technique, and radial artery placement. Younger patient age category, ASA III and IV status, cardiac surgery, and anesthesiologist placement were associated with increased odds of ultrasound use.

Diagnostic test accuracy for cessation of circulation during death determination: a systematic review

PURPOSE

To synthesize the available evidence comparing noninvasive methods of measuring the cessation of circulation in patients who are potential organ donors undergoing death determination by circulatory criteria (DCC) with the current accepted standard of invasive arterial blood pressure (IAP) monitoring.

SOURCE

We searched (from inception until 27 April 2021) MEDLINE, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials. We screened citations and manuscripts independently and in duplicate for eligible studies that compared noninvasive methodologies assessing circulation in patients who were monitored around a period of cessation of circulation. We performed risk of bias assessment, data abstraction, and quality assessment using Grading of Recommendations, Assessment, Development, and Evaluation in duplicate and independently. We presented findings narratively.

PRINCIPAL FINDINGS

We included 21 eligible studies (N = 1,177 patients). Meta-analysis was not possible because of study heterogeneity. We identified low quality evidence from four indirect studies (n = 89) showing pulse palpation is less sensitive and specific than IAP (reported sensitivity range, 0.76-0.90; specificity, 0.41-0.79). Isoelectric electrocardiogram (ECG) had excellent specificity for death (two studies; 0% [0/510]), but likely increases the average time to death determination (moderate quality evidence). We are uncertain whether point-of-care ultrasound (POCUS) pulse check, cerebral near-infrared spectroscopy (NIRS), or POCUS cardiac motion assessment are accurate tests for the determination of circulatory cessation (very low-quality evidence).

CONCLUSION

There is insufficient evidence that ECG, POCUS pulse check, cerebral NIRS, or POCUS cardiac motion assessment are superior or equivalent to IAP for DCC in the setting of organ donation. Isoelectric ECG is specific but can increase the time needed to determine death. Point-of-care ultrasound techniques are emerging therapies with promising initial data but are limited by indirectness and imprecision.

STUDY REGISTRATION

PROSPERO (CRD42021258936); first submitted 16 June 2021.

Epidemiological Analysis of the Emergency Vascular Access in Pediatric Trauma Patients: Single-Center Experience of Intravenous, Intraosseous, Central Venous, and Arterial Line Placements

Vascular access in severely injured pediatric trauma patients is associated with time-critical circumstances and low incidences, whereas only scarce literature on procedure performance is available. The purpose of this study was to analyze the performance of different vascular access procedures from the first contact at the scene until three hours after admission. Intubated pediatric trauma patients admitted from the scene to a single Level I trauma center between 2008 and 2019 were analyzed regarding intravenous (IV) and intraosseous (IO) accesses, central venous catheterization (CVC) and arterial line placement. Sixty-five children with a median age of 14 years and median injury severity score of 29 points were included, of which 62 (96.6%) underwent successful prehospital IV or IO access by emergency medical service (EMS) physicians, while it failed in two children (3.1%). On emergency department (ED) admission, IV cannulas of prehospital EMS had malfunctions or were dislodged in seven of 55 children (12.7%). IO access was performed in 17 children without complications, and was associated with younger age, higher injury severity and higher mortality. Fifty-two CVC placements (58 attempts) and 55 arterial line placements (59 attempts) were performed in 45 and 52 children, respectively. All CVC and arterial line placements were performed in the ED, operating room (OR) and intensive care unit (ICU). Ten mechanical complications related to CVC placement (17.8%) and seven related to arterial line placement (10.2%) were observed, none of which had outcome-relevant consequences. This case series suggests that mechanical issues of vascular access may frequently occur, underlining the need for special preparedness in prehospital, ED, ICU and OR environments.

Intraarterial papaverine for relief of catheter-induced peripheral arterial vasospasm during pediatric cardiac surgery: A randomized double-blind controlled trial

BACKGROUND

Maintaining the patency of peripheral arterial lines in pediatric patients during surgery can be challenging due to multiple factors, and catheter-related arterial vasospasm is a potentially modifiable cause. Papaverine, a potent vasodilator, improves arterial line patency when used as a continuous infusion in the pediatric intensive care setting, but this method is not convenient during surgery.

AIM

Extrapolating from the benefit seen in the intensive care unit, the authors hypothesize that a small-volume intraarterial bolus of papaverine immediately after arterial line placement will reduce vasospasm-related arterial line malfunction.

METHODS

This was a prospective, randomized, double-blind study. Patients less than 17 years of age undergoing cardiac surgery were enrolled. Patients were randomized into the heparin or papaverine groups. Immediately after arterial line insertion, an intraarterial bolus of heparin (2 units/ml, 1 ml) or papaverine (0.12 mg/ml, 1 ml) was administered (T1, Figure 1). An optimal waveform was defined as the ease of aspirating a standardized blood sample within 30 s, absence of cavitation when sampling, absence of color change at the catheter site during injection, and presence of a dicrotic notch. The primary outcome evaluated was the presence of an optimal arterial waveform at 5 min after the first randomized dose (T1 + 5 min). The secondary outcomes were the presence of optimal arterial waveform an hour after the first dose and the ability of papaverine to rescue suboptimal waveforms.

RESULTS

A total of 100 patients were enrolled in the study. Twelve patients were excluded from the analysis. Complete datasets after randomization were available in 88 patients (heparin group, n = 46; papaverine group, n = 42). At baseline, groups were similar for age, weight, arterial vessel size, and arterial line patency. At T1 + 5 min, an improvement in the waveform characteristics was observed in the papaverine group (heparin,39% [8/46] vs. papaverine, 64% [27/42]; p = .02; odds ratio, 2.8; 95% CI, 1.2 to 6.6, Figure 3, Table 2). At the end of 1 h, both groups showed continued improvement in arterial line patency. After the second dose, a higher number of patients in the heparin group had suboptimal waveforms and were treated with papaverine (heparin,37% [17/46] vs. papaverine,17% [7/42], p = .05). Patients in the heparin group treated with papaverine showed significant improvement in patency (13/17 vs. 3/7, p = .01). No serious adverse events were reported.

CONCLUSIONS

In pediatric patients, papaverine injection immediately after peripheral arterial catheter placement was associated with relief of vasospasm and improved initial arterial line patency. Further, papaverine can be used as a rescue to improve and maintain arterial line patency.

Iatrogenic vascular trauma and complications of vascular access in children

Vascular access is frequently a critical component of the diagnostic and therapeutic procedures required to manage childhood illnesses, including many emergent conditions and critical illnesses. Vascular access in the pediatric population presents unique challenges, and many clinical and technical factors must be considered to avoid complications that can occur with vascular access procedures. This article reviews various aspects of vascular access and associated iatrogenic trauma in children, including risk factors, management of complications, and preventive measures to avoid complications. It is only with a comprehensive understanding of the topic that vascular access in children can be performed safely, effectively, and efficiently.

Characteristics of arterial catheter use and related complications in dogs and cats in an intensive care unit

OBJECTIVE

To identify characteristics of arterial catheter use, including indwelling times and reasons for removal, and analyze potential risk factors for complications based on patient- and catheter-related variables.

DESIGN

Prospective clinical study from July 2012 to September 2016.

SETTING

University teaching hospital.

ANIMALS

One hundred ninety-eight dogs and 29 cats with an arterial catheter monitored in the ICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A questionnaire was used to obtain patient and catheter information for arterial catheters monitored in the ICU during the study period. Two hundred twenty-seven catheters met the inclusion criteria. Most catheters were placed in the dorsal metatarsal artery in dogs (90.4%) and either the dorsal metatarsal artery (51.7%) or coccygeal artery (48.3%) in cats. Weights ranged from 1.5 to 64 kg in dogs and 0.77 to 8.7 kg in cats. The median indwelling time was 24 hours for dogs and 12 hours for cats. Minor complications occurred in 19.2% of catheters in dogs and 17.2% of those in cats with removal of catheter due to complications in 13 of 198 (6.6%) for dogs and 2 of 29 (6.9%) for cats. There was no association between the incidence of complications and patient weight, catheter indwelling time, species, insertion site, catheter size, or level of consciousness during placement. There was also no association between the method of catheter maintenance (intermittent flushing or continuous pressure transducer) and the failure of a catheter to aspirate or flush.

CONCLUSIONS

Arterial catheter-related complications were relatively frequent, but most complications were minor and did not justify removal of the catheter. This suggests that the use of arterial catheters in both species is relatively safe. However, further research is needed to assess complications related to longer catheter indwelling times, particularly in cats.

Use of pulse contour technology for continuous blood pressure monitoring in pediatric patients

OBJECTIVES

This study evaluates the accuracy of continuous blood pressure monitoring using pulse contour technology with the ClearSight monitoring device, a noninvasive alternative to placing an invasive arterial line, in pediatric patients.

METHODS

Children younger than 18 years admitted to a pediatric ICU, who required an arterial line, and fit into the ClearSight finger cuff were included. Blood pressure measurement for systolic, diastolic, and mean arterial pressures (MAP) obtained by the ClearSight device were compared with those obtained with the intra-arterial catheter as well as automated cuff measurements using the mixed-effects model. Analysis was conducted for entire cohort, and measurements obtained with and without vasopressor use.

RESULTS

There were 213 measurements from 10 patients. There was a statistically significant difference in systolic blood pressure when comparing arterial line and ClearSight systolic and diastolic measurements between the two methods (P < 0.001). There was no statistical difference between arterial MAP and ClearSight MAP (P = 0.957). Results were similar when ClearSight measurements were compared with automated cuff measurements. Both the vasopressor use and nonvasopressor use groups showed a statistically significant difference between arterial and ClearSight measurements for systolic and diastolic pressures, but not for the MAP.

CONCLUSIONS

Measurements of MAP obtained by the ClearSight device were almost identical to those obtained by the intra-arterial catheter. Although there was a difference in systolic blood pressures between the two methods, in those patients receiving inotropic support, the difference was within the range of what is considered acceptable in validating blood pressure devices.

Variation in Arterial and Central Venous Catheter Use in Pediatric Intensive Care Units

OBJECTIVE

Describe patient and hospital characteristics associated with Arterial Catheter (AC) or Central Venous Catheter (CVC) use among pediatric intensive care units (ICUs).

DESIGN

Hierarchical mixed effects analyses were used to identify patient and hospital characteristics associated with AC or CVC placement. The ICU adjusted median odds ratios (ICU-AMOR) for the admission ICU, marginal R², and conditional intraclass correlation coefficient were reported.

SETTING

166 PICUs in the Virtual PICU Systems (VPS, LLC) Database.

PATIENTS

682,791 patients with unscheduled admissions to the PICU.

INTERVENTION

None.

MEASURES AND MAIN RESULTS

ACs were placed in (median, [interquartile range]) 8.2% [4.9%-11.3%] of admissions, and CVCs were placed in 14.9% [10.4%-19.3%] of admissions across cohort ICUs. Measured patient characteristics explained about 25% of the variability in AC and CVC placement. Higher Pediatric Index of Mortality 2 (PIM2) illness severity scores were associated with increased odds of placement (Odds Ratio (95th% Confidence Interval)) AC: 1.88 (1.87-1.89) and CVC: 1.82 (1.81-1.83) per 1 unit increase in PIM2 score. Primary diagnoses of cardiovascular, gastrointestinal, hematology/oncology, infectious, renal/genitourinary, rheumatology, and transplant were associated with increased odds of AC or CVC placement compared to a primary respiratory diagnosis. Presence of in-house attendings 24/7 was associated with increased odds of AC placement 1.32 (1.11-1.57). Admission ICU explained 4.9% and 3.5% of the variability in AC or CVC placement, respectively. The ICU-AMOR showed a patient would have a median increase in odds of 55% and 43% for AC or CVC placement, respectively, if the same patient moved from an ICU with lower odds of placement to an ICU with higher odds of placement.

CONCLUSIONS

Variation in AC or CVC use exists among PICUs. The admission ICU was more strongly associated with AC than with CVC placement. Further study is needed to understand unexplained variation in AC and CVC use.

Resource Use and Outcomes for Children Hospitalized With Severe Sepsis or Septic Shock

OBJECTIVE

To describe patient and hospital characteristics associated with in-hospital mortality, length of stay (LOS), and charges for children with severe sepsis or septic shock who often require specialized organ-supportive technology to enhance outcomes, availability of which might vary across hospitals.

DESIGN

Retrospective study among children hospitalized for severe sepsis or septic shock, using the 2012 Kids' Inpatient Database. Multivariate regression methods identified factors associated with mortality, LOS, and charges.

MEASUREMENTS AND MAIN RESULTS

Of an estimated 11 972 hospitalizations for pediatric severe sepsis or septic shock, most hospitalizations (85%) were to urban teaching hospitals. Hospitalizations were more frequent among neonates and older adolescents than other age groups. Mortality was 17%, average LOS was 24 days, and average hospital charges were US$314 950. Higher mortality was associated with neonates, cumulative organ dysfunction, more comorbidities, and cardiopulmonary resuscitation. Longer hospitalization and higher charges were associated with neonates, more comorbidities, higher illness severity, invasive medical technology, and urban hospitals.

CONCLUSIONS

Efforts to mitigate the substantial in-hospital mortality and resource use observed in pediatric severe sepsis or septic shock should be age-specific and focused on the influence of comorbidities and organ dysfunction on outcomes. Future research should elucidate reasons for higher resource use at urban hospitals.

Agreement Between Arterial Carbon Dioxide Levels With End-Tidal Carbon Dioxide Levels and Associated Factors in Children Hospitalized With Traumatic Brain Injury

IMPORTANCE

Alterations in the partial pressure of carbon dioxide, arterial (Paco2) can affect cerebral perfusion after traumatic brain injury. End-tidal carbon dioxide (EtCO2) monitoring is a noninvasive tool used to estimate Paco2 values.

OBJECTIVE

To examine the agreement between Paco2 and EtCO2 and associated factors in children with traumatic brain injury.

DESIGN, SETTING, AND PARTICIPANTS

A secondary analysis was conducted using data from a prospective cohort study of 137 patients younger than 18 years with traumatic brain injury who were admitted to the pediatric intensive care unit of a level I trauma center between May 1, 2011, and July 31, 2017. Analysis was performed from December 17, 2018, to January 10, 2019.

MAIN OUTCOMES AND MEASURES

The closest EtCO2 value obtained within 30 minutes of a Paco2 value and the closest systolic blood pressure value obtained within 60 minutes prior to a Paco2 value during the first 24 hours after admission were recorded. The main outcome of Paco2-EtCO2 agreement was defined as Paco2 between 0 and 5 mm Hg greater than the paired EtCO2 value, and it was determined using Bland-Altman analysis, Passing and Bablok regression, and the Pearson correlation coefficient. Multivariable regression models determined which factors were associated with agreement.

RESULTS

The analysis included 137 patients (34 girls and 103 boys; mean [SD] age, 10.0 [6.3] years) and 445 paired Paco2-EtCO2 data points. On average, Paco2 was 2.7 mm Hg (95% limits of agreement, -11.3 to 16.7) higher than EtCO2. Overall, 187 of all Paco2-EtCO2 pairs (42.0%) agreed. There was larger variation in the Paco2-EtCO2 difference during the first 8 hours compared with 9 to 24 hours after admission to the pediatric intensive care unit. Development of pediatric acute respiratory distress syndrome within 24 hours of admission was associated with a lower likelihood of Paco2-EtCO2 agreement (adjusted odds ratio, 0.20; 95% CI, 0.08-0.51) compared with no development of pediatric acute respiratory distress syndrome. A diagnosis of pediatric acute respiratory distress syndrome 1 to 7 days after admission was associated with a larger first-day Paco2-EtCO2 difference compared with those who never developed pediatric acute respiratory distress syndrome (mean [SD] difference, 4.48 [3.70] vs 0.46 [5.50] mm Hg).

CONCLUSIONS AND RELEVANCE

In this study of pediatric traumatic brain injury, Paco2-EtCO2 agreement was low, especially among patients with pediatric acute respiratory distress syndrome. Low Paco2-EtCO2 agreement early in hospitalization may be associated with future development of pediatric acute respiratory distress syndrome. Data on EtCO2 should not be substituted for data on Paco2 during the first 24 hours.

Insertion, management, and complications associated with arterial catheters in paediatric intensive care: A clinical audit

INTRODUCTION

Peripheral arterial catheters (PAC) are used for haemodynamic monitoring and blood sampling in paediatric critical care. Limited data are available regarding PAC insertion and management practices, and how they relate to device function and failure. This information is necessary to inform future interventional research.

OBJECTIVES

The primary objective of this study was to describe PAC insertion and management practices, and associated complications. Secondary objectives were to determine patient and clinical characteristics associated with risk of PAC successful insertion and failure.

METHODS

A prospective, observational study was conducted in the anaesthetic department and paediatric intensive care unit of a tertiary paediatric facility. Data were collected on PAC insertion, PAC management and PAC removal. Standard incidence and prevalence were calculated per 1,000 device days. Risk factors for multiple insertions and PAC failure were identified using Cox regression.

RESULTS

A total of 100 catheters in 89 children were examined capturing 472 device days. PACs were primarily inserted for blood sampling (78%) in the radial artery (78%) using ultrasound guidance (67%), with 31% inserted on first attempt. Heparin saline solution was used in 82% of devices. Median catheter dwell was 50.6 hours (IQR 24.0 - 158.0), with PAC failure occurring in 19 devices (20%), at a rate of 40.2 per 1000 catheter days (95% CI 25.7 - 63.1). Arm board immobilisation (HR 2.9; 95% CI 1.02-8.02; p = 0.05), higher PIM3 score (HR 1.06; 95% CI 1.03-1.09; p < 0.01) was associated with an increased the risk of PAC failure, and non-2% chlorhexidine antisepsis was associated with a decrease in PAC failure (HR 0.32; 95% CI 0.11-0.96; p = 0.04), in univariate analysis.

CONCLUSIONS

PAC insertion is challenging, and failure is common. Prospective clinical trial data is needed to identify high risk patient groups and to develop interventions which optimise practices, thereby reducing failure.