Central venous catheters for children with malignant disease: surgical issues

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

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

Outcomes, cost comparison, and patient satisfaction during long-term central venous access in cancer patients: Experience from a Tertiary Care Cancer Institute in South India

Introduction:

Prolonged treatment, frequent administration of chemotherapy, antibiotics and blood products in cancer patients requires long term venous access. Central venous catheters (CVC) inserted into the subclavian vein or internal jugular vein, peripherally inserted central venous catheters (PICC) and chemoport (CP) are the commonly used central venous access devices (CVAD).

Aim:

This study was envisaged to review our experience of CVADs over a one year period and analyze the outcome with regard to catheter life, reasons for removal, complications, patient satisfaction and cost comparison between the CVAD types in the Indian setting.

Settings and Design:

This was a prospective, observational study carried out in a tertiary care cancer institute.

Materials and Methods:

180 CVADs placed in patients with hematological malignancies and solid tumors from January 2014 to December 2014 were included.

Statistical Analysis Used:

Data was analyzed using descriptive statistics, Mann Whitney U test. P <0.05 was taken as statistically significant.

Results:

180 CVADs were placed in 160 patients. The median catheter indwelling period was 76 days (16 days to 313 days) for CVC, 59 days (20days – 313 days) for PICC and 137 days (70 days – 258 days) for CP. 66 out of 160 patients developed complications (41.2%). 108 complication events were noted in 66 patients. There were 40 episodes of CRBSI. Out of the 68 mechanical complications, 37 were encountered during insertion of the CVAD and 31 were during the catheter indwelling period. Out of 160 patients, 138 (86.25%) were satisfied with the CVAD. The cost incurred for CVC/PICC (INR 4,480) was lower than that for CP (INR 24,150) and it was statistically significant (P < 0.0001). Our patients were highly satisfied with the CVAD.

Conclusion:

Use of CVC and PICC is a safe, reliable and cost saving way of administration of chemotherapy in developing countries. The incidence of complications and catheter loss was acceptable. Our patients were highly satisfied with the CVAD.

Guidelines of the Italian Association of Pediatric Hematology and Oncology for the management of the central venous access devices in pediatric patients with onco-hematological disease

INTRODUCTION

Central venous accesses devices (CVADs) have a fundamental importance for diagnostic and therapeutic purposes in pediatric onco-hematological patients. The treatment of pediatric onco-hematological diseases is complex and requires the use of integrated multimodal therapies. Long-lasting and safe central venous access is therefore a cornerstone for any successful treatment.

METHODS

The aim of this work is to define pediatric guidelines about the management of CVADs in onco-hematology. A panel of experts belonging to the working groups on Infections and Supportive Therapy, Surgery and Nursing of the Italian Pediatric Hematology Oncology Association (AIEOP) revised the scientific literature systematically, scored the level of evidence and prepared these guidelines. The content of the following guidelines was approved by the Scientific Board of AIEOP.

RESULTS AND CONCLUSIONS

Important innovations have been developed recently in the field of CVADs, leading to new insertion methods, new materials and new strategy in the overall management of the device, especially in the adult population. These guidelines recommend how to apply these innovations in the pediatric population, and are directed to all physicians, nurses and health personnel active in the daily management of CVADs. Their aim is to update the knowledge on CVAD and improve the standard of care in pediatric patients with malignancies.

A Study of Use of "PORT" Catheter in Patients with Cancer: A Single-Center Experience

Background:

Effective and reliable venous access is one of the cornerstones of modern medical therapy in oncology.

Materials and methods:

This is a prospective observational study, which collected data of patients who require “PORT” catheter insertion for any cancer, at a tertiary care oncology hospital in Ahmadabad, Gujarat, India, during a 2-year period.

Aims and objectives:

The main objective of this study was to study the various complications and outcomes related to “PORT” catheters.

Results:

“PORT” catheter was inserted in 100 patients and was most commonly used in solid malignancies (n = 86, 86%), followed by hematologic malignancies (n = 14, 14%). Among the solid malignancies, breast cancer (38, 38%) was the most common underlying disease, whereas among the hematologic malignancies, acute lymphoblastic leukemia (6, 6%) was the most common underlying disease for “PORT” catheter insertion. Chemotherapy was started on the first day of “PORT” catheter in 74% of patients in the “PORT” study group. The various complications developed in the “PORT” study group in the descending order are as follows: 4 patients (4%) developed early infection (⩽30 days after “PORT” placement), 4 (4%) late infection (⩾30 days after “PORT” placement), 4 (4%) bloodstream infection, 2 (2%) local skin infection at the “PORT” insertion site, 2 (2%) dislodgment of the “PORT” catheter, 2 (2%) fracture of the “PORT” catheter, and 1 recurrent pleural effusion. One patient (1%) developed thrombosis as the complication of “PORT” catheter insertion.

Conclusions:

The most disturbing aspect of treatment for a patient with cancer is multiple painful venipunctures made for administration of cytotoxic agents, antibiotics, blood products, and nutritional supplements. The focus of this prospective observational research is to study the various underlying diseases for which “PORT” catheter is needed in different solid and hematologic malignancies and the various complications and outcomes in pediatric and adult patients with cancer.

A retrospective study of central venous catheters GCRI experience

BACKGROUND

The use of central venous catheters (CVCs) has greatly improved the quality-of-care in cancer patients, yet these catheters may cause serious infectious and thrombotic complications. The aim of this retrospective study was to study the various types of CVCs and their complications.

MATERIALS AND METHODS

We studied retrospectively 213 cases of CVCs in our institute with their indications, type and complications from August 2010 to July 2011.

RESULTS

A total of 213 CVCs were inserted in patients with hematological (62%) and solid organ malignancies (38%). Ninety-eight patients (46%) had peripheral inserted central catheter (PICC), 90 (42%) patients had Hickman catheters and 25 (12%) had a port. The median duration of retention of Hickman catheters was 104 days (3-365 days), for the peripherally inserted central catheters was 59 days (3-100 days) and for the port it was 280 days (45-365 days). Non-infective complications were more than infective (12% vs. 7%). The most common complication was non-infective occlusion and thrombophlebitis. In one patient with PICC thrombosis occurred in the cephalic, radial and ulnar vein and in one patient with port thrombosis occurred in the superior vena cava. Organisms were isolated in 60% (12 out of 20) of cultures. Common organisms isolated were Pseudomonas aeruginosa in 5 (42%), Staphylococcus aureus in 2 (16%), Escherichia coli in 2 (16%) and Aspergillus in 3 (25%) patients. 7 out of 12 infected patients had negative blood cultures within 7 days of antibiotic treatment, 5 patients remained positive for more than 7 days with antibiotics. In 155 patients (73%), the desired treatment protocol was completed and at present there are still 28 patients (13%) with catheters. 5 patients (2.3%) died of febrile neutropenia and septicemia with multi-organ failure. In 5 patients (2.3%), the catheters (1 Port, 1 Hickman and 3 PICC) were prematurely removed because of thrombosis.

CONCLUSION

CVCs are better options to facilitate the long-term vascular access provided infection is prevented with meticulous care and treated promptly with proper antibiotics. Most CVCs is acceptable to patients.

Risk factors for central venous catheter thrombotic complications in children and adolescents with cancer

BACKGROUND

The use of central venous catheters (CVCs) has greatly improved the quality of care in children with cancer, yet these catheters may cause serious infectious and thrombotic complications. The aim of this prospective registry study was to assess the host and CVC-related risk factors for CVC-created thrombotic complications.

METHODS

Patients undergoing CVC insertion for chemotherapy were followed prospectively for CVC complications. At the time of enrollment, demographic, clinical, and CVC-related data, and family history of thrombosis were collected. Survival and Cox regression analyses were performed.

RESULTS

A total of 423 CVCs were inserted into 262 patients for a total of 76,540 catheter days. The incidence of CVC-related deep-vein thrombosis (DVT) was 0.13 per 1000 catheter-days (95% confidence interval [CI], 0.06-0.24). Insertion of peripherally inserted central catheters (PICCs) and insertion in an angiography suite significantly increased the risk of symptomatic CVC-related DVT. The incidence of CVC occlusion was 1.35 per 1000 catheter-days (95% CI, 1.1-1.63). Positive family history of thrombosis significantly increased the risk of CVC occlusion (hazard ratio [HR], 2.16; 95% CI, 1.2-3.8). The CVC-related risk factors were insertion of Hickman catheters, insertion in angiography suite, and proximal-tip location. Patients developing at least 1 episode of both CVC occlusion and infection had an increased risk for developing symptomatic CVC-related DVT (HR, 4.15; 95% CI, 1.2-14.4).

CONCLUSIONS

Both patient-related and CVC-related factors are associated with higher risk of symptomatic thrombotic complications. These risk factors could be used in the clinical setting and in developing future studies for CVC thromboprophylaxis.

Port-A-Cath insertions in acute leukemia: does thrombocytopenia affect morbidity?

BACKGROUND

Unnecessary delay of insertion of Port-A-Cath indwelling venous catheters in thrombocytopenic patients may result from fear of potential morbidity. This study sought to compare the morbidity of Port-A-Cath insertions in acute leukemic patients with platelet counts below and above 50 x 10(9)/L.

METHOD

Incidence and profile of catheter-related bloodstream infections (CRBSIs) and other complications were determined in 80 consecutive Port-A-Cath insertions in pediatric patients with acute leukemia from January 2002 to December 2004. Subgroup analysis was performed for patients with platelet levels below and above the recommended safe level of 50 x 10(9)/L.

RESULTS

Twenty-two (27.5%) patients had insertions performed at platelet levels below the recommended level (median, 35.3; range, 10-49 x 10(9)/L); postoperative counts were correspondingly higher (median, 66.0; range, 20-207 x 10(9)/L) with perioperative platelet transfusion. Catheter-related bloodstream infection incidence was similar in patients with platelets less than and greater than the recommended threshold (18.2% vs 17.2%, respectively), and likewise for CRBSIs encountered in the immediate 30 postoperative days (4.6% and 5.2%, respectively). Only 2 episodes of postoperative bleeding occurred, both in the group with platelet counts greater than 50 x 10(9)/L, with an equally low incidence of other local and mechanical complications in both subgroups. Patient demographics and other preoperative blood parameters did not differ significantly.

CONCLUSION

Preoperative thrombocytopenia was not associated with increased incidence of postoperative complications for Port-A-Cath insertions in acute leukemic children.

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.

Catheter design influences recurrence of catheter-related bloodstream infection in children with cancer

PURPOSE

Multiple studies have demonstrated that catheter-related bloodstream infections (CRBI) can be successfully treated without catheter removal (in situ therapy), but there is insufficient information available to determine if catheter design can influence the eradication of bacteremia or recurrence.

PATIENTS AND METHODS

Bacteremic episodes in patients at St Jude Children's Research Hospital between January 1996 and May 2001 were identified and patient records were reviewed.

RESULTS

A total of 172 unique episodes of CRBI were identified. In situ therapy resulted in successful eradication of bacteremia in 87% of the episodes. Bacteremia recurred in 10% of the episodes. Although catheter design (Hickman and Broviac versus totally implantable central venous catheter) did not influence short-term eradication of bacteremia, totally implantable central venous catheters were significantly associated with recurrence of bacteremia (odds ratio, 10; 95% confidence interval, 3.1 to 33.3). In a multivariable analysis, this association between catheter design and recurrence remained statistically significant after adjustment for other factors that influenced recurrence in this study (isolation of coagulase-negative staphylococci and inadequate duration of initial antibiotic therapy).

CONCLUSION

This study demonstrates that patients with CRBI with a totally implantable central venous catheter in place are more likely to develop recurrent bacteremia. Management strategies to prevent recurrence in this setting should be explored.

Complications of central venous catheterization in critically ill children

OBJECTIVE: Analysis of central venous catheterization complications in different access sites with the Seldinger technique. Patients and Methods: A prospective study (May 1992 through December 1996) of 308 central venous catheterizations in children of different ages in a pediatric intensive care unit. RESULTS: Access sites were the subclavian vein (76.3%), femoral vein (20.4%), and jugular vein (3.2%). The frequency of catheter placement-related complications was 22%, and the frequency of serious catheter placement-related complications was 2.9% (pneumothorax 1.9%, hemothorax 1%). Catheter placement-related complications were more common in the subclavian than in the femoral vein (chi-square, p =.02) for the larger bore catheters (chi-square, p =.01) and for the higher number of attempts (Student's t -test, p <.001). Catheter placement-related complications were not related to the age, weight, or whether the procedure was performed by the staff physician or resident. The overall complication rate for maintenance-related complications was 36%. Maintenance-related complications were more common in younger children (Student's t -test, p =.03). The most frequent maintenance-related complications were mechanical complications (catheter obstruction and central venous thrombosis), and these were higher for femoral access (chi-square, p <.01) and for catheters indwelling for a longer period of time. Infection was found in 5.8% of patients, mainly due to Staphylococcus epidermidis. Infection was not related to the site of venous access or to the length of time the catheter was left indwelling. CONCLUSIONS: Central venous catheterization can be performed readily in children of all ages with an acceptable degree of risk. The immediate complications were more frequent and severe for subclavian vein catheterization, and the highest risk factor was the number of attempts at catheter insertion. Although the most frequent late complications were mechanical, which were higher for the femoral access and long-indwelling catheters, femoral catheters can be left indwelling for longer periods if routine ultrasound follow-up is performed. Infectious complications were independent of the venous access site or the duration of catheterization.

Right atrial catheter-related complications in pediatric oncology patients: the situation in a developing country

The complications of right atrial catheters (RACs) in pediatric oncology patients are unknown for centers in developing countries. This study examined the complications of RACs at Ankara University Medical School, Turkey. A total of 90 RACs were placed in 61 children for long-term chemotherapy with a total experience of 15,536 catheter days. The rate of catheter-related sepsis was 4.9 episodes per 1000 catheter days. Coagulase-negative staphylococci and Candida species were the most common organisms, accounting for 25.0 and 13.1% of all organisms, respectively. The most common reasons for the removal of the RACs were infection (42.4%) and dislodgement (32.2%). The rates of complications were significantly higher in this study than in western studies. This increase could be explained by the differences in catheter care practices in the Turkish center. In conclusion, the use of RACs in a developing country necessitates an appraisal of the benefits and risks for each patient and improvement of catheter care procedures.

Intravenous access in infants and children

At times, nothing is more difficult, time consuming or frustrating than obtaining vascular access in the pediatric patient. Today, technologic improvements in catheter design and imaging techniques have significantly facilitated line placement and increased the available options for vascular access. All clinicians involved in the care of pediatric patients should have knowledge of the various methods available for venous access, as well as their relative indications, advantages and disadvantages. This article discusses various sites used for venous access in the pediatric patient, as well as techniques that may be used by the pediatrician and those that require surgical consultation.

Comparison of diagnostic specimens and methods to evaluate infected venous access ports

BACKGROUND

Implanted venous access port infection can be difficult to diagnose and treat. If device removal is necessary, confirming port infection is problematic.

MATERIALS AND METHODS

Culture specimens from three sites, catheter tip (Tip), port pocket, and the material within the reservoir (Inside), were sent from ports removed for potential infection. The results of these cultures were compared to preremoval peripheral and central blood cultures.

RESULTS

Forty-five ports were removed for suspected infection. Confirmed port infection was defined as positive culture(s) from one or more experimental specimen(s). In 29 evaluable cases, the Inside specimens were completely predictive. Tip specimens were less accurate, even with a lower diagnostic threshold. In 7 of 19 confirmed infections, only the Inside culture was diagnostic.

CONCLUSION

The most predictive culture specimen in a potentially infected port is the thrombotic material inside the reservoir.

Venous access in pediatric oncology patients

Long-term central venous access is an integral part of the management of many, but not all children with cancer. The proper selection of those children who require this access and which access device (external vs. totally implanted) is best suited to that child is important to minimize complications and obtain optimal results. Although most of these devices can be expected to last the duration of the treatment protocol or the patient's life, complications (infection, occlusion, dislodgment) occur with higher than desired frequency, infection being the most common. No measures are clearly beneficial in preventing infection, but most infections can be treated successfully without device removal. Premature removal or dislodgement occurs more frequently with external catheters and may be minimized by techniques used at insertion. Occlusion, detected early, can be successfully managed by clot lysis in most children.

Comparison of saphenous versus jugular veins for central venous access in children with malignancy

A retrospective analysis was carried out to compare the performance and complications of central catheters inserted into either the saphenous (27) or jugular (52) veins. The saphenous route may be preferred in certain circumstances including extensive mediastinal pathology, prior neck surgery, previous catheter(s), and cosmetic reasons. There was no difference in complications (local or systemic catheter-related infections, catheter occlusions, or venous thrombosis). The incidence of catheter removal due to complications was also not different between sites. Hence, the saphenous route can provide an additional portal of vascular access in selected patients.

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

This is an interval analysis of the 2-year prospective multicenter Childrens Cancer Study Group study of 1,141 chronic venous access devices in 1,019 children with cancer. Device type was external catheter (EC) 72%, totally implantable (TID) 28%, and did not differ for diagnosis or age except more double-lumen devices in bone marrow transplant protocols (77%) and more TIDs in children less than 1 year old (17.7%). Insertion characteristics evaluated in 1,078 (95%) were: operating room placement 99%; general anesthesia 98%; cutdown 67%; percutaneous 33%; atrial position 50%, caval position 50%; and perioperative antibiotics 48%. Vein entry was the external jugular 33%, internal jugular 22%, subclavian 35%, cephalic 7%, and saphenous 3%. Insertion was difficult or very difficult in only 10% and operative complications occurred in only 0.7%. Degree of difficulty bore no relationship to device type or patient age. The reasons for removal in 736 devices (67%) were due to complications in 39%, of which infections were the most frequent. There was some variance between centers ranging from 8.5% to 31% for infection; 2.8% to 24% for dislodgment; and 0% to 13% for occlusion. ECs had a higher risk of dislodgment; elective removals were more frequent in TIDs; there was no difference in infection as a cause for removal between ECs and TIDs. Dislodgment was associated with the shortest distance of the cuff to the skin exit (mean, 4 cm): less than or equal to 2 cm, 49%; greater than 2 cm, 28% (P = .009) and occurred most frequently in the younger patient (18.9%, 0 to 1 years; 0.5%, greater than 8 years.

Central venous catheters in surgical neonates

Central venous catheters (CVCs) are widely used in neonates, but have significant complication rates. Over a 4-year period, 65 lines were inserted in 55 surgical neonates with a total of 877 catheter days. The mean length of insertion was 13.5 days, with a range of 1 to 35 days. Eighty percent of the surgical diagnoses were of necrotising enterocolitis, diaphragmatic hernia, or gastroschisis. Insertion was almost exclusively via the internal jugular vein. Only two Broviac catheters were used, the other catheters were noncuffed. Fourteen (22%) were inserted in the neonatal unit, with a similar complication rate to those inserted in the surgical theater. Overall, complications occurred with 22 lines (34%), seven of which (11%) were primary catheter sepsis (infection incidence, 1:125 days). One patient died as a result of catheter sepsis. Although the complication rate was similar, the complication incidence per day of catheter usage was higher than comparable reports. It is not clear if this was due to the pathological conditions of the surgical neonate, surgical or nursing technique, or the type of catheter used.

Continuous venous access in children with urological diseases

The placement of multipurpose silicone right atrial catheters for continuous venous access in children with complex urological diseases has become increasingly necessary. Between September 1985 and September 1987, 26 children with a variety of urological diseases required long-term central venous access, primarily for delivery of chemotherapy and blood products in 13 patients with malignancies, hemodialysis access in 7 undergoing renal transplantation, total parenteral nutrition in 5 (2 of whom were born with cloacal exstrophy), and fluid and antibiotic administration in 1 with dermatomyositis and acute pyelonephritis. Patient age at catheter placement ranged from 1 day to 15 years. A total of 11 complications was encountered during 4,500 catheter days: 10 were mechanical and 1 was infectious in nature. These complications led to replacement of the catheter in 3 patients and the remainder were managed successfully nonoperatively. The surgical techniques involved in placement of these catheters are discussed. The catheters not only allowed many of these patients to receive treatment on an outpatient basis but also ensured their survival. Our favorable experience with prolonged venous access in children should encourage urologists to include these techniques in their armamentarium.

Port-A-Cath in children during long-term chemotherapy: complications and outcome

Complications related to Port-A-Cath were studied prospectively during a period of 32 months in 31 patients, aged 1-18 years, with leukemias and solid tumors. There were 34 Port-A-Cath inserted, and the cumulative time for these catheters kept in place was 5899 days. No complications occurred in 18 patients (19 catheters) kept in place for a cumulative time of 3998 days with an average duration of 210 days (12-550 days). In 13 patients (15 catheters) there were 14 events of systemic infections; seven events were treated successfully with antibiotics, four events necessitated the extraction of the catheter (in one patient a combination of systemic and local infection), and in three events the catheters were kept unused, as the patients were in terminal stages. Nonsystemic complications occurred with five catheters; two local infections, two obstructions (catheters removed), and one local bleeding (catheter kept unused). Appropriate antimicrobial treatment of systemic infections enables the immunocompromised child to keep the Port-A-Cath in place for a long time.