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Bedoya MA, Raffini L, Durand R, Acord MR, Srinivasan A, Krishnamurthy G, Vatsky S, Escobar F, Cahill AM. Implantable venous access devices in children with severe hemophilia: a tertiary pediatric institutional experience. Pediatr Radiol 2020; 50:1148-1155. [PMID: 32390060 DOI: 10.1007/s00247-020-04668-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 02/25/2020] [Accepted: 03/26/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Clotting factor replacement forms the pillar of treatment for children with hemophilia. Most children can be treated using peripheral venipuncture, but very young children and children with poor venous access might require a central venous catheter. Short-term and long-term complications of implantable venous access device placement (also known as port placement) can result in important morbidity and mortality in children with hemophilia. OBJECTIVE The purpose of this study is to describe our experience with port placement in children and adolescents with severe hemophilia (<1% of the Factors VIII or IX). MATERIALS AND METHODS We performed a retrospective review over a 10-year period to identify port placement in pediatric patients with severe hemophilia. We reviewed demographic and procedural information, access frequency, mechanical complications, and central-line-associated bloodstream infections (CLABSI). Eighteen males were included, with median age at insertion of 3.9 years (0.7-22.7 years). Fifteen of the 18 patients had hemophilia Type A and 3/18 had Type B. Thirteen had high neutralizing inhibitor titers. RESULTS Technical success in port placement was achieved in 26/27 (96.3%) patients, with 1 port failure caused by venous occlusion from prior catheter placement. Port catheter size ranged from 5 French (Fr) to 7.5 Fr. All were single-lumen and placed via right (76.9%) or left (23.1%) internal jugular vein; 59.3% were placed during general anesthesia, and all had factor replacement prophylaxis. A peripherally inserted central catheter (PICC) was placed concurrently in 69.2% of the cases; per hospital policy, the port was only accessed 15 days post-placement to reduce the risk of site hematoma. Two patients were lost to follow-up. The total catheter days was 15,893. Ports were removed in 14/24 cases, most commonly because of CLABSI (7/24; 29.2%) and transition to peripheral infusion (3/24; 12.5%). Bleeding was the most common complication in the first 30 days after placement. There were nine CLABSI events (0.57 per 1,000 catheter days), all in patients with high neutralizing inhibitor titers. A higher frequency of port access (more or equal to daily vs. less than daily) correlated with higher infection rates (P=0.02). Median time from port insertion to first infection was 348 days (range 167-1,055 days). There were four fibrin-sheath-related catheter occlusions (0.25 per 1,000 catheter days): three catheters were salvaged with intra-catheter tissue plasminogen activator (tPA) instillation resulting in a salvage of an additional 1,214 catheter days, and one catheter was removed after tPA failure (0.06 per 1,000 catheter days). CONCLUSION Port maintenance in boys with severe hemophilia is challenging given the need for long-term frequent device access that is associated with catheter-related infections. The rate of bleeding or infection did not differ in patients whether the device was accessed immediately or 15 days post placement. With appropriate pre- and post-procedural factor replacement, immediate and early term severe complications are not common.
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Affiliation(s)
- Maria A Bedoya
- Department of Radiology, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA.
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Leslie Raffini
- Department of Radiology, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Rachelle Durand
- Department of Radiology, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael R Acord
- Department of Radiology, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Abhay Srinivasan
- Department of Radiology, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ganesh Krishnamurthy
- Department of Radiology, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Seth Vatsky
- Department of Radiology, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Fernando Escobar
- Department of Radiology, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anne Marie Cahill
- Department of Radiology, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Baskin KM, Mermel LA, Saad TF, Journeycake JM, Schaefer CM, Modi BP, Vrazas JI, Gore B, Drews BB, Doellman D, Kocoshis SA, Abu-Elmagd KM, Towbin RB. Evidence-Based Strategies and Recommendations for Preservation of Central Venous Access in Children. JPEN J Parenter Enteral Nutr 2019; 43:591-614. [PMID: 31006886 DOI: 10.1002/jpen.1591] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 03/19/2019] [Indexed: 12/16/2022]
Abstract
Children with chronic illness often require prolonged or repeated venous access. They remain at high risk for venous catheter-related complications (high-risk patients), which largely derive from elective decisions during catheter insertion and continuing care. These complications result in progressive loss of the venous capital (patent and compliant venous pathways) necessary for delivery of life-preserving therapies. A nonstandardized, episodic, isolated approach to venous care in these high-need, high-cost patients is too often the norm, imposing a disproportionate burden on affected persons and escalating costs. This state-of-the-art review identifies known failure points in the current systems of venous care, details the elements of an individualized plan of care, and emphasizes a patient-centered, multidisciplinary, collaborative, and evidence-based approach to care in these vulnerable populations. These guidelines are intended to enable every practitioner in every practice to deliver better care and better outcomes to these patients through awareness of critical issues, anticipatory attention to meaningful components of care, and appropriate consultation or referral when necessary.
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Affiliation(s)
- Kevin M Baskin
- VANGUARD, Venous Access (VANGUARD) Task Force, Society of Interventional Radiology (SIR), Pittsburgh, Pennsylvania, USA
| | - Leonard A Mermel
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | | | - Janna M Journeycake
- Jimmy Everest Center for Cancer and Blood Disorders in Children, University of Oklahoma, Oklahoma City, Oklahoma, USA
| | - Carrie M Schaefer
- Pediatric Interventional Radiology, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Biren P Modi
- Center for Advanced Intestinal Rehabilitation, Children's Hospital of Boston, Harvard Medical School, Boston, Massachusetts, USA
| | - John I Vrazas
- Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Beth Gore
- Association for Vascular Access, Herriman, Utah, USA
| | | | - Darcy Doellman
- Vascular Access Team, Children's Hospital of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Samuel A Kocoshis
- Pediatric Nutrition and Intestinal Care Center, Children's Hospital of Cincinnati Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Kareem M Abu-Elmagd
- Cleveland Clinics Foundation Hospitals and Clinics, Case Western Reserve University, Cleveland, Ohio, USA
| | - Richard B Towbin
- Department of Radiology, Phoenix Children's Hospital, Phoenix, Arizona, USA
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- VANGUARD, Venous Access (VANGUARD) Task Force, Society of Interventional Radiology (SIR), Pittsburgh, Pennsylvania, USA
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Campbell S, Parikh S, Tran HA. Complication rates of central venous access devices in patients with inherited bleeding disorders in Australia. Br J Haematol 2019; 186:e86-e88. [PMID: 30941760 DOI: 10.1111/bjh.15914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Sally Campbell
- Australian Centre for Blood Diseases, Monash University Alfred Hospital, Melbourne, VIC, Australia.,Australian Haemophilia Centre Directors Organisation (AHCDO), Melbourne, VIC, Australia.,Royal Children's Hospital, Haemophilia Treatment Centre, Melbourne, VIC, Australia
| | - Sumit Parikh
- Australian Haemophilia Centre Directors Organisation (AHCDO), Melbourne, VIC, Australia
| | - Huyen A Tran
- Australian Centre for Blood Diseases, Monash University Alfred Hospital, Melbourne, VIC, Australia.,Australian Haemophilia Centre Directors Organisation (AHCDO), Melbourne, VIC, Australia.,The Alfred Hospital, Haemophilia Treatment Centre, Melbourne, VIC, Australia
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Abstract
PURPOSE OF REVIEW Central venous catheters (CVCs) have a prominent role in the diagnostic and therapy of neonates and children. Herein, we describe the multiple indications for CVC use and the different devices available for central venous access. Given the prevalent use of CVCs, healthcare systems are focused on reducing complications from their use, particularly central line-associated bloodstream infections (CLABSIs). The most up-to-date information available sheds light on best practices and future areas of investigation. RECENT FINDINGS Large systematic reviews of randomized trials suggest that ultrasound guidance for placement of CVCs in children is safer than using blind technique, at least for internal jugular vein access. Appropriate catheter tip placement is associated with decreased complications. Furthermore, the prophylactic use of ethanol lock between cycles of parenteral nutrition administration has reduced the rates of CLABSI. A recent randomized trial in pediatric CVCs showed a benefit with antibiotic-coated CVCs. SUMMARY Based on the available evidence, multiple techniques for CVC placement are still valid, including the landmark technique based on practitioner experience, but ultrasound guidance has been shown to decrease complications from line placement. Adherence to CVC care protocols is essential in reducing infectious complications.
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