Role of serial ultrasound screening of venous thrombosis in oncologic children with central lines

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Medline, CINAHL, Embase, Web of Science, Scopus, Cochrane CENTRAL, clinical trial registries, and unpublished study databases were searched.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

Open versus Transcutaneous (Ultrasound-Guided and Based on Anatomic Landmarks) Tunneled Venous Access to the Right Internal Jugular Vein in Children: A Prospective Single-Center Study

BACKGROUND

The purpose of this study was to compare the immediate and long-term complications that are associated with the utilized techniques for the insertion of indwelling central venous catheters, that is the open surgical technique, the ultrasound-guided technique, and the transcutaneous technique based on external anatomical landmarks in the right internal jugular vein, to a pediatric population.

METHODS

This was a prospective randomized trial based on a pediatric patient population under 16 years of age of a tertiary pediatric-oncological hospital. The procedure was performed by a medical team with varying experience regarding the percutaneous and open insertion methods. We studied the outcome of our procedure, based on the immediate and delayed complication rate, as well as the needed time in order to complete the procedure and mean duration of line use.

RESULTS

The patients that were inserted in our protocol were divided into three subgroups based on the selected technique for the insertion of the central venous catheter. A total number of 88 insertions (25.4%) (out of 346) were based on the technique that was using external anatomical landmarks, 121 insertions were based on the ultrasound-guided transcutaneous technique (34.9%), whereas in 137 cases (39.5%) the open surgical technique was preferred. All cases that were related to catheter re-insertion were excluded from our study. We performed a statistical analysis regarding the catheter dwell time between the three subgroups of patients and no significant difference was recorded. Moreover, the development of thrombosis was investigated, and we noted that a higher percentage of this complication was related to the transcutaneous external landmark and open surgical technique. Also, the incidence of infection was taken into consideration, which manifested an increased incidence when the transcutaneous technique based on external landmarks was used.

CONCLUSIONS

Ultrasound-guided percutaneous insertion was considered to be a safe and effective technique for the insertion of central venous catheters. Our study also demonstrated a decrease in operating times when performed by operators with increasing expertise, increased preservation of the diameter of the venous lumen, and no increase in complication rates when the ultrasound-guided technique was selected.

Venous Thromboembolism in Pediatric Cancer Patients with Central Venous Catheter-A Systematic Review and Meta-analysis

Pediatric cancer patients hold an increased risk of venous thromboembolism (VTE) due to their cancer. Central venous catheters (CVCs) further increase the VTE risk. This systematic literature review elucidates the VTE incidence in pediatric cancer patients with CVC. MEDLINE and EMBASE were searched in August 2020 without time limits. We included studies reporting original data on patients ≤18 years with any CVC type and any cancer type, who were examined for VTE with ≥7 days follow-up. In total, 682 unique records were identified, whereof 189 studies were assessed in full text. Altogether, 25 studies were included, containing 2,318 pediatric cancer patients with CVC, of which 17% suffered VTE. Fifteen studies (n = 1,551) described CVC-related VTE and reported 11% CVC-related VTE. Concerning cancer type, 991 children suffered from acute lymphoblastic leukemia (ALL) and 616 from solid tumors. Meta-analysis revealed VTE incidence (95% confidence interval) of 21% (8-37) for ALL and 7% (0.1-17) for solid tumors. Additionally, 20% of children with tunneled or nontunneled CVC and 12% of children with implantable ports suffered VTE. In conclusion, pediatric cancer patients with CVC have substantial VTE risk. Children with ALL and CVC have higher VTE incidence than children with solid tumors and CVC. Implantable port catheter should be preferred over tunneled or nontunneled CVC to reduce VTE risk. Thrombophilia investigation does not seem relevant in pediatric cancer patients with CVC and VTE. To prevent VTE, intensified catheter care is recommended, especially in children with ALL.