Transhepatic Central Venous Catheters in Pediatric Patients With Congenital Heart Disease

An Alternative Central Venous Access Route for Pediatric Patients with Chronic Critical Illness: The Transhepatic Approach

OBJECTIVE

To evaluate the safety and functionality of the transhepatic approach as an alternative route for central venous catheterization in pediatric patients with chronic critical illness.

METHODS

The study included data of 12 chronic critically ill pediatric patients who underwent central venous catheterization with transhepatic approach. The indications, procedure details, mean patency time, and catheter-related complications were retrospectively analyzed.

RESULTS

A total of 16 central venous catheters were placed through the transhepatic approach. A 5F port catheter was used in eight attempts, a 5F PICC in two attempts, and an 8-14F Hickman-Broviac catheter in six attempts. All procedures were performed with technical success. The mean patency time of the catheters was 132.1 d (range: 12-540 d). In the long-term follow-up, catheter-related sepsis was detected in a patient, and six catheters lost functionality due to malposition.

CONCLUSION

The transhepatic approach is a safe and functional alternative route for central venous access in chronic critically ill pediatric patients requiring long-term vascular access. The procedure using ultrasonography and fluoroscopy can be performed with high technical success. In the long-term follow-up, Dacron felt cuff tunneled catheters placed in the subcostal space with a transhepatic approach remained functional for a long time.

Infection Associated With Invasive Devices in Pediatric Health Care: A Meta-analysis

CONTEXT

Indwelling invasive devices inserted into the body for extended are associated with infections.

OBJECTIVE

This study aimed to estimate infection proportion and rates associated with invasive devices in pediatric healthcare.

DATA SOURCES

Medline, CINAHL, Embase, Web of Science, Scopus, Cochrane CENTRAL, clinical trial registries, and unpublished study databases were searched.

STUDY SELECTION

Cohort studies and trials published from January 2011 to June 2022, including (1) indwelling invasive devices, (2) pediatric participants admitted to a hospital, (3) postinsertion infection complications, and (4) published in English, were included.

DATA EXTRACTION

Meta-analysis of observational studies in epidemiology guidelines for abstracting and assessing data quality and validity were used.

MAIN OUTCOMES AND MEASURES

Device local, organ, and bloodstream infection (BSIs) pooled proportion and incidence rate (IR) per-1000-device-days per device type were reported.

RESULTS

A total of 116 studies (61 554 devices and 3 632 364 device-days) were included. The highest number of studies were central venous access devices associated BSI (CVAD-BSI), which had a pooled proportion of 8% (95% confidence interval [CI], 6-11; 50 studies) and IR of 0.96 per-1000-device-days (95% CI, 0.78-1.14). This was followed by ventilator-associated pneumonia in respiratory devices, which was 19% (95% CI, 14-24) and IR of 14.08 per-1000-device-days (95%CI, 10.57-17.58).

CONCLUSIONS

Although CVAD-BSI and ventilator associated pneumonia are well-documented, there is a scarcity of reporting on tissue and local organ infections. Standard guidelines and compliance initiatives similar to those dedicated to CVADs should be implemented in other devices in the future.

Device Related Thrombosis and Bleeding in Pediatric Health Care: A Meta-analysis

CONTEXT

The risk of invasive device-related thrombosis and bleeding contributes to morbidity and mortality, yet their prevalence by device-types is poorly understood.

OBJECTIVES

This study aimed to estimate pooled proportions and rates of thrombotic and bleeding complications associated with invasive devices in pediatric health care.

DATA SOURCES

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

STUDY SELECTION

Cohort studies and trials published from January 2011 to June 2022, including (1) indwelling invasive devices, (2) pediatric participants admitted to a hospital, (3) reporting thrombotic and bleeding complications, and (4) published in English, were included.

DATA EXTRACTION

Meta-analysis of observational studies in epidemiology guidelines for abstracting and assessing data quality and validity were used.

MAIN OUTCOMES AND MEASURES

Device-specific pooled thromboses (symptomatic, asymptomatic, unspecified) and bleeding (major, minor).

RESULTS

Of the 107 studies, 71 (66%) focused on central venous access devices. Symptomatic venous thromboembolism in central venous access devices was 4% (95% confidence interval [CI], 3-5; incidence rate 0.03 per 1000 device-days, 95% CI, 0.00-0.07), whereas asymptomatic was 10% (95% CI, 7-13; incidence rate 0.25 per 1000 device-days, 95% CI, 0.14-0.36). Both ventricular assist devices (28%; 95% CI, 19-39) and extracorporeal membrane oxygenation (67%; 95% CI, 52-81) were often associated with major bleeding complications.

CONCLUSIONS

This comprehensive estimate of the incidence and prevalence of device-related thrombosis and bleeding complications in children can inform clinical decision-making, guide risk assessment, and surveillance.

Clinical and demographic factors associated with pediatric difficult intravenous access in the operating room

BACKGROUND

Pediatric intravenous catheter insertion can be difficult in the operating room due to the technical challenges of small diameter vessels and the need to rapidly gain intravenous access in anesthetized children. Few studies have examined factors associated with difficult vascular access in the operating room, especially accounting for the increased possibility to use ultrasound guidance.

AIMS

The primary aim of the study was to identify factors associated with pediatric difficult vascular access in the operating room. Our primary hypothesis was that Black race, Hispanic ethnicity, and ultrasound use would be associated with pediatric difficult vascular access.

METHODS

We performed a retrospective analysis of prospectively collected data from a cohort of pediatric patients who had intravenous catheters inserted in the operating room at an academic tertiary care children's hospital from March 2020 to February 2021. We measured associations among patients who were labeled as having difficult vascular access (>2 attempts at access) with demographic, clinical, and hospital factors.

RESULTS

12 728 intravenous catheter insertions were analyzed. Multivariable analysis showed significantly higher odds of difficult vascular access with Black non-Hispanic race (1.43, 95% CI: 1.06-1.93, p = .018), younger age (0.93, 95% CI: 0.89-0.98, p = .005), overweight (1.41, 95% CI: 1.04-1.90, p = .025) and obese body mass index (1.56, 95% 95% CI: 1.12-2.17, p = .008), and American Society of Anesthesiologists physical status III (1.54, 95% CI:1.11-2.13, p = .01). The attending anesthesiologist compared to all other practitioners (certified registered nurse anesthetist: (0.41, 95% CI: 0.31-0.56, p < .001, registered nurse: 0.25, 95% CI: 0.13-0.48, p < .001, trainee: 0.21, 95% CI: 0.17-0.28, p-value <.001 with attending as reference variable) and ultrasound use (2.61, 95% CI: 1.85-3.69, p < .001) were associated with successful intravenous catheter placement.

CONCLUSIONS

Black non-Hispanic race/ethnicity, younger age, obese/overweight body mass index, American Society of Anesthesiologists physical status III, and ultrasound were all associated with pediatric difficult vascular access in the operating room.

The Michigan Appropriateness Guide for Intravenous Catheters in children with congenital heart disease: miniMAGIC-CHD

BACKGROUND

The approach to vascular access in children with CHD is a complex decision-making process that may have long-term implications. To date, evidence-based recommendations have not been established to inform this process.

METHODS

The RAND/UCLA Appropriateness Method was used to develop miniMAGIC, including sequential phases: definition of scope and key terms; information synthesis and literature review; expert multidisciplinary panel selection and engagement; case scenario development; and appropriateness ratings by expert panel via two rounds. Specific recommendations were made for children with CHD.

RESULTS

Recommendations were established for the appropriateness of the selection, characteristics, and insertion technique of intravenous catheters in children with CHD with both univentricular and biventricular physiology.

CONCLUSION

miniMAGIC-CHD provides evidence-based criteria for intravenous catheter selection for children with CHD.

Selection and Insertion of Vascular Access Devices in Pediatrics: A Systematic Review

OBJECTIVE

To critically review the evidence for the selection and insertion of pediatric vascular access devices (VADs).

DATA SOURCES

Data were sourced from the US National Library of Medicine, Cumulative Index to Nursing and Allied Health, the Cochrane Library databases, Embase, and international clinical trial databases.

STUDY SELECTION

Clinical practice guidelines, systematic reviews, cohort designs, randomized control trials (RCTs), quasi RCTs, before-after trials, or case-control studies that reported on complications and/or risk as well as reliability of VADs in patients aged 0 to 18 years were included.

DATA EXTRACTION

Articles were independently reviewed to extract and summarize details on the number of patients and catheters, population, age of participants, VAD type, study method, indication, comparators, and the frequency of VAD failure or complications.

RESULTS

VAD selection and insertion decision-making in general hospitalized and some specialized patient populations were well evidenced. The use of single-lumen devices and ultrasound-guided techniques was also broadly supported. There was a lack of RCTs, and for neonates, cardiac patients, patients with difficult venous access, midline catheters, catheter-to-vein ratio, and near-infrared devices, the lack of evidence necessitated broadening the review scope.

LIMITATIONS

Limitations include the lack of formal assessment of the quality of evidence and the lack of RCTs and systematic reviews. Consequently, clinical decision-making in certain pediatric populations is not guided by strong, evidence-based recommendations.

CONCLUSIONS

This is the first synthesis of available evidence for the selection and insertion of VADs in pediatric patients and is important for determining the appropriateness of VADs in pediatric patients.

Traditional Long-Term Central Venous Catheters Versus Transhepatic Venous Catheters in Infants and Young Children

OBJECTIVES

Children with congenital heart disease may require long-term central venous access for intensive care management; however, central venous access must also be preserved for future surgical and catheterization procedures. Transhepatic venous catheters may be an useful alternative. The objective of this study was to compare transhepatic venous catheters with traditional central venous catheters regarding complication rate and duration of catheter service.

DESIGN

Retrospective review of 12 congenital heart disease patients from September 2013 to July 2015 who underwent placement of one or more transhepatic venous catheters.

SETTING

Single freestanding pediatric hospital located in the central United States.

PATIENTS

Pediatric patients with congenital heart disease who underwent placement of transhepatic venous catheter.

INTERVENTIONS

Cohort's central venous catheter complication rates and duration of catheter service were compared with transhepatic venous catheter data.

MEASUREMENTS AND MAIN RESULTS

Twelve patients had a total of 19 transhepatic venous lines. Transhepatic venous lines had a significantly longer duration of service than central venous lines (p = 0.001). No difference between the two groups was found in the number of documented thrombi, thrombolytic burden, or catheter sites requiring wound care consultation. A higher frequency of infection in transhepatic venous lines versus central venous lines was found, isolated to four transhepatic venous lines that had a total of nine infections. All but one was successfully managed without catheter removal. The difference in the proportion of infections to catheters in transhepatic venous lines versus central venous lines was significant (p = 0.0001), but no difference in the rate of infection-related catheter removal was found.

CONCLUSIONS

Without compromising future central venous access sites, transhepatic venous lines had superior duration of service without increased thrombosis, thrombolytic use, or insertion site complications relative to central venous lines. Transhepatic venous catheters had a higher infection rate, and further investigation into the etiology is warranted.

Conducting Prolonged General Anesthesia without Intravenous Access in a Child with Hypoplastic Left Heart Syndrome

Children with chronic medical conditions often need multiple intravenous (IV) access instances during their hospitalizations, both peripheral and central. Obtaining a working IV in this patient population undergoing general anesthesia can be challenging. In our case report, we describe a method of administering general anesthesia in an infant with partially repaired hypoplastic left heart syndrome without IV access.