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

Infection Associated With Invasive Devices in Pediatric Health Care: A Meta-analysis

CONTEXT

Indwelling invasive devices inserted into the body for extended are associated with infections.

OBJECTIVE

This study aimed to estimate infection proportion and rates associated with invasive devices in pediatric healthcare.

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Medline, CINAHL, Embase, Web of Science, Scopus, Cochrane CENTRAL, clinical trial registries, and unpublished study databases were searched.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) postinsertion infection 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 local, organ, and bloodstream infection (BSIs) pooled proportion and incidence rate (IR) per-1000-device-days per device type were reported.

RESULTS

A total of 116 studies (61 554 devices and 3 632 364 device-days) were included. The highest number of studies were central venous access devices associated BSI (CVAD-BSI), which had a pooled proportion of 8% (95% confidence interval [CI], 6-11; 50 studies) and IR of 0.96 per-1000-device-days (95% CI, 0.78-1.14). This was followed by ventilator-associated pneumonia in respiratory devices, which was 19% (95% CI, 14-24) and IR of 14.08 per-1000-device-days (95%CI, 10.57-17.58).

CONCLUSIONS

Although CVAD-BSI and ventilator associated pneumonia are well-documented, there is a scarcity of reporting on tissue and local organ infections. Standard guidelines and compliance initiatives similar to those dedicated to CVADs should be implemented in other devices in the future.

Cannulation via the external jugular vein--An alternative to conventional peripherally inserted central catheterisation for paediatric patients

PURPOSE

This study aimed to describe a peripherally inserted central catheterisation (PICC) for paediatric patients with inaccessible access and a high risk of general anaesthesia (GA).

METHODS

This was a retrospective observational study involving all paediatric inpatients who performed the PICC via an EJV approach without GA between September 2014 and September 2021 in a provincial key clinical speciality.

RESULTS

A total of 290 EJV line placement attempts were performed, and 29 were excluded due to missing placement results, resulting in a sample size of 261. The anatomical localisation, punctures, and catheterisation success rates for this practice were 100%, 100%, and 90.04%, respectively. The placement success rate in children younger than one year was 93.75% (45/48). The median line duration of use was 19 days, with a median length of catheter insertion of 13 cm. The most common complications were catheter malposition (n = 20) and dislodgement (n = 7).

CONCLUSION

The PICC via an EJV approach without GA is a feasible and safe practice with acceptable success and complication rates, and low costs. It might be an attractive alternative for obtaining central vascular access for paediatric patients.

Height-based formulas for predicting intravascular length of tunnelled neck central venous catheter in paediatric population

INTRODUCTION

Central venous catheter (CVC) placement is commonly performed in children. We aim to develop simple formulas to predict CVC intravascular length to minimise radiation exposure associated with the procedure.

METHODS

124 paediatric patients who received tunnelled neck CVCs and subsequent CT thorax at Hong Kong Children's Hospital from January 2020 to July 2022 were reviewed retrospectively. Formula development cohorts were subdivided by insertion sites-9 right external jugular vein (REJV), 41 right internal jugular vein (RIJV), 14 left external jugular vein (LEJV), 10 left internal jugular vein (LIJV). Using measurements from CT by two radiologists, formulas predicting the CVC intravascular length based on height and insertion sites were developed using a linear regression model. These formulas were tested with validation cohorts (10 randomly selected cases in REJV and RIJV groups respectively). Validation cohorts were not available for LEJV and LIJV groups due to small sample sizes.

RESULT

The goodness-of-fit (R^2) of all formulas are above 0.8. In the validation cohorts, the REJV formula was predictive of intravascular CVC length within 1 cm in 70% of CVC with mean absolute difference of 0.63 cm (SD 0.48 cm), and the RIJV formula was predictive of intravascular CVC length within 1 cm in 80% of CVC with mean absolute difference of 0.67 cm (SD 0.53 cm).

CONCLUSION

Intravascular CVC length can be estimated using simple formulas based on height and insertion sites. Further prospective validation of the LEJV and LIJV formulas is needed.

Surgical Experience Affects the Outcome of Central Venous Access Catheter Implantation in Children: A Retrospective Cohort Study

INTRODUCTION

Surgical complications occur in up to third of children, limiting the benefits of tunneled central venous catheters (tCVCs) in children. We aimed to identify risk factors for complications related to catheter implantation.

METHODS

All children and adolescents undergoing tCVC implantation at a single center over a period of 9 years were analyzed. Infection, thrombosis, dislocation, and catheter dysfunction were defined as complications. Both patient-related (ie, age, sex, vessel characteristics, revision surgery) and surgical factors (ie, sex of surgeon, surgical experience) were analyzed for their association with complications.

RESULTS

A total of 1024 catheters were inserted, 887 ports and 137 broviac catheters. In terms of patient-related factors, Broviac catheters, and nononcological patients had a higher complication rate. The use of the internal jugular vein and revision surgery was associated with significantly increased complications in patients with port catheters. Experience of the surgeon correlated with various outcome parameters. Implantation performed by an attending were associated with lower complication rates in comparison to those performed by residents. Within the resident group, insertions performed by experienced residents had more complications compared with those performed by residents during their first years.

CONCLUSION

The study suggests that the outcome of tCVCs insertion is affected by the type of catheter used, the utilized vessel and above all by surgical experience. Residents had significantly increased complication rates in comparison to board-certified surgeons and amongst resident's outcome got worse with increasing experience of the residents. The presence of an experienced attending did not compensate for this effect. To improve the outcome of tCVCs, strategies like direct feedback after every procedure to achieve proficiency should be implanted in residency programs.

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.

Simplify long-term venous access via external jugular vein in children

Background

Bone marrow transfer has begun to be widely used in complicated conditions, such as chemotherapy or hemodialysis, following the description of indwelling central venous catheters and demonstrating their suitability in pediatric patients. The widespread use of it has increased the incidence of complications as well. The use of external jugular vein catheterization, which is a safer route compared to the blind route of administration, has topographical difficulties. The findings obtained in this study showed that these difficulties could be overcome. Our study revealed that the catheterization was possible and described a facilitating technique. Of the pediatric patients involved in the bone marrow transfer programs, patients who were deemed eligible candidates for the use of external jugular vein, based on the preoperative assessment, were included in the present study.

Results

No early complication was observed in this study. The central catheter was placed on all patients in the same session. Catheters were inserted using the external jugular vein in 98 patients and percutaneous internal jugular vein in 2 patients. A central catheter was inserted through 105 interventions and 103 incisions in 100 patients. External jugular vein use, which was planned before the procedure, was achieved in 98 patients. The internal jugular vein was selected as the second option in 2 patients. The success rate of external jugular vein use was 95.1%.

Conclusions

The findings obtained in this study suggest that placement of a central catheter using an external jugular vein is an appropriate option. Application difficulties can be overcome. Mechanical and early complications are negligible compared to percutaneous blind techniques. The use of the external jugular vein route is easy, requires less equipment, has few complications, and the success of the procedure is a preoperatively predictable technique. External jugular vein catheterization is a better alternative compared to the Seldinger technique, in the absence of ultrasonography, which enhances the success of the percutaneous technique, and in cases where blind techniques, such as bleeding diathesis, may be unfavorable.

A retrospective analysis of the real-time ultrasound-guided supraclavicular approach for the insertion of a tunneled central venous catheter in pediatric patients

PURPOSE

Tunneled central venous catheter (tCVC) placement plays an important role in the management of pediatric patients. We adopted a real-time ultrasound (US)-guided supraclavicular approach to brachiocephalic vein cannulation. We evaluated the outcomes of tCVC placement via a US-guided supraclavicular approach.

METHODS

A retrospective study was performed for patients who underwent US-guided central venous catheterization of the internal jugular vein (IJV group) and brachiocephalic vein (BCV group) in our institution. The background information and outcomes were reviewed using medical records.

RESULTS

We evaluated 85 tCVC placements (IJV group: n = 59, BCV group: n = 26). Postoperative complications were recognized in 19 patients in the IJV group (catheter-related bloodstream infection (CRBSI), n = 14 (1.53 per 1000 catheter days); occlusion, n = 1 (1.7%, 1.09 per 1000 catheter days); accidental removal, n = 3 (5.2%, 0.33 per 1000 catheter days); and other, n = 1 (1.7%, 1.09 per 1000 catheter days)) and five patients in the BCV group (CRBSI, n = 2 (0.33 per 1000 catheter days); catheter damage, n = 1 (3.8%, 1.67 per 1000 catheter days); and accidental removal, n = 2 (7.7%, 0.33 per 1000 catheter days)). In the BCV group, despite that, the incidence of postoperative complications was lower (p = 0.205) and the period of placement was significantly longer in comparison to the IJV group (p = 0.024).

CONCLUSION

US-guided placement of tunneled CVC though the BCV results in a low rate of postoperative complications despite longer CVC indwelling times compared to IJV insertion. Our results suggest that BCV insertion of tunneled CVC in children may offer advantages in terms of device performance and patient safety.

Insertion of central venous catheters in children undergoing bone marrow transplantation: is there a platelet level for a safe procedure?

Background

Bone marrow transplantation (BMT) is a therapeutic procedure for the management of several hematological diseases and malignancies in pediatric population. Central venous catheters (CVCs) play a pivotal role during the process of BMT. The aim of this study was to compare the complications of CVCs placements in children undergoing BMT with platelet levels above and below 50,000/μL and also to detect if there is a platelet count for a safe insertion. This prospective study included all children who had placements of tunneled CVCs during BMT at our hospital between March 2017 and March 2020. Procedures were divided into two groups accordingly to preoperative platelet counts (above and below 50,000/μL). Data were compared between both groups regarding postoperative complications including bleeding or catheter-related blood stream infections (CRBSIs).

Results

Forty-six CVC insertions were performed in 40 patients. There were 20 procedures below 50,000/μL (median 27,500; range 5000–42,000) inserted with perioperative platelet transfusions, and their postoperative levels were median 59,500/μL, range 18,000–88,000. Allogeneic BMT was adopted in 39 patients (97.5%). Beta thalassemia major was the commonest indication (21/40, 52.5%), followed by acute lymphocytic leukemia in six patients (15%). There were nine postoperative complications (bleeding n = 2 and CRBSIs n = 7) encountered in all placements. Four of them occurred in insertions below 50,000/μL (two bleeding complications that managed conservatively, and two CRBSIs). Post-procedural morbidities regarding bleeding or CRBSIs did not differ significantly between both groups (p value = 0.099 and 0.695, respectively).

Conclusions

Postponement of CVC insertions in thrombocytopenic children due to the fear of potential complications seems unwarranted, as it has no significant impact on the morbidity. Placements of such catheters can be safe under cover of perioperative platelet transfusions irrespective of the preoperative platelet count.

Real-time ultrasound-guided supraclavicular technique as a possible alternative approach for Hickman catheter implantation

BACKGROUND

Tunneled Hickman/Broviac central venous catheter implantation is performed when patients require a central vein route for long-term therapy. The subclavian or internal jugular vein approach is often chosen for their implantation sites. However, access to the central vein can be difficult owing to thrombosis or stenosis when the same vein has already been accessed several times. In such situations, other possible alternative approaches to the central vein should be considered to avoid serious complications owing to further unsuccessful attempts.

DESCRIPTION OF OPERATIVE TECHNIQUE

We encountered a 1-year-old patient admitted to our hospital for a Hickman catheter implantation after multiple unsuccessful attempts at central venous catheter insertion via bilateral subclavian approaches in another hospital. An ultrasound showed that no more subclavian veins were available on either side. A real-time ultrasound-guided right supraclavicular approach was performed as a solution to this situation.

CONCLUSIONS

In this article, we introduce a real-time ultrasound-guided supraclavicular approach as a possible alternative method for Hickman catheter implantation. We present step-by-step instructions including figures and a video and further discuss the advantages and disadvantages of this procedure, comparing the right and left approaches with references to existing literature.

LEVEL OF EVIDENCE

Level I.

Hickman Central Venous Catheters in Children: Open Versus Percutaneous Technique

BACKGROUND

The ideal technique for insertion of tunneled central venous catheters (CVCs) in children is still debatable. This study aimed to compare the outcomes of open versus percutaneous technique for the insertion of tunneled CVCs.

METHODS

The study included 279 patients who had CVCs insertions from 2010 to 2020. Patients were divided into two groups according to the technique of insertion: group 1 (n = 90) included patients who had the open cutdown method and group 2 (n = 189) included patients who had the percutaneous technique.

RESULTS

There was no difference in age and gender distribution between groups (P = 0.152 and 0.102, respectively). Chemotherapy was the most common indication of insertion (77 [85.56%] vs. 165 [87.30%]); in group 1 vs. 2, P = 0.688). The left external jugular was the most common site of insertion in group 1 (n = 66; 73.33%), and the left subclavian was the most common site in group 2 (n = 77; 40.74%). Complications of insertion were nonsignificantly higher in group 2 (P = 0.170). Nine patients in group 2 required conversion to cutdown technique (4.76%). Complications during removal were nonsignificantly higher in group 2 (P = 0.182), and the most common was bleeding (n = 4; 2.12%). The most common indication for catheter removal was the completion of the treatment (36 [40%] vs. 85 [44.97%] in groups 1 and 2, respectively).

CONCLUSIONS

Percutaneous and open tunneled central venous catheter insertion are safe in pediatric patients who require long-term venous access. Both techniques have a low complication rate. The choice of each method should be tailored to the condition of each patient.

Safety of tunneled central venous catheters in pediatric hematopoietic stem cell recipients with severe primary immunodeficiency diseases

Tunneled central venous catheters (TCVCs) provide prolonged intravenous access for pediatric patients with severe primary immunodeficiency disease (PID) undergoing hematopoietic stem cell transplantation (HSCT). However, little is known about the epidemiology and clinical significance of TCVC-related morbidity in this particular patient group. We conducted the retrospective analysis of patients with severe PID who received percutaneous landmark-guided TCVC implantation prior to HSCT. We analyzed 92 consecutive TCVC implantations in 69 patients (median [interquartile range] age 3.0 [0-11] years) with severe combined immune deficiency (n = 39, 42.4%), chronic granulomatous disease (n = 17, 18.4%), and other rare PID syndromes (n = 36, 39.2%). The median length of TCVC observation was 144.1 (85.5-194.6) days with a total of 14,040 catheter days at risk (cdr). The overall rate of adverse events during catheter insertion was 17.4% (n = 16) and 25.0% during catheter dwell period (n = 23, catheter risk [CR] per 1000 cdr = 1.64). The most common complication was TCVC-related infection with an overall prevalence of 9.8% (n = 9, CR = 0.64), followed by late dislocation (n = 6, 6.5%, CR = 0.43), early dislocation (n = 4, 4.3%) and catheter dysfunction (n = 4, 4.3%, CR = 0.28). TCVCs are safe in children with severe PID undergoing HSCT with relatively low rates of TCVC-related infection.