The Impact of Central Venous Catheters on Pediatric Venous Thromboembolism

Venous Thromboembolism Prophylaxis in High-Risk Pediatric Trauma Patients

Importance

The indications, safety, and efficacy of chemical venous thromboembolism prophylaxis (cVTE) in pediatric trauma patients remain unclear. A set of high-risk criteria to guide cVTE use was recently recommended; however, these criteria have not been evaluated prospectively.

Objective

To examine high-risk criteria and cVTE use in a prospective multi-institutional study of pediatric trauma patients.

Design, Setting, and Participants

This cohort study was completed between October 2019 and October 2022 in 8 free-standing pediatric hospitals designated as American College of Surgeons level I pediatric trauma centers. Participants were pediatric trauma patients younger than 18 years who met defined high-risk criteria on admission. It was hypothesized that cVTE would be safe and reduce the incidence of VTE.

Exposures

Receipt and timing of chemical VTE prophylaxis.

Main Outcomes and Measures

The primary outcome was overall VTE rate stratified by receipt and timing of cVTE. The secondary outcome was safety of cVTE as measured by bleeding or other complications from anticoagulation.

Results

Among 460 high-risk pediatric trauma patients, the median (IQR) age was 14.5 years (10.4-16.2 years); 313 patients (68%) were male and 147 female (32%). The median (IQR) Injury Severity Score (ISS) was 23 (16-30), and median (IQR) number of high-risk factors was 3 (2-4). A total of 251 (54.5%) patients received cVTE; 62 (13.5%) received cVTE within 24 hours of admission. Patients who received cVTE after 24 hours had more high-risk factors and higher ISS. The most common reason for delayed cVTE was central nervous system bleed (120 patients; 30.2%). There were 28 VTE events among 25 patients (5.4%). VTE occurred in 1 of 62 patients (1.6%) receiving cVTE within 24 hours, 13 of 189 patients (6.9%) receiving cVTE after 24 hours, and 11 of 209 (5.3%) who had no cVTE (P = .31). Increasing time between admission and cVTE initiation was significantly associated with VTE (odds ratio, 1.01; 95% CI, 1.00-1.01; P = .01). No bleeding complications were observed while patients received cVTE.

Conclusions and Relevance

In this prospective study, use of cVTE based on a set of high-risk criteria was safe and did not lead to bleeding complications. Delay to initiation of cVTE was significantly associated with development of VTE. Quality improvement in pediatric VTE prevention may center on timing of prophylaxis and barriers to implementation.

Establishment and validation of a predictive nomogram for central venous catheter-related thrombosis in cancer patients: a retrospective nested case-control study

Background

Catheter-related thrombosis (CRT) is a common complication for patients who receive central venous catheter (CVC) placement. This study investigated the risk factors for CRT and developed a nomogram for CRT prediction among cancer patients.

Methods

This nested case-control study was conducted in the Third Affiliated Hospital of Kunming Medical University between January 2019 and February 2021. Univariable and multivariable logistic regression analyses were used to identify the risk factors for CRT. A nomogram was developed to predict CRT. Receiver operating curves (ROC), calibration curves, and decision curves were used to evaluate the performance of the nomogram in the training and validation sets.

Results

A total of 4,691 cancer patients were included in this study. Among them, 355 (7.57%) had CRT, and 70% of CRTs occurred in the first week of insertion. Among the 3,284 patients in the training set, the multivariable analysis showed that nine characteristics were independently associated with CRT, and a nomogram was constructed based on the multivariable analysis. The ROC analysis indicated good discrimination in the training set (area under the curve [AUC] = 0.832, 95% CI: 0.802-0.862) and the testing set (AUC = 0.827, 95% CI: 0.783-0.871) for the CRT nomogram. The calibration curves showed good calibration abilities, and the decision curves indicated the clinical usefulness of the prediction nomograms.

Conclusion

The validated nomogram accurately predicts CRT occurrence in cancer patients. This model may assist clinicians in developing treatment plans for each patient.

Complications of Pediatric Midline Catheters: A Prospective Observational Pilot Study

BACKGROUND

Midline catheters are peripheral intravenous (IV) catheters in which the tip of the catheter does not reach the central circulation. In children, the use of midline catheters could lead to decreased complications from central venous catheters. To validate the safety of midline catheter use in children, we aimed to describe the complications and dwell time of pediatric midline catheters. The primary outcome was the incidence of catheter-related venous thromboembolism (VTE).

METHODS

We conducted an observational, prospective study including consecutive patients at a tertiary multidisciplinary pediatric hospital. One hundred pediatric midline catheters were followed for thrombotic, infectious, and mechanical complications. After catheter removal, Doppler ultrasonography was performed to detect asymptomatic VTE.

RESULTS

The mean age was 6.0 years (standard deviation [SD], 4.7), and median catheter dwell time was 6 (4-8) days. Most midline catheters were inserted in arm veins, most commonly in the basilic vein (56%). Catheter-related VTE was diagnosed in 30 (30%; 95% confidence interval [CI], 21%-40%) cases, corresponding to an incidence rate of 39 (95% CI, 26-55) cases per 1000 catheter days. Eight of 14 saphenous vein catheters were complicated by VTE compared to 22 of 86 arm vein catheters, suggesting an imbalance in favor of arm vein insertion site. Two patients needed anticoagulation therapy due to catheter-related VTE. Thirty (30%) catheters were removed unintentionally or due to complications, 22 of these needed additional IV access to complete the intended therapy. No catheter-related bloodstream infection (95% CI, 0%-4%) occurred. Mechanical complications occurred in 33 (33%; 95% CI, 24%-43%) midline catheters.

CONCLUSIONS

In children, thrombotic and mechanical complications of midline catheters are common, but only few VTEs are severe enough to warrant anticoagulation therapy. Systemic infectious complications are rare. Seventy-eight percent of patients did not need additional venous access to complete short-term IV therapy. Considering the rate of clinically relevant complications and the catheter dwell time, pediatric midline catheters could be an alternative to central venous access for short-term (5-10 days) IV therapy.

Sonothrombolysis: State-of-the-Art and Potential Applications in Children

In recent years, advances in ultrasound therapeutics have been implemented into treatment algorithms for the adult population; however, the use of therapeutic ultrasound in the pediatric population still needs to be further elucidated. In order to better characterize the utilization and practicality of sonothrombolysis in the juvenile population, the authors conducted a literature review of current pediatric research in therapeutic ultrasound. The PubMed database was used to search for all clinical and preclinical studies detailing the use and applications of sonothrombolysis, with a focus on the pediatric population. As illustrated by various review articles, case studies, and original research, sonothrombolysis demonstrates efficacy and safety in clot dissolution in vitro and in animal studies, particularly when combined with microbubbles, with potential applications in conditions such as deep venous thrombosis, peripheral vascular disease, ischemic stroke, myocardial infarction, and pulmonary embolism. Although there is limited literature on the use of therapeutic ultrasound in children, mainly due to the lower prevalence of thrombotic events, sonothrombolysis shows potential as a noninvasive thrombolytic treatment. However, more pediatric sonothrombolysis research needs to be conducted to quantify the safety and ethical considerations specific to this vulnerable population.

A Case of Severe Neonatal Hypocalcemia Treated With Continuous Enteral Calcium

Background/Objective

Hypocalcemia is a common, treatable cause of neonatal seizures. The rapid repletion of calcium is essential for restoring normal calcium homeostasis and resolving seizure activity. The accepted approach to administer calcium to a hypocalcemic newborn is via peripheral or central intravenous (IV) access.

Case Report

We discuss a case of a 2-week-old infant who presented with hypocalcemia and status epilepticus. The etiology was determined to be neonatal hypoparathyroidism secondary to maternal hyperparathyroidism. Following an initial dose of IV calcium gluconate, the seizure activity abated. However, stable peripheral intravenous access could not be maintained. After weighing the risks and benefits of placing a central venous line for calcium replacement, it was decided to use continuous nasogastric calcium carbonate at a rate of 125 mg of elemental calcium/kg/d. Ionized calcium levels were used to guide the course of the therapy. The infant remained seizure-free and was discharged on day 5 on a treatment regimen that included elemental calcium carbonate, calcitriol, and cholecalciferol. He remained seizure free since discharge and all medications were discontinued by 8 weeks of age.

Discussion

Continuous enteral calcium is an effective alternate therapy for restoration of calcium homeostasis in a neonate presenting with hypocalcemic seizures in the intensive care unit (ICU).

Conclusion

We propose that continuous enteral calcium be considered as an alternative approach for calcium repletion in neonatal hypocalcemic seizures, one that avoids the potential complications of peripheral or central IV calcium administration.

Risk of venous thromboembolism in pediatric hospitalized patients undergoing noncardiac surgery: A report from the Children's Hospital-Acquired Thrombosis consortium

Background

Surgery is a known risk factor for hospital-acquired venous thromboembolism (HA-VTE) in children.

Objectives

To assess whether the odds of HA-VTE differs across six anatomic sites of noncardiac surgery and to identify risk factors for HA-VTE in these children.

Methods

This was a multicenter, case-control study. Anatomic sites of surgery and risk factors for HA-VTE were collected on hospitalized pediatric patients who had undergone a single noncardiac surgery and developed HA-VTE (cases), and those who did not develop HA-VTE (controls), via the Children's Hospital-Acquired Thrombosis (CHAT) Registry. Logistic regression estimated the odds ratio (OR) and 95% confidence intervals (CIs) between six anatomic sites of surgery and 16 putative HA-VTE risk factors. Variables with a p value of 0.10 or less in unadjusted analyses were included in adjusted models for further evaluation. The final model used backward selection, with a significance level of 0.05.

Results

From January 2012 to March 2020, 163 cases (median age, 5.7 years; interquartile range [IQR], 0.3-14.2) and 208 controls (median age of 7.5 years; IQR, 3.7-12.9) met our criteria. There was no statistically significant increased odds of VTE among the types of noncardiac surgery. In the final adjusted model, central venous catheter (CVC; OR, 14.69; 95% CI, 7.06-30.55), intensive care unit (ICU) stay (OR, 5.31; 95% CI, 2.53-11.16), and hospitalization in the month preceding surgery (OR, 2.75; 95% CI, 1.24-6.13) were each independently significant risk factors for HA-VTE.

Conclusion

In children undergoing noncardiac surgery, placement of CVCs, admission/transfer to the ICU, or hospitalization in the month prior to surgery were positively associated with HA-VTE.

Prophylactic Enoxaparin Against Catheter-Associated Thrombosis in Postoperative Cardiac Children: An Interrupted Time Series Analysis

OBJECTIVES

The effectiveness of pharmacologic prophylaxis against catheter-associated thrombosis in children is unclear. We evaluated the compliance and outcomes associated with a prophylactic enoxaparin protocol in postoperative cardiac children.

DESIGN

The protocol was implemented as a quality improvement initiative and then analyzed using interrupted time series method. Data collected from November 2014 to December 2018 were divided into preprotocol (period 1), protocol implementation (period 2), and protocol revision (period 3).

SETTING

A 12-bed academic pediatric cardiac ICU.

PATIENTS

Children less than or equal to 18 years old with congenital heart disease admitted postoperatively with central venous catheter in situ for greater than or equal to 1 day.

INTERVENTIONS

Before 2016, prophylactic enoxaparin was administered according to physician preference. In January 2016, an enoxaparin protocol was implemented with a goal anti-Xa range of 0.25-0.49 international units/mL. Protocol was revised in February 2017 to increase the starting dose by 25% for infants less than 1 year old.

MEASUREMENTS AND MAIN RESULTS

We analyzed 780 hospitalizations from 636 children. Median percentage of catheter-days on prophylactic enoxaparin was 33% (interquartile range [IQR], 23-47%), 42% (IQR, 30-51%), and 38% (IQR, 35-52%) in periods 1-3, respectively. Percentage of catheter-days on enoxaparin showed immediate increase of 90% (95% CI, 17-210%) between periods 1 and 2 and sustained increase of 2% (95% CI, 0.3-4%) between periods 2 and 3. Median rates of thrombosis per 1,000 catheter-days were 5.8 (IQR, 0-9.3), 3.8 (IQR, 0-12), and 0 (IQR, 0-5.3) in periods 1-3, respectively. Rate of thrombosis showed immediate decrease of 67% (95% CI, 12-87%) between periods 1 and 2 and sustained decrease of 11% (95% CI, 2-18%) between periods 1 and 3.

CONCLUSIONS

The temporal association between increase in percentage of catheter-days on enoxaparin and decrease in rate of thrombosis suggests the effectiveness of prophylactic enoxaparin.

Association of low serum albumin with venous thrombosis in pediatric patients

OBJECTIVES

The incidence of venous thromboembolism (VTE) in children is increasing, attributed in part to increased utilization of central venous catheters (CVCs). Children with protein losing disorders (PLDs) and low serum albumin may have an increased incidence of thrombosis. We sought to determine the prevalence of PLDs and hypoalbuminemia at the time of diagnosis of VTE in pediatric patients and its relationship to central venous catheters.

METHODS

We performed a single institution retrospective study of 65 consecutive hospitalized pediatric patients with an acute VTE. Data collected included clinical diagnoses, type of thrombosis, presence or absence of a CVC, and serum albumin level, if available.

RESULTS

Of 65 patients with acute VTE, 51 % (33/65) had catheter-related thrombosis (CRT), including 71 % (19/27) of patients <12 years of age and 37 % (14/38) of patients aged 12 to 23 (P = 0.008). Eleven VTEs occurred in patients with a diagnosis of a PLD; of these, ten (91 %) were CRT and one (9 %) was a non-CRT (P = 0.003). Serum albumin levels obtained within four days of diagnosis of VTE were available for 38 patients. An albumin level below the lower limit of the age-adjusted normal reference range was documented in 27/38 (71 %) patients with VTE compared to 1011/3028 (33 %) of all pediatric patients admitted to the hospital during a two-year period (P < 0.0001). Albumin levels were low in 19/22 (86 %) patients with CRT compared with 8/16 (50 %) patients with non-CRT (P = 0.019).

CONCLUSION

Low serum albumin levels are highly prevalent among pediatric patients with VTE, especially in those patients with CRT.

Management of Contraception in Adolescent Females With Hormone-Related Venous Thromboembolism

PURPOSE

Management of contraception in adolescent females with hormone-related venous thromboembolism (VTE) is challenging. We examined the characteristics of this patient population and outcomes, including recurrent VTE, heavy menstrual bleeding, and pregnancy.

METHODS

We performed a single-institution retrospective cohort study of adolescents with a new diagnosis of VTE and concurrent use of estrogen- and/or progestin-containing medication (N = 89). We collected data on additional risk factors for thrombosis, management of hormone therapy, and anticoagulation. We compared outcomes between patients with prescribed contraception within the year after their VTE diagnosis (n = 52) with those without (n = 37).

RESULTS

At least one additional risk factor for thrombosis was identified in 92% of patients, and 73% had two or more. The most common additional thrombosis risk factors were obesity (35%), family history (33%), and recent immobility (33%). Ninety-seven percent of patients were receiving combined hormonal medications, and 42% of patients had their medication stopped and not replaced with an alternative. Heavy menstrual bleeding was reported while on anticoagulation in 46% of patients with a documented menstrual history. Recurrent VTE occurred in 9.0% of patients. The group without prescribed contraception had a significantly higher rate of pregnancy in the two years after VTE diagnosis (18% vs. 1.9%, p = .04). Two pregnancies occurred while on warfarin.

DISCUSSION

Early assessment of contraceptive needs and menstrual bleeding symptoms are needed after diagnosis of hormone-related VTE in adolescent females. Access to contraceptive methods associated with low thrombosis risk is important for the prevention of unplanned pregnancy in this patient population.

Diagnostic challenges with central venous catheter studies

A central venous catheter is typically made of silicone rubber or polyurethane and inserted into a large central vein to provide prolonged and direct access to central venous circulation. These catheters provide a safe and effective method to administer intravenous medications, nutritional supplements, fluids and blood products. However, a myriad of complications is associated with central venous catheters, including, but not limited to, mechanical malfunction or fracture, kinking, erroneous placement, line infection, fibrin sheath formation and venous thrombosis. Following clinical and radiographic evaluation, contrast-enhanced line studies constitute the next best diagnostic tool to assess the functionality of central venous catheters. However, there is a lack of standardization in the literature outlining how these studies should be performed. In addition, the interpretation of these studies can be problematic for general pediatric radiologists, many of whom are often not familiar with placement or manipulation of these catheters. In this pictorial review, we highlight the challenges associated with performing and interpreting fluoroscopically guided contrast injection studies, using case studies drawn from a large tertiary children's hospital database for illustration. Revealing these challenges and understanding their causative mechanisms can improve the performance of these line studies.

Spectrum of Interventional Procedures During Hybrid Central Line Placement in Pediatric Intestinal Rehabilitation Patients With End-Stage Vascular Access

Background

Loss of available central vein access sites for parenteral nutrition delivery represents one of the main indications for intestinal transplantation in children with intestinal failure. Placement of central venous catheters can be challenging in advanced loss of patent venous pathways. We recently described the hybrid technique (interventional plus surgical approach) of central line placement in children. The aim of this study was to describe and analyze the interventions used during the hybrid procedures regarding feasibility, safety and outcome.

Methods

We retrospectively analyzed the course of all children in our intestinal rehabilitation program undergoing hybrid central line placement. We evaluated patients' conditions, interventional techniques and surgical peculiarities as well as outcome.

Results

203 children were treated in our intestinal rehabilitation program between 2010 and 2021. Due to loss of venous access, hybrid technique was performed in 53 children during 76 interventions. In 40 cases the same vessel was reused via Seldinger technique. Among the 30 ultrasound-guided new vessel punctures, 12 were performed by puncture of collateral vessels. Extended interventions due to thoracic central venous obstruction and/or thrombosis requiring additional access via a femoral vein for rehabilitation of the vascular system was performed during 29 procedures including catheter extraction (1), angioplasties (18), stent placement (1), revascularization (5) and thrombectomy (4). Placement of a central line was not possible in 6 children which eventually underwent extended thoracic/vascular surgery: in three children the previously placed catheter could not be removed, in one child, placement of a thrombectomy-catheter was not possible because of inferior vena cava occlusion, and in two children, revascularization failed. Intestinal transplantation was considered in one patient because of impending loss of vascular access. Two self-limiting minor extravasations and one intervention-associated pericardial effusion occurred.

Conclusions

Hybrid interventions for central venous catheter placement and vascular rehabilitation enable a high success rate in children with intestinal failure and end-stage vascular access, circumventing the need for intestinal transplantation or advanced surgery. The relevant procedures are complex and require a foresighted and individualized approach with a wide range of interventional techniques. If performed with expertise, this combined interventional/surgical approach is feasible and safe.

The risk of fatal bleeding complications in jugular catheterization in patients with coagulopathy: A retrospective analysis of death cases in closed claims and the Medical Accident Investigating System in Japan

Background

To prevent recurrence of medical accidents, the Medical Accident Investigating System was implemented in October 2015 by the Japan Medical Safety Research Organization (Medsafe Japan) to target deaths from medical care that were unforeseen by the administrator. Medsafe Japan analyzed the 10 cases of central venous catheterization-related deaths reported in the system and published recommendations in March 2017. However, the particular emphasis for the prevention of central venous catheterization-related deaths is unclear.

Methods

This study aimed to identify the recommendation points that should be emphasized to prevent recurrence of central venous catheterization-related deaths. We assessed central venous catheterization in 8530 closed-claim cases between January 2002 and December 2016 covered by the medical insurer Sompo-Japan. Moreover, we compared central venous catheterization-related death in closed-claim cases with death in reported cases.

Results

The background, error type, anatomic insertion site, and fatal complication data were evaluated for 37 closed-claim cases, of which 12 (32.4%) were death cases. Of the 12 closed-claim cases and 10 reported cases, 9 (75.0%) closed-claim cases and 9 (90.0%) reported cases were related to vascular access. Among these, 5 closed-claim cases (41.7%) and 7 reported cases (77.8%) were related to internal jugular vein catheterization (p = 0.28). Coagulopathy was observed in 3 (60.0%) of 5 closed-claim cases and 6 (85.7%) of 7 reported cases.

Conclusions

The risk of internal jugular catheterization in patients with coagulopathy must be carefully considered.

Thromboembolic Complications of Vascular Catheters Used for Pediatric Continuous Renal Replacement Therapy: Prevalence in a Single-Center, Retrospective Cohort

OBJECTIVES

Pediatric venous thromboembolic events are commonly associated with in situ central venous catheters. The risk for severe venous thromboembolism increases if a larger portion of the vessel lumen is occupied by the central venous catheter. A functioning vascular catheter is required when the continuous renal replacement therapy is used in critically ill children. Due to the high blood flow required for continuous renal replacement therapy, the external diameter of the catheter needs to be larger than a conventional central venous catheter used for venous access, potentially increasing the risk of venous thromboembolism. However, children on continuous renal replacement therapy often receive systemic anticoagulation to prevent filter clotting, possibly also preventing venous thromboembolism. The frequency of catheter-related venous thromboembolic events in this setting has not been described. Our main objective was to determine the prevalence of catheter-related venous thromboembolism in pediatric continuous renal replacement therapy.

DESIGN

Retrospective cohort study.

SETTING

Tertiary multidisciplinary academic pediatric hospital.

PATIENTS

Patients 0-18 years old with a vascular catheter used for continuous renal replacement therapy.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

In our series of 80 patients, we used 105 vascular catheters. The median age of the patients was 10 months and PICU mortality rate was 21%. Venous thromboembolic events were considered to be catheter related if located in the same vein as the vascular catheter and radiologically verified. Six (5.7%) catheter-related venous thromboembolic events were found. The clinically relevant complications of venous thromboembolism included superior vena cava syndrome and catheter dysfunction. In one patient, severe and life-threatening pulmonary embolism occurred. In comparison with patients without venous thromboembolism, venous thromboembolic events were associated with lower body weight (p = 0.03) and longer durations of continuous renal replacement therapy (p < 0.01), mechanical ventilation (p = 0.03), and PICU stay (p < 0.01). Five out of six venous thromboembolisms appeared in neonates.

CONCLUSIONS

Catheter-related venous thromboembolism is a clinically relevant complication of pediatric continuous renal replacement therapy, with a prevalence of 5.7% in our cohort. Clinicians involved in pediatric continuous renal replacement therapy need to be vigilant for symptoms of venous thromboembolisms and initiate appropriate treatment as soon as possible.

Atypical use of PICC as centrally inserted central catheter in infants and neonates: Report of a 10-year experience

PURPOSE

The aim was to determine the success, safety and post procedure complications of peripherally inserted central catheters as centrally inserted central catheters (CICC).

MATERIALS AND METHOD

One hundred and sixty-one consecutive infants and neonates, who underwent image guided tunnelled central venous catheter insertion were retrospectively evaluated between April 2008 and April 2018. Patient's demographics, site of access and procedure details were recorded. Outcomes included technical success and post procedure complications.

RESULTS

One hundred and eighty-two CICCs were inserted in 161 patients (49.7%, n = 80 male). Mean patient age was 100 days (range: 0-342) with a mean weight of 4.20 kg (range 1.80-9.40). The most common indication was for antibiotics administration (41%; n = 66). Technical success was 99% (181/182). Early complications (<7 days) were seen in 8.8% (n = 13). This included inadvertent line removal in 5.5%, catheter-related bloodstream infection in 1.1% and catheter occlusion in 2.2% (n = 4). Average line functional duration prior to removal was 26 days (range 0-180). 77.5% of the lines lasted for the intended duration of treatment. In the neonate subgroup, 84.1% (37/44 lines) of lines remained in situ for the intended duration of treatment.

CONCLUSION

Tunnelled central venous catheters using non-cuffed peripherally inserted central catheters in infants is a safe technique with excellent success rate and minimal complications rates.

Aligning Patient Safety and Stewardship: A Harm Reduction Strategy for Children

Purpose of review

Review important patient safety and stewardship concepts and use clinical examples to describe how they align to improve patient outcomes and reduce harm for children.

Recent findings

Current evidence indicates that healthcare overuse is substantial. Unnecessary care leads to avoidable adverse events, anxiety and distress, and financial toxicity. Increases in antimicrobial resistance, venous thromboembolism, radiation exposure, and healthcare costs are examples of patient harm associated with a lack of stewardship. Studies indicate that many tools can increase standardization of care, improve resource utilization, and enhance safety culture to better align safety and stewardship.

Summary

The principles of stewardship and parsimonious care can improve patient safety for children.

Rates of Venous Thromboembolism and Central Line-Associated Bloodstream Infections Among Types of Central Venous Access Devices in Critically Ill Children

OBJECTIVES

Central venous access devices, including peripherally inserted central catheters and central venous catheters, are often needed in critically ill patients, but also are associated with complications, including central-line associated bloodstream infections and venous thromboembolism. We compared different central venous access device types and these complications in the PICU.

DESIGN

Multicenter, cohort study.

SETTING

One hundred forty-eight participating Virtual PICU Systems, LLC, hospital PICU sites.

PATIENTS

Pediatric patients with central venous access placed from January 1, 2010, to December 31, 2015.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patient and central venous access device variables postulated to be associated with central-line associated bloodstream infection and venous thromboembolism were included. Data were analyzed using Pearson chi-square test or Fisher exact test for categorical variables, Mann-Whitney U test for continuous variables, and logistic regression and classification trees for multivariable analysis that examined significant predictors of venous thromboembolism or central-line associated bloodstream infection. Analysis included 74,196 first lines including 4,493 peripherally inserted central catheters and 66,194 central venous catheters. An increased rate of venous thromboembolism (peripherally inserted central catheter: 0.93%, central venous catheter: 0.52%; p = 0.001) (peripherally inserted central catheter: 8.65/1,000 line days, central venous catheter: 6.29/1,000 line days) and central-line associated bloodstream infection (peripherally inserted central catheter: 0.73%, central venous catheter: 0.24%; p = 0.001) (peripherally inserted central catheter: 10.82/1,000 line days, central venous catheter: 4.97/1,000 line days) occurred in peripherally inserted central catheters. In multivariable analysis, central venous catheters had decreased association with central-line associated bloodstream infection (odds ratio, 0.505; 95% CI, 0.336-0.759; p = 0.001) and venous thromboembolism (odds ratio, 0.569; 95% CI, 0.330-0.982; p = 0.043) compared with peripherally inserted central catheters.

CONCLUSIONS

Peripherally inserted central catheters are associated with higher rates of central-line associated bloodstream infection and venous thromboembolism than central venous catheters in children admitted to the PICU.

Accuracy of Bedside Ultrasound Femoral Vein Diameter Measurement by PICU Providers

OBJECTIVES

Perform a needs assessment by evaluating accuracy of PICU provider bedside ultrasound measurement of femoral vein diameter prior to utilization of the catheter-to-vein ratio for central venous catheter size selection.

DESIGN

Prospective observational cohort study.

SETTING

PICU within a quaternary care children's hospital.

PATIENTS

PICU patients greater than 30 days and less than 6 years without a femoral central venous catheter.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Gold-standard femoral vein diameter measurements were made by a radiologist, sonographer, or bedside ultrasound expert. PICU providers then repeated the femoral vein diameter measurements, and results were compared by Bland-Altman analysis with a priori accuracy goal of limits of agreement ± 15%. Among recruited patients (n = 27), the median age was 1.1 years (interquartile range 0.5-2.3 yr), weight was 9.0 kg (interquartile range 7.0-11.5 kg), and reference femoral vein diameter was 0.36 cm (interquartile range 0.28-0.45 cm). Providers performed 148 femoral vein diameter measurements and did not meet goal accuracy when compared with the reference measurement with a bias of 4% (95% of limits of agreement -62% to 70%). A majority of patients would have a catheter-to-vein ratio greater than 0.5 using either age-based central venous catheter size selection criterion (14/27) or the provider bedside ultrasound femoral vein diameter measurement (18/27).

CONCLUSIONS

PICU provider measurement of femoral vein diameter by bedside ultrasound is inaccurate when compared with expert reference measurement. Central venous catheter size selection based on age or PICU provider femoral vein diameter measurement can lead to a catheter-to-vein ratio greater than 0.5 and potentially increase the risk of catheter-associated venous thromboembolism. Structured bedside ultrasound training with assessment of accuracy is necessary prior to implementation of venous thromboembolism reduction efforts based on catheter-to-vein ratio recommendations.

Concordance of Identified Cases of Pediatric HA-VTE with American College of Physicians and Cincinnati Children's Hospital HA-VTE Prophylaxis Guidelines Over a 10-Year Period

Objective: Our aim is to (1) ascertain the proportion of pediatric patients at a tertiary hospital in Western Massachusetts over a 10-year period with hospital-acquired venous thromboembolism (VTE) of particular characteristics and (2) determine whether ACCP or Cincinnati Children’s guidelines would have recommended VTE prophylaxis in these patients. Setting: Urban teaching hospital in the United States. Participants: Data from 98 477 pediatric hospital admissions (roughly 10 000 admission per year) from 2008 to 2017 were reviewed. There were a total of 177 VTE cases identified. Outcome measures: Hospital-acquired venous thromboembolism (including deep venous thrombosis and pulmonary embolism). Result: 177 charts were extracted that carried the diagnosis of VTE based on ICD-9 and ICD-10 codes over a 10-year-period. Among these patients, 34 (19%) met the inclusion criteria for HA-VTE; 5 (16%) would qualify for prophylaxis according to ACCP and 7 (21%) according to Cincinnati Children’s guideline. The most common age group to have a VTE was infants under 1 year of age (41%), and the most common characteristic was the presence of a central line (82%). Age outside of the recommended range was the sole reason that excluded patients from prophylaxis qualification per Cincinnati Children’s. Conclusion: HA-VTE carries increased morbidity and mortality. Although recognition and prevention of HA-VTE in adult populations are routine, prophylaxis for pediatric HA-VTE is not commonly practiced. This may be due to paucity of strong evidence supporting prophylaxis and the challenge of identifying risk factors for HA-VTE. Our results suggest that published guidelines recommend prophylaxis in only a minority of pediatric patients who would have subsequently developed HA-VTE. Further modification and validation of current guidelines are needed to effectively prevent pediatric HA-VTE.

Risk Factors for Central Venous Access Device-Related Thrombosis in Hospitalized Children: A Systematic Review and Meta-Analysis

OBJECTIVE

 To identify the potential associations of patient-, treatment-, and central venous access device (CVAD)-related factors with the CVAD-related thrombosis (CRT) risk in hospitalized children.

METHODS

 A systematic search of PubMed, EMBASE, Web of Science, the Cochrane Library, China National Knowledge Infrastructure, Wanfang, and VIP database was conducted. RevMan 5.3 and Stata 12.0 statistical software were employed for data analysis.

RESULTS

 In terms of patient-related factors, the patient history of thrombosis (odds ratio [OR] = 3.88, 95% confidence interval [CI]: 2.57-5.85), gastrointestinal/liver disease (OR = 1.85, 95% CI: 0.99-3.46), hematologic disease (OR = 1.45, 95% CI: 1.06-1.99), and cancer (OR = 1.58, 95% CI: 1.01-2.48) were correlated with an increased risk of CRT. In terms of treatment-related factors, parenteral nutrition (PN)/total PN (OR = 1.70, 95% CI: 1.21-2.39), hemodialysis (OR = 2.17, 95% CI: 1.34-3.51), extracorporeal membrane oxygenation (OR = 1.51, 95% CI: 1.31-1.71), and cardiac catheterization (OR = 3.92, 95% CI: 1.06-14.44) were associated with an increased CRT risk, while antibiotics (OR = 0.46, 95% CI: 0.32-0.68) was associated with a reduced CRT risk. In terms of the CVAD-related factors, CRT risk was more significantly increased by peripherally inserted central catheter than tunneled lines (OR = 1.81, 95% CI: 1.15-2.85) or totally implantable venous access port (OR = 2.81, 95% CI: 1.41-5.60). And subclavian vein catheterization significantly contributed to a lower CRT risk than femoral vein catheterization (OR = 0.36, 95% CI: 0.14-0.88). Besides, multiple catheter lines (OR = 4.06, 95% CI: 3.01-5.47), multiple catheter lumens (OR = 3.71, 95% CI: 1.99-6.92), central line-associated bloodstream infection (OR = 2.66, 95% CI: 1.15-6.16), and catheter malfunction (OR = 1.65, 95% CI: 1.07-2.54) were associated with an increased CRT risk.

CONCLUSION

 The exact identification of the effect of risk factors can boost the development of risk assessment tools with stratifying risks.

Occurrence and Risk Factors for Unplanned Catheter Removal in a PICU: Central Venous Catheters Versus Peripherally Inserted Central Venous Catheters

OBJECTIVES

We aimed to identify the occurrence and risk factors for unplanned catheter removal due to catheter-associated complications and the effects on catheter survival probability in a PICU.

DESIGN

Retrospective, single-center, observational study of cases involving conventional central venous catheters or peripherally inserted central venous catheters.

SETTING

The PICU of a tertiary children's hospital.

PATIENTS

Consecutive PICU patients with central venous catheters between April 2016 and February 2019.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We identified unplanned catheter removals that were related to central line-associated bloodstream infection, thrombosis, and mechanical complications. During the study period, 582 central venous catheters and 474 peripherally inserted central venous catheters were identified. The median durations of catheter placement were 4.0 days for central venous catheters and 13.0 days for peripherally inserted central venous catheters (p < 0.001), and unplanned catheter removals due to catheter-associated complications were in 52 (8.9%) central venous catheter cases and 132 (27.8%) peripherally inserted central venous catheter cases (p < 0.001) (15.0 and 16.0 per 1,000 catheter-days, respectively [p = 0.75]). Unplanned catheter removal was associated with a peripheral catheter tip position among both central venous catheters and peripherally inserted central venous catheters (p < 0.001 and p = 0.001), and it was associated with surgical patient status among peripherally inserted central venous catheters (p = 0.009). In contrast, the use of ultrasound-guided insertion was associated with a lower occurrence of unplanned catheter removal among peripherally inserted central venous catheters (p = 0.01). With regard to catheter survival probability, there was no significant difference between central venous catheters and peripherally inserted central venous catheters (p = 0.23). However, peripherally inserted central venous catheters had a lower occurrence of central line-associated bloodstream infection than central venous catheters (p = 0.03), whereas there was no significant difference in the rates of thrombosis (p = 0.29) and mechanical complications (p = 0.84) between central venous catheters and peripherally inserted central venous catheters.

CONCLUSIONS

In a PICU, peripherally inserted central venous catheters had lower occurrence of central line-associated bloodstream infection than central venous catheters; however, similar catheter survival probabilities were observed between both catheters. A central catheter tip position for both catheters and ultrasound-guided insertion for peripherally inserted central venous catheters may help limit unplanned catheter removal due to catheter-associated complications.

Central Venous Catheter Utilization and Complications in the Pediatric Cardiac ICU: A Report From the Pediatric Cardiac Critical Care Consortium (PC4)

OBJECTIVES

Current central venous catheter utilization in patients within pediatric cardiac ICUs is not well elucidated. We aim to describe current use of central venous catheters in a multi-institutional cohort and to explore the prevalence and risk factors for central line-associated thrombosis and central line-associated bloodstream infections.

DESIGN

Observational analysis.

SETTING

Pediatric Cardiac Critical Care Consortium hospitals.

PATIENTS

Hospitalizations with at least one cardiac ICU admission from October 2013 to July 2016.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

There were 17,846 hospitalizations and 69% included greater than or equal to one central venous catheter. Central venous catheter use was higher in younger patients (86% neonates). Surgical hospitalizations included at least one central venous catheter 88% of the time compared with 35% of medical hospitalizations. The most common location for central venous catheters was internal jugular (46%). Central venous catheters were in situ a median of 4 days (interquartile range, 2-10). There were 248 hospitalizations (2% overall, 1.8% medical, and 2.1% surgical) with at least one central line-associated thrombosis (271 total thromboses). Thrombosis was diagnosed at a median of 7 days (interquartile range, 4-14) after catheter insertion. There were 127 hospitalizations (1% overall, 1.4% medical, and 1% surgical) with at least one central line-associated bloodstream infection (136 total infections) with no association with catheter type or location. Central line-associated bloodstream infection was diagnosed at a median of 19 days (interquartile range, 8-36) after catheter insertion. Significant risk factors for central line-associated thrombosis and central line-associated bloodstream infection were younger age, greater surgical complexity, and total catheter days.

CONCLUSIONS

Utilization of central venous catheters in pediatric cardiac ICUs differs according to indication for hospitalization. Although thrombosis and central line-associated bloodstream infection are infrequent complications of central venous catheter use in cardiac ICU patients, these events can have important short- and long-term consequences for patients. Total central venous catheter line days were the only modifiable risk factor identified. Future study must focus on understanding central venous catheter practices in high-risk patient subgroups that reduce the prevalence of thrombosis and central line-associated bloodstream infection.

Hospital Charges Associated with Central Venous Stenosis in Pediatric Patients Requiring Long-Term Central Venous Access

OBJECTIVE

To evaluate the hospital charges associated with central venous stenosis in pediatric patients requiring long-term central venous catheters, via associated charges and hospital length of stay (LOS).

STUDY DESIGN

This institutional review board-approved retrospective review identified pediatric patients with central venous catheters and either short bowel syndrome (SBS) or end-stage renal disease (ESRD) diagnosed between 2008 and 2015 using the Pediatric Health Information System. These 2 cohorts were selected because long-term central venous access is commonly required for survival. Prevalence of central venous stenosis, total number of admissions, procedures, LOS, and associated charges were recorded. Statistical analysis performed with Wilcoxon nonparametric and 2-sample t test with a significance of P < .05.

RESULTS

Of 4952 patients with SBS and 4665 patients with ESRD, 169 (3.4%) patients with SBS and 191 (4.1%) patients with ESRD were diagnosed with central venous stenosis (360 patients total [3.7%]). The cumulative median admissions and LOS was higher in patients with SBS with central venous stenosis (15 admissions and 156 days) vs those without central venous stenosis (5 admissions and 110 days) (P < .001). The cumulative median number of admissions and LOS was higher in patients with ESRD with central venous stenosis (13 admissions and 72 days) vs those without central venous stenosis (7 admissions and 42 days) (P < .001). The mean cumulative charges for patients with SBS with central venous stenosis were higher than for those without central venous stenosis ($1.89 million vs $1.11 million, respectively) (P < .001). Similarly, the mean cumulative charges for patients with ESRD with central venous stenosis were higher than for those without central venous stenosis ($1.17 millions vs $702 000, respectively) (P < .001).

CONCLUSIONS

Pediatric patients with central venous stenosis have significantly higher total charges, imaging charges, number of admissions, and longer LOS. Attention to mitigate the incidence of central venous stenosis in pediatric patients requiring long-term central venous access is warranted.

Prophylaxis for Pediatric Venous Thromboembolism: Current Status and Changes Across Pediatric Orthopaedic Society of North America From 2011

INTRODUCTION

Pediatric venous thromboembolism (VTE) is a concern for orthopaedic surgeons. We sought to query the Pediatric Orthopaedic Society of North America (POSNA) members on current VTE prophylaxis practice and compare those results with those of a previous survey (2011).

METHODS

A 35-question survey was emailed to all active and candidate POSNA members. The survey consisted of questions on personal and practice demographics; knowledge and implementation of various VTE prophylaxis protocols, mechanical and chemical VTE prophylaxis agents, and risk factors; and utilization of scenarios VTE prophylaxis agents for various clinical scenarios. One- and two-way frequency tables were constructed comparing results from the current survey and those of the 2011 survey.

RESULTS

Two hundred thirty-nine surveys were completed (18% respondent rate), with most respondents from an academic/university practice reporting one or two partners (>60%). Half were in practice ≥15 years, and >90% reported an almost exclusive pediatric practice. One-third of the respondents reported familiarity with their institution-defined VTE prophylaxis protocol, and 20% were aware of an institutionally driven age at which all patients receive VTE prophylaxis. The most frequently recognized risk factors to guide VTE prophylaxis were oral contraceptive use, positive family history, and obesity. Respondents indicated a similar frequency of use of a VTE prophylaxis agent (either mechanical or chemical) for spinal fusion, hip reconstruction, and trauma (60% to 65%), with lower frequency for neuromuscular surgery (34%) (P < 0.001). One hundred thirty-seven respondents had a patient sustain a deep vein thrombosis, and 66 had a patient sustain a pulmonary embolism. Compared with responses from 2011, only 20 more respondents reported familiarity with their institution VTE prophylaxis protocol (75 versus 55). In 2018, aspirin was used more frequently than in 2011 (52% versus 19%; P < 0.0001) and enoxaparin was used less frequently (20% versus 41%; P < 0.0001).

DISCUSSION

Over the past 7 years since the first POSNA survey on VTE prophylaxis, most POSNA members are still unaware of their institution specific VTE prophylaxis protocol. Most respondents agree that either mechanical or chemical VTE prophylaxis should be used for spinal fusion, hip reconstruction, and trauma. The use of aspirin as an agent of chemical VTE prophylaxis has increased since 2011.

LEVEL OF EVIDENCE

Level IV. Type of evidence: therapeutic.

Safety Checklist Implementation Did Not Reduce Central Venous Catheter Duration in Pediatric Cardiac ICU Patients

The Center for Disease Control recommends prompt removal of nonessential central venous catheters (CVCs) to reduce the risk for central line-associated bloodstream infections. Safety checklists have been trialed to reduce nonessential CVC days, but pediatric studies are lacking. Our specific aim was to detect >10% reduction in mean CVC duration after implementation of a safety checklist addressing CVCs in our unit.

Methods

All patients admitted to the Congenital Cardiovascular Care Unit at New York University Langone Medical Center who had a CVC placed between January 1, 2012, and December 31, 2017, were included. We implemented a checklist addressing CVC use in our unit on June 7, 2013, and modified it on March 10, 2016. We analyzed quarterly mean CVC duration and postsurgical CVC duration over the study period using statistical process control charts.

Results

We placed 778 CVCs for 7,947 CVC days during the study period. We noted special cause variation from Q4 2013 to Q2 2014 and a centerline shift in mean CVC duration from 8.91 to 11.10 days in Q1 2015. In a subgroup analysis of the 657 lines placed in surgical patients, there was a centerline shift in mean CVC duration from 6.48 to 8.86 days in Q4 2013.

Conclusions

Our study demonstrated an unexpected increase in mean CVC duration after the implementation of a safety checklist designed to decrease nonessential CVC days. Additional studies are needed to identify the ideal method to detect and remove nonessential CVCs and reduce the risk of preventable harm.

Symptomatic catheter-associated thrombosis in pediatric trauma patients: Choose your access wisely

BACKGROUND

Traumatic injury and the presence of a central venous catheter are 2 of the strongest risk factors for venous thromboembolism in children. The purpose of this study was to determine the incidence of symptomatic, catheter-associated thrombosis in critically injured children. We hypothesized that femoral venous catheters are associated with a greater rate of thrombotic complications when compared with all other central venous access points.

METHODS

We reviewed a retrospective cohort (2006-2016) of injured children (≤18 years) admitted to a pediatric intensive care unit with central access placed ≤7 days from admission. Symptomatic, catheter-associated thrombosis was determined by radiographic evidence. Poisson regression was used to compare the incidence of catheter-associated thrombosis per 1,000 catheter days between femoral and nonfemoral catheters. All comparisons were 2-tailed with α = 0.05.

RESULTS

We examined 209 pediatric trauma patients with central access (65% femoral, 19% subclavian, 11% arm vein, and 5% internal jugular). Femoral catheters were removed earlier (median [interquartile range] 4 [2-7] vs 8 [3-12] days, P < .001) and were larger in diameter (5 Fr [4-7] vs 4 Fr [4-4], P < .001) when compared with all other catheters. Catheter-associated thrombosis was more frequent in femoral versus nonfemoral catheters (18.4 vs 3.5 per 1,000 catheter days, P = .01).

CONCLUSION

Femoral venous catheters are associated with a greater incidence of symptomatic, catheter-associated thrombosis in pediatric trauma patients. When central venous access is indicated for injured children, the femoral site should be avoided. If a femoral venous catheter is necessary, use of a smaller catheter should be considered.

Promising biomarkers for the prediction of catheter-related venous thromboembolism in hospitalized children: An exploratory study

BACKGROUND

Pediatric venous thromboembolism (VTE) has increased over the past 10 years, with central venous catheters (CVC) being the strongest risk factor. Current tools are not sufficient to predict VTE risk. The utility of biomarkers in predicting CVC-related VTE has been minimally explored. Our objective is to determine the utility of microparticles (MPs), factor VIII (FVIII) activity, and thrombin generation (TG) in prospectively predicting VTE occurrence in hospitalized children with CVCs.

PROCEDURE

In this nested case-control pilot study, consecutive hospitalized children needing CVC placement (1 month to 21 years) were enrolled. Venous samples were collected prior to or within 24 h of CVC placement. MPs were measured using factor Xa initiated clot-based assay. FVIII was measured using a one-stage clot-based assay. TG was measured using calibrated automated thrombogram.

RESULTS

There were three CVC-related VTE events (7%) in our cohort of 42 subjects. Xa clotting time (XaCT) ratio was lower (0.68 ± 0.07 vs 0.95 ± 0.21, P = .4), while FVIII (461 ± 120 vs 267 ± 130, P = .02), peak thrombin (418 ± 89 vs 211 ± 101, P = .001), endogenous thrombin potential (ETP) (1828 ± 485 vs 1282 ± 394, P = .03), and velocity index (VI) (182 ± 28 vs 75 ± 53, P = .001) were higher in subjects with CVC-related VTE compared to those without CVC-related VTE. Sensitivity/specificity analysis revealed optimal cutoff values for XaCT ratio (0.75), FVIII (370), ETP (1680), peak (315), and VI (130), with receiver operating characteristic area under the curve values >0.9.

CONCLUSION

MPs, FVIII, and TG can potentially predict pediatric CVC-related VTE in a prospective fashion. Stratification according to VTE risk may aid in guiding preventative efforts in future studies.

Central Venous Line Associated Deep Vein Thrombosis in Hospitalized Children

An increase in the incidence of deep vein thrombosis (DVT) has been reported in pediatric patients over the past decade. The presence of central venous line (CVL) is a major contributing risk factor with conflicting data on the relative risk of DVT with various types of central lines. We aimed to assess the incidence of and identify potential risk factors for DVT overall and with different types of CVL individually. A retrospective chart review of pediatric patients with a CVL placed at Cleveland Clinic Children's from 2011 to 2016 was conducted. Data collected included demographics, potential risk factors, CVL characteristics and related thrombotic events. The study cohort consisted of 376 CVLs in 325 patients between 0 and 26 years of age. There were 1.6 thrombi per 10,000 line-days (95% confidence interval: 1.0, 2.5), and the overall incidence of DVT was 5.1%. The incidence of DVT was highest with tunneled catheters (5/16=31%) versus with peripherally inserted central catheters (4/111=3.6%) or with ports (10/249=4%, P<0.001), and whereas there were overarching significant risk factors for CVL-associated thrombi, these risk factors differed in significance when analyzed by the CVL type. The study supports the need for continued improvement in pediatric hospital practices for early identification of patients at a higher thrombosis risk.

Increased Use of Noninvasive Ventilation Associated With Decreased Use of Invasive Devices in Children With Bronchiolitis

To assess how a change in practice to more frequent use of high-flow nasal cannula for the treatment of bronchiolitis would affect the use of invasive devices in children.

Central Venous Catheter-Related Deep Vein Thrombosis in the Pediatric Cardiac Intensive Care Unit

BACKGROUND

Central venous catheter (CVC) use is common in the management of critically ill children, especially those with congenital heart disease. CVCs are known to augment the risk of deep vein thrombosis (DVT), but data on CVC-associated DVTs in the pediatric cardiac intensive care unit (CICU) are limited. In this study, we aim to identify the incidence of and risk factors for CVC-related DVT in this high-risk population, as its complications are highly morbid.

MATERIALS AND METHODS

The PC4 database and a radiologic imaging database were retrospectively reviewed for the demographics and outcomes of patients admitted to the Texas Children's Hospital CICU requiring CVC placement, as well as the incidence of DVT and its complications.

RESULTS

Between January 2017 and December 2017, 1215 central lines were placed over 851 admissions. DVT was diagnosed in 8% of admissions with a CVC, 29% of which demonstrated thrombus in the inferior vena cava. The risk factors significantly associated with DVT included the presence of >1 line, higher total line hours, longer intubation times, and extended CICU stay. A diagnosis of low cardiac output syndrome, sepsis, central line-associated bloodstream infection, and cardiac catheterization were also significant risk factors. Interestingly, cardiac surgery with cardiopulmonary bypass appeared to be protective of clot development. DVT was a highly significant risk factor for mortality in these patients.

CONCLUSIONS

CVC-related DVTs in critically ill children with congenital heart disease are associated with higher risks of morbidity and mortality, highlighting the need for well-designed studies to determine the best preventative and treatment strategies and to establish guidelines for appropriate monitoring and follow-up of these patients.

Evidence-Based Strategies and Recommendations for Preservation of Central Venous Access in Children

Children with chronic illness often require prolonged or repeated venous access. They remain at high risk for venous catheter-related complications (high-risk patients), which largely derive from elective decisions during catheter insertion and continuing care. These complications result in progressive loss of the venous capital (patent and compliant venous pathways) necessary for delivery of life-preserving therapies. A nonstandardized, episodic, isolated approach to venous care in these high-need, high-cost patients is too often the norm, imposing a disproportionate burden on affected persons and escalating costs. This state-of-the-art review identifies known failure points in the current systems of venous care, details the elements of an individualized plan of care, and emphasizes a patient-centered, multidisciplinary, collaborative, and evidence-based approach to care in these vulnerable populations. These guidelines are intended to enable every practitioner in every practice to deliver better care and better outcomes to these patients through awareness of critical issues, anticipatory attention to meaningful components of care, and appropriate consultation or referral when necessary.

Increasing rate of pulmonary embolism diagnosed in hospitalized children in the United States from 2001 to 2014

Although rare in children, pulmonary embolism (PE) can cause significant morbidity and mortality. Overall rates of venous thromboembolism (VTE) are increasing in hospitalized children. By using the Pediatric Health Information System database, we evaluated incidence, treatment, and outcome of PE in children younger than age 18 years from 2001 to 2014. Demographic characteristics for those admitted with VTE alone and those admitted with PE were compared. Rates of PE by year were compared with the number of hospital and VTE admissions. Trends in medication use were analyzed. Over the period of the study, patients with PE made up 15.8% of VTE discharges. The overall rate of PE increased 200% (P < .001). Compared with all other age groups, adolescents (age 13-18 years) had the highest prevalence (55%; P < .001), the rate of which increased from 9.8 to 24.7 per 10 000 hospital discharges (152%; P < .001), and from 17.5 to 34.1 per 100 VTE discharges (95%; P < .001). Individuals with PE had a higher mortality (8.3% vs 6%; P < .001) and were less likely to have a complex chronic condition (58% vs 65%; P < .001) than those with VTE alone. However, PE mortality rates decreased over the time period studied. African American and Hispanic patients were more likely to experience recurrent PE than white patients (12% and 10.7% vs 8%; P = .002). During the study period, the use of unfractionated heparin decreased (P < .001), and the use of low molecular weight heparin increased (P < .001). Further research is required to determine what factors contribute to the higher rate of PE in adolescents and influence recurrence in African American and Hispanic patients.

Clinical Impact of Chronic Venous Changes Induced by Central Lines in Children: A Cohort with Abnormal Venograms

PURPOSE

To explore the hypothesis that central venous stenosis/obstructions (CVS/O) in children are influenced by prior central venous access devices (CVADs) and are associated with future risk for thromboses.

MATERIAL AND METHODS

A convenience sample of 100 patients with abnormal venography (stenosis, collaterals, occlusions) documented during peripherally inserted central catheter (PICC) placements were identified from consecutive PICC placements (January 2008 to November 2012). The patients (41 males, 59 females, median age 2.7 years, median weight 11 kg) were categorized based on venographic presence (Group A, n = 53) or absence (Group B, n = 47) of visible connection to the superior vena cava. Each patient's CVAD history, before and after venography, was analyzed (until October 2016).

RESULTS

Before venogram, Group B patients were associated with a higher number of previous CVADs, larger diameter devices, greater incidence of malposition, and more use of polyurethane catheters than Group A patients (P < .001). An ipsilateral PICC was successfully placed in 98% of Group A, compared to 32% of Group B (P < .001). After venogram, significantly more Doppler ultrasounds (DUS) were performed and thromboses diagnosed in Group B (57% and 36%) compared to Group A (21% and 8%) (P < .003; P = .001), respectively.

CONCLUSIONS

Previous catheter characteristics influenced the severity of venographic changes of CVS/O (Group B). Group B was associated with more subsequent symptomatic thromboses. This information may assist parents and referring physicians to anticipate potential adverse sequelae from CVS/O on the child's venous health.

Effect of impregnated central venous catheters on thrombosis in paediatric intensive care: Post-hoc analyses of the CATCH trial

Purpose

The CATheter infections in CHildren (CATCH) trial reported reduced risks of bloodstream infection with antibiotic impregnated compared with heparin-bonded or standard central venous catheters (CVC) in paediatric intensive care. CVC impregnation did not increase the risk of thrombosis which was recorded in 24% of participants. This post-hoc analysis determines the effect of CVC impregnation on the risk of thrombosis leading to CVC removal or swollen limb.

Methods

We analysed patients in the CATCH trial, blind to CVC allocation, to define clinically relevant thrombosis based on the clinical sign most frequently recorded in patients where the CVC was removed because of concerns regarding thrombosis. In post-hoc, three-way comparisons of antibiotic, heparin and standard CVCs, we determined the effect of CVC type on time to clinically relevant thrombosis, using Cox proportional hazards regression.

Results

Of 1409 participants with a successful CVC insertion, the sign most frequently resulting in CVC removal was swollen limb (37.6%; 41/109), with lower rates of removal of CVC following 2 episodes of difficulty withdrawing blood or of flushing to unblock the CVC. In intention to treat analyses (n = 1485), clinically relevant thrombosis, defined by 1 or more record of swollen limb or CVC removal due to concerns about thrombosis, was recorded in 11.9% (58/486) of antibiotic CVCs, 12.1% (60/497) of heparin CVCs, and 10.2% (51/502) of standard CVCs. We found no differences in time to clinically relevant thrombosis according to type of CVC.

Conclusions

We found no evidence for an increased risk of clinically relevant thrombosis in antibiotic impregnated compared to heparin-bonded or standard CVCs in children receiving intensive care.

Development and Implementation of a Bedside Peripherally Inserted Central Catheter Service in a PICU

OBJECTIVES

To create a bedside peripherally inserted central catheter service to increase placement of bedside peripherally inserted central catheter in PICU patients.

DESIGN

Two-phase observational, pre-post design.

SETTING

Single-center quaternary noncardiac PICU.

PATIENTS

All patients admitted to the PICU.

INTERVENTIONS

From June 1, 2015, to May 31, 2017, a bedside peripherally inserted central catheter service team was created (phase I) and expanded (phase II) as part of a quality improvement initiative. A multidisciplinary team developed a PICU peripherally inserted central catheter evaluation tool to identify amenable patients and to suggest location and provider for procedure performance. Outcome, process, and balancing metrics were evaluated.

MEASUREMENTS AND MAIN RESULTS

Bedside peripherally inserted central catheter service placed 130 of 493 peripherally inserted central catheter (26%) resulting in 2,447 hospital central catheter days. A shift in bedside peripherally inserted central catheter centerline proportion occurred during both phases. Median time from order to catheter placement was reduced for peripherally inserted central catheters placed by bedside peripherally inserted central catheter service compared with placement in interventional radiology (6 hr [interquartile range, 2-23 hr] vs 34 hr [interquartile range, 19-61 hr]; p < 0.001). Successful access was achieved by bedside peripherally inserted central catheter service providers in 96% of patients with central tip position in 97%. Bedside peripherally inserted central catheter service central line-associated bloodstream infection and venous thromboembolism rates were similar to rates for peripherally inserted central catheters placed in interventional radiology (all central line-associated bloodstream infection, 1.23 vs 2.18; p = 0.37 and venous thromboembolism, 1.63 vs 1.57; p = 0.91). Peripherally inserted central catheters in PICU patients had reduced in-hospital venous thromboembolism rate compared with PICU temporary catheter in PICU rate (1.59 vs 5.36; p < 0.001).

CONCLUSIONS

Bedside peripherally inserted central catheter service implementation increased bedside peripherally inserted central catheter placement and employed a patient-centered and timely process. Balancing metrics including central line-associated bloodstream infection and venous thromboembolism rates were not significantly different between peripherally inserted central catheters placed by bedside peripherally inserted central catheter service and those placed in interventional radiology.

Analysis of Patient Characteristics and Risk Factors for Thrombosis After Surgery for Congenital Heart Disease

OBJECTIVES

Thrombosis is a cause of morbidity in 4-15% of children who undergo pediatric cardiac surgery. Data on how to prevent this complication are sorely needed. We aimed to identify risk factors for thrombosis following pediatric cardiac surgery and determine if use of low molecular weight heparin prophylaxis is associated with a reduction in thrombosis risk.

DESIGN

Retrospective cohort study.

SETTING

Tertiary pediatric cardiovascular ICU.

PATIENTS

Patients who underwent cardiac surgery between June 2014 and December 2015.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data from patients with venous or arterial thrombosis confirmed by radiologic studies were matched two-to-one to controls based on age, Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery mortality category, and gender. Thrombosis was detected in 33 patients (6.2%): 25 patients (76%) had venous thromboses, five patients (15%) had arterial thromboses, and three patients (9%) had both. Median time to thrombosis detection was 13 days (25-75%; 7-31 d). On multivariate analysis, which included adjustment for postoperative disease severity, fresh frozen plasma exposure was independently associated with thrombosis (odds ratio, 3.7; 95% CI, 1.4-9.4). Twenty-eight patients (85%) had central venous catheter-related thromboses. Low molecular weight heparin prophylaxis use in this subset of patients was not statistically different from controls (50% vs 45%, respectively; p = 0.47). On multivariable analysis, fresh frozen plasma exposure was also independently associated with central venous catheter-related thrombosis (odds ratio, 3.6; 95% CI, 1.2-10.6).

CONCLUSIONS

The occurrence of thrombosis after pediatric cardiac surgery at our institution was 6.2%, similar to what has been reported in other studies, despite frequent use of low molecular weight heparin. Further study is needed to determine the role of low molecular weight heparin for thromboprophylaxis and the relationship between fresh frozen plasma and thrombosis risk in children who undergo cardiac surgery.

Pediatric issues in thrombosis and hemostasis: The how and why of venous thromboembolism risk stratification in hospitalized children

Multiple observational studies have identified risk factors for venous thromboembolism (VTE) in hospitalized children, but very few interventional studies have assessed the safety and efficacy of thromboprophylaxis in this population. In recent years, however, evidence in pediatric VTE risk stratification has grown considerably. This has led to the conception of a pediatric subpopulation-specific risk-based paradigm for mechanical and pharmacological thromboprophylaxis in hospitalized children. More research is required to validate and further refine pediatric subpopulation-specific risk models and to subsequently investigate risk-stratified thromboprophylaxis strategies for hospitalized children.