Complications of indwelling central venous catheters in pediatric liver transplant recipients

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Medline, CINAHL, Embase, Web of Science, Scopus, Cochrane CENTRAL, clinical trial registries, and unpublished study databases were searched.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Medline, CINAHL, Embase, Web of Science, Scopus, Cochrane CENTRAL, clinical trial registries, and unpublished study databases were searched.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

Outcomes of Pediatric Osteogenesis Imperfecta Patients Requiring Port-a-Cath Placement for Long-Term Vascular Access

Intravenous (iv) bisphosphonates are widely used to treat the skeletal manifestations of osteogenesis imperfecta (OI). Obtaining peripheral iv access in pediatric patients with OI is often difficult and traumatic. Although this may be mitigated with surgically placed iv ports (port-a-caths), surgeons may be hesitant to perform this procedure on these children because of the lack of safety data. This study aims to gain better insight into the safety and efficacy of port-a-cath use in this population and identify risk factors for port-a-cath complications. In the present study, we conducted a retrospective cohort analysis of patient characteristics and the incidence of port-a-cath-related complications in children with OI. Fifty-three port-a-caths were placed in 29 children (21 males and 8 females). Of the 29 patients, most are OI type III (n = 18), followed by type I (n = 4), type IV (n = 4), and type V (n = 3). At the time of initial port-a-cath placement, the median age was 52 months (10-191 months), and the median weight was 7.9 kg (5.1-41.1 kg). Most patients (n = 20) weighed less than 10 kg during initial placement. Weight correlated significantly with OI type (p = 0.048), sex (p = 0.03), and vessel used (p = 0.02). Median initial port-a-cath longevity was 43 months (1-113 months), and we found no significant difference in port-a-cath longevity between sexes, OI types, or vessels used. Most patients (n = 19) required multiple port-a-cath placements. There is a significant difference (p = 0.02) between the number of placements and OI type, with type IV having more than type III. Port-a-cath removal was almost always due to mechanical complications (n = 19) but also for infection (n = 1) and malposition (n = 1). Eight patients still had their initial port-a-caths in place at the conclusion of this study. These findings indicate that complications associated with port-a-cath placement are mild and can be used to safely deliver iv bisphosphonates to pediatric OI patients. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Bacteremia in Pediatric Liver Transplant Recipients

BACKGROUND

We aimed to determine the frequency of bacteremia, septic shock and bacterial meningitis in pediatric liver transplant recipients (pLTRs) in the outpatient setting and to identify clinical factors associated with bacteremia.

METHODS

Multicenter retrospective study of pLTRs evaluated in the emergency department or outpatient clinic between 2010 and 2018 for suspected infection, defined as fever ≥38 °C or a blood culture obtained. We excluded patients with nontransplant immunodeficiency, multiorgan transplants or intestinal failure. The primary outcome was bacteremia; secondary outcomes included fluid-refractory septic shock, bacterial meningitis and antibiotic resistance. The unit of analysis was the encounter.

RESULTS

A total of 151 children had 336 encounters for infection evaluation within 2 years of transplant. Of 307 (91.4%) encounters with blood cultures, 17 (5.5%) had bacteremia, with 10 (58.8%) occurring within 3 months of transplant. Fluid-refractory septic shock and bacterial meningitis occurred in 7 out of 307 (2.8%) and 0 out of 307 encounters, respectively. Factors associated with bacteremia included closer proximity to transplant (<3 months) [odds ratio (OR): 3.6; 95% confidence interval (CI): 1.3-9.8; P = 0.01], shorter duration of illness (OR: 4.3; 95% CI: 1.5-12.0; P < 0.01) and the presence of a central venous catheter (CVC) (OR: 12.7; 95% CI: 4.4-36.6; P < 0.01). However, 5 (29.4%) encounters with bacteremia had none of these factors. Among Gram-positive pathogens, 1 out of 7 (14.2%) isolates were resistant to vancomycin. Among Gram-negative pathogens, 3 out of 13 (23.1%) isolates were resistant to 3rd generation cephalosporins.

CONCLUSIONS

Bacteremia was an important cause of infection within 2 years of pLTR. Clinical factors increased the risk of bacteremia. Further, large sample studies should derive multivariable models to identify those at high and low risk of bacteremia to optimize antibiotic use.

Long-term vascular access for infants with moderate to severe osteogenesis imperfecta

PURPOSE

Osteogenesis imperfecta (OI) is a genetic disorder that causes skeletal fragility. For the most fragile infants and young children with OI, intravenous (IV) bisphosphonate administration is essential, but IV access attempts often cause fractures. Port-a-caths help prevent these events, but some surgeons are hesitant to insert these devices in these infants due to lack of data on their safety.

METHODS

Retrospective study of pediatric patients with OI who underwent port-a-cath placement from 1999 to 2018; incidence of complications such as infection and thrombosis and need for reoperation or replacement are described.

RESULTS

Port-a-caths were placed in 17 patients with OI (median age, 8 mos [5-23 mos]; median weight, 5.8 kg [3.96-9.08 kg]) and remained in place for a median of 53.5 mos (10-127 mos). One port-a-cath was replaced because of thrombosis. Two port-a-caths were removed because of malfunction, one for skin erosion, and one for infection. In these five cases, replacement was not needed because patients could safely tolerate IV access. Two patients have their port-a-cath in place and the remaining ten patients had theirs removed electively as it was no longer needed.

CONCLUSION

Port-a-cath placement in pediatric patients with OI is safe and efficacious for durable central access, enabling reliable IV bisphosphonate delivery and reducing iatrogenic trauma.