Access In Pediatric Patients Research Articles

Challenges of long-term vascular access in pediatric hemodialysis: Recommendations for practitioners.

Kidney transplantation is the preferred treatment of end-stage renal disease in children. However, time to transplant varies, making a well-functioning long-term vascular access essential for performing hemodialysis efficiently and without disruption until a kidney becomes available. However, establishing long-term vascular access in pediatric patients can present distinct challenges due to this population's unique characteristics, such as smaller body size and lower-diameter blood vessels. There are three main pediatric long-term vascular access options, which include central venous catheters (CVC), arteriovenous fistula (AVF), and arteriovenous graft (AVG). CVC are currently the most widely used modality, although various studies and guidelines recommend AVF or AVG as the preferred option. Although AVF should be used whenever possible, it is crucial that clinicians consider factors such as patient size, physical exam findings, comorbidities, predicted duration of treatment to decide on the most optimal long-term vascular access modality. This article reviews the three long-term vascular access methods in children and the benefits and complications of each.

Transradial approach for pediatric interventions: A review and analysis of the literature.

Transradial access for interventions has been well studied in the adult population, but there is a paucity of literature of its use in the pediatric population. We conducted a systematic literature review and gathered and synthesized all of the available data into a cohesive resource for review and analysis of the topic. Pooled analysis of the available data shows that transradial access in pediatric patients has a success rate of 91%, a vasospasm rate of 11.4%, and loss of pulse rate of 3.0% for a total complication rate of 14%. No permanent complications, or complications requiring surgery, were observed in any study. After stratifying for indication of intervention, neurological indications were associated with a lower complication rate compared to cardiac indications (0.1 vs 0.43, respectively, p = 0.004). In addition, studies published after 2013 were associated with a lower complication rate compared to those published during or before 2013 (0.11 vs 0.33, respectively, p = 0.01). Compared to prior studies on pediatric transfemoral access, transradial access has a higher complication rate. But there may be a lower rate of complications that require surgical intervention. Further studies are needed to clarify any advantages that transradial access may have over transfemoral access for pediatric patients.

Safety of tunneled central venous catheters in pediatric hematopoietic stem cell recipients with severe primary immunodeficiency diseases.

Tunneled central venous catheters (TCVCs) provide prolonged intravenous access for pediatric patients with severe primary immunodeficiency disease (PID) undergoing hematopoietic stem cell transplantation (HSCT). However, little is known about the epidemiology and clinical significance of TCVC-related morbidity in this particular patient group. We conducted the retrospective analysis of patients with severe PID who received percutaneous landmark-guided TCVC implantation prior to HSCT. We analyzed 92 consecutive TCVC implantations in 69 patients (median [interquartile range] age 3.0 [0-11] years) with severe combined immune deficiency (n = 39, 42.4%), chronic granulomatous disease (n = 17, 18.4%), and other rare PID syndromes (n = 36, 39.2%). The median length of TCVC observation was 144.1 (85.5-194.6) days with a total of 14,040 catheter days at risk (cdr). The overall rate of adverse events during catheter insertion was 17.4% (n = 16) and 25.0% during catheter dwell period (n = 23, catheter risk [CR] per 1000 cdr = 1.64). The most common complication was TCVC-related infection with an overall prevalence of 9.8% (n = 9, CR = 0.64), followed by late dislocation (n = 6, 6.5%, CR = 0.43), early dislocation (n = 4, 4.3%) and catheter dysfunction (n = 4, 4.3%, CR = 0.28). TCVCs are safe in children with severe PID undergoing HSCT with relatively low rates of TCVC-related infection.

Feasibility and safety of transradial access for pediatric neurointerventions

BackgroundDiagnostic cerebral angiograms are increasingly being performed by transradial access (TRA) in adults, following data from the coronary literature supporting fewer access-site complications. Despite this ongoing trend in neuroangiography, there...

Pediatric Prehospital Intraosseous Access During Combat Operations in Iraq and Afghanistan.

Vascular access in critically ill pediatric patients can be challenging with delays potentially leading to worse outcomes. Intraosseous (IO) access has a low rate of complications and can be utilized to administer lifesaving medications. Combat medics are trained to treat adults but may also be required to treat children in the deployed setting. Vascular access in children can be challenging, especially in a hypovolemic state. There are limited data on prehospital lifesaving interventions in children in the combat setting. We sought to characterize the use of IO access in pediatric patients who sustained trauma in the combat setting. We queried the Department of Defense Trauma Registry for all pediatric patients admitted to fixed-facilities and forward surgical teams in Iraq and Afghanistan from January 2007 to January 2016. Within that population, we searched for all subjects with a documented prehospital IO or intravenous (IV) access obtained. Subjects with both an IO and IV documented were placed into the IO category. We separated subjects by age groupings: younger than 1, 1 to 4, 5 to 9, 10 to 14, and 15 to 17 years. During the study period, there were 3439 subjects 17 years or younger. There were 177 in the IO cohort and 803 in the IV cohort. Most subjects in the IO cohort were in the 10- to 14-year-old age group (35.6%), male (79.1%), located in Afghanistan (95.5%), and injured by explosive (52.0%), with lower survival rates than the IV cohort (68.9% vs 90.7%, P < 0.001). Hemostatic dressing application, tourniquet application, intubation, cardiopulmonary resuscitation, sedative administration, ketamine administration, and paralytic administration were all higher in the IO cohort. Pediatric IO placement in the prehospital setting occurred infrequently. Pediatric subjects receiving an IO had higher injury severity scores and higher mortality rates compared with those who received an IV only. Intraosseous use appears to be used more often in critically ill pediatric subjects.

Current Management of Difficult Central Venous Access in Pediatric Patients

The central venous catheter (CVC) has become an integral part of various long term parenteral therapies including chemotherapy and parenteral nutrition. In pediatric patients with a long term CVC, multiple repeated accesses and catheter-related complications may lead to difficulty in reestablishment of a line. Strategies in CVC management in these patients should begin with choosing an appropriate catheter according to its purpose, choosing the right access site and prompt treatment of potential complications, especially catheter-related thrombosis. In patients with severe restriction of the superior vena cava and its tributaries, end-stage central venous access is diagnosed. Management of this situation requires a multidisciplinary team and alternative routes of venous access including access through small collateral veins, or through an unusual vein such as the hepatic vein or a gonadal vein, and/or use of alternative surgical techniques. This article provides a comprehensive review regarding the current approach and surgical options in pediatric patients with end-stage central venous access.

The attitude of novice physicians towards the intraosseus access in pediatric patients under cardiopulmonary resuscitation

The attitude of novice physicians towards the intraosseus access in pediatric patients under cardiopulmonary resuscitation

A novel technique for removing a fibrin sheath from a mediport catheter in the pediatric population.

Mediport (also known as port, portacath or Infusaport) is a commonly placed central venous access in pediatric patients. Fibrin sheath formation around the central venous catheter is a common biological response leading to port malfunction in the form of inability to aspirate but preserved capacity for infusion of fluids. If fibrinolytic therapy fails, percutaneous fibrin sheath stripping via transfemoral route or replacement with a new mediport are routine/conventional treatments for a fibrin sheath. We describe a novel technique for removing a fibrin sheath by exteriorizing the catheter through the neck entry site, stripping the fibrin sheath from the catheter manually under sterile conditions and replacing the catheter via a peel-away sheath introduced through the same skin incision as an alternative to complete port replacement or attempted catheter stripping.

Racial Disparities and Sociodemographic Differences in Incidence and Survival Among Pediatric Patients in the United States With Primary Liver Cancer

Primary liver cancer, including Hepatoblastoma (HB) and hepatocellular carcinoma (HCC), in pediatric populations is often fatal. The outcomes are poor despite universal health care access in pediatric patients. We investigated the sociodemographic factors affecting outcomes in pediatric patients with primary liver cancer. This is a large population database study of Surveillance, Epidemiology, and End Results cancer registry data from 1973 to 2011. HB and HCC were analyzed regarding age, sex, race, geographic area, and treatment-related information including survival. In total, 998 patients, the median age at time of diagnosis was 1 year for HB [0-19; 95% confidence interval (CI), 1.5-1.9] and 14 years for HCC (0-19; 95% CI, 12.1-13.3) (P<0.001). Overall Survival (OS) in HB was 374 months (25% failures 19) versus HCC 21 months (25% failures 5; P<0.0001). In HCC, the fibrolamellar subgroup OS was 41 months (32-.) versus 16 months (11-21) in all others [hazard ratio (HR) 2.0; P=0.005]. Diagnosis between 2000 and 2011 (HB: 25% failures not reached; HCC: 38) versus diagnosis 1973 to 1999 (HB: 374; HCC: 12) had different survival (P=0.01; HR 1.9). For HB, OS in patients with age of diagnosis under 2, 25% failures was not reached versus 374 months over the age of 2 (HR 1.7; P<0.0007). African American children with HB had OS of 67 (17-.) versus all others (25% failures 21) and 48% of African American children were diagnosed after the age of 2 versus 34% of whites (HR 1.9; P=0.01). Later diagnosis and decreased survival in African American children with HB warrants further research.

Upper pole access is safe and effective for pediatric percutaneous nephrolithotomy

Upper pole access in percutaneous nephrolithotomy (PCNL) provides a straight tract to the ureter, resulting in easier placement of a guidewire to the ureter, good exposure of the pelvis, calices, and upper ureter, and comfortable manipulations. However, despite these benefits, upper pole access is usually avoided because of the risk of chest complications in both pediatric and adult patients. We aimed to evaluate the safety and morbidity of single upper pole access in pediatric patients undergoing PCNL. We retrospectively reviewed patients aged ≤17 years with renal stones who underwent PCNL with a single access between August 2004 and February 2016. The patients were separated into two groups: the single upper pole access group (SUPAG) and the single other pole access group (SOPAG). We compared the SUPAG and SOPAG in terms of the demographic features of the patients, stone burden and location, operative data, and postoperative outcomes. Complications were classified according to the modified Clavien system. During the study period, 101 PCNL procedures were performed, 77 of which were managed with only one access. The median age of the 77 patients managed with a single access was 12 years (range 3-17 years). The number of cases in the SUPAG and SOPAG was 10 and 67, respectively. There were no statistically significant differences between the SUPAG and SOPAG in terms of age, sex, stone location, hydronephrosis status, stone area, side of kidney, and previous stone treatment or renal surgery. Furthermoret, there were no significant differences between the groups in terms of the operative parameters. Although the difference was insignificant, the median operation times in the SUPAG and SOPAG were 37 and 45min, respectively. There was no chest complication or bleeding that required transfusion in the SUPAG. Two cases required transfusion, and one case was managed with a double pigtail catheter (double-J) placement because of prolonged extravasation in the SOPAG. The stone-free ratios were 100% and 82.1% in the SUPAG and SOPAG, respectively. Upper pole access provides similar outcomes to other (middle and lower) pole accesses, and may be performed without serious complications. These results indicate that this is a safe and effective approach of PCNL, and it presents a good alternative for removal of renal stones in pediatric patients.

Safety of Outpatient Parenteral Antimicrobial Therapy in Children.

Outpatient parenteral antimicrobial therapy (OPAT) provides numerous benefits but may pose unique risks in children. We aimed to determine rates of OPAT antimicrobial- and intravenous access-related complications and their associations with specific antimicrobials and type of intravenous access in pediatric patients. Observational cohort study of patients receiving OPAT from August 2008 to May 2015 cared for by the Infectious Diseases service at a tertiary children's hospital. Primary outcome was antimicrobial discontinuation (AD) because of OPAT-associated complications. Secondary outcomes were unplanned outpatient healthcare visits and readmissions from OPAT-associated complications. Seven hundred and seven intravenous antimicrobials were prescribed in 540 cases. Nondevice-associated musculoskeletal infection was the most common diagnosis (39%). Ceftriaxone (30%), cefazolin (27%) and vancomycin (22%) were the most commonly used antimicrobials. Complications led to AD, ≥1 unplanned outpatient healthcare visit and ≥1 readmission in 23%, 30% and 17% of cases, respectively. Compared with use of ceftriaxone, use of oxacillin was associated with a significantly higher risk of AD because of any antimicrobial-related complication [hazard ratio (HR), 3.3; 95% confidence interval (CI): 1.2-9.7) and because of hepatic transaminitis (HR, 32.8; 95% CI: 4.02-268.2). Subjects treated with intravenous clindamycin (HR, 2.6; 95% CI: 1.1-5.8) and with a peripherally inserted central catheter (HR, 2.6; 95% CI: 1.04-6.3) were more likely to have unplanned outpatient visits. Use of oxacillin during OPAT was associated with higher rate of AD. Patients treated with clindamycin and those with a peripherally inserted central catheter had higher rates of unplanned outpatient visits. Providers should strongly consider alternative treatment options when possible.

Intranasal ketamine for peripheral venous access in pediatric patients: A randomized double blind and placebo controlled study

Procedural sedation and analgesia (PSA) are frequently used for fracture reduction in pediatric emergency departments (ED). Combining intranasal (IN) fentanyl with inhalation of nitrous oxide (N2O) allow for short recovery time and obviates painful and time-consuming IV access insertions.We performed a bicentric, prospective, observational cohort study. Patients aged 4–18 years were included if they received combined PSA with IN fentanyl and N2O for the reduction of mildly/moderately displaced fracture or of dislocation. Facial Pain Scale Revised (FPS-R) and Face, Leg, Activity, Cry, Consolability (FLACC) scores were used to evaluate pain and anxiety before, during and after procedure. University of Michigan Sedation Score (UMSS), adverse events, detailed side effects and satisfaction of patients, parents and medical staff were recorded at discharge. A follow up telephone call was made after 24–72 h.90 patients were included. There was no difference in FPS-R during the procedure (median score 2 versus 2), but the FLACC score was significantly higher as compared to before (median score 4 versus 0, Δ 2, 95% CI 0, 2). Median UMSS was 1 (95% CI 1, 2). We recorded no serious adverse events. Rate of vomiting was 12% (11/84). Satisfaction was high among participants responding to this question 85/88 (97%) of parents, 74/83 (89%) of patients and 82/85 (96%) of physicians would want the same sedation again.PSA with IN fentanyl and N2O is effective and safe for the reduction of mildly/moderately displaced fracture or dislocation, and has a high satisfaction rate.

Ultrasound-guided internal jugular catheterisation in paediatric cardiac surgical patients: a prospective observational study

Background Obtaining central venous access in paediatric patients is challenging and failure rates range from 5 to 19%. Ultrasound guidance has been newly introduced to our resource-limited set-up, and our aim was to evaluate the success rate during internal jugular catheterization in paediatric cardiac surgical patients. Patients and methods Over a period of 6 months, 106 consecutive paediatric patients scheduled for cardiac surgery requiring cannulation of the right internal jugular vein were enrolled in the study. The outcome measure was to find out the correlating factors for the number of attempts required and the rate of complications along with the success rate and time taken for successful cannulation. Results The overall success rate was 100% with a rate of successful catheterization in the first attempt being 76.41% [95% confidence interval (95% CI): 68.33–84.49]; second attempt was required in 16.98% (95% CI: 9.83–24.13) and the third attempt in 5.66% (95% CI: 1.26–10.06). The mean number of attempts for successful cannulation was 1.29±0.59. The mean time from skin prick to blood aspiration after successful cannulation was 134.06±81.59 s. The overall complication was 10.4% (95% CI: 4.59–16.21) among which arterial puncture and haematoma formation was seen in all 11 cases; pneumothorax and haemothorax were seen in one (0.9%) of those patients The number of attempts required showed weak negative correlation with age, height, body weight, body surface area and cross-sectional area. Conclusion Ultrasound guidance for central venous cannulation in paediatric patients has acceptable success rates. Arterial puncture with haematoma formation is the most common complication. The overall complication rate is directly related to the number of pricks.

Routine Use of Distal Arterial Perfusion in Pediatric Femoral Venoarterial Extracorporeal Membrane Oxygenation.

Lower-extremity ischemia is a significant complication in children on femoral venoarterial extracorporeal membrane oxygenation (VA ECMO). Our institution currently routinely uses distal perfusion catheters (DPCs) in all femoral arterial cannulations in attempts to reduce ischemia. We performed a single-center, retrospective review of pediatric patients supported with femoral VA ECMO from January 2005 to November 2015. The outcomes of patients with prophylactic DPC placement at cannulation (prophylactic DPC) were compared to a historical group with DPCs placed in response only to clinically evident ischemic changes (reactive DPC). Ischemic complication requiring invasive intervention (fasciotomy or amputation) was the primary outcome. Twenty-nine patients underwent a total of 31 femoral arterial cannulations, 17 with prophylactic DPC and 14 with reactive DPC. Ischemic complications requiring invasive intervention developed in 2 of 17 (12%) prophylactic DPC patients versus 4 of 14 (29%) reactive DPC. In the reactive DPC group, 7 of 14 (50%) had ischemic changes postcannulation, six underwent DPC placement, and three out of six of these patients still required invasive intervention. One of the seven patients had ischemic changes, did not undergo DPC, and required amputation. While a greater percentage of patients in the prophylactic group was cannulated during extracorporeal cardiopulmonary resuscitation (ECPR), statistical significance was not otherwise demonstrated. We demonstrate feasibility of superficial femoral artery (SFA) access in pediatric patients. We note fewer ischemic complications with prophylactic DPC placement, and observe that salvaging a limb with a reactive DPC was only successful 50% of the time. Although there was no statistical difference in the primary outcome between the two groups, limitations and confounding factors include small sample size and a greater percentage of patients in the prophylactic DPC group cannulated with ECPR in progress.

Innominate Artery Cannulation Access in Pediatric Patients Undergoing Redo Sternotomy

Redo sternotomy in pediatric patients can be complicated due to the unsuitability of many arterial cannulation sites for the pediatric population. Innominate artery cannulation provides a safe and easily reproducible alternative and prevents many of the disadvantages seen in femoral and axillary artery cannulation. Its use in pediatric cardiac surgery has seen a rise [1]. Herein, we describe the technique for innominate artery cannulation in pediatric patients undergoing redo sternotomy and review our experience with the technique.

A Review of Pediatric Ultrasound-Guided Peripheral Intravenous Access

Point-of-care ultrasound is at an early developmental stage in the field of pediatric emergency medicine. Ultrasound-guided vascular access has been identified as a key procedural application by several published educational guidelines and surveys of pediatric emergency medicine directors, fellowship directors, and fellows, and ultrasound-guided peripheral vascular access is well suited for the pediatric population. This article reviews the current literature on pediatric ultrasound-guided peripheral vascular access methods and demonstrates the suitability of point-of-care ultrasound as a safe, effective, patient-centered, timely, efficient, and equitable means of establishing peripheral vascular access in pediatric patients.

Thrombosis as a complication of central venous access in pediatric patients with malignancies: a 5-year single-center experience.

BackgroundReliable central venous access (CVC) is essential for hematology–oncology patients since frequent puncture of peripheral veins—e.g., for chemotherapy, antibiotic administration, repeated blood sampling, and monitoring—can cause unacceptable pain and psychological trauma, as well as severe side effects in cases of extravasation of chemotherapy drugs. However, CVC lines still carry major risk factors, including thrombosis, infection (e.g., entry site, tunnel, and luminal infections), and catheter dislocation, leakage, or breakage.MethodsHere we performed a retrospective database analysis to determine the incidence of CVC-associated thrombosis in a single-center cohort of 448 pediatric oncologic patients, and to analyze whether any subgroup of patients was at increased risk and thus might benefit from prophylactic anticoagulation.ResultsOf the 448 patients, 269 consecutive patients received a CVC, and 55 of these 269 patients (20%) also had a thrombosis. Of these 55 patients, 43 had at least one CVC-associated thrombosis (total number of CVC-associated thrombosis: n = 52). Among all patients, the median duration of CVC exposure was 464 days. Regarding exposure time, no significant difference was found between patients with and without CVC-associated thrombosis. Subclavia catheters and advanced tumor stages seem to be the main risk factors for the development of CVC-associated thrombosis, whereas pharmacologic prophylaxis did not seem to have a relevant impact on the rate of thrombosis.ConclusionsWe conclude that pediatric surgeons and oncologists should pay close attention to ensuring optimal and accurate CVC placement, as this appears the most effective tool to minimize CVC-associated complications.

The NOVEL Project Update

The NOVEL Project Update

Outcomes with arteriovenous fistulas in a pediatric population

Kidney Disease Outcome Quality Initiative guidelines recommend permanent access in dialysis patients aged 0 to 19years who weigh >20kg and are unlikely to receive a transplant within 1year. Unfortunately, >80% of these patients currently receive dialysis through a permanent catheter and are exposed to the associated risks and shortcomings. With a clear imperative to increase the incident use of permanent access in pediatric patients, our objective was to examine the long-term outcomes of pediatric arteriovenous fistulas (AVFs). A retrospective review was performed of all AVFs created in a hemodialysis (HD) population aged 0 to 19years at a single institution from 1999 to 2012. Data abstracted included age, weight, etiology of renal failure, time on dialysis, central venous catheter history, and transplantation history. Data were analyzed to determine the influence of these variables on primary and secondary patency. During the study period, 101 AVFs were performed in 93 patients, of whom 65 patients (70%) were male. Mean patient age was 14years (range, 3-19years), and mean weight was 51kg (range, 12-131kg). At the time of AVF creation, 66 patients (82%) were already receiving HD, with a mean length of HD dependence of 18months. At the time of surgery, 78% of patients had a previous central venous catheter, and 24% had two or more catheters. Procedures performed included 43 radiocephalic fistulas, 29 brachiocephalic fistulas, 20 basilic vein transpositions, and 9 femoral vein transpositions. Mean follow-up was 2.5years. The 2-year and 4-year primary and secondary patency rates were 83% and 92%, and 65% and 83%, respectively. Increasing age was correlated with improved primary patency (P= .02) but had no effect on secondary patency. Weight, etiology, catheter location, and catheter history were not significantly associated with primary or secondary patency. During the postoperative period, 68 patients (75%) received a renal transplant, with a mean time to transplant of 556days. AVFs demonstrate excellent long-term patency with minimal complications in pediatric HD patients, regardless of weight. Concerted efforts should be made to improve the incident use of AVFs in all pediatric patients with end-stage renal disease.

Long-Term Central Venous Access in Pediatric Patients at High Risk: Conventional versus Antibiotic–Impregnated Catheters

PurposeTo study selective use of antibiotic–impregnated catheters in children at increased risk of venous catheter–related infections (CRIs). Materials and MethodsFrom December 2008 to June 2009, 428 peripherally inserted central catheters (PICCs) were placed by the interventional radiology service of a large metropolitan children’s hospital. This retrospective study analyzed demographic and outcome data for the 125 patients in this group at high risk for venous CRI. Patients at high risk were those with active systemic infection, previous complicated central venous access, intensive care unit (ICU) admission, intestinal failure, transplantation, complex congenital heart disease, or renal failure. Patients (age, 7.6 y ± 7.0; 73 male and 52 female) received a conventional or antibiotic-impregnated PICC, with 17 receiving more than one catheter. ResultsOf the 146 of 428 qualifying patient encounters (34%), 53 patients received an antibiotic-impregnated PICC and 93 received a conventional PICC, representing 5,080 total catheter-days (CDs). The rates of CRIs per 1,000 CDs, including catheter exit site infections and catheter-related bloodstream infections, were 0.86 for antibiotic-impregnated PICCs and 5.5 for conventional PICCs (P = .036). A propensity-based model predicts 15-fold greater infection-free survival over the lifetime of the catheter in patients who receive an antibiotic-impregnated PICC (P < .001). Antibiotic-impregnated PICC recipients with active infection or ICU admission at the time of insertion had no catheter-associated infections, compared with 3.42 and 9.46 infections per 1,000 CDs, respectively, for patients who received conventional PICCs. Patients with intestinal failure had 1.49 and 10 infections per 1,000 CDs with antibiotic-impregnated versus conventional PICCs, respectively. ConclusionsAntibiotic-impregnated long-term PICCs significantly improve infection-free catheter survival in pediatric patients at high risk.