Complications of central venous access in children

Abstract

Central venous access has become a frequent requirement in the management of seriously ill or injured infants and children with a wide variety of conditions. This report evaluates the complications observed with the use of central venous catheters in 1,378 cases. Central venous catheters (n = 2,281) were placed in 1,378 children (728 boys:650 girls). There were 1,012 temporary catheters (noncuffed/percutaneously placed) while 1,268 were inserted operatively, including 37 portacaths and 1,231 with dacron cuffs (Hickman, Broviac) for long-term use. A single catheter was inserted in 542 cases and multiple catheters in 836. Indications for catheter insertion included emergency resuscitation or access (501), malignancy (462), and intestinal dysfunction (415). Catheter infection occurred in 430 cases (18.8%). Of 219 infected temporary access catheters, 123 were removed while 96 were changed over a guide wire. Of 211 infected permanent catheters, 18 were immediately removed while 193 were treated with i.v. (vancomycin, gentamicin) antibiotics. Forty-seven of 193 (24%) catheters were eventually removed because of persistent or recurrent infection (16 cases) or subsequent fungal sepsis due to Candida albicans (31 cases). Only 3 of 37 portacaths were removed because of infection. Bacterial isolates were single in 125 cases and multiple in 86. Organisms included Staphylococcus epidermidis in 104 cases, Staph. aureus in 65, Klebsiella pneumoniae in 51, Escherichia coli in 51, and others in 18. Catheter complications occurred in 107 (5%) cases, including symptomatic vessel thrombosis in 49, pneumothorax in 26, catheter migration in 25, vessel injury in 5, and catheter embolus in 2. Despite the relatively high complication rate there were no catheter-related deaths. Multiple-lumen catheters had twice the complication rate and infection rate of single lumen catheters (P < 0.05). Temporary percutaneous catheters had a complication/infection rate 1.5 times greater than permanent catheters (P < 0.05) that were operatively placed. Bacterial infection cleared with antibiotics in 76% of cases with catheter sepsis, however secondary fungal infection necessitated prompt catheter removal. These data indicate that percutaneously placed catheters and multilumen catheters are associated with significantly higher complication and infection rates. Surgeons should balance the risks of convenience vs. complications in their choice of catheters and methods of insertion.