Percutaneous central venous catheterization in a pediatric intensive care unit: a survival analysis of complications

Comparison of LED-Based Transillumination Device with Traditional Vein Viewing Methods for Difficult Intravenous Cannulation in Indian Children: A Nonrandomized Controlled Trial

OBJECTIVES

To compare the utility of transillumination device with traditional vein viewing in situations with difficult peripheral venous access in pediatric patients.

METHODS

This was a nonrandomized, controlled trial. All the children aged between 3 to 36 mo admitted in tertiary care referral hospital, who satisfied difficult intravenous access (DIVA) score of equal to or more than 4 were included in the study. The children were assigned to transillumination device group (intervention) and traditional vein viewing group (traditional). The proportion of successful cannulation in the first attempt and median number attempts required to successfully cannulate in each group were estimated.

RESULTS

A total of 509 children were included in the study. The proportion of single attempt cannulation was significantly higher in the intervention group as compared to traditional group (p value = 0.001). The median number of attempts to successfully cannulate was found to be significantly less in the interventional group (median 1 vs. 2; p value = 0.001). On bivariate analysis, use of transillumination device was found to have a 2.64 times higher likelihood to successfully cannulate in the first attempt.

CONCLUSION

The use of transillumination device significantly improves the first attempt success rate and number of attempts for successful cannulation.

Role of endothelial glycocalyx in sliding friction at the catheter-blood vessel interface

Catheterization is a common medical operation to diagnose and treat cardiovascular diseases. The blood vessel lumen is coated with endothelial glycocalyx layer (EGL), which is important for the permeability and diffusion through the blood vessels wall, blood hemodynamics and mechanotransduction. However EGL’s role in catheter-blood vessel friction is not explored. We use a porcine aorta to mimic the blood vessel and a catheter loop was made to rub in reciprocating sliding mode against it to understand the role of catheter loop curvature, stiffness, normal load, sliding speed and EGL on the friction properties. Trypsin treatment was used to cause a degradation of the EGL. Decrease in catheter loop stiffness and EGL degradation were the strongest factors which dramatically increased the coefficient of friction (COF) and frictional energy dissipation at the aorta-catheter interface. Increasing sliding speed caused an increase but increase in normal load first caused a decrease and then an increase in the COF and frictional energy. These results provide the basic data for safety of operation and damage control during catheterization in patients with degraded EGL.

Jugular vs femoral vein for central venous catheterization in pediatric cardiac surgery (PRECiSE): study protocol for a randomized controlled trial

Background

Placement of central venous catheters (CVCs) is essential and routine practice in the management of children with congenital heart disease. The purpose of the present protocol is to evaluate the risk for infectious complications in terms of catheter colonization, catheter line–associated bloodstream infections, and catheter-related bloodstream infections (CRBSIs), and the mechanical complications from different central venous access sites in infants and newborns undergoing cardiac surgery.

Methods

One hundred sixty patients under 1 year of age and scheduled for cardiac surgery will be included in this randomized controlled trial (RCT); patients will be randomly allocated to the jugular or femoral vein arms. CVC insertion will be performed by one of three selected expert operators.

Discussion

The choice of the insertion site for central venous catheterization can influence the incidence and type of infectious complications in adults but this is not unanimously evidenced in the pediatric setting. The experimental hypothesis of this RCT is that the jugular insertion site is less likely to induce catheter colonization and CRBSI than the femoral site.

Trial registration

ClinicalTrials.gov Identifier: NCT03282292. Registered on 12 September 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2717-1) contains supplementary material, which is available to authorized users.

Complications in the surgical management of children with malignant solid tumors

With improvement in the outcomes for children with cancer has come an increasing focus on minimizing the morbidity from therapeutic interventions, including surgical procedures, while continuing to have a high likelihood of cure. Thus, an appreciation for the potential complications of surgery, both acute and long term, is critical when considering the risks and benefits of any procedure performed on a child with cancer. Although not meant to be an exhaustive review, here we discuss the most common and significant surgical complications that may occur when performing diagnostic, therapeutic, or supportive procedures in children with the most common malignant solid tumors.

Intravascular Catheter Colonization and Related Bloodstream Infection in Critically III Neonates

Intravascular catheter tip colonization was prospectively evaluated in critically ill neonates to determine its relationship to the type of device used, duration of catheterization, insertion site and nosocomial bloodstream infection. Sixty-one percent (376 of 621) of all intravascular catheter tips were retrieved from 91 infants. Thirteen percent (41 of 310) of peripheral intravenous, 14% (6 of 42) of umbilical, 21% (3 of 11) of central venous, 36% (4 of 11) of peripheral arterial and 100% (2 of 2) of femoral catheters were colonized. Duration of catheterization was significantly longer for colonized lines (p < .001). Eight of 26 (30.8%) peripheral intravenous catheters remaining in place for more than three days were colonized, compared with 33 of 284 (11.6%) at three days or less (p = 0.012). Coagulase-negative staphylococcus was the organism most frequently isolated from catheter tips and bloodstream infections. Catheter colonization rates in this population were higher than those found in adults. Heavily manipulated devices and those in place for longer periods of time were the most frequently colonized.

Optimal insertion lengths of right and left internal jugular central venous catheters in children

BACKGROUND

Knowledge of the optimal lengths for central venous catheterization prior to the procedure may lessen the need for repositioning and prevent vascular complications.

OBJECTIVE

To establish the optimal lengths for non-tunneled central venous catheter insertion through the right and left internal jugular veins.

MATERIALS AND METHODS

We included 92 children who received US-guided central venous catheterization via right or left internal jugular veins in intensive care units. The calculated distance between the skin and carina was considered the optimal length for right and left internal jugular venous catheterization. Univariate and multivariate linear regression analyses was used to identify predictors.

RESULTS

Age, height and weight showed significant correlations with optimal insertion lengths for right and left internal jugular vein approaches on univariate analysis, while height was the only significant independent predictor of optimal insertion length.

CONCLUSION

The optimal insertion lengths (cm) suggested by our data are, for the right internal jugular vein 0.034 × height (cm) + 3.173, and for the left 0.072 × height (cm) + 2.113.

Guideline for Prevention of Intravascular-Device–Related Infections

The “Guideline for Prevention of Intravascular Device-Related Infections” is designed to reduce the incidence of intravascular device-related infections by providing an over view of the evidence for recommendations considered prudent by consensus of Hospital Infection Control Practices Advisor y Committee (HICPAC) members. This two-part document updates and replaces the previously published Centers for Disease Control's (CDC) Guideline for Intravascular Infections (Am J Infect Control1983;11:183-199). Part I, “Intravascular Device-Related Infections: An Over view” discusses many of the issues and controversies in intravascular-device use and maintenance. These issues include definitions and diagnosis of catheter-related infection, appropriate barrier precautions during catheter insertion, inter vals for replacement of catheters, intravenous (IV) fluids and administration sets, catheter-site care, the role of specialized IV personnel, and the use of prophylactic antimi-crobials, flush solutions, and anticoagulants. Part II, “Recommendations for Prevention of Intravascular Device-Related Infections” provides consensus recommendations of the HICPAC for the prevention and control of intravascular device-related infections. A working draft of this document also was reviewed by experts in hospital infection control, internal medicine, pediatrics, and intravenous therapy. However, all recommendations contained in the guideline may not reflect the opinion of all reviewers.

Infection control in the intensive care unit

It is critical for health care personnel to recognize and appreciate the detrimental impact of intensive care unit (ICU)-acquired infections. The economic, clinical, and social expenses to patients and hospitals are overwhelming. To limit the incidence of ICU-acquired infections, aggressive infection control measures must be implemented and enforced. Researchers and national committees have developed and continue to develop evidence-based guidelines to control ICU infections. A multifaceted approach, including infection prevention committees, antimicrobial stewardship programs, daily reassessments-intervention bundles, identifying and minimizing risk factors, and continuing staff education programs, is essential. Infection control in the ICU is an evolving area of critical care research.

Catheter dwell time and CLABSIs in neonates with PICCs: a multicenter cohort study

OBJECTIVE

To determine whether the daily risk of central line-associated bloodstream infections (CLABSIs) increases over the dwell time of peripherally inserted central catheters (PICCs) in high-risk neonates.

METHODS

Multicenter retrospective cohort including NICU patients with a PICC inserted between January 2005 and June 2010. We calculated incidence rates and used Poisson regression models to assess the risk of developing CLABSI as a function of PICC dwell time.

RESULTS

A total of 4797 PICCs placed in 3967 neonates were included; 149 CLABSIs occurred over 89,946 catheter-days (incidence rate 1.66 per 1000 catheter-days). In unadjusted analysis, PICCs with a dwell time of 8 to 13 days, 14 to 22 days, and ≥23 days each had an increased risk of infection compared with PICCs in place for ≤7 days (P < .05). In adjusted analysis, the average predicted daily risk of CLABSIs after PICC insertion increased during the first 2 weeks after PICC insertion and remained elevated for the dwell time of the catheter. There was an increased risk of CLABSIs in neonates with concurrent PICCs (adjusted incidence rate ratio 2.04, 1.12-3.71). The incidence of Gram-negative CLABSIs was greater in PICCs with dwell times >50 days (incidence rate ratio 5.26, 2.40-10.66).

CONCLUSIONS

The risk of CLABSIs increased during the 2 weeks after PICC insertion and then remained elevated until PICC removal. Clinicians should review PICC necessity daily, optimize catheter maintenance practices, and investigate novel CLABSI prevention strategies in PICCs with prolonged dwell times.

Minimizing complications associated with percutaneous central venous catheter placement in children: recent advances

OBJECTIVES

To summarize existing knowledge regarding the prevalence of complications associated with temporary percutaneous central venous catheters placed in critically ill children, and to review evolving strategies to minimize the prevalence of these complications.

DATA SOURCES

Literature review was performed: PubMed and EBSCOhost were searched using the terms central venous catheter, children, ultrasound, infection, thrombosis, and thromboembolism in various combinations. Citations of interest from identified articles were also reviewed.

STUDY SELECTION

The review focused primarily on pediatric literature relevant to the topic of interest.

DATA EXTRACTION AND SYNTHESIS

Randomized clinical trials and other prospective studies were discussed in greater detail than retrospective, single-center investigations.

CONCLUSIONS

Complications during percutaneous central venous catheter placement in children are not rare and may be in part attributable to abnormalities in vascular anatomy. Thromboses in children with central venous catheters are increasingly recognized as an important problem for which evidence-based preventive measures are lacking. Catheter-associated bloodstream infection rates in critically ill children have markedly decreased over the last decade, associated with an increased emphasis on staff education and the use of insertion and maintenance bundles. Available evidence tends to support the use of two-dimensional ultrasound to augment the landmark technique for catheter placement, but more studies are needed.

The reduction of risk in central line-associated bloodstream infections: knowledge, attitudes, and evidence-based practices in health care workers

BACKGROUND

We set out to acquire information about the knowledge, attitudes, and evidence-based practices associated with the insertion and maintenance of central vascular catheters (CVC) for the prevention of central line-associated bloodstream infections (CLABSI).

METHODS

We selected all health care workers (HCW) in all units using CVCs in the Calabria region of Italy.

RESULTS

Correct answers about the knowledge of physicians and nurses ranged from 43% to 72.9% and were significantly higher in respondents who worked in intensive care unit (ICU) wards in hospitals that had a written policy about CVC maintenance and had active formal training. Respondents' attitudes toward general aspects of CLABSI prevention were very positive and were significantly higher for HCWs working in regional general hospitals, practicing in ICU wards, and having appropriate knowledge. Concerning HCWs, 83.9% reported that, if patients had any manifestations suggesting local or bloodstream infection, the dressing was removed for assessment purposes; this practice was significantly more likely to occur in HCWs having appropriate knowledge and positive attitudes and who worked in hospitals with a written policy about CVC maintenance.

CONCLUSION

The study demonstrated that written policies, formal training, and years of experience contributed to an increase in knowledge, practice, and positive attitudes toward CLABSI prevention. In addition the paper demonstrates how great this need is, having reported many non-evidence-based practices still continuing despite new evidence.

The effect of passive leg elevation and/or trendelenburg position on the cross-sectional area of the internal jugular vein in infants and young children undergoing surgery for congenital heart disease

BACKGROUND

In this study we evaluated the effect of passive leg elevation (LE) and Trendelenburg (T) position on the cross-sectional area (CSA) of the internal jugular vein (IJV) in infants and young children undergoing surgery for congenital heart disease. A secondary aim was to compare the CSA of the IJV between subjects with right-to-left (RL) shunt and left-to-right (LR) shunt.

METHODS

Ninety infants and small children from 10 days to 31 months old weighing from 1.5 to 9.7 kg were assigned to group RL (n = 48) or LR (n = 42). In both groups, the CSA, transverse, and vertical diameters of the IJV on both sides of the neck were measured using a 2-dimensional ultrasound transducer in the following positions: supine position, 15° of T position, supine position with 50° of LE, and 15° of Trendelenburg position with 50° of LE (TLE). A more than 25% increase in mean CSA of the IJV was considered clinically significant.

RESULTS

In group LR, T, LE, and TLE significantly increased CSA of both right (at least 12.3%, 10.3%, and 18.3%, respectively, "at least" refers to the lower 95% confidence limits) and left (at least 15.8%, 15.0%, and 18.9%, respectively) IJVs, whereas only TLE increased the CSA of both IJVs significantly in group RL (at least 8.2% and 7.7% in the right and left, respectively). The increase in the CSA of the right IJV related to T and TLE was larger in group LR than in group RL (at least 12.3% vs 1.2% for T and at least 18.3% vs 8.2% for TLE, respectively). A clinically significant increase in CSA was achieved in both right and left IJVs with TLE in group LR (mean 28.6% and 26.3%, respectively). The CSA of the right IJV was larger than that of the left IJV in most (at least 69.2%) patients.

CONCLUSIONS

Passive LE was as effective as T position to increase the CSA of the IJV, but there was no clinically significant increase in the CSA with any single maneuver. Only T position with passive LE achieved a clinically significant increase in the CSA of both IJVs in infants and young children with LR shunt, but not in the same age group with RL shunt.

Epidemiology of central line-associated bloodstream infections in the pediatric intensive care unit

OBJECTIVE

Describe central line-associated bloodstream infection (CLA-BSI) epidemiology in pediatric intensive care units (PICUs).

DESIGN

Descriptive study (29 PICUs); cohort study (18 PICUs).

SETTING

PICUs in a national improvement collaborative.

PATIENTS/PARTICIPANTS

Patients admitted October 2006 to December 2007 with 1 or more central lines.

METHODS

CLA-BSIs were prospectively identified using the National Healthcare Safety Network definition and then readjudicated using the revised 2008 definition. Risk factors for CLA-BSI were examined using age-adjusted, time-varying Cox proportional hazards models.

RESULTS

In the descriptive study, the CLA-BSI incidence was 3.1/1,000 central line-days; readjudication with the revised definition resulted in a 17% decrease. In the cohort study, the readjudicated incidence was 2.0/1,000 central line-days. Ninety-nine percent of patients were CLA-BSI-free through day 7, after which the daily risk of CLA-BSI doubled to 0.27% per day. Compared with patients with respiratory diagnoses (most prevalent category), CLA-BSI risk was higher in patients with gastrointestinal diagnoses (hazard ratio [HR], 2.7 [95% confidence interval {CI}, 1.43-5.16]; P < .002 ) and oncologic diagnoses (HR, 2.6 [CI, 1.06-6.45]; P = .037). Among all patients, including those with more than 1 central line, CLA-BSI risk was lower among patients with a central line inserted in the jugular vein (HR, 0.43 [CI, 0.30-0.95]; [P < .03).

CONCLUSIONS

The 2008 CLA-BSI definition change decreased the measured incidence. The daily CLA-BSI risk was very low in patients during the first 7 days of catheterization but doubled thereafter. The risk of CLA-BSI was lower in patients with lines inserted in the jugular vein and higher in patients with gastrointestinal and oncologic diagnoses. These patients are target populations for additional study and intervention.

Central line-associated bloodstream infections: prevention and management

Approximately 80,000 central venous line-associated bloodstream infections (CLA-BSI) occur in the United States each year. CLA-BSI is most commonly caused by coagulase-negative staphylococci, Staphylococcus aureus, Candida spp, and aerobic gram-negative bacilli. These organisms commonly gain entrance in into the bloodstream via the catheter-skin interface (insertion site) or via the catheter hub. Use of strict aseptic technique for insertion is the key method for the prevention of CLA-BSI. Various methods can be used to reduce unacceptably high rates of CLA-BSI, including use of an antiseptic- or antibiotic-impregnated catheter, daily chlorhexidine baths/washes, and placement of a chlorhexidine-impregnated sponge over the insertion site.

Catheter duration and risk of CLA-BSI in neonates with PICCs

OBJECTIVE

To determine whether the risk of central line-associated bloodstream infections (CLA-BSIs) remained constant over the duration of peripherally inserted central venous catheters (PICCs) in high-risk neonates.

PATIENT AND METHODS

We performed a retrospective cohort study of NICU patients who had a PICC inserted between January 1, 2006, and December 31, 2008. A Poisson regression model with linear spline terms to model time since PICC insertion was used to evaluate potential changes in the risk of CLA-BSI while adjusting for other variables.

RESULTS

Six hundred eighty-three neonates were eligible for analysis. There were 21 CLA-BSIs within a follow-up period of 10 470 catheter-days. The incidence of PICC-associated CLA-BSI was 2.01 per 1 000 catheter-days (95% confidence interval [CI]: 1.24-3.06). The incidence rate of CLA-BSIs increased by 14% per day during the first 18 days after PICC insertion (incidence rate ratio [IRR]: 1.14 [95% CI: 1.04-1.25]). From days 19 through 35 after PICC insertion, the trend reversed (IRR: 0.8 [95% CI: 0.66-0.96]). From days 36 through 60 after PICC insertion, the incidence rate of CLA-BSI again increased by 33% per day (IRR: 1.33 [95% CI: 1.12-1.57]). There was no statistically significant association between the risk of CLA-BSI and gestational age groups, birth weight groups, or chronological age groups.

CONCLUSIONS

Our data suggest that catheter duration is an important risk factor for PICC-associated CLA-BSI in the NICU. A significant daily increase in the risk of CLA-BSI after 35 days may warrant PICC replacement if intravascular access is necessary beyond that period.

Ultrasound-guided central venous catheter placement decreases complications and decreases placement attempts compared with the landmark technique in patients in a pediatric intensive care unit

OBJECTIVE

To determine whether ultrasound (US) increases successful central venous catheter (CVC) placement, decreases site attempts, and decreases CVC placement complications.

DESIGN AND SETTING

A prospective observational cohort study evaluating a transition by the Pediatric Critical Care Medicine service to US-guided CVC placement. Medical and surgical patients in a 21-bed quaternary multidisciplinary pediatric intensive care unit had CVCs placed by attendings, fellows, residents, and a nurse practitioner.

PATIENTS

Ninety-three patients were prospectively enrolled into the landmark (LM) group and 119 into the US group.

INTERVENTIONS

: After collection of prospective LM data, training with US guidance was provided. CVCs were subsequently placed with US guidance.

MEASUREMENTS AND MAIN RESULTS

Operator information, disease process, emergent/routine, sites attempted, and complications were recorded. Procedure time was from initial skin puncture to guidewire placement. There was no difference overall in success rates (88.2% LM vs. 90.8% US, p = 0.54) or time to successful placement (median seconds 269 LM vs. 150 US, p = 0.14) between the two groups. Median number of attempts were fewer with US for all CVCs attempted (3 vs. 1, p < 0.001) as were attempts at >1 anatomical site (20.7% LM vs. 5.9% US, p = 0.001). Use of US was associated with fewer inadvertent artery punctures (8.5% vs. 19.4%, p = 0.03). Time to successful placement by residents was decreased with US (median 919 seconds vs. 405 seconds, p = 0.02). More internal jugular CVCs were placed during the US period than during the LM period (13.4% vs. 2.1%).

CONCLUSIONS

US-guided CVC placement in children is associated with decreased number of anatomical sites attempted and decreased number of attempts to gain placement. Time to placement by residents was decreased with US, but not the time to placement by other operators. US guidance increased the use of internal jugular catheter placement and decreased artery punctures. US guidance did not improve success rates.

Veinlite transillumination in the pediatric emergency department: a therapeutic interventional trial

OBJECTIVES

We hypothesized that transillumination would increase peripheral intravenous (IV) insertion success rates in pediatric emergency department patients. Primary outcome was success in first attempt, and secondary outcome was success within 2 attempts.

METHODS

We evaluated IV insertion by pediatric emergency department physicians and nurses using the Veinlite (TransLite, Sugar Land, Tex). Patients who required nonemergent IV insertion were enrolled if younger than 3 years or aged 3 to 21 years with a history of difficult access. Participants were randomly assigned to transillumination or nontransillumination. Analyses were performed using a mixed-effects logistic regression model adjusting for provider effect.

RESULTS

We evaluated 240 patients. After adjusting for significant covariates (safety catheter [P = 0.008], visibility [P = 0.01], and palpability [P = 0.03]) and controlling for provider effect, IV placement was more likely successful in first attempt in transilluminated patients (P = 0.03; odds ratio, 2.1 [95% confidence interval, 1.1-3.9]). After adjusting for significant covariates (safety catheter [P < 0.001], location [P = 0.005], and palpability [P = 0.05]) and controlling for provider effect, IV placement was more likely successful within 2 attempts in transilluminated patients (P = 0.01; odds ratio, 3.5 [95% confidence interval, 1.4-8.9]). Intracluster correlation for random effect of provider was 10% in first attempt and 16% within 2 attempts.

CONCLUSIONS

After adjusting for multiple significant covariates and controlling for random effect of provider, our results indicated a benefit in the use of Veinlite transillumination for IV insertion in first attempt and within 2 attempts. This technique seemed to facilitate nonemergent IV placement in pediatric patients compared with standard practice.

Complications of central venous catheterization in critically ill children

BACKGROUND

Placement of central venous catheter is essential in the management of critically ill children. The purpose of the present paper was to evaluate the success rate, mechanical and thrombotic complications and risk factors associated with these complications from different central venous access sites in critically ill children.

METHODS

A prospective study was undertaken from February 2000 to March 2005 of 369 central venous catheterizations in children in a pediatric intensive care unit.

RESULTS

The veins most frequently used were femoral vein (45%), subclavian vein (32.2%), and internal jugular vein (22.8%). Mean +/- SD duration of catheterization was 9.5 +/- 6.5 days. The procedure was performed under emergency conditions in 18% of patients with an overall success rate of 92.4%. The success rate was significantly lower in younger patients with subclavian catheterization. Insertion-related complications were noted, including 33 arterial punctures (8.9%), 27 cases of malposition (7.3%), 19 hematomas (5.2%), 12 cases of minor bleeding (3.3%), and three cases of pneumothorax (0.8%), and they were more common in the subclavian vein than in the internal jugular and femoral vein. Multiple attempts and failed attempts significantly correlated with higher incidence of complications. Maintenance-related complications included obstruction (n = 26; 7%), accidental removal (n = 14; 3.8%), central venous thrombosis (n = 8; 2.2%), subcutaneous extravasation (n = 14; 3.8%), dislodgment (n = 1; 0.25%), and extravascular infusion (n = 1; 0.25%). The frequency of catheter maintenance-related complications was significantly higher in femoral catheterizations and increased significantly with an increase in the duration of catheterization. A total of five serious complications were seen (pneumothorax in three, dislodgment in one and extravascular infusion in one) in the present series.

CONCLUSIONS

Central venous catheterization in critically ill children is a relatively safe procedure, with a 1.3% rate of serious complications and no mortality. It seems safer to choose initially the femoral or internal jugular vein instead of the subclavian vein because of high success rate without serious insertion-related complications.

Observational trial of antibiotic-coated central venous catheters in critically ill pediatric patients

BACKGROUND

Catheter-associated bloodstream infections (CABSI) are among the most common and serious adverse events experienced by critically ill children. Randomized trials have demonstrated that the use of central venous catheters (CVC) coated with antiseptic solutions reduces rates of CABSI in adult patients; however, their efficacy in children has not been evaluated.

OBJECTIVE

To compare the incidence of CABSI, rate of complications, and microbiology of infection in critically ill children treated with antibiotic-coated or noncoated CVC (NC-CVC).

METHODS

A prospective observational trial was conducted in the pediatric intensive care unit (PICU) during a 13-month period. A minocycline-rifampin-coated CVC (MR-CVC) or NC-CVC was placed by PICU physicians who nonpreferentially selected CVC type.

RESULTS

We studied the outcomes associated with the first CVC placed in 225 patients, including 69 MR-CVC and 156 NC-CVC. Patients who received MR-CVC, as compared with NC-CVC, were similar in gender, age, and severity of illness at time of PICU admission. The incidence density of CABSI did not vary by catheter type [MR-CVC: 7.53 per 1000 catheter-days (95% confidence interval 2.05-19.17); NC-CVC: 8.64 CABSI per 1000 catheter-days (95% confidence interval 3.74-16.96)]. However, the median time to infection in children with MR-CVC was 3-fold longer than in children with NC-CVC [18 versus 5 days (P = 0.053)]. No difference was seen in the incidence of complications, including thrombosis and catheter site reaction, between MR- and NC-CVC. No significant difference was observed in the types of organisms recovered from patients with MR- and NC-CVC.

CONCLUSIONS

The use of MR-CVC significantly delayed the onset of CABSI in PICU patients. Larger, randomized trials are needed to better define potential differences in the incidence of CABSI, rate of complications, and microbiology of infection among pediatric patients treated with antiseptic-coated CVC and NC-CVC.

Ultrasound imaging in vascular access

Physicians spend a considerable amount of time and effort inserting catheters and needles into patients. Central venous catheters are the mainstay of measuring hemodynamic variables that cannot be assessed by noninvasive procedures. These catheters also allow hemodialysis, parenteral nutritional support, delivery of medications, and catecholamine administration. Arterial pressure catheters are frequently used for hemodynamic monitoring and for obtaining arterial blood gases in critically ill patients. Such use of arterial and central venous catheters, however, is potentially associated with severe complications that can be injurious to patients and expensive to treat. Techniques involving the use of anatomic landmarks have been the traditional mainstay of accessing the central venous system for decades. With the development and refinement of portable and affordable high-resolution ultrasound devices, imaging vascular access has changed the role of the traditional landmark techniques. In this article, we explain the use of ultrasound for vascular access to reduce complications associated with cannulation of veins and arteries. We will also provide a brief overview of the current literature regarding ultrasound-guided vascular access.

Infectious complications of percutaneous central venous catheterization in pediatric patients: a Spanish multicenter study

OBJECTIVE

Analysis of infectious complications and risk factors in percutaneous central venous catheters.

DESIGN

One-year observational, prospective, multicenter study (1998-1999).

SETTING

Twenty Spanish pediatric intensive care units.

PATIENTS

Eight hundred thirty-two children aged 0-14 years.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

One thousand ninety-two catheters were analyzed. Seventy-four (6.81%) catheter-related bloodstream infections (CRBSI) were found. The CRBSI rate was 6.4 per 1,000 CVC days (95% CI 5.0-8.0). Risk factors for CRBSI were weight under 8 kg (p < 0.001), cardiac failure (RR 2.69; 95% CI 1.95-4.38; p < 0.001), cancer (RR 1.66; 95% CI 0.97-2.78; p=0.05), silicone catheters (RR 2.82; 95% CI 1.49-5.35; p = 0.006), guidewire exchange catheterization (p=0.002), obstructed catheters (RR 2.67; 95% CI 1.63-4.39; p<0.001), and more than 12 days' indwelling time (RR 5.9; 95% CI 3.63-9.41; p<0.001). Multivariate Cox regression identified lower patient weight (HR 2.4; 95% CI 1.11-5.19; p=0.002), guidewire exchange catheterization (HR 2.2; 95% CI 1.07-4.54; p=0.049) and more than 12 days' indwelling time (HR 1.97; 95% CI 0.89-4.36; p=0.089) as significant independent predictors of CRBSI. Factors which protected against infection were the use of povidone-iodine on hubs (HR 0.42; 95% CI 0.19-0.96; p=0.025) and porous versus impermeable dressing (HR 0.41; 95% CI 0.23-0.74; p=0.004). Two children (0.24%) died from endocarditis following catheter-related sepsis due to Stenotrophomonas maltophilia in one case and P. aeruginosa in the other.

CONCLUSIONS

Catheter-related sepsis is associated with lower patient weight and more than 12 days' indwelling time, but not with the insertion site. Cleaning hubs with povidone-iodine protects from infection.

Central venous cannulation: are routine chest radiographs necessary after B-mode and colour Doppler sonography check?

BACKGROUND

After the insertion of a central venous catheter, a chest radiograph is usually obtained to ensure correct positioning of the catheter tip.

OBJECTIVE

To determine in a paediatric population whether B-mode and colour Doppler sonography after central venous access is useful to evaluate catheter position, thus obviating the need for a postprocedural radiograph.

MATERIALS AND METHODS

A prospective study of 107 consecutive central venous access procedures placed in a paediatric intensive care unit was performed. At the end of the procedure, B-mode and colour Doppler sonography were used to assess catheter position and check for complications. A postprocedural chest radiograph was obtained in all patients.

RESULTS

In 96 patients postprocedural B-mode and colour Doppler sonography showed colour Doppler signals within the vena cava. Among the 11 patients predicted to have a potential complication, there was one pneumothorax and ten malpositions. Chest radiography showed a total of 13 complications-1 pneumothorax and 12 malpositions. The concordance between colour Doppler sonography and chest radiography was 98.1% in the detection of catheter position; sonography had a sensitivity of 84.6% and a specificity of 100%.

CONCLUSIONS

The close concordance between B-mode and colour Doppler sonography and chest radiography justifies the more frequent use of sonography to evaluate catheter position because ionizing radiation is eliminated. Chest radiography may then be performed only when there is suspected inappropriate catheter tip position after sonography.

Central venous catheter placement in children: a prospective study of complications in a Brazilian public hospital

Central venous access is frequently used in infants and children with a wide variety of conditions. This report evaluates our experience and the complications from central venous catheters (CVC) placed percutaneously in children at a public hospital of a developing country-Brazil. To identify associated complications, data were collected prospectively and 155 consecutive catheterizations in children at a public hospital over a nearly 8-month period were analyzed. Data collected included sex, age, weight, primary diagnosis, indication for placement, presence of blood coagulation disturbance, hospital department for procedure, type of anesthesia, type of catheter (diameter, lumen number, material), site of catheterization, number of attempts, number of puncture sites, complications during puncture, the time catheter remained in place, later complications (mechanical, infectious) and reason for catheter removal. A total of 155 catheters were placed in 127 patients. There were 130 neck lines and 25 groin lines. The success rate was 81.9% at the initially chosen puncture site and rose to 100% with the inclusion of the second site. Perioperative complications occurred in nine (5.8%) cases, including six (3.9%) hematomas and three (1.9%) arterial puncture. There was no pneumothorax, hemothorax or hydrothorax. During the time the catheter remained in place, there were 51 (32.9%) complications, of which 33 (21.3%) were mechanical and 18 (11.6%) suspected catheter-related infection. These complications were responsible for the removal of the catheter. Despite the relatively high complication rate there were no catheter-related deaths. Body weight was significantly lower for children who underwent more than one puncture site (P=0.01). Age, sex, type of catheter and primary diagnosis were not associated with complications. Knowledge of anatomy and familiarity with the Seldinger technique highly increase the catheterization success rate, with few surgical complications. A better nursing care of CVC is emphasized. The available modern venous catheters at a public hospital in Brazil have contributed to improve the quality of pediatric medical care. Nowadays, the percutaneous CVC is the preferred method in pediatric patients.

Two dimensional ultrasound guidance in central venous catheter placement; a postal survey of the practice and opinions of consultant pediatric anesthetists in the United Kingdom

BACKGROUND

Recent guidelines from the UK National Institute for Clinical Excellence (NICE) recommend the use of ultrasound guidance for central venous catheter (CVC) insertion in children. We conducted a survey of pediatric anesthetists to determine current practice and opinion on the appropriate use of ultrasound guidance.

METHOD

A confidential postal questionnaire was sent to all members of the Association of Paediatric Anaesthetists working in the UK. After 4 weeks a follow-up questionnaire was sent to nonrespondents. Members were questioned on availability and use of ultrasound, and its place in clinical practice and training.

RESULTS

A total of 250 questionnaires were returned, a response rate of 63%. Of those members who placed CVCs in children (n = 196), 85% had access to ultrasound, and 68% stated that they used ultrasound guidance. Thirty-nine percent of clinicians who used ultrasound did so routinely. The remaining 61% used either a landmark or an ultrasound technique depending on circumstances. Regarding its mandatory use, 76% of responders believed that ultrasound guidance was beneficial in certain circumstances but did not need to be used routinely. Seventy-five percent of responders agreed that all pediatric anesthetists should have training and access to ultrasound for CVC placement.

CONCLUSIONS

In the UK most pediatric anesthetists placing CVCs in children currently have access to ultrasound guidance. Despite a lack of widespread support for its routine use, most agree ultrasound is a useful tool, and that all pediatric anesthetists should have access and training in the use of this technology.

Pediatric catheter-related bloodstream infections: latest strategies to decrease risk

Central venous catheters are often mandatory devices when caring for critically ill children. They are required to deliver medications, nutrition, and blood products, as well as for monitoring hemodynamic status and drawing laboratory samples. Any foreign object that is introduced to the body is at risk for infection. Central venous catheters carry a particularly high risk of infection and these infections can be life threatening. Advanced practice nurses possess the power to influence catheter-related line infections in their critical care units. Understanding current recommendations for catheter material selection, site selection, site preparation, and site care can affect rates of catheter-related bloodstream infections. This article discusses risk factors for developing catheter-related bloodstream infections in critically ill children, as well as measures to decrease incidence of catheter-related bloodstream infections, including a review of recommendations from the Centers for Disease Control and Prevention.

Clinical review: vascular access for fluid infusion in children

The current literature on venous access in infants and children for acute intravascular access in the routine situation and in emergency or intensive care settings is reviewed. The various techniques for facilitating venous cannulation, such as application of local warmth, transillumination techniques and epidermal nitroglycerine, are described. Preferred sites for central venous access in infants and children are the external and internal jugular veins, the subclavian and axillary veins, and the femoral vein. The femoral venous cannulation appears to be the most safe and reliable technique in children of all ages, with a high success and low complication rates. Evidence from the reviewed literature strongly supports the use of real-time ultrasound techniques for venous cannulation in infants and children. Additionally, in emergency situations the intraosseous access has almost completly replaced saphenous cutdown procedures in children and has decreased the need for immediate central venous access.

NICE guidelines for central venous catheterization in children. Is the evidence base sufficient?

BACKGROUND

Recent guidelines from the National Institute for Clinical Excellence (NICE) recommend the use of ultrasound guidance for central venous catheterization in children. This study prospectively examined the use of ultrasound guidance for central venous catheterization in children undergoing heart surgery.

METHODS

One hundred and twenty-four infants and children were randomized to either ultrasound-guided or traditional landmark-guided central venous catheterization.

RESULTS

Success rates were significantly greater in the landmark group compared with the ultrasound group (89.3% vs 78%, P<0.002), and arterial puncture rates were significantly lower in the landmark group (6.2% vs 11.9%, P<0.03). There was no significant difference between the two groups in the time taken to perform the catheterization.

CONCLUSIONS

These results are different from the published results on which the NICE guidelines were based; however, the evidence base in children is small. There is currently insufficient evidence to support the use of ultrasound guidance for central venous catheterization in children.

Low inferior vena caval catheters for hemodynamic and pulmonary function monitoring in pediatric critical care patients

OBJECTIVE

To assess the value of low inferior vena caval (LIVC) catheters for estimating central venous pressure in pediatric intensive care patients and to assess influences of intra-abdominal pressures and mean airway pressure on these measurements.

DESIGN

Prospective cohort of consecutive patients.

SETTING

Pediatric intensive care unit.

PATIENTS

Thirty patients ranging in age (18, 0-1 yrs; four, 1-3 yrs; four, 3-10 yrs; four, > or =10 yrs).

INTERVENTIONS

Interventions included catheterizations via internal jugular, subclavian, and common femoral veins, as well as direct right atrial catheterization during surgery; arterial catheter placement; airway pressure monitoring during mechanical ventilation; indirect intra-abdominal pressure monitoring via bladder catheter pressure readings; and arterial and central venous blood gas analysis. LIVC vein catheters were placed below the origin of the renal veins.

MEASUREMENTS AND MAIN RESULTS

LIVC pressure was highly correlated with central venous pressure (n=30, r2=.965, p=.0001). LIVC pressure did not correlate with intra-abdominal pressure (n=18, r2=.000). Mean airway pressure did not correlate with central venous pressure (n=11, r2=.106). The pH of LIVC blood was similar to that of central venous blood (n=18, r2=.941, p=.0001). PCO2 values of inferior vena cava and central venous blood correlated (r2=.945, p=.0001). However, agreement between inferior vena cava and central venous PO2 and oxyhemoglobin saturation was poor (PO2, r2=.066; oxyhemoglobin saturation, r2=.000).

CONCLUSIONS

LIVC catheters whose tips lie below the origin of the renal veins predict central venous pressure in pediatric intensive care unit patients. Intra-abdominal pressure and mean airway pressure do not affect this relationship, within the wide range of values for these variables included in this study. Blood samples drawn from femoral venous catheters can be used to monitor acid-base balance and partial pressure of carbon dioxide.

Guidelines for the Prevention of Intravascular Catheter–Related Infections

These guidelines have been developed for practitioners who insert catheters and for persons responsible for surveillance and control of infections in hospital, outpatient, and home health-care settings. This report was prepared by a working group comprising members from professional organizations representing the disciplines of critical care medicine, infectious diseases, health-care infection control, surgery, anesthesiology, interventional radiology, pulmonary medicine, pediatric medicine, and nursing. The working group was led by the Society of Critical Care Medicine (SCCM), in collaboration with the Infectious Disease Society of America (IDSA), Society for Healthcare Epidemiology of America (SHEA), Surgical Infection Society (SIS), American College of Chest Physicians (ACCP), American Thoracic Society (ATS), American Society of Critical Care Anesthesiologists (ASCCA), Association for Professionals in Infection Control and Epidemiology (APIC), Infusion Nurses Society (INS), Oncology Nursing Society (ONS), Society of Cardiovascular and Interventional Radiology (SCVIR), American Academy of Pediatrics (AAP), and the Healthcare Infection Control Practices Advisory Committee (HICPAC) of the Centers for Disease Control and Prevention (CDC) and is intended to replace the Guideline for Prevention of Intravascular Device–Related Infections published in 1996. These guidelines are intended to provide evidence-based recommendations for preventing catheter-related infections. Major areas of emphasis include 1) educating and training health-care providers who insert and maintain catheters; 2) using maximal sterile barrier precautions during central venous catheter insertion; 3) using a 2% chlorhexidine preparation for skin antisepsis; 4) avoiding routine replacement of central venous catheters as a strategy to prevent infection; and 5) using antiseptic/antibiotic impregnated short-term central venous catheters if the rate of infection is high despite adherence to other strategies (i.e., education and training, maximal sterile barrier precautions, and 2% chlorhexidine for skin antisepsis). These guidelines also identify performance indicators that can be used locally by health-care institutions or organizations to monitor their success in implementing these evidence-based recommendations.

Guidelines for the prevention of intravascular catheter-related infections. The Hospital Infection Control Practices Advisory Committee, Center for Disease Control and Prevention, U.S

These guidelines have been developed for practitioners who insert catheters and for persons responsible for surveillance and control of infections in hospital, outpatient, and home health-care settings. This report was prepared by a working group comprising members from professional organizations representing the disciplines of critical care medicine, infectious diseases, health-care infection control, surgery, anesthesiology, interventional radiology, pulmonary medicine, pediatric medicine, and nursing. The working group was led by the Society of Critical Care Medicine (SCCM), in collaboration with the Infectious Disease Society of America (IDSA), Society for Healthcare Epidemiology of America (SHEA), Surgical Infection Society (SIS), American College of Chest Physicians (ACCP), American Thoracic Society (ATS), American Society of Critical Care Anesthesiologists (ASCCA), Association for Professionals in Infection Control and Epidemiology (APIC), Infusion Nurses Society (INS), Oncology Nursing Society (ONS), Society of Cardiovascular and Interventional Radiology (SCVIR), American Academy of Pediatrics (AAP), and the Healthcare Infection Control Practices Advisory Committee (HICPAC) of the Centers for Disease Control and Prevention (CDC) and is intended to replace the Guideline for Prevention of Intravascular Device-Related Infections published in 1996. These guidelines are intended to provide evidence-based recommendations for preventing catheter-related infections. Major areas of emphasis include 1) educating and training health-care providers who insert and maintain catheters; 2) using maximal sterile barrier precautions during central venous catheter insertion; 3) using a 2% chlorhexidine preparation for skin antisepsis; 4) avoiding routine replacement of central venous catheters as a strategy to prevent infection; and 5) using antiseptic/antibiotic impregnated short-term central venous catheters if the rate of infection is high despite adherence to other strategies (ie, education and training, maximal sterile barrier precautions, and 2% chlorhexidine for skin antisepsis). These guidelines also identify performance indicators that can be used locally by health-care institutions or organizations to monitor their success in implementing these evidence-based recommendations.

Percutaneous Subclavian Central Venous Catheterization in Children Younger than One Year of Age

Children younger than one year of age frequently require central venous lines (CVLs) for total parenteral nutrition, intravenous antibiotics, and chemotherapy. In many instances surgical cut-down has been favored over percutaneous access. The purpose of this study was to demonstrate the safety and success of percutaneous central venous access in children less than one year of age. Percutaneous access of the subclavian vein was obtained by Seldinger technique. Using the medical procedure code index we reviewed the charts of those patients less than one year of age from January 1, 1999 through December 31, 1999 requiring central venous access. Age, diagnosis, number of CVLs required, site placed, success rate, and weight were recorded. In 1999 a total of 84 patients younger than one year of age received a total of 110 CVLs. In patients less than 6 months of age the success rate for percutaneous access of the subclavian vein was 78.8 per cent and for those children over 6 months the success rate was 96 per cent. The average weight for those less than 6 months was 3.1 kg and for those older than 6 months was 7.63 kg. There were no complications from the procedure. Percutaneous CVL placement in children younger than one year of age is safe and effective. This paper details our technique and reviews infant venous anatomy in the subclavian area.

Central venous catheters in pediatric patients--subclavian venous approach as the first choice

BACKGROUND

It is critical to establish a safe and functional i.v. access in severely sick patients. We evaluated the frequency of application and complications of central venous catheters in a pediatric intensive care unit.

METHODS

Pediatric patients in whom central venous catheters were inserted between March 1997 and May 1999 in the Pediatric Emergency Room and Intensive Care Unit were enrolled in this study. Patients were evaluated with respect to age, sex, weight, central venous catheter indication, site, duration of catheter stay and complications.

RESULTS

During the study period a total of 156 central venous catheters were successfully inserted into 146 patients. Of the 156 central venous catheter attempts, 148 (94.9%) were placed into the subclavian vein, six were inserted into the femoral vein, and two into the jugular vein. In 156 attempts, arterial injuries occurred in 20 cases (12.8%). Pneumothorax developed in two patients on mechanical ventilation. Three catheters had to be removed due to catheter related infections. The mortality rate was 0%.

CONCLUSIONS

We concluded that subclavian central venous catheterization is a safe procedure with minimal complications in pediatric patients. Arterial injury was the most frequent complication. In experienced hands, the success rate was 100%. Subclavian central venous catheter insertion may be considered as the first approach in critically ill patients.

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.

Scheduled replacement of central venous catheters is not necessary

Although half of intensivists routinely replace their central venous catheters (CVCs), this practice is not supported by data from randomized control studies or by pathophysiology of CVC infection. The daily risk of CVC infection is considered to be a constant; the risk of catheter infection is directly related to the duration of catheter insertion. Consequently, the routine change of the catheter is able to decrease the number of infections per catheter but not to modify the number of infections per day of catheter insertion. This assertion is supported by evidence-based medicine: scheduled replacement every 3 or 7 days has not been shown to alter the infectious risks of CVCs in randomized studies or a meta-analysis. Moreover, routine replacement at a new site exposes the patient to an increased risk of mechanical complications. The overall rate of mechanical complications per catheter inserted is approximately 3%. Guidewire exchange of the catheters may reduce the risk of mechanical complications, but unfortunately is associated with a higher rate of catheter colonization and catheter-related bacteremia. Routine replacement of CVCs is not necessary.

Dialysis and central venous catheter infections in critically ill patients: results of a prospective study

OBJECTIVE

To determine the incidence of dialysis catheter (DC)-related infections in intensive care unit (ICU) patients, and to compare the frequency of DC and central venous catheter (CVC) infections in an ICU setting.

DESIGN

Prospective, descriptive survey.

SETTING

An adult, 10-bed medical/surgical ICU at a university hospital.

PATIENTS

A total of 151 DCs and 230 CVCs placed in 170 patients were evaluated.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Catheter colonization was defined by a quantitative catheter tip culture yielding > or =10(3) colony-forming units/mL, catheter-related bacteremia was defined as catheter colonization and blood culture positive for the same organism, and site infection was defined as the presence of pus at the insertion site. The mean duration of catheterization was 6.8+/-6 days for DCs and 5.9+/-4.6 for CVCs (p = .52). There was no difference between DCs and CVCs in catheter colonization and catheter-related bacteremia incidence rates per 1000 days of catheter use (24.2 vs. 19.8 [p = .46] and 0.96 vs. 1.5 [p = .60], respectively). Site infection was observed in one patient (CVC placement). For DCs and CVCs the duration of catheterization was associated with catheter infection (p = .0007 and p = .04, respectively), but when the catheters were examined over 5-day intervals, the incidence of catheter infections did not increase with duration of catheter use (p = .23 and p = .10, respectively).

CONCLUSIONS

DC-related infections are associated with DC longevity. As shown by the 5-day-interval analysis, the incidence of DC-related infections did not increase with DC duration, suggesting that the risk for DC-related infections remained unchanged with time. The characteristics of DC-related infections in ICU patients were comparable to those previously reported for CVC-related infections.

Methods of obtaining peripheral venous access in difficult situations

Peripheral venous access is frequently required in the hospital environment. This can occasionally be difficult to obtain. We have reviewed the pertinent literature and propose a structured algorithmic approach to reduce patient discomfort and to minimise the time involved in securing venous access.

Catheter-Related Bloodstream Infection

Central venous catheters are associated with the vast majority of nosocomial, catheter-related bloodstream infections (CR-BSI). Despite identification of multiple effective methods for preventing CR-BSI, it remains an important clinical problem. Catheters coated with anti-infective substances, such as chlorhexidine and silver sulfadiazine or rifampin and minocycline, have shown promising results in recent clinical trials, but confirmatory studies by different investigators are still needed. Concern has also been raised about widespread use of clinically important antibiotics on catheter surfaces, which may promote the development of antibiotic resistance. More accurate and cost-effective methods of diagnosing CR-BSI are desirable. Recent studies have evaluated endoluminal brush sampling and differential blood culture growth rates, which may provide acceptable accuracy without requiring removal of long-dwelling catheters, but the accuracy of these techniques needs to be confirmed in other studies.

Venous thromboembolic events in pediatric patients. Diagnosis and management

Venous thromboembolism is a rapidly increasing secondary complication in children being treated for serious, life-threatening, primary diseases. Most current management guidelines and recommendations for imaging techniques have been extrapolated from the results of trials in adults. This may be less than optimal for children as there are important differences. The purpose of this article is to summarize the information on venous thromboembolism in children, and offer some guidelines for diagnosis, prophylaxis, and therapeutic intervention based on the best available evidence.

Negative outcomes of intravascular therapy in infants and children

Intravascular therapy is essential in the care of acutely ill infants and children, but it is not without risks. The purpose of this article is to discuss potential intravascular, extravascular, and systemic complications related to peripheral and central intravascular therapy in infants and children. The formation of thrombi, infiltration, and sepsis are the most common complications. Less common complications are phlebitis, arterial spasm, catheter retention, catheter embolus, air emboli, dysrhythmias, and hemorrhage. Financial implications of long-term negative outcomes and nursing liability are discussed, and a proposed standard of preventative nursing care for intravascular therapy is presented.