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Upadhyay B, Anstead MI, Keshavamurthy S, Gurley J. Management of superior vena cava syndrome during lung transplantation for a patient with cystic fibrosis. BMJ Case Rep 2024; 17:e262156. [PMID: 39414317 DOI: 10.1136/bcr-2024-262156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2024] Open
Abstract
Central venous catheters including totally implantable venous access devices (TIVADs) have revolutionised the management of pulmonary infections and exacerbations in patients with cystic fibrosis (CF). While being better tolerated by the patient, these have allowed aggressive intravenous antibiotic therapies during recurrent hospitalisations. Given improvement in procedural strategies and operator experience, many patients with CF undergo lung transplants in the course of their disease nowadays. TIVADs can be associated with thrombosis leading to superior vena cava (SVC) obstruction and SVC syndrome which can pose a challenge, especially during the transplant surgery. We describe a case of successful management of SVC syndrome in a patient with CF undergoing a lung transplant, highlighting the strategies used to minimise risks associated with such a procedure.
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Affiliation(s)
| | - Michael I Anstead
- Adult and Pediatric Pulmonary, Critical Care and Sleep Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Suresh Keshavamurthy
- Cardiovascular & Thoracic Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - John Gurley
- Division of Cardiology, Department of Internal Medicine, University of Kentucky, Lexington, Kentucky, USA
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Dehbozorgi A, Jandali B, Turner R, Rohr A, Custer B, Young K, Walter C, Clark L, Li Y, Polineni D, Mermis J. Safety of non-cuffed tunneled central venous catheters in adults with cystic fibrosis. Respir Med Res 2024; 85:101073. [PMID: 38157768 DOI: 10.1016/j.resmer.2023.101073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 11/16/2023] [Accepted: 11/20/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Peripherally inserted central catheters (PICCs) are the most common route of intravenous (I.V.) access for treatment of cystic fibrosis (CF) pulmonary exacerbations, but repeated PICC placement can result in upper extremity peripheral venous stenosis. Once peripheral stenosis develops, a non-cuffed tunneled central venous catheter (NcTCVC) is an alternative route for IV access. While these are regularly used at some CF centers, the safety and complication rate compared to PICCs in adults with CF has not been reported. This study aims to describe the safety of NcTCVCs in adults with CF. METHODS A retrospective cohort study was performed at a CF Foundation accredited institution including adults with CF who received NcTCVCs in interventional radiology from 7/19/2007 to 3/09/2020. Complications analyzed included catheter related deep venous thrombosis (DVT), central line associated blood stream infection (CLABSI), and catheter related central venous stenosis. Complications were considered attributable if they occurred while the catheter was in place or within 30 days of catheter removal. RESULTS During the study duration, 386 NcTCVCs were placed in 60 unique patients (55 % female) with a mean of 6.4 catheters per patient. Majority of NcTCVCs placed were 4 French (61.4 %). Average duration of indwelling NcTCVC was 16.2 days. No patients demonstrated catheter attributable symptomatic DVT. The incidence of DVT, CLABSI, and central venous stenosis was 0 (0 %), 4 (1 %), and 1 (0.3 %), respectively. CONCLUSIONS Many adults with CF have required insertion of numerous PICCs for the treatment of recurrent pulmonary exacerbations. In those adults that develop PICC-associated peripheral vein stenosis precluding PICC placement, these results indicate NcTCVCs are a safe alternative.
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Affiliation(s)
- Arshan Dehbozorgi
- Department of Radiology, University of Kansas Medical Center, Kansas City, KS, United States
| | - Badr Jandali
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Robert Turner
- University of Kansas School of Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Aaron Rohr
- Department of Radiology, University of Kansas Medical Center, Kansas City, KS, United States
| | - Brandon Custer
- Department of Radiology, University of Kansas Medical Center, Kansas City, KS, United States
| | - Kate Young
- Department of Radiology, University of Kansas Medical Center, Kansas City, KS, United States
| | - Carissa Walter
- Department of Radiology, University of Kansas Medical Center, Kansas City, KS, United States
| | - Lauren Clark
- Department of Radiology, University of Kansas Medical Center, Kansas City, KS, United States
| | - Yanming Li
- Department of Radiology, University of Kansas Medical Center, Kansas City, KS, United States
| | - Deepika Polineni
- Department of Pediatrics, Division of Allergy and Pulmonary Medicine, Washington University School of Medicine, United States
| | - Joel Mermis
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas Medical Center, Kansas City, KS, United States.
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Woywodt A, Dhanda R, van Dellen D, So B, Bright-Thomas RJ. Kidney and combined kidney and pancreas transplantation may be under-utilized in cystic fibrosis. FRONTIERS IN TRANSPLANTATION 2022; 1:992985. [PMID: 38994374 PMCID: PMC11235247 DOI: 10.3389/frtra.2022.992985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 09/05/2022] [Indexed: 07/13/2024]
Abstract
Cystic fibrosis (CF) is a multisystem disorder and represents the most common inherited condition leading to death in Western countries. Previous reports of chronic kidney disease (CKD) in CF focus on cases post lung, or other solid organ, transplantation but CKD in CF patients pre transplantation is increasingly recognized as a challenging complication of CF. CKD can evolve as a sequel to acute kidney injury for example after prolonged treatment with aminoglycoside antibiotics during episodes of infection. Nephrolithiasis, diabetic nephropathy and a variety of glomerular lesions, such as amyloidosis and Immunoglobulin A nephropathy are also seen. Muscle depletion is common in CF, hence creatinine-based estimates of kidney function may underestimate the degree of renal impairment and lead to delayed diagnosis and management. Improved treatment options for CF patients have resulted in a sustained increase in life expectancy with increasing numbers of CF patients with CKD approaching end-stage renal failure prior to consideration of lung transplantation. We believe that kidney or combined kidney-pancreas transplantation are under-utilized in this population. We provide a brief primer on the landscape of CF and CKD and discuss transplant options. Suitable patients with CF and advanced CKD should be formally assessed for kidney or kidney-pancreas transplantation.
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Affiliation(s)
- Alexander Woywodt
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Royal Preston Hospital, Preston, United Kingdom
| | - Raman Dhanda
- Manchester Centre for Transplantation, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - David van Dellen
- Manchester Centre for Transplantation, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Beng So
- Department of Renal Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Royal Preston Hospital, Preston, United Kingdom
| | - Rowland J Bright-Thomas
- Manchester Adult Cystic Fibrosis Centre, Manchester University NHS Foundation Trust, Manchester, United Kingdom
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Mahan KS, Ahmad H, Keenan AG, Prekker ME, Kempainen RR. Yield of chest computed tomography angiogram in cystic fibrosis patients with suspected pulmonary embolism. THE CLINICAL RESPIRATORY JOURNAL 2022; 16:226-233. [PMID: 35060348 PMCID: PMC9060046 DOI: 10.1111/crj.13473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 08/14/2021] [Accepted: 11/25/2021] [Indexed: 11/27/2022]
Abstract
Introduction Individuals with cystic fibrosis (CF) may be at increased risk of pulmonary embolism (PE). Symptoms of PE overlap substantially with those of CF respiratory exacerbations. CF patients commonly undergo chest computed tomography (CT) angiograms (CTPA) to evaluate for PE, but little is known about the clinical presentation and diagnosis of PE in this population. Objectives The objectives of this study are to determine the diagnostic yield of CTPA for PE in adult patients with CF and assess the utility of the Revised Geneva Score (RGS) in this population. Methods Retrospective review of all CTPA results was performed on CF patients with suspected PE at a large CF center from 1 January 2011 through 31 March 2017. Patient demographics, medical history, and presenting signs and symptoms were abstracted by chart review. Results A total of 103 unique CTPA studies were performed in 68 patients. Most were hospitalized at the time of CTPA, predominantly for respiratory manifestations of CF. CTPA identified four patients with PE. The small number of positive studies precluded analysis of predictors of PE. Fewer PE were diagnosed than predicted by the Revised Geneva Score, which was intermediate probability in 77/103 (75%) patients. Conclusion The prevalence of PE in CF patients undergoing CTPA for suspected PE was 4%, which is lower than predicted by the Revised Geneva Score. This may be due to a large overlap in the signs and symptoms of PE and exacerbations of CF lung disease.
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Affiliation(s)
- Kathleen Suzanne Mahan
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine University of Minnesota, Twin Cities Minneapolis Minnesota USA
| | - Hamna Ahmad
- Division of Pulmonary, Allergy, and Critical Care Medicine Hennepin Healthcare Minneapolis Minnesota USA
| | - Andrew George Keenan
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine University of Minnesota, Twin Cities Minneapolis Minnesota USA
| | - Matthew Erren Prekker
- Division of Pulmonary, Allergy, and Critical Care Medicine Hennepin Healthcare Minneapolis Minnesota USA
| | - Robert Ralph Kempainen
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine University of Minnesota, Twin Cities Minneapolis Minnesota USA
- Division of Pulmonary, Allergy, and Critical Care Medicine Hennepin Healthcare Minneapolis Minnesota USA
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Regard L, Martin C, Chassagnon G, Burgel PR. Acute and chronic non-pulmonary complications in adults with cystic fibrosis. Expert Rev Respir Med 2018; 13:23-38. [PMID: 30472915 DOI: 10.1080/17476348.2019.1552832] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Cystic fibrosis (CF) is a genetic disease that primarily affects the respiratory system and often leads to respiratory failure and premature death. Although pulmonary complications contribute to 85% of deaths, non-pulmonary complications are responsible for significant morbidity and mortality in adults with CF. Areas covered: This review summarizes acute and chronic non-pulmonary complications in CF patients, with emphasis on emerging complications and in the context of the current growth and aging of the CF adult population. It also addresses the potential benefits of CF transmembrane conductance regulator modulator therapy. Complications that occur after solid organ (e.g. lung and/or liver) transplantation have been excluded. The review is based on an extensive search of the available literature, using PubMed and international guidelines, and on the authors' clinical experience. Expert commentary: Acute non-pulmonary complications have been well described but should be recognized and managed carefully. Managing chronic non-pulmonary complications is an important and changing aspect of CF patient care, particularly with the emergence of novel complications in adults. Early detection of non-pulmonary complications is essential to the development of prevention and treatment strategies that aim to further improve the survival and health status of adult CF patients.
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Affiliation(s)
- Lucile Regard
- a Faculté de Médecine , Paris Descartes University , Sorbonne Paris Cité , Paris , France.,b Pulmonology Department , Cochin Hospital, AP-HP , Paris , France
| | - Clémence Martin
- a Faculté de Médecine , Paris Descartes University , Sorbonne Paris Cité , Paris , France.,b Pulmonology Department , Cochin Hospital, AP-HP , Paris , France
| | - Guillaume Chassagnon
- a Faculté de Médecine , Paris Descartes University , Sorbonne Paris Cité , Paris , France.,c Radiology Department , Cochin Hospital, AP-HP , Paris , France
| | - Pierre-Régis Burgel
- a Faculté de Médecine , Paris Descartes University , Sorbonne Paris Cité , Paris , France.,b Pulmonology Department , Cochin Hospital, AP-HP , Paris , France
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Lafoeste H, Regard L, Martin C, Chassagnon G, Burgel PR. [Acute pulmonary and non-pulmonary complications in adults with cystic fibrosis]. REVUE DE PNEUMOLOGIE CLINIQUE 2018; 74:267-278. [PMID: 30343944 DOI: 10.1016/j.pneumo.2018.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Cystic fibrosis (CF) is a genetic disease primarily affecting the lungs, which could lead to chronic respiratory failure and premature death. CF patients are usually followed in specialized centers, but may present outside of these centers when they seek care for acute pulmonary and/or non-pulmonary complications. The aim of this paper is to provide appropriate knowledge necessary for managing respiratory and non-respiratory emergencies in CF adults. METHODS The review is based on international guidelines, extensive search of the available literature using Pubmed, and experience of the CF reference center at Cochin hospital (Paris, France). Complications occurring after solid organ transplantation (e.g., lung and/or liver) are excluded from this review. RESULTS Main acute respiratory complications are pulmonary exacerbations, hemoptysis, pneumothorax and allergic bronchopulmonary aspergillosis. Acute non-respiratory complications include hyponatremic dehydration, acute pancreatitis, acute complications of gallstones, distal intestinal obstruction syndrome, symptomatic nephrolithiasis, acute kidney injury, drug intolerances and catheter-related acute complications. CONCLUSION This review summarizes acute pulmonary and non-pulmonary complications occurring in adults with CF, focusing on diagnosis and principles of treatment, with the aim of providing a reference that can be used in clinical practice.
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Affiliation(s)
- H Lafoeste
- Université Paris Descartes, Sorbonne Paris cité, 75005 Paris, France; Service de pneumologie, centre de référence maladies rares : mucoviscidose et affections liées à une anomalie de CFTR (Site coordonnateur national), hôpital Cochin, AP-HP, 75014 Paris, France
| | - L Regard
- Université Paris Descartes, Sorbonne Paris cité, 75005 Paris, France; Service de pneumologie, centre de référence maladies rares : mucoviscidose et affections liées à une anomalie de CFTR (Site coordonnateur national), hôpital Cochin, AP-HP, 75014 Paris, France
| | - C Martin
- Université Paris Descartes, Sorbonne Paris cité, 75005 Paris, France; Service de pneumologie, centre de référence maladies rares : mucoviscidose et affections liées à une anomalie de CFTR (Site coordonnateur national), hôpital Cochin, AP-HP, 75014 Paris, France
| | - G Chassagnon
- Université Paris Descartes, Sorbonne Paris cité, 75005 Paris, France; Service de radiologie, hôpital Cochin, AP-HP, 75014 Paris, France
| | - P-R Burgel
- Université Paris Descartes, Sorbonne Paris cité, 75005 Paris, France; Service de pneumologie, centre de référence maladies rares : mucoviscidose et affections liées à une anomalie de CFTR (Site coordonnateur national), hôpital Cochin, AP-HP, 75014 Paris, France.
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Woods D, Hayashi RJ, Binkley MM, Sparks GW, Hulbert ML. Increased complications of chronic erythrocytapheresis compared with manual exchange transfusions in children and adolescents with sickle cell disease. Pediatr Blood Cancer 2017; 64. [PMID: 28544309 DOI: 10.1002/pbc.26635] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 03/30/2017] [Accepted: 04/14/2017] [Indexed: 11/09/2022]
Abstract
BACKGROUND Children and adolescents with sickle cell disease (SCD) are at high risk of strokes and are frequently treated with red blood cell (RBC) transfusions. The goal is to suppress hemoglobin (Hb) S while minimizing transfusion-induced iron overload. RBCs may be given via simple transfusion, manual exchange transfusion (MET), or erythrocytapheresis (aRBCX). Chronic transfusion practices vary among institutions. METHODS This single-institution, retrospective cohort study compares Hb S control and therapy complication rates between MET and aRBCX in a cohort of children and adolescents with SCD and stroke during a 5-year period from 2008 through 2012. Duration and mode of transfusion therapy, achievement of Hb S suppression goal, iron burden by ferritin levels, and catheter complications were evaluated. RESULTS Thirty-seven children were included in analysis. The prevalence of catheter complications was 75% in aRBCX recipients compared with 0% in MET recipients (P < 0.001). There was no significant difference between modalities in achieving Hb S suppression or ferritin goals, but those receiving aRBCX had a greater likelihood of discontinuing chelation therapy. Among aRBCX recipients, adherence to >90% of transfusion appointments was associated with achieving Hb S suppression goals. CONCLUSION aRBCX may have increased complication risks compared with MET for chronic transfusion therapy in SCD. Risks and benefits of aRBCX and MET should be considered when selecting a chronic transfusion modality. Transfusion therapy modalities should be compared in prospective studies for stroke prevention in children with SCD.
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Affiliation(s)
- Deborah Woods
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Robert J Hayashi
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Michael M Binkley
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| | | | - Monica L Hulbert
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
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Complications of long and intermediate term venous catheters in cystic fibrosis patients: A multicenter study. J Cyst Fibros 2017; 17:96-104. [PMID: 28579360 DOI: 10.1016/j.jcf.2017.04.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 04/27/2017] [Accepted: 04/28/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Totally implantable venous access devices (TIVADs) or peripherally inserted central venous catheters (PICCs) are commonly used in the care of patients with cystic fibrosis (CF), but they are associated with various complications, including thrombosis, infection, and insertion site symptoms. METHODS We conducted a retrospective review of PICC and TIVAD use in adults and children with CF over an 8-year period at 3 accredited care centers. Patient attributes included CFTR genotype, comorbidities, lung function, body mass index, use of anticoagulation, and respiratory tract microbiology. Catheter data included line type, caliber, and lumen number. We assessed practice variation by surveying physicians. RESULTS In a population of 592 CF patients, 851 PICC and 61 TIVADs were placed between January 1, 2003 and July 1, 2011. Larger catheter caliber and increased lumen number were risk factors for PICC complications in adults. Patient-related risk factors for PICC complications included poor nutritional status, infection with Burkholderia cepacia spp., and having ≥5 lines inserted during the study period. The probability of a PICC complication varied across centers (2.6% to 14.1%, p=0.001) and remained significant after adjustment for patient-and line-related risk factors. The median complication-free survival of TIVADs, however, did not vary significantly by center (p=0.85). CONCLUSIONS This is the first longitudinal, multicenter assessment of complication rates for PICCs and TIVADs in a large cohort of adults and children with CF. Specific patient- and catheter-related characteristics were associated with increased risk of complications. Center effects on complication rates were observed for PICCs.
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Ronan NJ, Elborn JS, Plant BJ. Current and emerging comorbidities in cystic fibrosis. Presse Med 2017; 46:e125-e138. [PMID: 28554721 DOI: 10.1016/j.lpm.2017.05.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 05/09/2017] [Accepted: 05/09/2017] [Indexed: 01/09/2023] Open
Abstract
Cystic fibrosis transmembrane conductance regulator (CFTR) is expressed ubiquitously throughout the body. Thus, while respiratory manifestations dominate much of cystic fibrosis (CF) care, there are prominent multi-organ manifestations and comorbidities. In the general population, the number of comorbidities increases with aging. Few illnesses have experienced such a dramatic improvement in survival as CF, which has been transformed from an illness of childhood death to one of adult survival. Hence, as longevity increases in CF, it is paralleled by an increasing number of patients with multicomplex comorbidities availing of care from adult CF multi-disciplinary teams. This review gives an overview of the traditional CF associated comorbidities and those emerging in an aging adult cohort. While historically the treatment of CF focused on the consequences of CFTR dysfunction, the recent advent of CFTR modulators with the potential to enhance CFTR function represents an opportunity to potentially reverse or delay the development of some of the comorbidities associated with CF. Where evidence is available for the impact of CFTR modulatory therapy, namely ivacaftor on comorbidities in CF, this is highlighted.
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Affiliation(s)
- Nicola J Ronan
- Cork university hospital, university college Cork, Cork adult cystic fibrosis centre, HRB clinical research facility, Wilton,T12 DFK4 Cork, Ireland
| | - Joseph Stuart Elborn
- London and Queen's university Belfast, National heart and lung institute, Imperial College, Royal Brompton hospital, London, United Kingdom
| | - Barry J Plant
- Cork university hospital, university college Cork, Cork adult cystic fibrosis centre, HRB clinical research facility, Wilton,T12 DFK4 Cork, Ireland.
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Vender RJ, Vender RL. Clinical Impact of Blood Culture Results in Acutely Ill Hospitalized Adult Patients With Cystic Fibrosis. J Clin Med Res 2016; 8:859-862. [PMID: 27829951 PMCID: PMC5087625 DOI: 10.14740/jocmr2764w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2016] [Indexed: 01/02/2023] Open
Abstract
Background Blood cultures are obtained clinically to confirm site and source of acute infection as well as to guide effective antibiotic therapies. Patients with cystic fibrosis (CF) are at risk for blood stream infection (BSI) as identified from positive blood culture results. Methods A retrospective chart review was performed of 190 adult CF patients from January 1, 2001 through December 1, 2015. All positive blood culture results were identified as to clinical relevance and source of BSI. Results There were a total of 3,053 blood cultures. One hundred fifty-one positive blood cultures were considered pathogenic and clinically significant. Venous access device-related BSI was identified in 31 evaluable patients and 106 blood cultures. Nineteen patients and 45 positive blood cultures were attributable to organ-specific sources. Conclusion Two patterns of BSI were identified: 1) venous access device infections without causal mortality and 2) organ-specific site infections with associated 26% mortality.
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Affiliation(s)
- Robert J Vender
- Penn State College of Medicine, 500 University Drive, Hershey, PA 17033, USA
| | - Robert L Vender
- Department of Medicine, Penn State Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033, USA
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11
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Bansal M, Ren CL. Anti-coagulant therapy with dabigatran for cystic fibrosis patients. Pediatr Pulmonol 2016; 51:E29-30. [PMID: 27128852 DOI: 10.1002/ppul.23419] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 03/10/2016] [Accepted: 03/28/2016] [Indexed: 11/09/2022]
Abstract
Patients with cystic fibrosis (CF) are at increased risk of venous thromboembolism, especially in association with central venous catheter use. Coumarin drugs and low molecular weight heparin are frequently used for anti-coagulant therapy, but are more challenging to administer in CF patients. Dabigatran, an oral thrombin antagonist, is an alternative anti-coagulant medication, but its use in CF has not been reported. We describe our experience in successfully using dabigatran for long-term anti-coagulation therapy in two CF patients. Our experience suggests that dabigatran can serve as an option for anticoagulation therapy in CF. Pediatr Pulmonol. 2016;51:E29-E30. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Manvi Bansal
- Division of Pediatric Pulmonology, Golisano Children's Hospital, University of Rochester, Rochester, New York
| | - Clement L Ren
- Division of Pediatric Pulmonology, Golisano Children's Hospital, University of Rochester, Rochester, New York
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12
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Smitherman AB, Alexander T, Connelly M, Snavely AC, Weston BW, Liles EA, Steiner MJ. The incidence of catheter-associated venous thrombosis in noncritically ill children. Hosp Pediatr 2015; 5:59-66. [PMID: 25646197 DOI: 10.1542/hpeds.2014-0041] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Previous studies estimated the incidence of catheter-associated venous thrombosis to be between 2% and 81%. Our goals were to define the incidence rate of catheter-related thrombosis in a hospitalized, noncritically ill, pediatric population and to determine modifiable factors that alter the risk of thrombosis. METHODS A retrospective cohort study was performed at the North Carolina Children's Hospital from 2009 to 2012. Chart review was performed with extraction of patient characteristics and line-related variables. Presence of symptomatic catheter-associated venous thrombosis was the primary outcome. Bivariable analysis and multivariable logistic regression were used to explore associations between line-related variables and thrombosis. RESULTS A total of 1135 lines were placed in 815 patients for 118,023 catheter-days. Thirty-six were complicated by venous thrombosis (3.2%) yielding a rate of 0.3 events per 1000 catheter-days. In multivariable analysis, increasing age (odds ratio [OR] 1.08, 95% confidence interval [CI] 1.03-1.13; P=.002), renal dialysis (OR 3.2, 95% CI 1.09-9.66; P=.035), and a diagnosis of inflammatory bowel disease or short bowel syndrome (OR 4.3, 95% CI 1.2-15.0; P=.02) were associated with increased risk of thrombosis. Modifiable risk factors, such as line site, size, and lumens, were not significantly associated with thrombosis. No thromboembolic events were observed. CONCLUSIONS We observed a lower incidence rate of catheter-associated venous thrombosis than in most previous reports. No modifiable characteristics altered the risk of thrombosis. Additional investigation of measures to prevent thrombosis is warranted in higher-risk populations, such as patients undergoing dialysis or patients with inflammatory bowel disease.
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Affiliation(s)
- Andrew B Smitherman
- Division of Pediatric Hematology Oncology, UNC Lineberger Comprehensive Cancer Center, North Carolina Cancer Hospital, Chapel Hill, North Carolina; and
| | - Thomas Alexander
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, and Department of Internal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Mark Connelly
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, and
| | - Anna C Snavely
- UNC Lineberger Comprehensive Cancer Center, North Carolina Cancer Hospital, Chapel Hill, North Carolina; and Department of Internal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Brent W Weston
- Division of Pediatric Hematology Oncology, UNC Lineberger Comprehensive Cancer Center, North Carolina Cancer Hospital, Chapel Hill, North Carolina; and UNC Hemophilia and Thrombosis Center, Chapel Hill, North Carolina
| | - Edmund A Liles
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, and Department of Internal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Michael J Steiner
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, and
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13
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Quality improvement initiative to reduce deep vein thrombosis associated with peripherally inserted central catheters in adults with cystic fibrosis. Ann Am Thorac Soc 2015; 11:1404-10. [PMID: 25295962 DOI: 10.1513/annalsats.201404-175oc] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Peripherally inserted central catheters (PICCs) are common in the treatment of patients with cystic fibrosis (CF). Previous reports suggest that patients with CF are at increased risk for PICC-associated deep vein thrombosis (DVT). OBJECTIVES We assessed potential risk factors for symptomatic PICC-associated DVT with subsequent implementation of a quality improvement (QI) initiative to reduce PICC-associated DVT in patients with CF. METHODS This was a 5-year retrospective cohort study with subsequent 21-month prospective observation following implementation of a QI intervention in adults (aged 18 yr or older) with CF. All patients with a PICC inserted from July 2006 to March 2013 at our CF Foundation-accredited center were included. Symptomatic DVT was diagnosed by Doppler ultrasound. PICC insertions were analyzed, and nine risk factors for DVT were analyzed to formulate a QI initiative to reduce risk of PICC-associated DVT. The QI program focused on staff education and included modification to PICC order entry with a 4 French (F) single-lumen (SL) catheter as standard for all patients with CF. MEASUREMENTS AND MAIN RESULTS A total of 369 PICCs were analyzed in 117 unique patients for a total of 5,437 PICC-days of placement. Symptomatic DVT was diagnosed in 28 (7.6%) of the 369 PICCs analyzed. Using regression analysis, the strongest predictors for DVT occurrence were warfarin use (odds ratio [OR] = 9.2, P = 0.006) and history of PICC-associated DVT (OR = 2.97, P = 0.08). Insertion of a 4F SL PICC resulted in zero symptomatic DVT. Zero episodes of DVT associated with 4F PICC insertion prevented use of PICC size in regression analysis. However, univariate analysis revealed that insertion of a 4F SL PICC instead of either 5F double lumen or 6F triple lumen was associated with a reduction in PICC-associated DVT (P = 0.001). After the QI intervention, 4F SL catheter insertion substantially increased to 65.8% of all PICCs inserted, whereas 6F triple-lumen catheter insertion declined to 6.8% of PICCs inserted. The QI initiative resulted in an absolute risk reduction in DVT per PICC placed of 6.1% (P = 0.055). CONCLUSIONS To reduce risk of PICC-associated DVT in patients with CF, QI strategies should focus on insertion of smaller-diameter 4F PICCs and reduction in PICC use in high-risk patients when possible.
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Complications of Peripherally Inserted Central Catheters in Adults with Cystic Fibrosis or Bronchiectasis. J Vasc Access 2015; 16:245-9. [DOI: 10.5301/jva.5000347] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2014] [Indexed: 12/13/2022] Open
Abstract
Background Peripherally inserted central catheters (PICCs) are increasingly used in patients with cystic fibrosis (CF) or with non-CF bronchiectasis, but little data exist on catheter-related complications in this setting. Methods Prospective follow-up of consecutive PICCs inserted for intravenous (IV) antibiotics in adults with CF or with non-CF bronchiectasis at Cochin Hospital (Paris, France). Results Between March 2009 and December 2011, 182 PICCs were prescribed in 117 adults (67 CF and 50 non-CF patients). Ultrasound-guided placement of catheter was successful in 174/182 (95.6%) procedures; no insertion complication occurred. The mean ± SD catheter dwell time was 15 ± 9 days. No catheter-associated bloodstream infection occurred; main complications were symptomatic upper limb deep vein thrombosis (2%), catheter obstruction (18%) and persistent pain after catheter insertion (18%). Patients' satisfaction was high and PICC could be used to perform antibiotic courses in most patients. Conclusions PICCs were generally safe for performing IV antibiotic courses in patients with CF or non-CF bronchiectasis, but prolonged pain and/or catheter obstruction occurred in approximately 20% of cases.
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Betegnie AL, Cracowski C, Bedouch P, Segond C, Robein-Dobremez MJ, Pin I, Allenet B. Le PICC line, un nouvel accès veineux pour les cures antibiotiques de la mucoviscidose de l’adulte. Rev Mal Respir 2014; 31:822-30. [DOI: 10.1016/j.rmr.2013.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Accepted: 09/11/2013] [Indexed: 10/26/2022]
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Otani S, Westall GP, Levvey BJ, Marasco S, Lyon S, Snell GI. Managing central venous obstruction in cystic fibrosis recipients--lung transplant considerations. J Cyst Fibros 2014; 14:255-61. [PMID: 25174332 DOI: 10.1016/j.jcf.2014.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 07/29/2014] [Accepted: 08/03/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND The superior vena cava (SVC) syndrome in cystic fibrosis (CF) patients is rare, but presents unique challenges in the peri-transplant period. We reviewed our experience of SVC syndrome in CF recipients undergoing lung transplantation. METHODS This is a retrospective case series from a single center chart-review. SVC obstruction is defined by clinically significant stenosis or obstruction of the SVC as detected by contrast studies. RESULTS We identified SVC obstruction in seven post-transplant cases and one pre-transplant case. All eight patients had previous or current history of indwelling central venous catheters. Three recipients experienced operative complications. Five of the seven recipients suffered at least one episode of post-operative SVC obstruction or bleeding despite prophylactic anticoagulation. At a median follow-up of 29 months, six of the seven patients transplanted are well. CONCLUSIONS Strategies are available to minimize the risks of intra/peri-operative acute life-threatening SVC obstruction in CF patients.
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Affiliation(s)
- Shinji Otani
- Lung Transplant Service, Department of Allergy, Immunology and Respiratory Medicine, Alfred Hospital and Monash University, 55 Commercial Road, Melbourne, VIC 3004, Australia
| | - Glen P Westall
- Lung Transplant Service, Department of Allergy, Immunology and Respiratory Medicine, Alfred Hospital and Monash University, 55 Commercial Road, Melbourne, VIC 3004, Australia
| | - Bronwyn J Levvey
- Lung Transplant Service, Department of Allergy, Immunology and Respiratory Medicine, Alfred Hospital and Monash University, 55 Commercial Road, Melbourne, VIC 3004, Australia
| | - Silvana Marasco
- Department of Cardiothoracic Surgery, Alfred Hospital and Monash University, 55 Commercial Road, Melbourne, VIC 3004, Australia
| | - Stuart Lyon
- Medical Imaging Department, Alfred Hospital and Monash University, 55 Commercial Road, Melbourne, VIC 3004, Australia
| | - Gregory I Snell
- Lung Transplant Service, Department of Allergy, Immunology and Respiratory Medicine, Alfred Hospital and Monash University, 55 Commercial Road, Melbourne, VIC 3004, Australia.
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Munck A, Kheniche A, Alberti C, Hubert D, Martine RG, Nove-Josserand R, Pin I, Bremont F, Chiron R, Couderc L, Dalphin ML, Darviot E, Delaisi B, Dominique S, Durieu I, Fanton A, Fayon M, Gérardin M, Giniès JL, Giraut C, Grenet D, Guillot M, Huet F, Le Bourgeois M, Murris-Epin M, Ramel S, Sardet A, Sermet-Gaudelus I, Varaigne F, Wanin S, Weiss L, Hurtaud MF. Central venous thrombosis and thrombophilia in cystic fibrosis: A prospective study. J Cyst Fibros 2014; 14:97-103. [PMID: 25107684 DOI: 10.1016/j.jcf.2014.05.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 05/20/2014] [Accepted: 05/20/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIMS Catheter venous thrombosis may result in life-threatening embolic complications. Recently, a thrombophilic tendency was described in cystic fibrosis (CF), the significance of which remains unclear. The aims of this study were to (1) document the frequency of catheter venous thrombosis detected by colour-Doppler-ultrasound (Doppler-US), (2) assess genetic and acquired thrombophilia risk factors for catheter venous thrombosis and hypercoagulability status and (3) provide recommendations on laboratory screening when considering insertion of a totally implantable vascular access device (TIVAD) in CF patients. METHODS We designed a multicentre prospective study in patients selected at the time of catheter insertion. Doppler-US was scheduled at 1 and 6months after insertion and before insertion in case of a previous central line. Blood samplings were drawn at insertion and at 1 and 6months later. RESULTS One-hundred patients received a TIVAD and 90 completed the 6-month study. Prevalence of thrombophilia abnormalities and hypercoagulability was found in 50% of the cohorts. Conversely, catheter venous thrombosis frequency was low (6.6%). CONCLUSION Our data do not support biological screening at the time of a TIVAD insertion. We emphasise the contribution of a medical history of venous thromboembolism and prospective Doppler-US for identifying asymptomatic catheter venous thrombosis to select patients who may benefit from biological screening and possible anticoagulant therapy.
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Affiliation(s)
- Anne Munck
- Assistance publique-Hôpitaux de Paris, Hôpital Robert Debré, Paediatric Gastroenterology and Respiratory Department, CF Centre, Université Paris 7, France.
| | - Ahmed Kheniche
- Assistance publique-Hôpitaux de Paris, Hôpital Robert Debré, Imaging Department, Université Paris 7, France
| | - Corinne Alberti
- Université Paris Diderot, Sorbonne Paris Cité, France; Inserm, CIE 5, Paris, France; Assistance publique-Hôpitaux de Paris, Hôpital Robert Debré, Clinical Epidemiology Unit, Paris, France
| | - Dominique Hubert
- Assistance publique-Hôpitaux de Paris, Hôpital Cochin, CF Centre, Université Paris Descartes, Sorbonne Paris Cité, France
| | | | - Raphaele Nove-Josserand
- Adult CF centre, Hospices Civils de Lyon, Groupe hospitalier Sud, Université de Lyon, France
| | - Isabelle Pin
- Pédiatrie, Pole Couple Enfants, CHU de Grenoble; INSERM U 823, Institut Albert Bonniot, Université Joseph Fournier, Grenoble, France
| | | | - Raphael Chiron
- CF centre, Hôpital Arnaud de Villeneuve, Montpellier, France
| | - Laure Couderc
- Department of Pneumology, Rouen University Hospital, France
| | | | | | - Bertrand Delaisi
- Assistance publique-Hôpitaux de Paris, Hôpital Robert Debré, Paediatric Gastroenterology and Respiratory Department, CF Centre, Université Paris 7, France
| | | | - Isabelle Durieu
- Adult CF centre, Hospices Civils de Lyon, Groupe hospitalier Sud, Université de Lyon, France
| | | | - Michael Fayon
- CF centre, Hopital Pellegrin CIC 005, CHU Bordeaux, France
| | - Michèle Gérardin
- Assistance publique-Hôpitaux de Paris, Hôpital Robert Debré, Paediatric Gastroenterology and Respiratory Department, CF Centre, Université Paris 7, France
| | | | | | | | | | - Frédéric Huet
- CF centre, Hôpital d'enfants du Bocage, Dijon, France
| | - Muriel Le Bourgeois
- Assistance publique-Hôpitaux de Paris, Hôpital Necker Enfants-Malades, CF centre, University Paris 5, France
| | | | | | | | - Isabelle Sermet-Gaudelus
- Assistance publique-Hôpitaux de Paris, Hôpital Necker Enfants-Malades, CF centre, University Paris 5, France
| | | | - Stéphanie Wanin
- Hospices Civils de Lyon, Hopital Femme-Mère-Enfant, CF centre, Bron, France
| | | | - Marie-Francoise Hurtaud
- Assistance publique-Hôpitaux de Paris, Hôpital Robert Debré, Biological Hematology Department, Université Paris 7, France
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Ng MY, Flight W, Smith E. Pulmonary complications of cystic fibrosis. Clin Radiol 2013; 69:e153-62. [PMID: 24361142 DOI: 10.1016/j.crad.2013.10.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 10/29/2013] [Accepted: 10/30/2013] [Indexed: 01/15/2023]
Abstract
The life expectancy of patients with cystic fibrosis (CF) has steadily increased over recent decades with a corresponding increase in the frequency of complications of the disease. Radiologists are increasingly involved with managing and identifying the pulmonary complications of CF. This article reviews the common manifestations of CF lung disease as well as updating radiologists with a number of less well-known complications of the condition. Early and accurate detection of the pulmonary effects of CF are increasingly important to prevent irreversible lung damage and give patients the greatest possibility of benefiting from the new therapies becoming available, which correct the underlying defect causing CF.
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Affiliation(s)
- M Y Ng
- Department of Radiology, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK.
| | - W Flight
- Manchester Adult Cystic Fibrosis Centre, University Hospital of South Manchester NHS Foundation Trust, UK
| | - E Smith
- Department of Radiology, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
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Gowraiah V, Culham G, Chilvers MA, Yang CL. Embolization of a central venous catheter due to pinch-off syndrome. Acta Paediatr 2013; 102:e49-50. [PMID: 23228151 DOI: 10.1111/apa.12085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- V Gowraiah
- Division of Respiratory Medicine; Department of Pediatrics; British Columbia Children's Hospital; Vancouver; BC; Canada
| | - G Culham
- Department of Radiology; British Columbia Children's Hospital; Vancouver; BC; Canada
| | - MA Chilvers
- Division of Respiratory Medicine; Department of Pediatrics; British Columbia Children's Hospital; Vancouver; BC; Canada
| | - CL Yang
- Division of Respiratory Medicine; Department of Pediatrics; British Columbia Children's Hospital; Vancouver; BC; Canada
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Withers AL. Management issues for adolescents with cystic fibrosis. Pulm Med 2012; 2012:134132. [PMID: 22991662 PMCID: PMC3444048 DOI: 10.1155/2012/134132] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Accepted: 08/15/2012] [Indexed: 11/17/2022] Open
Abstract
The healthy adolescent will encounter major changes in biological and psychosocial domains. The adolescent period can be greatly affected by a chronic illness. Cystic fibrosis is a terminal illness that can significantly affect an adolescent's biological, mental and psychosocial health. This paper discusses general issues to consider when managing an adolescent with a chronic medical condition, and specifically how cystic fibrosis may impact upon puberty, body image, risk-taking behaviours, mental health, independence, nonadherence, reproductive health, transition, lung transplantation, and end of life care.
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Affiliation(s)
- Adelaide Lindsay Withers
- Department of Respiratory Medicine, Princess Margaret Children's Hospital, Level 3, Harry Boan Building, Roberts Road, Subiaco, WA 6009, Australia
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22
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A-Rahman AKM, Spencer D. Totally implantable vascular access devices for cystic fibrosis. Cochrane Database Syst Rev 2012; 2012:CD004111. [PMID: 22592694 PMCID: PMC7175774 DOI: 10.1002/14651858.cd004111.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Totally implantable vascular access devices are widely used in people with cystic fibrosis to provide intermittent venous access for therapeutic infusions. Their use is associated with some complications such as thrombosis, embolism and infection. OBJECTIVES To assess if totally implantable venous access devices provide a safe and effective route for venous access for intermittent administration of intravenous antibiotics in people with cystic fibrosis. Also to assess strategies to reduce possible complications of totally implantable venous access devices (e.g. anticoagulants to reduce the risk of thrombosis). SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic database searches, handsearches of relevant journals and abstract books of conference proceedings.Date of the most recent search: 05 April 2012. SELECTION CRITERIA Randomised and quasi-randomised controlled trials which compared the use of totally implantable venous access devices in people with cystic fibrosis to other means of vascular access, trials which compared the different types of these devices against each other and trials which assessed strategies to reduce complications of these devices. DATA COLLECTION AND ANALYSIS No relevant trials were identified. MAIN RESULTS No trials were included in this review. AUTHORS' CONCLUSIONS Totally implantable vascular access devices are widely used in people with cystic fibrosis to provide intermittent venous access for therapeutic infusions. Reports of their use in people with cystic fibrosis suggest that they are safe and effective. These reports also suggest that certain interventions might reduce the risk of complications; however, it is disappointing that these reports have not been assessed by randomised controlled trials. This systematic review identifies the need for a multicentre randomised controlled trial assessing both efficacy and possible adverse effects of totally implantable venous access devices in cystic fibrosis.
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Nazareth D, Stables R, Ledson M, Walshaw M, Greenwood J. Fracture and Intra-Cardiac Embolisation of a Totally Implantable Vascular Access Device. Respiration 2012; 83:553. [DOI: 10.1159/000337255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Takemoto CM. Venous thromboembolism in cystic fibrosis. Pediatr Pulmonol 2012; 47:105-12. [PMID: 22006666 DOI: 10.1002/ppul.21566] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Accepted: 09/13/2011] [Indexed: 01/13/2023]
Abstract
The incidence of venous thromboembolism (VTE) is increasing in the pediatric population. Individuals with cystic fibrosis (CF) have an increased risk of thrombosis due to central venous catheters (CVCs), as well as acquired thrombophilia secondary to inflammation, or deficiencies of anticoagulant proteins due to vitamin K deficiency and/or liver dysfunction. CVC-associated thrombosis commonly results in line occlusion, but may develop into serious life-threatening conditions such as deep venous thrombosis (DVT), superior vena cava syndrome or pulmonary embolism (PE). Post-thrombotic syndrome (PTS) may be a long complication. Local occlusion of the catheter tip may be managed with instillation of thrombolytics (such as tPA) within the lumen of the catheter; however, CVC-associated thrombosis involving the proximal veins is most often is treated with systemic anticoagulation. Initial treatment with heparin is a standard approach, but thrombolytic therapy, which may carry higher bleeding risks, should be considered for life and limb threatening episodes of VTE. Recommended duration of anticoagulation with low molecular weight heparin (LMWH) or warfarin ranges from 3 to 6 months for major removable thrombotic risks; longer anticoagulation is considered for recurrent thrombosis, major persistent thrombophilia, or the continued presence of a major risk factor such as a CVC. While CVCs are the most common risk for development of VTE in children, studies have not demonstrated a clear benefit with routine use of systemic thromboprophylaxis. The incidence and risk factors of VTE in CF patients will be reviewed and principles of diagnosis and management will be summarized.
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Affiliation(s)
- Clifford M Takemoto
- Division of Pediatric Hematology, The Johns Hopkins University, Baltimore, Maryland, USA.
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25
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Freudenberger S, Kessler R, Canuet M, Boujan F, Santelmo N, Massard G, Falcoz PE. [Superior vena cava obstruction without symptoms?]. Rev Mal Respir 2011; 28:933-7. [PMID: 21943542 DOI: 10.1016/j.rmr.2010.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2009] [Accepted: 04/01/2010] [Indexed: 11/17/2022]
Affiliation(s)
- S Freudenberger
- Pôle de pathologie thoracique, service de pneumologie, nouvel hôpital Civil, 1, place de l'Hôpital, 67100 Strasbourg, France.
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Cummings M, Hearse N, McCutcheon H, Deuter K. Improving antibiotic treatment outcomes through the implementation of a midline: Piloting a change in practice for cystic fibrosis patients. JOURNAL OF VASCULAR NURSING 2011; 29:11-5. [DOI: 10.1016/j.jvn.2010.11.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Revised: 11/15/2010] [Accepted: 11/16/2010] [Indexed: 10/18/2022]
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Smith D, Reid D, Slaughter R, Masel P, Tai A, Bell S. Superior vena cava obstruction due to total implantable venous access devices in cystic fibrosis: Case series and review. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.rmedc.2010.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Batacchi S, Zagli G, Peris A, Braccini G, Bresci S. Totally Implantable Vascular Access Devices in Adult Patients for Cystic Fibrosis Management. Am J Respir Crit Care Med 2011; 183:133-4; author reply 134. [DOI: 10.1164/ajrccm.183.1.133a] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Cho TH, Janho K, Mohan IV. The Role of Stenting the Superior Vena Cava Syndrome in Patients With Malignant Disease. Angiology 2010; 62:248-52. [DOI: 10.1177/0003319710382772] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Superior vena cava (SVC) obstruction occurs in patients with intrathoracic malignancies. Clinical symptoms can be distressing but presentation is insidious. We investigated the outcome of endovascular management for patients with SVC syndrome. We retrospectively reviewed the case histories of 17 patients (9 men) from January 2003 to June 2009. All patients had malignant disease. There were 24 interventions (2 patients with 2 interventions and 2 patients with 3 interventions). All had SVC stenosis over 90%. All patients were treated with intrathoracic angioplasty and stenting. All procedures were technically successful, and all patients had insertion of 10 to 18 mm diameter stents with symptom resolution in 16 patients. There were 2 occlusions at 1 and 6 weeks and 2 patients with restenosis (3 and 7 months). Endovascular intervention is technically feasible for SVC occlusion, relieves symptoms, and is a useful palliation measure.
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Affiliation(s)
- Tae H. Cho
- University Department of Vascular Surgery, Westmead Hospital, Wentworthville, Sydney, Australia
| | - Kristi Janho
- University Department of Vascular Surgery, Westmead Hospital, Wentworthville, Sydney, Australia
| | - Irwin V. Mohan
- University Department of Vascular Surgery, Westmead Hospital, Wentworthville, Sydney, Australia,
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Thrombolysis for indwelling catheter related thrombosis and superior vena cava obstruction in cystic fibrosis: a case series. Ir J Med Sci 2010; 179:469-70. [DOI: 10.1007/s11845-010-0488-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2009] [Accepted: 04/27/2010] [Indexed: 12/31/2022]
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JENG MR, O’BRIEN M, WONG W, ZOLAND J, LEA J, TANG N, GLADER B. Monthly recombinant tissue plasminogen activator administration to implantable central venous access devices decreases infections in children with haemophilia. Haemophilia 2009; 15:1272-80. [DOI: 10.1111/j.1365-2516.2009.02063.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Bui S, Babre F, Hauchecorne S, Christoflour N, Ceccato F, Boisserie-Lacroix V, Clouzeau H, Fayon M. Intravenous peripherally-inserted central catheters for antibiotic therapy in children with cystic fibrosis. J Cyst Fibros 2009; 8:326-31. [DOI: 10.1016/j.jcf.2009.07.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2008] [Revised: 07/08/2009] [Accepted: 07/13/2009] [Indexed: 11/25/2022]
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Incidence of Deep Vein Thrombosis Associated with Peripherally Inserted Central Catheters in Adults with Cystic Fibrosis. J Vasc Interv Radiol 2009; 20:347-51. [DOI: 10.1016/j.jvir.2008.11.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2007] [Revised: 11/12/2008] [Accepted: 11/24/2008] [Indexed: 11/21/2022] Open
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Ali A, Zayed H, Wilkins J, Wyatt H, Rashid H. Endovascular port-a-cath insertion in a patient with cystic fibrosis and occluded superior vena cava. Vasc Endovascular Surg 2009; 43:280-3. [PMID: 19164301 DOI: 10.1177/1538574408329270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Port-a-cath insertion, for long-term intravenous antibiotic therapy, is an ideal solution for patient with cystic fibrosis. However, indwelling lines are liable to many complications including catheter thrombosis especially in patients having cystic fibrosis with hypercoagulable state. METHODS An endovascular technique for insertion of a port-a-cath in a patient having cystic fibrosis with occluded superior vena cava is reported. The technique is described in detail. In addition, a review of literature for the various methods of saving a failed central venous access in these patients was performed. RESULTS The line was successfully inserted and remained patent without need of any further intervention for 20 months. CONCLUSION In this report, several endovascular skills were used for central venous access salvage that can be used in similar situations with chronic superior vena cava occlusion, which may not be suitable for thrombolysis or stenting.
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Affiliation(s)
- Ahmed Ali
- Department of Vascular Surgery, King's College Hospital, Denmark Hill, London, United Kingdom
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Ghayyda SN, Roland D, Cade A. Seat belt associated central line fracture—A previously unreported complication in cystic fibrosis. J Cyst Fibros 2008; 7:448-9. [DOI: 10.1016/j.jcf.2008.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2008] [Accepted: 03/10/2008] [Indexed: 10/22/2022]
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Abstract
Cystic fibrosis patients with an implantable venous access device (IVAD) and a patent foramen ovale (PFO) are at an increased risk of developing paradoxical embolism. A 33-year-old patient who had a cerebrovascular accident in the above setting is described. She had been anticoagulated because she had thrombosis of the tip of the indwelling catheter, and her PFO was closed percutaneously followed by replacement of her IVAD. She made a full neurological recovery. Echocardiography and prophylactic closure of the PFO, when present, as primary prevention for paradoxical embolism may be warranted in cystic fibrosis patients before placement of an IVAD.
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MESH Headings
- Adult
- Anticoagulants/therapeutic use
- Cardiac Catheterization/methods
- Catheterization, Central Venous
- Catheters, Indwelling
- Cystic Fibrosis/complications
- Embolism, Paradoxical/diagnosis
- Embolism, Paradoxical/drug therapy
- Embolism, Paradoxical/etiology
- Embolism, Paradoxical/surgery
- Female
- Heart Septal Defects, Atrial/complications
- Heart Septal Defects, Atrial/diagnosis
- Heart Septal Defects, Atrial/drug therapy
- Heart Septal Defects, Atrial/surgery
- Humans
- Prosthesis Implantation/instrumentation
- Stroke/etiology
- Treatment Outcome
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Affiliation(s)
| | - Pearce Wilcox
- Correspondence: Dr Pearce Wilcox, Pacific Lung Health Centre, St Paul’s Hospital, 8B Providence Wing, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6. Telephone 604-806-8818, fax 604-806-8839, e-mail
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37
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Gaber KA, Shenton L, Oades P, Colville A, Sheldon CD. Fungal septicaemia in patients with cystic fibrosis associated with totally implantable venous access device system. J Cyst Fibros 2007; 6:317-9. [PMID: 17293171 DOI: 10.1016/j.jcf.2006.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2006] [Accepted: 10/20/2006] [Indexed: 11/21/2022]
Abstract
Fungal septicaemia is a serious and potentially fatal condition. We report 4 cases in patients with Cystic Fibrosis (CF) associated with totally implantable venous access device system (TIVADS).
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Affiliation(s)
- K A Gaber
- Department of Respiratory Medicine, Southmead Hospital, Bristol, UK.
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38
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Smith KJ, Elidemir O, Dishop MK, Eldin KW, Tatevian N, Moore RH. Intravenous injection of pharmaceutical tablets presenting as multiple pulmonary nodules and declining pulmonary function in an adolescent with cystic fibrosis. Pediatrics 2006; 118:e924-8. [PMID: 16923925 DOI: 10.1542/peds.2006-0085] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Here we present the unusual case of an adolescent with cystic fibrosis presenting with declining pulmonary function and diffuse micronodular pulmonary disease. This case illustrates the radiographic and pathologic findings associated with the intravenous injection and pulmonary arterial embolization of insoluble pharmaceutical-tablet constituents. The number of first-time users reporting nonmedical use of prescription pain relievers is increasing dramatically, especially in adolescents. Recognition of both the diagnostic imaging features and histologic features on lung biopsy are critical steps for early diagnosis, intervention, and potential prevention of sudden death in these at-risk patients.
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Affiliation(s)
- Kelly J Smith
- Department of Pediatric Pulmonology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas 77030, USA.
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39
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Serisier D, Carroll M. Catheter-related thrombosis associated with elevated factor VIII levels in cystic fibrosis. J Cyst Fibros 2006; 5:201-4. [DOI: 10.1016/j.jcf.2006.02.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2005] [Revised: 02/21/2006] [Accepted: 02/21/2006] [Indexed: 11/30/2022]
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40
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Garwood S, Flume PA, Ravenel J. Superior vena cava syndrome related to indwelling intravenous catheters in patients with cystic fibrosis. Pediatr Pulmonol 2006; 41:683-7. [PMID: 16703584 DOI: 10.1002/ppul.20388] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Patients with cystic fibrosis (CF) often need long-term implanted vascular-access devices for intravenous antibiotics for chronic lower respiratory tract infections. These devices are not without complications, including infection, occlusion, and vascular thrombosis. Such thrombosis can result in superior vena cava (SVC) syndrome due to the position of the catheter proximal to the right atrium. SVC syndrome in CF patients, however, is rarely reported in the literature, suggesting that its incidence is uncommon. We describe three patients with SVC syndrome as a consequence of implanted vascular-access devices.
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Affiliation(s)
- Susan Garwood
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina 29425, USA
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41
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Barraza ML, Strickland JR, Zepeda H, Taylor JB, Krehbiel CR, Bell GS, Klotz JL. Gross and histopathological observations of long-term catheterized vessels in experimental sheep. ACTA ACUST UNITED AC 2006; 53:230-8. [PMID: 16737512 DOI: 10.1111/j.1439-0442.2006.00824.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Chronic indwelling central vessel catheters provide vascular access for compartmental infusion or sampling. However, complications with catheter patency during the postoperative and/or experimental period often arise. In order to identify physiological occurrences common with such complications, 10 multicatheterized sheep (61.8 +/- 7.8 kg BW), obtained from a previous nutrient flux study were used for gross and histopathological investigation. Catheters had been surgically placed in a hepatic portal vein (PVC), a hepatic vein (HVC), a distal mesenteric vein (MVC) and a mesenteric artery (MAC). In the previous study, catheters (PVC, HVC and MAC) were used to collect blood samples or infuse (MVC) p-aminohippurate. Catheters were maintained for a total of 58 days prior to necropsy. Histopathological findings indicated that catheter failures were associated with the following tissue responses: (i) thromboses with frequent focal vasculitis; (ii) euplastic tissues associated with extensive fibrosis; (iii) granulomas; (iv) neo-vascularization of the media; (v) calcification processes; and (vi) micro-abscesses. Additional studies are needed that address and incorporate improvement of catheter design and placement to minimize irritation of endothelium, improvement of catheter treatments and therapeutic regimes, and development and use of alternative anti-coagulants. A greater understanding of the mechanisms leading to failure will help researchers improve catheter performance and patency.
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Affiliation(s)
- M L Barraza
- USDDA-ARS, Forage-Animal Production Research Unit, Lexington, KY 40456, USA
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42
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Raffini LJ, Raybagkar D, Blumenstein MS, Rubenstein RC, Manno CS. Cystic fibrosis as a risk factor for recurrent venous thrombosis at a pediatric tertiary care hospital. J Pediatr 2006; 148:659-64. [PMID: 16737881 DOI: 10.1016/j.jpeds.2005.11.032] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2005] [Revised: 09/08/2005] [Accepted: 11/11/2005] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To evaluate risk factors for recurrent thrombosis in pediatric patients. STUDY DESIGN This prospective observational cohort study enrolled 120 patients with acute venous thromboembolism from January 2003 to April 2005. Data collection included medical and family history, radiologic and laboratory studies, therapy, and follow-up. RESULTS The overall prevalence of recurrent thrombosis in our cohort was 19/120 (15.8%). Patients with recurrence were older, with a median age of 14.8 years (range 2 weeks-23.6 years), compared with 10.1 years (range newborn 23.4 years) in patients without recurrence (P = .03). Six of the 19 patients with recurrent thrombosis had cystic fibrosis (CF), compared with 0/101 without recurrence (P < .001). Five of these 6 patients were colonized with Burkholderia cepacia in their sputum. Central venous catheters were associated with most, but not all, of the thromboses in patients with CF. CONCLUSIONS In this study, patients with CF had a high risk of recurrent venous thrombosis, as well as a high prevalence of colonization with B cepacia. The cause of this risk has not been defined. This observation may have important implications for thromboprophylaxis, particularly in the setting of central venous catheters.
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Affiliation(s)
- Leslie J Raffini
- Division of Hematology, The Children's Hospital of Philadelphia, Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia 19104-4399, USA.
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43
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Abstract
Central venous lines are used in critically ill children and in children with chronic conditions for the administration of intravenous therapy, such as fluids, medications, total parenteral nutrition and blood products. Although the use of central venous lines has greatly improved the quality of care in these children, these catheters may cause serious mechanical, infectious and thrombotic complications. The reported frequency of catheter thrombosis in children is low as 5% in studies including only symptomatic cases and high as 50% in studies where patients are systematically screened for catheter-related thrombosis. The risk factors for catheter-related thrombosis in children are associated with the methods used for catheter insertion and with individual patient characteristics, underlying diagnosis and treatment. The management of catheter-related thrombosis is largely dependent on the requirement of the catheter. If no longer required or nonfunctioning the catheter should be removed. If access is still required and the catheter is functioning, treatment with anticoagulation is recommended in the absence of contraindications. The management of radiographically detected asymptomatic thrombosis in children is less clear. Clinical studies of prophylaxis for catheter-related thrombosis are inconclusive and no definitive recommendations for prophylaxis in adults or in children with central venous thrombosis can be made. Properly designed studies are needed to assess the role of prophylactic anticoagulation for preventing catheter-related thrombosis.
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Affiliation(s)
- Shoshana Revel-Vilk
- Pediatric Hematology/Oncology Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
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44
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Journeycake JM, Eshelman D, Buchanan GR. Post-thrombotic syndrome is uncommon in childhood cancer survivors. J Pediatr 2006; 148:275-7. [PMID: 16492443 DOI: 10.1016/j.jpeds.2005.09.033] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2005] [Revised: 08/24/2005] [Accepted: 09/28/2005] [Indexed: 11/18/2022]
Abstract
Deep vein thrombosis occurs in up to 50% of children with tunneled central venous catheters (CVCs). CVC-related deep vein thrombosis involving the upper extremity is usually asymptomatic but can result in post-thrombotic syndrome (swelling, pain, skin changes, and functional impairment). In a cohort of childhood cancer survivors evaluated clinically a mean of 7.5 +/- 2.8 years after completion of therapy who previously had CVCs in place for a median 15.5 months, none of 50 patients (95% CI = 0% to 6%) had these features diagnostic of post-thrombotic syndrome. Five patients had arm circumference 3% to 5% greater ipsilateral to the prior CVC.
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Affiliation(s)
- Janna M Journeycake
- Division of Hematology-Oncology, Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, Dallas, TX 75390-9063, USA.
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45
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Abstract
Malignancy is the most common cause of the superior vena cava (SVC) syndrome. With the increasing use of intravascular devices, the incidence of the SVC syndrome arising from benign etiologies is increasing. We reviewed the etiology and outcome of 78 patients with SVC syndrome over 5 years. Malignancy was the etiology in 60% of the cases, and bronchogenic carcinoma was the most common malignancy. Small cell and non-small cell lung cancer accounted for 17 (22%) and 19 (24%) cases, respectively, but a higher percentage of patients with small-cell lung cancer developed the syndrome (6% vs 1%). Lymphoma and germ cell tumors were other significant malignant causes (8% and 3% of cases, respectively). An intravascular device was the most common etiology in benign cases (22 of 31 cases; 71%), with fibrosing mediastinitis the second most common benign etiology (6 cases). The most frequent signs and symptoms were face or neck swelling (82%), upper extremity swelling (68%), dyspnea (66%), cough (50%), and dilated chest vein collaterals (38%). Dyspnea at rest, cough, and chest pain were more frequent in the patients with malignancy. Procedures performed for diagnostic or treatment purposes did not increase morbidity or mortality.
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Affiliation(s)
- Todd W Rice
- From the Division of Allergy, Pulmonary, and Critical Care Medicine (TWR, RMR, RWL), Vanderbilt University School of Medicine; and Division of Pulmonary and Critical Care (RMR, RWL), Saint Thomas Hospital, Nashville, Tennessee
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46
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Abstract
In some children with cystic fibrosis (CF), percutaneous long lines occlude sooner than expected (due to thrombophlebitis or thrombosis), and many have a totally implantable venous access device (TIVAD), a recognized complication of which is thrombosis. This complication is more likely if the child has an underlying thrombotic tendency, which may be enhanced in the presence of inflammatory lung disease. There are no reports of an identified association of heritable thrombophilia with CF, although individual cases have been recognized. Our aim was to determine the incidence of thrombophilia in children with CF. In a tertiary pediatric CF center, blood was screened for thrombophilia at annual review, and retested if abnormal. A thrombotic abnormality was found in 41/204 (20%) patients. These included activated protein C resistance (10/204, 5%) with a prevalence similar to that expected, but the following abnormalities had an increased prevalence: antithrombin deficiency (2/204, 1%), protein S deficiency (11/204, 5%), protein C deficiency (8/204, 4%), and lupus anticoagulant (18/204, 9%). There were no differences found in those with thrombophilia for the following parameters: age, gender, genotype, lung function, presence of Pseudomonas aeruginosa, prothrombin time, serum IgE, aspergillus-specific IgE, liver function, and blood inflammatory markers. Fifteen children had TIVADs, 4 of whom had evidence of thrombophilia. In conclusion, a significant proportion of patients had a thrombophilic abnormality. We recommend that thrombophilia screening be performed prior to insertion of a TIVAD, and also in those with a history of venous thrombosis, blocked TIVADs, or recurring problems with long lines.
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Affiliation(s)
- I M Balfour-Lynn
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
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47
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Barker M, Thoenes D, Döhmen H, Friedrichs F, Pfannenstiel C, Heimann G. Prevalence of thrombophilia and catheter-related thrombosis in cystic fibrosis. Pediatr Pulmonol 2005; 39:156-61. [PMID: 15633202 DOI: 10.1002/ppul.20158] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Venous thrombosis in children and young adults is frequently associated with predisposing conditions and with an indwelling catheter or totally implantable venous access device (TIVAD). These systems are commonly used for the delivery of antibiotic therapy in patients with cystic fibrosis (CF). We reviewed our CF center's history of catheter-related events over 13 years and prospectively investigated the presence of risk factors for thrombosis in 66 children and adults with CF (age, 3-38 years; 32 females). Five thrombotic events had occurred in 4 patients, 2 of whom carried the factor V Leiden mutation. Five asymptomatic patients were diagnosed with heterozygous mutations of the factor V or prothrombin gene. Functional activity of protein C was decreased in 13 subjects, with a correlation to impaired liver function. Protein S activity was abnormal in 20 patients and was related to CF genotype. Anti-phospholipid antibodies (APA) were present in 6 asymptomatic patients. A reinvestigation after 3 years confirmed protein S deficiency in 12 of 14 patients, while most abnormalities for protein C or APA were inconsistent. In conclusion, a thrombophilic state was detected in 53% of patients, and 2 out of 4 subjects with TIVAD-related thrombosis carried a genetic defect. It may thus be helpful to include a hemostatic evaluation in the clinical decision process for or against TIVAD insertion in eligible CF patients.
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Affiliation(s)
- Michael Barker
- Department of Pediatrics, University Hospital, University of Technology-Aachen, Aachen, Germany.
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48
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Campbell WB, Elworthy S, Peerlinck I, Vanslembroek K, Bangur R, Stableforth D, Sheldon CD. Sites of implantation for central venous access devices (ports): a study of the experiences and preferences of patients. Eur J Vasc Endovasc Surg 2004; 28:642-4. [PMID: 15531201 DOI: 10.1016/j.ejvs.2004.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2004] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To obtain information which might guide vascular specialists and their patients in the choice of site for implantation of central venous access devices (CVADs). DESIGN Questionnaire study. METHODS Questionnaires were sent to 69 patients with cystic fibrosis and 54 (78%) responded (39 females: age 5-63, median 24 years). They had received a total of 79 CVADs placed in the upper chest (60), lower chest (13), thigh (3) and arm (3). Only 46% patients had been offered a choice of site. RESULTS Questions about 14 specific areas of disability or concern found problems most frequently with discomfort (54%), wearing a seatbelt (51%), cosmetic appearance (44%), scarring (44%), choice of clothing (42%) and lying in bed or sleeping (42%). There were no significant differences between upper and lower chest CVADs. Patients with upper chest CVADs seldom had any problems with use of their arm (12%). 81% CVADs could not be accessed by the patients, and in 39% of these cases patients would have liked to do so. CONCLUSIONS Many patients complain of few problems with their CVADs, regardless of site, but half have some persistent discomfort. Cosmetic considerations frequently cause concern and patients should be given choice in the site of their CVADs.
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Affiliation(s)
- W B Campbell
- Royal Devon and Exeter Hospital, Wonford, Exeter EX2 5DW, UK.
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49
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Hengartner H, Berger C, Nadal D, Niggli FK, Grotzer MA. Port-A-Cath infections in children with cancer. Eur J Cancer 2004; 40:2452-8. [PMID: 15519519 DOI: 10.1016/j.ejca.2004.07.017] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2004] [Revised: 07/12/2004] [Accepted: 07/16/2004] [Indexed: 10/26/2022]
Abstract
Implanted subcutaneous (s.c.) central venous port accesses including Port-A-Cath (PAC) facilitate the administration of chemotherapy or blood products and are frequently used in children with cancer. The incidence of PAC-related infections was determined in 155 consecutive paediatric cancer patients with PAC followed for a total of 134,773 days (median, 738; range, 25-2080). Overall, 48 bloodstream infections occurred in 26 patients. 12 (25%) of these infections and 3 local infections at the insertion site were treatment-resistant and demanded removal of the PAC. Coagulase-negative staphylococci were involved in 12 of these 15 episodes. The rate of clearly PAC-related infections in this so far largest reported series was 0.11 episodes per 1000 PAC days, one of the lowest in the literature. Although catheter-related infections demanded PAC removal in 8% of our patients, the long periods PAC were in use and their benefits argue for continued PAC use in the paediatric cancer population.
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Affiliation(s)
- H Hengartner
- Division of Oncology, University Children's Hospital of Zurich, Steinwiesstrasse 75, Zurich 8032, Switzerland
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50
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Abstract
Central venous access devices (CVADs) can facilitate repeated and/or urgent administration of coagulation factors in haemophilic patients. We conducted a systematic review and meta-analysis of complication rates and risk factors for poor outcome. Forty-eight studies with a total of 2704 patients and 2973 CVADs were included. The primary indications for CVADs were immune tolerance therapy (34.9% of patients), difficult venous access (31.8%) and prophylaxis (29.1%). Fully implanted CVADs were employed in 77.4% of cases and external CVADs in 22.6%. A total of 1190 infections were reported, and the pooled incidence of infection was 0.66 per 1000 CVAD days [confidence interval (CI), 0.44-0.97 per 1000 CVAD days]. Among patients developing infection, the pooled time to first infection was 295 days (CI, 181-479 days). Presence of inhibitors was an independent risk factor for infection with an incidence rate ratio (IRR) of 1.67 (CI, 1.15-2.43). Infection was less likely in patients >6 years of age (IRR, 0.46; CI, 0.27-0.79) and recipients of fully implanted CVADs (IRR, 0.31; CI, 0.12-0.86). Available information on thrombosis was limited, with only 55 cases being reported. Eventually, 31.3% of CVADs were removed, and infection was the reason for removal in 69.9% of cases and thrombosis in 4.1%. The pooled time period CVADs remained indwelling prior to removal or the expiration of the study observation period was 578 days per CVAD (CI, 456-733 days per CVAD). CVADs can confer major benefits in patients with haemophilia requiring long-term venous access, and serious complications are rare.
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Affiliation(s)
- L A Valentino
- RUSH Hemophilia and Thrombophilia Center, RUSH University and RUSH Children's Hospital, Chicago, IL 60612-3833, USA.
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