Commentary

Abstract

The previous two articles emphasize the very important risks associated with placement of central venous catheters in neonates and young infants. In the report by Lambert and associates, placement of a Broviac catheter in the superior vena cava in a premature infant resulted in thromboembolism into the pulmonary artery tree. This necessitated a thromboendarterectomy procedure when the child was 6 months old. In the report by Petäjä and colleagues, the authors studied the effect of routine transfusion of antithrombin III concentrate when the measured level in neonates in the early postoperative period was less than 50% of the adult mean. The authors have calculated that the cost of this protocol in Finland is $8000 in US currency per avoided case of central venous thrombosis. In their previous report in the Journal (1996;112:883-9; Central Venous Thrombosis After Cardiac Operations in Children), the authors commented that in the 20 neonates and young infants whom they identified as having had a central venous thrombosis, “anatomic correlation between catheter and thrombus location is evident; 10 patients had thrombosis at the site of the catheter tip and/or along the catheter route. Even in the rest of the patients the catheter and thrombi were close enough to each other to make a triggering effect of the catheter highly likely.” My own observations regarding central venous thrombosis in neonates and young infants have been identical to those of the authors, namely, that this phenomenon is almost always secondary to placement of either an internal jugular or subclavian line. My response to this observation, however, has been different from that of the authors. My colleagues and I now simply avoid placement of such lines other than in very unusual circumstances. A neonate or young infant is unlikely to be undergoing reoperative surgery, so that major hemorrhage and therefore need for massive transfusion before the heart is fully exposed should essentially never occur. At the end of the procedure, we place a right atrial line through the right atrial appendage, bringing the line out through the chest wall to allow central access and monitoring of right atrial pressure. This is a routine that we have practiced for many years. A previous report has confirmed the minimal risk of these catheters, which can be readily maintained for access and monitoring for between 1 and 2 weeks before the risk of sepsis becomes unacceptable.1Gold JP Jonas RA Lang P Elixson EM Mayer JE Castaneda AR Transcutaneous intracardiac monitoring lines in pediatric surgical patients: a 10 year experience.Ann Thorac Surg. 1986; 42: 185-191Abstract Full Text PDF PubMed Scopus (64) Google Scholar If a central line must be placed at that time, careful attention must be paid to using as narrow gauge a catheter as is reasonable for the purpose of the catheter and for the size of the child, as well as appropriate heparinization of the fluids being infused through the line. Perhaps antithrombin III monitoring described by Petäjä and colleagues would also be cost-effective in such patients. In conclusion, I believe very strongly that there is no place for routine placement of internal jugular and subclavian lines in neonates and young infants undergoing cardiac surgery. This philosophy, without question, results in a very much lower incidence of the very debilitating complication of central venous thrombosis in the neonate and young infant.