Complications of Hickman-Broviac catheters in children with malignancies

Incidence and risk factors of complications during central venous access devices removal in children

PURPOSE

To quantify the rates and identify risk factors for the complications of central venous access devices (CVADs) removal in children.

METHOD

Retrospective (2018-2023) review of children undergoing CVADs removal at a single institution. Data are reported as frequency, percentages and median. Logistic regression analysis was used to identify risk factors associated with difficult removal. Receiver Operating Characteristic Curve (ROC) analysis was conducted to identify the age cut-off and positive likelihood ratio (+LH) for the indwelling time associated with complicated removal. p-Value <0.05 were considered statistically significant.

RESULTS

We identified 208 CVAD removals with a median age of 7.2 (0.2-18.4) years including 116 (55.8%) males. The median CVAD placement duration was 1.26 years (0.4-5.7) years. Indications for insertion included acute lymphoblastic leukaemia (ALL; 78/208, 37.5%), lymphomas (31/208, 14.9%), other malignancies (58/208, 27.9%). Removal indications included completion of treatment (144/208, 69.2%), infection (22/208, 10.6%), malfunction (7/208, 3.4%) and other reasons (35/208, 16.8%). There were 20 (9.6%) complications characterised by difficulty removing the CVAD. Complicated removals were more likely to occur in children with ALL as the primary diagnosis (p = 0.001); independently of the indication for insertion, longer indwelling time was associated with higher risk of complicated removal (p < 0.001). Indwelling time >2.09 years was associated with a 2.87 increased risk of difficult removal.

CONCLUSION

In our experience, almost 10% of CVAD removals in children result in complications. These findings are associated with an indwelling time >2 years; strategies to prevent complicated removals should be considered in children requiring long-term central venous access.

Catheter-associated Bloodstream Infection in Children with Tunneled Central Venous Catheters: A Single-center Experience

Background

Tunnelled catheters improve venous access in haematological diseases and malignancies, but are associated with complications. We prospectively analysed the episodes of CABSI and its associated risk factors.

Aims

To study the incidence and risk factors for CABSI in children with tunnelled central venous catheters (both Hickmans and Chemoports).

Materials and Methods

This is a prospective observational study done at our institute. Children under the age of 18 who underwent insertion of a Hickman or Chemoport from March 2018 to Dec 2022 were enrolled. Episodes of CABSI were noted and its risk factors were analysed.

Results

In total, 258 catheters were inserted in 250 children. Age ranged from 1 month to 18 years (median 67 months) with 60% being boys. A total of 152 Hickmans, 106 chemoports were inserted. Indications for insertions were for requirement of BMT and chemotherapy in majority of cases. CABSI were seen in 28.6% of catheters. Younger children (< 4years), Neutropenia (counts < 1000) and use of TPN were significantly associated with CABSI(p value<0.05). Infection was more with externalized catheters (Hickman) than implantable ports (Chemoports) but was not statistical significant(p value>0.05). Almost 30% of catheters with CABSI required removal because of florid sepsis. Others could be salvaged with aggressive antibiotics.

Conclusions

CABSI is a serious complications related to tunnelled catheter. Smaller children (<4 years), neutropenia and usage of TPN is a risk factor for development of CABSI. It can be treated with appropriate antibiotics and required removal in almost a third of all the cases.

Trainee educational curriculum to standardize central venous catheter repair

INTRODUCTION

Children may require durable central venous catheters (CVCs) for various reasons. CVC-related integrity complications are common and can often be repaired at the bedside to increase lifetime. Variability in repair techniques can lead to complications, including the need for repeat repair and Central Line Associated Blood Stream Infection (CLABSI).

METHODS

The impact of an educational curriculum to standardize tunneled CVC repairs for trainees on a pediatric surgery service was studied, focusing on comfort level with tunneled CVC repair and to determine the impact on complication rates. Rotating trainees studied a dedicated audiovisual educational curriculum comprised of a video, educational slides, and a practical component from November 2020 through January 2022. Experience and comfort level with tunneled CVC repairs were assessed before and after the rotation. CVCs repaired during the duration of the study were evaluated and compared to the period prior.

RESULTS

Forty-nine individuals completed the pre- and post-training survey. Respondents (34.7%, n = 17) most commonly reported one year of surgical experience, and (79.6%, n = 39) had never observed or assisted in a repair previously. Following training, respondents felt more comfortable with all aspects of the CVC repair process (p < 0.001). There were no statistically significant differences in re-repair rates or CLABSI rates following the implementation of the curriculum.

CONCLUSIONS

Tunneled CVC procedural repair variability can be standardized with a dedicated educational curriculum for rotating trainees, which improves knowledge and comfort with such procedures.

Intestinal failure among adults and children: Similarities and differences

Intestinal failure (IF) is a complex medical condition that is caused by a constellation of disorders, resulting in the gut's inability to adequately absorb fluids and nutrients to sustain hydration, growth, and survival, thereby requiring the use of parenteral fluid and/or nutrition. Significant advancements in intestinal rehabilitation have resulted in improved survival rates for individuals with IF. There are distinct differences, however, related to etiology, adaptive potential and complications, and medical and surgical management when comparing children with adults. The purpose of this review is to contrast the similarities and differences between these two distinct groups and provide insight for future directions, as a growing population of pediatric patients will cross into the adult world for IF management.

Impact of light-activated curcumin and curcuminoids films for catheters decontamination

BACKGROUND

Biofilms are microbial communities protected by an extra polymeric matrix, which promotes a defense against antimicrobial agents. Cells attached in surfaces and promote infections. Photodynamic inactivation (PDI) is one of the strategies to eliminate infections due to the facility of use and the absence of resistance by bacteria. The study combines formulation with curcuminoids and with Photogem^(R), illuminating them with 450 nm and 630 nm, respectively.

METHODS

Films were prepared with pectin, glycerin, Sodium Lauryl Sulfate, curcumin, curcuminoids, or Photogem^(R) (0.75; 0.75 mg/mL and 0.03 mg/mL respectively). Bacterial biofilms were formed during 3, 4, or 7 days on catheters and illumination with LED devices at 450 nm and 630 nm.

RESULTS

The best PDI applied in S. aureus 7-days biofilm with curcuminoid film. Photogem film was the best strategy for PDI in E. coli 7-day biofilm. Curcumin film promoted similar results with S. aureus and E. coli. Light penetration demonstrated a similar decreased exponential curve along the increase of thickness of biofilm.

CONCLUSION

Curcuminoids, curcumin and Photogem® show efficient solubilization and availability in formulation with relevant results in PDI. S aureus biofilms were more susceptible to curcuminoid film. E coli biofilms were more susceptible to Photogem film.

High Rates of Central Venous Line Replacement or Revision in Children With Cancer at US Children's Hospitals

BACKGROUND

Most children with cancer utilize a central venous line (CVL) for treatment. Complications often necessitate early replacement, revision, or addition (RRA), but the rate of these procedures is not known. This study sought to determine rates of RRA in pediatric oncology patients, and associated risk factors.

MATERIALS AND METHODS

Data queried from the Pediatric Health Information System including patients ≤18 years old with malignancy and CVL placement. Analysis included: first CVL placement of the calendar year and subsequent procedures for 6 months thereafter.

RESULTS

A total of 6553 children met inclusion criteria (55.9% male, median age 6 years, interquartile range: 2 to 12). RRA within 6 months was required in 25.6% of patients, with 1.7% requiring 5 or more lines. Patients with Central Line-Associated Bloodstream Infection (CLABSI) were 2.78 times more likely to require RRA within 6 months of initial CVL placement, but accounted for only 16% of RRA patients. Factors associated with RRA were age below 1 year, CLABSI, hematologic malignancy, malnutrition, clotting disorder, deep vessel thromboembolism, and obesity. Patients with implantable ports as initial CVL (42%) were less likely to need RRA.

CONCLUSION

Twenty-five percent require at least 1 RRA within 6 months, with associated morbidity and costs. Though strongly associated, most revisions were not related to CLABSI episodes.

Radiologic placement of Hickman catheters using intravenous sedation in pediatric patients under 20 kg

Surgeons generally perform Hickman catheter insertion in children under general anesthesia. At times, it is difficult to perform procedures with an anesthesiologist for an interventional radiologist. Several diagnostic and therapeutic procedures are efficiently and safely conducted using intravenous (IV) sedation in children with a pediatrician. This study aims to evaluate the efficacy and safety of radiologically placed Hickman catheters using IV sedation in children under 20 kg.Fifty-nine catheters were inserted in 45 children under IV sedation. With continuous monitoring of vital signs, IV midazolam and ketamine were slowly infused by a pediatrician. Mean age and body weights were 3.2 years and 15.2 kg, respectively. Acute leukemia was the most common disease for the procedure (72.9%). The location of the catheter tip was evaluated by measuring the height of the thoracic vertebra.Technical success rate was 100%, and IV sedation-related complications did not occur. The right internal jugular vein was accessed for 51 catheters (86.4%), and the mean procedure time was 21.5 minutes. The 2 vertebral body units below the carina were the cavoatrial junction on a fluoroscopy image. Mean catheter life was 285 days, and catheters were removed post-treatment (35.6%). During follow-up, complications occurred in 29 cases (1.72 per 1000 catheter-days). Catheter-related infections were suspected in 4 patients (6.8%), with 1 positive result.Radiological Hickman catheter placement in children under 20 kg using IV sedation by pediatricians is effective and safe, with minimal complications. The carina is a landmark to estimate the cavoatrial junction in pediatric patients.

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.

Pharmacokinetics, Tissue Distribution, and Efficacy of VIO-001 (Meropenem/Piperacillin/Tazobactam) for Treatment of Methicillin-Resistant Staphylococcus aureus Bacteremia in Immunocompetent Rabbits with Chronic Indwelling Vascular Catheters

Methicillin-resistant Staphylococcus aureus (MRSA) infections of surgically implanted subcutaneous vascular catheters (SISVCs) cause serious morbidity in patients with chronic illnesses. Previous in vitro and murine models demonstrated the synergistic interaction of equimolar concentrations of meropenem/piperacillin/tazobactam (MPT) (VIO-001) against MRSA infection. We investigated the pharmacokinetics (PK) and efficacy of VIO-001 for the treatment of MRSA bacteremia in immunocompetent rabbits with SISVCs. In PK studies, we determined that optimal dosing to achieve a time above 4× MIC (T_>4×MIC) of a duration of 3 to 3.30 h required a 1-h infusion with every-4-h (Q4h) dosing. Study groups in efficacy experiments consisted of MPT combinations of 100/150/100 mg/kg of body weight (MPT100), 200/300/200 mg/kg (MPT200), and 400/600/400 mg/kg (MPT400); vancomycin (VAN) at 15 mg/kg; and untreated controls (UC). The inoculum of MRSA isolate USA300-TCH1516 (1 × 10³ organisms) was administered via the SISCV on day 1 and locked for 24 h. The 8-day therapy started at 24 h postinoculation. There was a significant reduction of MRSA in blood cultures from the SISVCs in all treatment groups, with full clearance on day 4, versus UCs (P < 0.05). Consistent with the clearance of SISVC-related infection, full eradication of MRSA was achieved in lungs, heart, liver, spleen, and kidneys at the end of the study versus UC (P < 0.01). These results strongly correlated with time-kill data, where MPT in the range of 4/6/4 μg/ml to 32/48/32 μg/ml demonstrated a significant 6-log decrease in the bacterial burden versus UC (P < 0.01). In summary, VIO-001 demonstrated a favorable PK/pharmacodynamic (PD) profile and activity against SISCV MRSA infection, bacteremia, and disseminated infection. This rabbit model provides a new system for understanding new antimicrobial agents against MRSA SISVC-related infection, and these data provide a basis for future clinical investigation.

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.

Centrally inserted tunnelled peripherally inserted central catheter: Off-label use for venous access in oncology patients

Purpose:

Vascular access in oncology patients can often be challenging, especially after a few cycles of chemotherapy through peripheral lines which can cause veins to become attenuated. We evaluated the feasibility of centrally placed non-cuffed tunnelled peripherally inserted central catheter in the chest as an alternative to conventional peripherally inserted central catheter.

Method:

Patients referred for peripherally inserted central catheter found to have inadequate peripheral venous access in their arms due to prior chemotherapy, and therefore they were offered placement of the non-cuffed tunnelled peripherally inserted central catheter in the chest. Adult patients were subjected to the procedure under local anaesthesia, while paediatric patients underwent this procedure under general anaesthesia. Ultrasound guidance was used for venous access, and fluoroscopy was used for tip positioning. Using internal jugular vein access, BARD Groshong-valved 4F peripherally inserted central catheter was placed with its tip in the cavo-atrial junction. Proximal end of the catheter was brought out through the subcutaneous tunnel, so that the exit point of the peripherally inserted central catheter lies over the upper chest. Extra length of the catheter was trimmed, and extensions were attached. The device was stabilized with adhesive and sutures.

Results:

Out of 19 patients, 18 patients were male (4–72 years). Technical success was achieved in 100% cases. No catheter-related bloodstream infection was noted within 30 days of peripherally inserted central catheter. Overall, during 1966 catheter days, no catheter-related bloodstream infection was observed. The purpose of peripherally inserted central catheter was achieved in 15 patients (78.9%) either in the form of completion of chemotherapy (8/15) or maintained peripherally inserted central catheter line till death (7/15). Partial or complete pullout was observed in four patients (20.1%), which required cuffed tunnelled catheter or implantable port. External fracture was noted in one patient, which was successfully corrected using repair kit. No exit site infection, bleeding, catheter occlusion, catheter dysfunction, venous thrombosis, venous stenosis or catheter embolizations were noted in our series.

Conclusion:

Centrally placed tunnelled peripherally inserted central catheter is a promising alternative method, when conventional arm peripherally inserted central catheter placement is not feasible. It is an easy and safe procedure that can be performed under local anaesthesia.

Outcome of landmark-guided percutaneously inserted tunneled central venous catheters in infants and children under 3 years with cancer

BACKGROUND

There is a paucity of information on procedural and long-term outcomes of tunneled central venous catheters (TCVC) in infants and children younger than 3 years undergoing anticancer therapy. This study aims to evaluate the success, safety, and complications leading to surgical revision or premature removal of TCVC in this particular patient group.

METHODS

The clinical course of pediatric patients with percutaneous inserted TCVC, including Groshong (GC) and Hickman/Broviac (HB) catheters, has been analyzed retrospectively. The data analysis includes patient and device characteristics, adverse events during insertion, and dwell period complications.

RESULTS

A consecutive series of 238 children undergoing implantation of 273 TCVC, including 148 (54.2%) GC and 125 (45.8%) HB catheters, with a total of 38,209 catheter days at risk (cdr) were reviewed. The patient cohort consisted of 65 (23.8%) infants, 77 (28.2%) children aged 1-2 years, and 131 (48.0%) aged 2-3 years. The overall rate of adverse events during catheter insertion was 12.8% (n = 35) with no differences between age groups or devices. The overall rate of long-term complication was 28.2% (n = 77, catheter risk [CR] per 1,000 cdr = 1.75), with the highest prevalence in infants (P = 0.01). The most common complication was late dislocation (n = 24, 8.8%, CR = 0.47), followed by early dislocation (n = 20, 7.3%) and infection (n = 18, 7.4%, CR = 0.42).

CONCLUSION

Percutaneous landmark-guided insertion of TCVC in neonates and small children with cancer is safe. Patterns of long-term complications are different from those for older children and should be prevented through appropriate management.

Removal and insertion of central venous catheters in cancer patients is associated with high symptom burden

OBJECTIVES

To assess the symptom burden associated with CVC removal and insertion in cancer patients.

METHODS

We collected patient-reported symptom-burden outcomes for 60 consecutive cancer patients: 30 undergoing CVC removal and 30 undergoing CVC insertion. Cancer patients self-administered the MD Anderson Symptom Inventory to rate the severity of 21 different symptoms immediately after the procedure Results: Symptoms were present in up to 57% to 67% of patients undergoing CVC insertion and removal respectively. Nineteen patients (32%) were moderately symptomatic with a symptom burden of four or more: ten insertion and nine removal patients. Symptoms with a score of 4 or more clustered around physical symptoms (pain, pressure or burning) or more generalized symptoms (fatigue, sleep, distress, dry mouth, and drowsiness). Nine (15%) patients rated at least one symptom as eight or more, five (17%) being insertion patients.

CONCLUSIONS

CVCs are essential for the management of cancer patients. However, they can become infected and may need to be removed. Catheter removal and insertion produced moderate to severe symptom burden in cancer patients. Safe interventions that would salvage the vascular access without worsening the infectious outcome should be explored to alleviate morbidity associated with the symptom burden of removal and re-insertion.

A comparison of Broviac® and peripherally inserted central catheters in children with intestinal failure

PURPOSE

Central venous catheters (CVCs) are a source of morbidity for children with intestinal failure (IF). Complications include infection, breakage, occlusion, and venous thrombosis. Broviacs® have traditionally been preferred, but peripherally inserted central catheters (PICCs) are gaining popularity. This study compares complications between Broviacs® and PICCs in children with IF.

METHODS

After IRB approval, children with IF receiving parenteral nutrition (2012-2016) were reviewed. Complications were compared between Broviacs® and PICCs using the generalized estimation equation population-averaged Poisson regression model. P values <0.05 were considered significant.

RESULTS

36 children (0.1-16years) with IF were reviewed, accounting for 27,331 catheter days, 108 Broviacs® (3F-9F), and 54 PICCs (2-11F). Broviacs® had a significantly higher infection rate (4.2 vs. 2.6/1000 catheter days, p=0.011), but PICCs were more likely to break (1.56 vs. 0.26/1000 catheter days, p=0.002). When comparing same size catheters (3F), there were no significant differences in infection, breakage, or occlusion. Twelve children (33%) had central venous thrombosis, all after Broviac® placement. Three children (8%) had basilic vein thrombosis after PICC placement.

CONCLUSION

Although Broviacs® and PICCs had similar complication rates, there were fewer central venous thromboses associated with PICCs. This should be considered when choosing catheters for children with IF.

LEVEL OF EVIDENCE

11b (Prognosis Study).

Cohort Study: Central Venous Catheter-Related Complications in Children with Hematologic Diseases at a Single Center

Objective:

This study aims to document and analyze the central venous catheter (CVC)-related complications in children with hematological diseases who were treated within a single institution.

Materials and Methods:

A retrospective investigation was conducted in 106 pediatric patients in whom 203 CVCs were inserted. A total of 175 catheter-related complications occurred in 5 years.

Results:

The rates of clinical catheter infections, local catheter infections, venous thromboembolism, bleeding, and mechanical complications were 2.6, 1.1, 0.2, 0.2, and 0.2 per 1000 catheter days. Methicillin-resistant Staphylococcus epidermidis was the predominant infectious organism in blood and catheter cultures. The children with leukemia had a significantly higher frequency of clinical catheter infections (p=0.046). The children who underwent bone marrow transplantation had a significantly lower frequency of clinical catheter infections (p=0.043) and higher frequency of local catheter infections (p=0.003). The children with implanted catheters had a significantly lower frequency of clinical catheter infections (p=0.048). The children with thrombocytopenia had significantly fewer local catheter infections and significantly more clinical catheter infections and catheter-related bleeding (respectively p=0.001, p=0.042, and p=0.024).

Conclusion:

Leukemia, bone marrow transplantation, and thrombocytopenia are risk factors for CVC-associated complications. The relatively higher number of interventions performed via permanent catheters may be responsible for the significantly increased incidence of systemic infections and mechanical injury.

Complications of indwelling central venous catheters in pediatric liver transplant recipients

In pLT recipients, the advantages of ICVCs need to be weighed against the risk of complications. This single-center retrospective study aimed to review ICVC complications in our cohort of pLT recipients. We performed chart reviews of pLT patients having undergone transplant between 01/2000 and 03/2014 and who underwent ICVC placement either before or after LT. We identified 100 ICVC in 85 patients. Overall observation time was 90 470 catheter-days. There was no difference in catheter lifespan between those inserted pre- or post-transplant; 46% of ICVC presented a complication. Most frequent complications were MD and infection. The infection rate was 0.09 per 1000 catheter-days, and MD rate was 0.36 per 1000 catheter-days. Patients having received technical variant grafts were more at risk of complications. To the best of our knowledge, this is the first study examining ICVC complications in pLT recipients. We conclude that ICVC have a high rate of MD. Children receiving technical variants may be more at risk of complications. By removing ICVC in a select number of patients at six months post-insertion, we might avoid as much as 60% of complications.

Central venous Access device SeCurement And Dressing Effectiveness (CASCADE) in paediatrics: protocol for pilot randomised controlled trials

INTRODUCTION

Paediatric central venous access devices (CVADs) are associated with a 25% incidence of failure. Securement and dressing are strategies used to reduce failure and complication; however, innovative technologies have not been evaluated for their effectiveness across device types. The primary aim of this research is to evaluate the feasibility of launching a full-scale randomised controlled efficacy trial across three CVAD types regarding CVAD securement and dressing, using predefined feasibility criteria.

METHODS AND ANALYSIS

Three feasibility randomised, controlled trials are to be undertaken at the Royal Children's Hospital and the Lady Cilento Children's Hospital, Brisbane, Australia. CVAD securement and dressing interventions under examination compare current practice with sutureless securement devices, integrated securement dressings and tissue adhesive. In total, 328 paediatric patients requiring a peripherally inserted central catheter (n=100); non-tunnelled CVAD (n=180) and tunnelled CVAD (n=48) to be inserted will be recruited and randomly allocated to CVAD securement and dressing products. Primary outcomes will be study feasibility measured by eligibility, recruitment, retention, attrition, missing data, parent/staff satisfaction and effect size. CVAD failure and complication (catheter-associated bloodstream infection, local infection, venous thrombosis, occlusion, dislodgement and breakage) will be compared between groups.

ETHICS AND DISSEMINATION

Ethical approval to conduct the research has been obtained. All dissemination will be undertaken using the CONSORT Statement recommendations. Additionally, the results will be sent to the relevant organisations which lead CVAD focused clinical practice guidelines development.

TRIAL REGISTRATION NUMBERS

ACTRN12614001327673; ACTRN12615000977572; ACTRN12614000280606.

Reduced central line infection rates in children with leukemia following caregiver training: A quality improvement study

Infections are a leading cause of morbidity and mortality in children with acute leukemia. Central-line (CL) devices increase this population's risk of serious infections.Within the context of a quality improvement (QI) project, we tested the effect of caregiver education on CL management on the CL-associated bloodstream infection (CLABSI) rate among children with acute leukemia seen at a large referral center in Italy. The intervention consisted of 9 in-person sessions for education and practice using mannequins and children.One hundred and twenty caregivers agreed to participate in the initiative. One hundred and five (87.5%) completed the training, 5 (4.1%) withdrew after the first session, and 10 (8.3%) withdrew during practical sessions. After educational intervention, the overall CLABSI rate was reduced by 46% (from 6.86 to 3.70/1000 CL-days). CLABSI rate was lower in children whose caregivers completed the training (1.74/1000 CL-days, 95% CI 0.43-6.94) compared with those who did not receive any training (12.2/1000 CL-days, 95% CI 7.08-21.0, P < 0.05) or were in-training (3.96/1000 CL-days, 95% CI 1.98-7.91) at the time of infection.Caregiver training in CL management, applied within a multifaceted QI approach, reduced the rate of CLABSI in children with acute leukemia. Specific training and active involvement of caregivers in CL management may be effective to reduce CLABSI in high-risk children.

Complications of Central Venous Access Devices: A Systematic Review

CONTEXT

The failure and complications of central venous access devices (CVADs) result in interrupted medical treatment, morbidity, and mortality for the patient. The resulting insertion of a new CVAD further contributes to risk and consumes extra resources.

OBJECTIVE

To systematically review existing evidence of the incidence of CVAD failure and complications across CVAD types within pediatrics.

DATA SOURCES

Central Register of Controlled Trials, PubMed, and Cumulative Index to Nursing and Allied Health databases were systematically searched up to January 2015.

STUDY SELECTION

Included studies were of cohort design and examined the incidence of CVAD failure and complications across CVAD type in pediatrics within the last 10 years. CVAD failure was defined as CVAD loss of function before the completion of necessary treatment, and complications were defined as CVAD-associated bloodstream infection, CVAD local infection, dislodgement, occlusion, thrombosis, and breakage.

DATA EXTRACTION

Data were independently extracted and critiqued for quality by 2 authors.

RESULTS

Seventy-four cohort studies met the inclusion criteria, with mixed quality of reporting and methods. Overall, 25% of CVADs failed before completion of therapy (95% confidence interval [CI] 20.9%-29.2%) at a rate of 1.97 per 1000 catheter days (95% CI 1.71-2.23). The failure per CVAD device was highest proportionally in hemodialysis catheters (46.4% [95% CI 29.6%-63.6%]) and per 1000 catheter days in umbilical catheters (28.6 per 1000 catheter days [95% CI 17.4-39.8]). Totally implanted devices had the lowest rate of failure per 1000 catheter days (0.15 [95% CI 0.09-0.20]).

LIMITATIONS

The inclusion of nonrandomized and noncomparator studies may have affected the robustness of the research.

CONCLUSIONS

CVAD failure and complications in pediatrics are a significant burden on the health care system internationally.

Conservative Management of Downhill Esophageal Varices Secondary to Central Line-related Thrombosis After Hematopoietic Stem Cell Transplant

Occlusive central line-related complications are not infrequent in children undergoing cancer therapy, but are generally not associated with life-threatening complications. Thrombosis of the superior vena cava (SVC) is rarely described in such patients, and downhill esophageal varices have been described in children and adults as a complication of altered SVC blood flow. The management of patients with SVC thrombosis and associated varices is complicated by the need to treat the thrombus weighed against bleeding risk. We present a 14-year-old adolescent with a history of acute leukemia and central line-related complications, including SVC thrombosis with subsequent formation of downhill esophageal varices. Conservative management consisting of anticoagulation alone resulted in resolution of the varices with no bleeding complications.

Central venous line complications with chronic ambulatory infusion of prostacyclin analogues in pediatric patients with pulmonary arterial hypertension

Chronic infusion of prostacyclin (PGI2) via a Broviac central venous line (CVL) is attended by risk of CVL-related complications, but we know of only one report regarding CVL-associated bloodstream infection (BSI) with PGI2 in children and none regarding other complications. We conducted a retrospective cohort study involving pediatric patients with pulmonary hypertension treated with chronic intravenous infusion of PGI2 at Boston Children's Hospital and determined the rate (per 1,000 line-days) of various CVL-related complications. We also determined how often complications necessitated line replacement and hospitalization, time to replacement of CVLs, and interpatient variability in the incidence of complications. From 1999 until 2014, 26 patients meeting follow-up criteria had PGI2 infusion, representing 43,855 line-days; mean follow-up was 56 months (range, 1.4-161 months). The CVL complication rates (per 1,000 line-days) were as follows: CVL-BSI, 0.25; superficial line infection, 0.48; impaired integrity, 0.59; occlusion, 0.09; and malposition, 0.32. The total complication rate was 1.73 cases per 1,000 line-days. All CVL-BSI and malposition cases were treated with CVL removal and replacement. Of CVLs with impaired integrity, 23 could be repaired and 3 required replacement. Six of 21 superficial CVL infections required replacement of the CVL. Three of 4 occluded CVLs were replaced. CVL complications occasioned 65 hospitalizations. There was marked interpatient variability in the rate of complications, much but not all of which appeared to be related to duration of CVL placement. We conclude that non-BSI complications are very significant and that efforts to teach and emphasize other aspects of line care are therefore very important.

Invasive bacterial and fungal infections in paediatric patients with cancer: incidence, risk factors, aetiology and outcomes in a UK regional cohort 2009-2011

BACKGROUND

Cancer is the second most common cause of childhood deaths in the United Kingdom and infection contributes to a quarter of all cancer-related deaths. This study aimed to estimate the risk, aetiology and outcome of bloodstream bacterial and fungal infections in children with cancer within a geographically defined region in South-West London over a 3-year period.

METHODS

Web-based questionnaires were completed using case records of children with positive blood cultures admitted to five London hospitals during 2009-2011.

RESULTS

A total of 112 children with a median age of 5.4 (IQR 3.6-11.2) years had 266 significant blood cultures during 149 infection episodes. Haematological malignancy affected 68 patients (60.7%) and solid tumours 44 (39.3%). The overall bloodstream infection rate was 1.5 episodes per 1,000 days-at-risk (95% CI, 1.2-1.8) and was similar for those with haematological malignancies and solid tumours. Most episodes were attributed to central venous catheter infection (120/149, 80.5%). Coagulase-negative staphylococci were isolated in almost half the bloodstream infections (127/266; 47.7%), while Gram-negative organisms accounted for a further quarter (64/266; 24.1%). Fungal isolates from blood were uncommon (8/112 children, 7.1%) but significantly associated with neutropenia (18/149 [12.1%] vs. 1/114 [0.9%], P = 0.0004). Six children (5.4%) died, including three (2.7%; 95% CI, 0.6-7.6%) whose deaths were infection-related.

CONCLUSIONS

This study provides an updated risk estimate for bloodstream infections in children with cancer and adds to the framework for developing evidence-based guidance for management of suspected infections in this highly vulnerable group.

Infantile Crohn's disease is one of the risk factors for catheter-related bloodstream infection

BACKGROUND

Central venous catheterization is recognized as a lifeline that is important for chemotherapy or nutritional support in pediatric patients with malignant disease and intestinal failure. This study analyzed the risk of infection with Broviac line use among these patients at a single Japanese center.

METHODS

Two hundred and four Broviac lines were inserted in patients in the pediatric ward from January 2003 to October 2011. We analyzed the risk of catheter-related bloodstream infection (CR-BSI) using clinical characteristics including underlying disease, sepsis history, inserted situation, drug use, and laboratory data at the time of Broviac insertion or before CR-BSI.

RESULTS

During the study period, data from a total of 15 lines were excluded because of missing blood culture data. In the remaining 189 Broviac lines, 52 lines developed CR-BSI. On univariate analysis, leukemia, infantile Crohn's disease, sepsis history before Broviac insertion, existence of a stoma opening, and immunosuppressant use before CR-BSI were risk factors for CR-BSI. On multivariate logistic regression analysis infantile Crohn's disease, sepsis history before Broviac insertion, and immunosuppressant use before CR-BSI were independently associated with CR-BSI (P = 0.015, P = 0.045, and P = 0.043, respectively).

CONCLUSIONS

Infantile Crohn's disease carries a high risk for CR-BSI because of its pathological condition, the therapeutic drugs required, and surgical intervention.

Cost and safety of pediatric intensive care physician-placed broviac catheters

OBJECTIVE

To compare the cost and safety of placement of Broviac catheters in children by pediatric intensivists in a sedation suite versus placement by pediatric surgeons in the operating room.

DESIGN

Single-center retrospective analysis.

SETTING

Pediatric sedation suite and operating rooms in a tertiary care children's hospital.

PATIENTS

All pediatric patients with Broviac catheters placed (n = 253) at this institution over a 3-year period from 2007 to 2009.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We reviewed the charts of all pediatric patients with Broviac catheters placed, either by intensivists or surgeons, and compared cost and outcomes. Procedure safety was assessed and categorized into immediate, short-term (within 2 wk of procedure), and long-term outcomes. Anesthetic safety and billing data for the procedure were also collected. Among similar patient populations, immediate complications, such as pneumothorax, procedure failure (p > 0.999), and anesthetic complications (p = 0.60), were not significantly different. Short-term outcomes, including infection (p = 0.27) and catheter malfunction (p > 0.999), were not different. Long-term outcomes, including mean indwelling catheter days (p = 0.60) and removal due to catheter infection (p = 0.09), were not different between the groups. Overall cost of the procedure was significantly different: $7,031 (± $784) when performed by surgeons and $3,565 (± $311) when performed by intensivists (p < 0.001).

CONCLUSIONS

Pediatric critical care physicians can place Broviac catheters as safely as pediatric surgeons and at a lower cost in a defined patient population.

Implantable versus cuffed external central venous catheters for the management of children and adolescents with acute lymphoblastic leukaemia

PURPOSE

The aim of this study was to determine if there is a difference between complications for totally implantable central venous catheters (ports) and tunnelled external central venous catheters (external CVCs) that result in early removal of the central venous catheter (CVC) in children and adolescents with acute lymphoblastic leukaemia (ALL).

METHODS

All children hospitalised between November 1996 and December 2007 with ALL who had a CVC were included retrospectively. We analysed data regarding the patient's first CVC.

RESULTS

We included 322 patients. 254 received a port and 68 received an external CVC. There were 102 CVC complications that required removal of the CVC prior to the completion of chemotherapy (65 in patients with ports, 37 in patients with external CVCs). Overall complications requiring CVC removal were significantly less likely to occur in the patient's with ports (p < 0.001). Ports were significantly less likely to require removal prior to the end of treatment overall (p < 0.001) and for specific complications such as infection (p < 0.001) and dislodgement (p = 0.001). However, when adjusted for disease severity there is no difference in premature CVC removal rates.

CONCLUSION

When patients are risk-stratified for disease severity there is no difference in rates of CVC removal prior to completion of treatment.

Complications of Central Venous Catheters in Children Undergoing Hematopoietic Stem Cell Transplantation in Turkey

Although central venous catheters (CVCs) have become an integral element of the care of patients undergoing hematopoietic stem cell transplantation (HSCT), the associated complications can lead to treatment delays and negatively affect the child and family’s quality of life. The aim of this study was to identify the types, rate of, and risk factors for the complications relating to CVCs used in children undergoing HSCT in Turkey. One hundred children were followed prospectively to track catheter-related complications in the transplantation unit. Overall, 186 complications were documented. The most frequent complications were catheter-related infections and malfunctions. Children who had nonhematological disease had a higher rate of complications than those with hematological disease. HSCT nurses should follow and apply evidence-based clinical practice guidelines to support the management of catheters. Nurse staffing ratios and workload may be an issue in developing countries. The authors believe that proper maintenance of CVCs contributes to the reduction of catheter-related complications despite these issues and that problems can be overcome by hiring experienced staff, appropriate nursing education, and by organizing and improving home care programs for HSCT patients.

Avaliação da mortalidade de neonatos e crianças relacionada ao uso do cateter venoso central: revisão sistemática

OBJETIVO: Avaliar a mortalidade relacionada às infecções no uso de cateter venoso central em recém-nascidos e crianças hospitalizadas. MÉTODOS: Trata-se de uma revisão sistemática, cujos estudos foram identificados nas bases de dados Medline, Embase, Lilacs, Cinahl, SciELO e Cochrane, em referências bibliográficas de artigos e outras revisões. Dois revisores independentes identificaram os estudos relevantes, analisaram a qualidade metodológica e, posteriormente, os dados foram extraídos. RESULTADOS: Foram encontrados 1.000 artigos, dos quais 16 se relacionavam à infecção de cateter e só dois mencionaram mortalidade. Dos estudos achados, verificou-se que a sepse primária foi a principal complicação relacionada ao uso de cateter venoso central, e sendo os micro-organismos mais prevalentes nestas infecções a Candida sp e Enterococcus sp com impacto significante para a mortalidade em neonatos e crianças. CONCLUSÃO: Observou-se nesta revisão que a sepse primária foi a complicação mais prevalente relacionada ao cateter central.

Catheter-related bloodstream infection with removal of catheter in pediatric oncology patients: a 10-year experience in Taiwan

BACKGROUND

Long-term central venous catheter (CVC) implantation has become more affordable in Taiwan since 1995. Surgical removal of the catheter may be the essential treatment for catheter-related bloodstream infections (CRBSI). The aim of this study was to evaluate the clinical features and microbial isolates in pediatric cancer patients with removal of CVC for CRBSI.

PROCEDURE

The records of positive blood culture from hospitalized pediatric oncology patients between 1995 and 2004 were reviewed. One hundred and forty-three patients implanted with a long-term CVC were further identified.

RESULTS

Seventeen catheters in 16 patients developed catheter-related bacteremia that needed catheter removal. The rate of catheter removal was 11.9%. The median device life was 7.7 months. Six catheters were removed within 3 months of insertion. Nine of the 17 catheters were removed from patient younger than 2 years. Eight infections occurred during severe neutropenia, and 6 patients had refractory or relapsed underlying disease. The cultural isolates were Gram-negative bacilli in 7, Gram-positive in 5, fungi in 5, and atypical mycobacterium in 1. The frequency of catheter removal for infection control was significantly higher in the first 5 years (1994-1999) compared to the last 5 years (2000-2004) (30.9 vs. 4.0%, p = 2.3 × 10(-4)).

CONCLUSIONS

Factors such as microbiological isolates, age of infection, the status of malignancy, and neutropenia are related to catheter outcome. The reduction in patients with positive cultures needing removal of the catheters can be related to improved nursing care and more aggressive antibiotic therapy.

Peripherally inserted central catheters

Peripherally inserted central catheters are increasingly used in the pediatric and adolescent population for long-term central access. This article reviews the indications, insertion techniques, and complications of peripherally inserted central catheter lines.

Management of non-infectious central venous access device complications

OBJECTIVES

To review the central venous access device (VAD) complications of inadvertent device damage, device malfunction, and various causes of mechanical occlusion and to describe the limitations of VAD complication data.

DATA SOURCES

Journal articles, legal cases, case reports, manufacturers' product information, personal experience.

CONCLUSION

The available data on VAD complications are difficult to interpret and apply in practice because of the many limitations of the studies that have been conducted (eg, single-institution, mixed patient populations, inconsistent measurement of complications). However, considerable information is known about the signs and symptoms of non-thrombotic, non-infectious VAD complications and their management.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses routinely use central VADs and are on the frontline for detecting VAD complications. Well-informed nurses can serve as patient advocates and help ensure that patients' VADs are functional and safe to use.

Placing of tunneled central venous catheters prior to induction chemotherapy in children with acute lymphoblastic leukemia

BACKGROUND

Tunneled central venous catheters (CVCs) are inevitable in children with acute lymphoid leukemia (ALL). The aim of this study was to evaluate the risk of CVC-related complications in children with ALL in relation to timing of catheter placement and type of catheter.

PROCEDURE

All children hospitalized from January 2000 to March 2008 with newly diagnosed ALL and with double-lumen total implantable devices (TIDs) or tunneled external catheters (TEs) were included retrospectively. We only used data related to the patient's first catheter.

RESULTS

We included 98 children; 35 received a TID and the remaining 63 received a TE. A total number of 29,566 catheter days and 93 catheter-associated blood stream infections (CABSI) was identified. We found a CABSI rate of 3.1/1,000 catheter days (5.4/1,000 catheter days for TEs and 1.4/1,000 catheter days for TIDs, incidence rate ratio (IRR) 3.82 (95% CI 2.37-6.35) P = 0.0001). No difference was found in CABSI between neither early versus later placed TIDs (IRR = 0.99 (95% CI 0.41-2.45) P = 0.98) nor early versus later placed TEs (IRR = 0.81 (95% CI 0.40-1.86) P = 0.54). We found no difference between early and later placed catheters regarding non-elective removal (RR = 0.86 (95% CI 0.72-1.03) P = 0.09). TEs had a higher risk of non-elective removal compared with TIDs (RR = 3.95 (95% CI 1.88-8.29) P < 0.001).

CONCLUSIONS

The study did not find that children with ALL and with early placed CVCs experienced significantly more complications compared with children with late placed catheters. This study found that children with ALL and TEs experienced more complications than children with TIDs.

Retained intravascular fragments after removal of indwelling central venous catheters: a single institution experience

There are few reports regarding the presence of retained fixed fragments after removal of indwelling central venous catheters in children. We conducted a retrospective study of 355 patients who underwent removal of central venous catheter from 1996 to 2008. Six patients (1.6%) had a failed attempt of removal, resulting in a remnant of catheter left in the central venous system. All of them had underlying malignant disorders and received chemotherapy for a prolonged period of time. In 2 patients, a second attempt of retrieval was performed that was partially successful. After an average follow-up of 3.5 +/- 1.8 years, 1 patient has developed mild symptoms that could be related to the remaining fragment within the vascular system. Therefore, the incidence of complications caused by retained fixed fragments is low. Patients whose line has been in place for more than 48 months (P = 0.009) and those located in the saphenous vein (P = 0.01) are more prone to experience fragment retention. The decision of retrieval should be balanced according to the presence of symptoms and the length of the fragment retained.

Anesthetic considerations for the pediatric oncology patient--part 3: pain, cognitive dysfunction, and preoperative evaluation

In part three of this three-part review, we continue with discussion of the effects of tumor and its therapy as they impact neurocognitive functioning, psychosocial issues of the patient and family, and the mechanisms and experience of pain in the child with cancer. A discussion of preanesthetic testing and evaluation in this patient population is next presented for the reader, focusing on the factors which pose the commonest and greatest risks to the child undergoing surgery. Lastly, an algorithmic approach to evaluating and managing key components of the medical history of pediatric patients is presented.