Incidents and complications of totally implanted vascular access devices in children: a prospective study

Iatrogenic vascular trauma and complications of vascular access in children

Vascular access is frequently a critical component of the diagnostic and therapeutic procedures required to manage childhood illnesses, including many emergent conditions and critical illnesses. Vascular access in the pediatric population presents unique challenges, and many clinical and technical factors must be considered to avoid complications that can occur with vascular access procedures. This article reviews various aspects of vascular access and associated iatrogenic trauma in children, including risk factors, management of complications, and preventive measures to avoid complications. It is only with a comprehensive understanding of the topic that vascular access in children can be performed safely, effectively, and efficiently.

Risk factors for central line-associated bloodstream infection in pediatric oncology patients with a totally implantable venous access port: A cohort study

BACKGROUND

Totally implantable venous access ports (TIVAPs) are used for prolonged central venous access, allowing the infusion of chemotherapy and other fluids and improving the quality of life of children with cancer. TIVAPs were developed to reduce the infection rates associated with central venous catheters; however, infectious events remain common and have not been fully investigated in pediatric oncology patients.

PROCEDURE

A retrospective cohort was formed to investigate risk factors for central line-associated bloodstream infection (CLABSI) in pediatric cancer patients. Sociodemographic, clinical, and TIVAP insertion-related variables were evaluated, with the endpoint being the first CLABSI. A Kaplan-Meier analysis was performed to determine CLABSI-free catheter survival.

RESULTS

Overall, 188 children were evaluated over 77,541 catheter days, with 94 being diagnosed with CLABSI (50%). Although coagulase-negative staphylococci were the pathogens most commonly isolated, Gram-negative microorganisms (46.8%) were also prevalent. In the multivariate analysis, factors that increased the risk for CLABSI were TIVAP insertion prior to chemotherapy (risk ratio [RR] = 1.56; P < 0.01), white blood cell count less than 1,000 mm^-3 on the day of implantation (RR = 1.64; P < 0.01), and chronic malnutrition (RR = 1.41; P < 0.05). Median time without CLABSI following TIVAP insertion was 74.5 days.

CONCLUSIONS

Risk factors for CLABSI in pediatric cancer patients with a TIVAP may be related to the severity of the child's condition at catheter insertion. Insertion of the catheter before chemotherapy and unfavorable conditions such as malnutrition and bone marrow aplasia can increase the risk of CLABSI. Protocols must be revised and surveillance increased over the first 10 weeks of treatment.

Complications of Central Venous Access Devices: A Systematic Review

CONTEXT

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

OBJECTIVE

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Frequent Accesses to Totally Implanted Vascular Ports in Pediatric Oncology Patients are Associated with Higher Infection Rates

Purpose

Totally implanted vascular (TIVA) ports are used in children for repeated blood samples or intravenous treatments. We have recently published a prospective evaluation of surgical incidents and early complications associated with these devices. This work is the final part of the same study, assessing late complications over a follow-up of 2 yrs.

Methods

From January 2006 to January 2008, children older than 1 yr of age with a diagnosis of solid or blood cell malignancy were included. Insertion technique and care of the device were standardized. Every manipulation was prospectively recorded by specialized nurses. Obstruction was documented clinically. When bacteremia was suspected, routine central and peripheral blood cultures were drawn.

Results

Forty-five consecutive patients were enrolled in the study. Mean age at the time of the procedure was 8.5 yrs. There was no catheter-related infection within the first 4 weeks post-surgery. No device had to be removed because of infection or obstruction during follow-up. Frequent accesses to the port (≥3 per day over a 10–day period) were associated with an 8–fold risk of infection.

Conclusion

Insertion and use of TIVA devices were frequently associated with complications. No device had to be removed because of infection or obstruction over the follow-up period, although no prophylactic antibiotic agent was used. Restrictive use of antibiotics may prevent opportunistic infection. Frequent access to the device was significantly associated with line infection (odds ratio=8.43). No risk factor was identified for obstruction which occurred at a rate of 5.3 per 10,000 accesses.

Ultrasound guided internal jugular vein access in children and infant: a meta-analysis of published studies

INTRODUCTION

Central venous catheter placement is technically difficult in pediatric population especially in the younger patients. Ultrasound prelocation and/or guidance (UPG) of internal jugular vein (IJV) access has been shown to decrease failure rate and complications related to this invasive procedure. The goal of the present study was to perform a systematic review of the advantages of UPG over anatomical landmarks (AL) during IJV access in children and infants.

MATERIAL AND METHODS

A comprehensive literature search was conducted to identify clinical trials that focused on the comparison of UPG to AL techniques during IJV access in children and infants. Two reviewers independently assessed each study to meet inclusion criteria and extracted data. Data from each trial were combined to calculate the pooled odds ratio (OR) or the mean differences (MD), and their 95% confidence intervals [CI 95%]. I(2) statistics were used to assess statistics heterogeneity and to guide the use of fixed or random effect for computation of overall effects. Subgroup analysis was used to clarify the effects of the techniques used (prelocation or guidance) or the experience of practitioners.

RESULTS

Literature found five articles. Most of the patients were cardiac surgery patients. In comparison with AL, UPG had no effect on IJV access failure rate (OR = 0.28 [0.05, 1.47], I(2) = 75%, P = 0.003), the rate of carotid artery puncture (OR = 0.32 [0.06, 1.62], I(2) = 68%, P = 0.01), haematoma, haemothorax, or pneumothorax occurrence (OR = 0.40 [0.14, 1.13], I(2) = 17%, P = 0.30, OR = 0.72, OR = 0.81 [0.18, 3.73], I(2) = 0%, P = 0.94, respectively) and time to IJV access and haemothorax/pneumothorax occurrence. Subgroup analysis found an efficacy of ultrasound when used by novice operators or during intraoperative use.

DISCUSSION

This current meta-analysis does not found the utility of ultrasound during IJV access in children and infants in increasing the success rate and in decreasing complications.