Double lumen port access in patients receiving allogeneic blood stem cell transplantation

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.

Infectious morbidity by catheter type in neutropenic children with cancer

BACKGROUND

Three central venous catheters types are commonly used in pediatric cancer: totally implantable catheters (ICs; eg, mediports, portacaths), tunneled externalized catheters (eg Broviac® or Hickman® catheters [Bard Medical]) and peripherally inserted central catheters. While previous studies have examined risks for catheter-related infections, this is the first large multicenter study to compare catheter-associated infectious morbidity through patient outcomes and hospital utilization.

METHODS

A historical cohort analysis was conducted using data from the Pediatric Health Information System reporting 1167 hospitalizations of neutropenic patients with childhood cancer and a central venous catheters. Multivariate analyses controlled for age, ethnicity, gender, malignancy category and transplant status. Outcomes included incidence of serious bacterial infection, mortality, duration of hospitalization, time and use of intensive care unit and antibiotic usage.

RESULTS

Neutropenic cancer patients with totally ICs (n = 429) have a statistically significant approximately 50% decrease in length of hospitalization (P < 0.001), risk for requiring an intensive care unit stay (P = 0.002), documented serious bacterial infection (P = 0.001) and days on antibiotics (P < 0.001) when compared with patients with tunneled externalized catheters (n = 463). Similar differences were found comparing hospitalizations of patients with ICs to those with peripherally inserted central catheters (n = 275). No difference in mortality was observed among catheters groups.

CONCLUSIONS

In neutropenic pediatric oncology patients with a central venous catheters, ICs are associated with the least hospital utilization including shortest duration of hospitalization, intensive care unit time and antibiotic therapy when compared with tunneled external catheters and peripherally inserted central catheters. The impact of differences in catheter-associated infectious morbidity on patient outcomes and hospital utilization should be included in clinical decision making.

Double-lumen central venous port catheters: simultaneous application for chemotherapy and parenteral nutrition in cancer patients

PURPOSE

This study was designed to evaluate the clinical benefit of low-profile double-lumen port catheters in patients receiving simultaneous chemotherapy and parenteral nutrition (PN). Potential advantages, complications, and the durations of simultaneous and single use of the catheter were assessed.

METHODS

At a university teaching hospital, 10 patients received a double-lumen port catheter (5 men, 5 women; mean age 61.5 ± 12 years). All port implantations were performed under ultrasonographic and fluoroscopic guidance in the radiologic interventional suite. Procedure-related immediate, early, and late complications were recorded until removal of the device, patient's death, or completion of follow-up period. Application times and durations for chemotherapy or PN were determined.

RESULTS

No immediate complications were observed. First use of the port system for chemotherapy was within 12 days (± 25 days, range 0-84 days) and within 17 hours (± 22 hours, range 0-72 hours) for PN on average. During the application of PN, no delay or interruption of chemotherapy was observed. The port catheter was used for the simultaneous application of chemotherapy and PN for a total of 1,216 hours. One port catheter was removed after 30 days due to suspected port infection.

CONCLUSION

Central venous double-lumen port systems as a therapeutic option in patients requiring chemotherapy and PN can increase safety during those simultaneous applications, while offering improved patient comfort.

Central venous port systems as an integral part of chemotherapy

BACKGROUND

Port systems are easy to implant on an in- or outpatient basis and provide reliable, long-lasting central venous access. They are used mainly for cancer patients.

METHODS

This article is based on a selective literature review, the guidelines of the German Society for Nutrition Medicine and of the European Society for Clinical Nutrition and Metabolism, and the recommendations of the German Society for Pediatric Oncology and Hematology.

RESULTS

In modern oncology, central venous port systems are increasingly replacing short-term and permanently tunneled central venous catheters. They are indicated for patients who need long-term intravenous treatment involving, e.g., the repeated administration of chemotherapeutic drugs, parenteral nutrition, transfusions, infusions, injections, and/or blood sample collection. Port systems can markedly alleviate the burden of intravenous therapy and thereby improve these patients' quality of life. The planning, preparation, and performance of port system implantation require meticulous attention to detail. The rate of implantation-associated complications is less than 2% in experienced hands; overall complication rates have been reported from 4.3% to as high as 46%. The proper postoperative use and care of the port system are of decisive importance to the outcome. Reported infection rates during port system use range from 0.8% to 7.5% in current clinical studies.

CONCLUSION

The treatment, follow-up care, and rehabilitation of cancer patients are interdisciplinary tasks. Optimal treatment and complication avoidance require a collaborative effort of all of the involved specialists-not just the physician implanting the port system, but also the oncologists, nutritionists, visiting nurses, and other home health care providers. Continuing medical education, too, plays a role in improving outcomes.

Patients' perceptions of having a central venous catheter or a totally implantable subcutaneous port system-results from a randomised study in acute leukaemia

GOALS OF WORK

The selection process of type of central venous access device (CVAD) in patients with acute leukaemia (AL) is generally based on appropriate catheter capacity/function and risk of complications in relation to the planned length of therapy. Advantages and disadvantages of the CVAD from the patient's perspective should also be important parts in the selection of type of device. Perceptions on having a CVAD were thus analysed in a series of adult patients with AL included in a prospective randomised study evaluating the use of a double lumen totally implantable subcutaneous port system (PORT) or a double lumen central venous catheter (CVC) regarding survival time and complication rate.

MATERIALS AND METHODS

Perceptions were registered in 32 patients (median age 68 years, range 24-83 years) on three occasions (T1; the day after placement, T2; 3 weeks after placement and T3 after 12 weeks and/or when the CVAD was removed) with the use of two study specific questionnaires.

MAIN RESULTS

Overall, many patients reported minor catheter related discomfort, feelings of anxiety and restrictions. Half of the patients (6/11) who experienced a local bleeding after CVAD insertion described the placement procedure as unpleasant. More patients in the CVC group compared with the PORT group stated that they thought of having a CVAD (T3; p = 0.02) and that the CVAD interfered when dressing themselves (T2; p = 0.02 and T3; 0.04) or taking a shower (T3; p = 0.009).

CONCLUSION

Our findings support the view that the PORT is less restrictive in daily life than the CVC.