Catheters In Pediatric Patients Research Articles

Hemodialysis and peritoneal dialysis access related outcomes in the pediatric and adolescent population

BackgroundThere is paucity of comparative data on the objective performance of arteriovenous fistulas (AVF), grafts (AVG), hemodialysis (HD) catheter and peritoneal dialysis (PD) catheter in the pediatric population. MethodsA retrospective analysis of all patients <21 years in the United States Renal Database System who had an AVF, AVG, HD catheter or PD catheter placed for dialysis access between 1/2007 and 12/2014 was performed. Multivariable cox regression was used to evaluate mortality, patency (primary, primary-assisted and secondary), maturation and catheter survival. ResultsThe 11,575 patients studied comprised of 9445 (82%) HD, 1435 (12%) PD, 528 (4.6%) HD to PD and 167 (1.4%) PD to HD patients. The HD subcohort comprised of 1296 (13.7%) AVF initiates, 199 (2.1%) AVG initiates, 1347 (14.3%) AVF converts after initial HD catheter use, 292 (3.1%) AVG converts and 6311 (67%) patients who persistently utilized HD catheters. There was no difference between PD and HD in patients 0–5 (aHR: 1.36; 95% CI: 0.89–2.07; P = 0.15) and 6–12 years (aHR: 1.05; 95% CI: 0.72–1.52; P = 0.8). However, PD was associated with 73% and 76% increase in mortality relative to HD among patients in the 13–17 (aHR: 1.73; 95% CI: 1.35–2.21; P < 0.001) and 18–20 (aHR: 1.76; 95% CI: 1.38–2.24; P < 0.001) age categories. AVG was associated with 78% increase in mortality compared to AVF (aHR: 1.78; 95% CI: 1.41–2.25; P < 0.001). Persistent use of HD catheters was associated with 29% increase in mortality (aHR: 1.29; 95% CI: 1.07–1.57; P = 0.009) compared to initiation and persistent use of AVF. Conversion from HD catheter to AVF was associated with 66% decrease in mortality compared to persistent HD catheter use (aHR: 0.34; 95% CI: 0.28–0.40; P < 0.001). Primary, primary assisted and secondary patency were higher for AVF compared to AVG. ConclusionThere was no difference in risk adjusted mortality between HD and PD in children less than 13 years. PD is associated with higher mortality compared to HD in adolescents. Initiation of HD with AVF is associated with better patency and patient survival relative to AVG and persistent use of HD catheters in pediatric patients irrespective of transplant potential. Conversion from HD catheter to AVF or AVG in patients who inevitably initiate HD with a catheter is associated with better survival compared to persistent HD catheter use. Type of studyRetrospective cohort study. Level of evidenceLevel II.

A Retrospective Chart Review to Assess Indications, Risk Factors and Complications Associated with the Use of Indwelling Catheters in Pediatric Patients with Sickle Cell Disease - a Single Institution Experience

Background: Sickle cell disease (SCD) and its complications are associated with frequent hospital visits and treatment often requires venous access for administration of fluids, medications and blood transfusions. Due to frequent use, peripheral venous access can become difficult over time because of venous scarring. Moreover, certain interventions such as chronic simple or exchange transfusions require reliable venous access for prolonged periods of time. Implantable central venous devices such as ports offer definitive access and mitigate the need for frequent peripheral access attempts. However, existing knowledge on the use of these devices in pediatric patients with SCD is limited. Due to possible increased risks of thrombosis and mechanical occlusion from hypercoagulable state, risk of infectious complications and need for surgical placement, ports are often not used routinely. We review the indications and complications associated with placement of ports in the pediatric cohort of patients with SCD - to better define the scope of port placement in this group. Methods: We performed an IRB-approved, retrospective chart review to assess the indications, complications and risk factors associated with port placement in children and adolescents with SCD at the University of Oklahoma Health Sciences Center (OUHSC). The study period analyzed was 17.5 years from January 1st, 2000 to July 30th, 2018 and included patients from birth to 21 years of age, diagnosed with SCD who had homozygous sickle cell disease (HbSS) or compound heterozygous SCD - either sickle cell-β0-thalassemia, sickle cell-β+-thalassemia or sickle cell-hemoglobin C (HbSC) disease, and had ports in place for more than 7 days. Patients were identified systematically by querying the OUHSC Clinical Data Warehouse using diagnostic codes followed by chart review. Results: Thirty-two patients with SCD and ports were identified during the study period, out of which 31 patients had HbSS and one patient had HbSC disease. The median age at first port insertion was 8 years (range 1-20 years). A total of 63 ports were placed for a total of 99,272 port days with a median port life span of 1340 days. The two main indications for port placement were - either chronic transfusions for which 48 ports were placed for a total of 80,238 port days, or poor venous access (PVA) for which 15 ports were placed for a total of 19,034 port days. Out of the 48 ports placed for chronic transfusions, 6 ports were for transfusions for primary stroke prophylaxis, 22 ports were for transfusions for secondary stroke prophylaxis, 17 ports were for transfusions for recurrent vaso-occlusive episodes (VOE) and 3 ports were for transfusions after multi-organ failure. A total of 54 port complications occurred (malfunction=29, infection=20, thrombosis=3, difficult port access=1, and intractable pain over port site=1). From the data available, more ports were placed in the left subclavian vein (LSV=20) than right subclavian vein (RSV=4) and right internal jugular (RIJ=2), however rate of overall complications were similar between LSV and RSV - 0.57 complications/1,000 catheter days in LSV and 0.58 complications/1,000 catheter days in RSV. The rate of port associated infection, defined as a positive blood culture drawn from the port, was 0.2 per 1,000 port days. A total of 20 infections identified mostly gram-positive organisms (n=15) predominantly Staphylococcus, compared to gram-negatives (n=3), fungus with Candida albicans (n=1) and a rare acid-fast bacilli infection with Mycobacterium mucogenicum (n=1). The rate of thrombosis, identified radiologically using vascular doppler ultrasound, was 0.03 per 1,000 port days. The rate of premature port removal arising from complications was 0.36 per 1,000 port days. Ports placed for chronic transfusions had a lower rate of removal (0.31 per 1,000 port days) compared to ports placed for poor venous access (0.58 per 1,000 port days) with a ratio of 0.54 which approached statistical significance (p=0.09; CI 0.26-1.21). Conclusion: Ports in pediatric patients with SCD are associated with low rates of thrombosis, infection and malfunction. Ports may be a reasonable alternative for vascular access in patients with SCD - especially in patients who require chronic simple or exchange transfusions and have difficult access. Larger prospective studies will be needed to further assess the scope of use of ports in this population. Disclosures No relevant conflicts of interest to declare.

Ultrasonographic Detection of Micro-Bubbles in the Right Atrium to Confirm Peripheral Venous Catheter Position in Children.

In pediatric patients, indwelling peripheral venous catheters are sometimes displaced to extravascular positions, causing infiltration or extravasation. No reliable techniques are available to confirm accurate IV catheterization. However, ultrasonographic detection of micro-bubble turbulence in the right atrium after saline injection has been reported to be useful in confirming central venous catheter positions in both adults and children. This study evaluated whether this micro-bubble detection test can offer better confirmation of peripheral venous catheter positions compared with the smooth saline injection technique in pediatric patients. Randomized controlled study. Single tertiary PICU. Pediatric patients (weighing < 15 kg) who already had or required a peripheral venous catheter. Patients were randomly allocated to either of the two groups (150 patients per group): undergoing either the micro-bubble detection test (M group) or the smooth saline injection test (S group). The peripheral venous catheters were confirmed to be IV located in the final position in 137 and 139 patients in the M and S groups, respectively. In properly located catheters, the tests were positive in 100% (n = 137/137; sensitivity, 100%; 95% CI, 97.8-100), and in 89% (n = 124/139; 95% CI, 82.8-93.8) of the M and S groups, respectively (p = 0.0001). Among the catheters located in extravascular positions, the tests were negative in 100% (n = 13/13; specificity, 100%; 95% CI, 79.4-100), and in 64% (n = 7/11; 95% CI, 30.8-89.1) of the M and S groups, respectively (p = 0.017). The micro-bubble detection test is a useful technique for detecting extravasation and confirming proper positioning of peripheral IV catheters in pediatric patients.

Superiority of Dynamic Needle Tip Positioning for Ultrasound-Guided Peripheral Venous Catheterization in Patients Younger Than 2 Years Old: A Randomized Controlled Trial.

This study evaluated whether the dynamic needle tip positioning technique increased the success rate of ultrasound-guided peripheral venous catheterization in pediatric patients with a small-diameter vein compared with the static ultrasound-guided technique. Randomized controlled study. Single institution, Osaka Women's and Children's Hospital. The study population included 60 pediatric patients less than 2 years old who required peripheral venous catheterization in the PICU. Patients were randomly divided into the dynamic needle tip positioning (n = 30) or static group (n = 30). Each group received ultrasound-guided peripheral venous catheterization with or without dynamic needle tip positioning, respectively. The Fisher exact test, Kaplan-Meier curve plots, log-rank tests, and Mann-Whitney U test were used in the statistical analysis. The first-attempt success rate was higher in the dynamic needle tip positioning group than in the static group (86.7% vs 60%; p = 0.039; relative risk = 1.44; 95% CI, 1.05-2.0). The overall success rate within 10 minutes was higher in the dynamic needle tip positioning group than in the static group (90% vs 63.3%; p = 0.03; relative risk = 1.42; 95% CI, 1.06-1.91). Significantly fewer attempts were made in the dynamic needle tip positioning group than in the static group (median [interquartile range, range] = 1 [1-1, 1-2] vs 1 [1-2, 1-3]; p = 0.013]). The median (interquartile range) catheterization times were 51.5 seconds (43-63 s) and 71.5 seconds (45-600 s) in the dynamic needle tip positioning and static groups, respectively (p = 0.01). Dynamic needle tip positioning increased the first-attempt and overall success rates of ultrasound-guided peripheral venous catheterization in pediatric patients less than 2 years old.

Reduction of ventriculostomy-associated CSF infection with antibiotic-impregnated catheters in pediatric patients: a single-institution study.

External ventricular drains (EVDs) are commonly used in the neurosurgical population. However, very few pediatric neurosurgery studies are available regarding EVD-associated infection rates with antibiotic-impregnated EVD catheters. The authors previously published a large pediatric cohort study analyzing nonantibiotic-impregnated EVD catheters and risk factors associated with infections. In this study, they aimed to analyze the EVD-associated infection rate after implementation of antibiotic-impregnated EVD catheters. A retrospective observational cohort of pediatric patients (younger than 18 years of age) who underwent a burr hole for antibiotic-impregnated EVD placement and who were admitted to a quaternary care ICU between January 2011 and January 2019 were reviewed. The ventriculostomy-associated infection rate in patients with antibiotic-impregnated EVD catheters was compared to the authors' historical control of patients with nonantibiotic-impregnated EVD catheters. Two hundred twenty-nine patients with antibiotic-impregnated EVD catheters were identified. Neurological diagnostic categories included externalization of an existing shunt (externalized shunt) in 34 patients (14.9%); brain tumor (tumor) in 77 patients (33.6%); intracranial hemorrhage (ICH) in 27 patients (11.8%); traumatic brain injury (TBI) in 6 patients (2.6%); and 85 patients (37.1%) were captured in an "other" category. Two of 229 patients (0.9% of all patients) had CSF infections associated with EVD management, totaling an infection rate of 0.99 per 1000 catheter days. This is a significantly lower infection rate than was reported in the authors' previously published analysis of the use of nonantibiotic-impregnated EVD catheters (0.9% vs 6%, p = 0.00128). In their large pediatric cohort, the authors demonstrated a significant decline in ventriculostomy-associated CSF infection rate after implementation of antibiotic-impregnated EVD catheters at their institution.

Dynamic Needle Tip Positioning for Ultrasound-Guided Placement of a Peripherally Inserted Central Catheter in Pediatric Patients

Although a few studies have reported the efficacy of ultrasound-guided peripherally inserted central catheter placement for pediatric patients, the procedure still is challenging. Ultrasound-guided dynamic needle tip positioning technique is useful for vascular catheterization. There have been no reports on using dynamic needle tip positioning for peripherally inserted central catheter placement. The authors assessed the rate of successful peripherally inserted central catheter placement with dynamic needle tip positioning. Case series. Single tertiary institution. Forty patients <5 years old who were admitted to the pediatric intensive care unit after cardiac surgeries and required peripherally inserted central catheter placement. Peripherally inserted central catheter placement was performed under ultrasound guidance with dynamic needle tip positioning. The authors recorded the first attempt and overall success rates of peripherally inserted central catheter and outer cannula placement, time needed for outer cannula and peripherally inserted central catheter placement, and number of attempts. The first attempt and overall success rates of peripherally inserted central catheter placement were 85% (n = 34) and 97.5% (n = 39), respectively. The first attempt and overall success rates of outer cannula placement were 87.5% (n = 35) and 100% (n = 40), respectively. Time needed for outer cannula placement was 59.5 (interquartile range 40.5-80.5) seconds and for peripherally inserted central catheter placement was 112.5 (interquartile range 91.5-159.5) seconds. The number of attempts was 1 (interquartile range 1-1 [range 1-5]). In pediatric patients, ultrasound-guided peripherally inserted central catheter placement using dynamic needle tip positioning attained a high success rate.

Evaluation of a Novel Bony Landmark-Based Method for Teaching Percutaneous Insertion of Subclavian Venous Catheters in Pediatric Patients.

Surgical trainees performing subclavian vein (SCV) cannulation often incorrectly perceive needle trajectory and anatomical relations. As surface landmark-based methods derived from adult surgical practice may be less effective in younger patients, we developed and evaluated a novel bony landmark-based method for teaching SCV cannulation for central venous access device (CVAD) placement in children. Over 2 sequential 3-year periods, pediatric surgical trainees were taught infraclavicular SCV cannulation via surface- and bony-landmark approaches, respectively. We prospectively recorded patient, surgeon and operative details on all Hickman line and port-a-cath insertions placed by trainees as the first surgeon via percutaneous infraclavicular SCV puncture and compared procedural outcomes and complications across both periods. Of 271 cases included in the study, trainees performed 52 (50.5%) and 92 (54.8%) procedures in the first and second periods, respectively. Patients in both periods did not differ by gender, disease, CVAD device, or prior CVAD, chemotherapy or infection status. In the second (bony landmark) period, although patients were younger (6.0 vs. 8.7years, P = 0.003) mean procedural duration was shorter (42.5 vs. 58.3min, P < 0.001). Also, cannulation attempts and complication rates did not differ significantly between study periods (P = 0.257 and 1.0, respectively). With the bony landmark approach, trainees could perform the procedures faster despite operating on younger patients, without impacting complication rates and cannulation attempts. Bony landmarks may better approximate SCV position across a range of ages, thus improving the consistency of SCV cannulation in CVAD placements in children.

Separating the Trees From the Ivy? Catheter Choice

Research Article| April 01 2019 Separating the Trees From the Ivy? Catheter Choice AAP Grand Rounds (2019) 41 (4): 41. https://doi.org/10.1542/gr.41-4-41 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Separating the Trees From the Ivy? Catheter Choice. AAP Grand Rounds April 2019; 41 (4): 41. https://doi.org/10.1542/gr.41-4-41 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: catheters, trees (plant), central line-associated bloodstream infection, venous thromboembolism Source: Noonan PJ, Hanson SJ, Simpson PM, et al. Comparison of complication rates of central venous catheters versus peripherally inserted central venous catheters in pediatric patients. Pediatr Crit Care Med. 2018; 19(12): 1097– 1105; doi: https://doi.org/10.1097/PCC.0000000000001707Google Scholar Investigators from the Medical College of Wisconsin, Milwaukee, and Children’s Hospital of Wisconsin conducted a retrospective cohort study comparing rates of central line–associated bloodstream infections (CLABSIs) and venous thromboembolism (VTE) in children treated with either a nontunneled central venous catheter (CVC) or peripherally inserted central catheters (PICCs). Electronic medical record and billing data at one quaternary care pediatric hospital were reviewed to identify placement of CVCs or PICCs in patients 1 day to 18 years old from October 2012 to March 2016. Outcomes of CLABSI and VTE were collected prospectively during the study period as part of a hospital quality improvement initiative. Only VTE confirmed by means of radiographic imaging were included. An outcome of CLABSI was based on CDC definitions. Rates of CLABSI and VTE in patients treated with either PICCs or CVCs were compared using regression analysis after controlling for the number of catheter days and other confounding variables and adjusting for clustering within patients. Analyses to identify risk factors for CLABSI and VTE among those treated with PICCs and CVCs were also conducted. Data were analyzed for 2,709 catheters, including 1,126 PICCs and 1,583 CVCs. The median age of patients treated with PICCs was significantly younger than that of those treated with CVCs (1.4 and 2.7 years old, respectively; P=.003); age was not statistically associated with either CLABSI or VTE. A total of 53 CLABSIs were identified. The rate of CLABSI was 1.03 per 1,000 catheter days for those treated with PICCs and 0.56 per 1,000 catheter days in those treated with CVCs. The only factors associated with risk of CLABSI were PICCs (OR, 3.15; 95% CI, 1.74–5.71) and number of catheter days (OR, 1.003; 95% CI, 1.002–1.005). A total of 70 VTEs occurred. Rates of VTE were 1.28 and 0.83 per 1,000 catheter days, respectively, in patients treated with PICCs or CVCs (OR, 2.71; 95% CI, 1.65–4.45, after adjusting for catheter days and anatomic side of placement). The risks of both CLABSI and VTE were significantly higher with PICCs inserted in lower (vs upper) extremities. For CVCs, placement in the internal jugular vein was associated with significantly lower risks of CLABSI and VTE than was placement at other anatomic sites. The authors conclude that use of PICCs is associated with higher risk of CLABSI and VTE than is use of CVCs in hospitalized pediatric patients. Dr Bratton has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. Prevention of CLABSI is an established quality metric for both adult and pediatric patient care.1 CLABSI and VTE prolong hospital stay and increase costs and mortality. Focused multidisciplinary care teams implementing care bundles have... You do not currently have access to this content.

Mobilized peripheral blood stem cell apheresis via Hickman catheter in pediatric patients.

Autologous stem cell transplantation remains an integral treatment tool for certain childhood malignancies. In children, a central venous catheter is typically necessary to provide adequate flow rates for preparative apheresis. In this study, the feasibility and efficiency of collecting CD34+ cells via an indwelling Hickman catheter, preimplanted for chemotherapy, instead of placing an additional temporary central venous catheter was evaluated. Forty-eight pediatric leukaphereses for autologous hematopoietic stem cell transplantation using Spectra Optia MNC, Version 3.0 were reviewed. We compared preimplanted Hickman catheters with a temporary Shaldon catheter, inserted for apheresis. Apheresis was considered successful if a dose of 2 × 106 CD34+ peripheral blood stem cells/kg BW was achieved. In 43 (89.6%) of the 48 patients, a Hickman catheter was used for leukapheresis. Only 5 patients (10.4%) received a temporary Shaldon catheter. In both groups, apheresis was performed without apparent adverse reactions. The dose of collected CD34+ peripheral blood stem cells was 12.7 × 106 (range, 2.3-70.7 × 106 ) cells/kg BW in the Hickman group and 16.2 × 106 (range, 3.8-48.4 × 106 ) cells/kg BW in the Shaldon group, showing no statistically significant difference (p = 0.58). In both groups, the primary endpoint of a minimal CD34+ cell concentration of 2 × 106 cells/kg BW was achieved at a maximum of two leukapheresis sessions. Apheresis efficacy was further confirmed by the collection efficiency of 40.2% in the Hickman group and 27.8% in the Shaldon group (p = 0.32). These data indicate the reliable feasibility and efficacy of mobilized apheresis via an indwelling Hickman catheter. In light of this, the routine insertion of a dialysis catheter for the purpose of leukapheresis should be critically reconsidered.

Continuous transverse abdominis plane catheter for postoperative analgesia in pediatric abdominal surgery

Transversus abdominis plane (TAP) block is relatively newer method for the management of postoperative pain after abdominal surgery in pediatric patients. Although there is emerging evidence proving the safety and efficacy of TAP blocks, there is limited literature on use of TAP catheters in pediatric patients. This technique involves the injection of local anesthetics into the plane between the internal oblique and transversus abdominis muscle and thus giving pain relief. The technique when performed under ultrasound guidance or under vision after dissection of the plane between two muscles is most effective and safe. This helps in significant reduction in the analgesic requirement postoperatively and hence the side effects with their use. We report successful pain management postoperatively in three pediatric patients, in whom neuraxial block was contraindicated.

Dynamic Needle Tip Positioning for Ultrasound-Guided Arterial Catheterization in Infants and Small Children With Deep Arteries: A Randomized Controlled Trial

Arterial catheterization for infants and small children is technically challenging. This study evaluated whether the dynamic needle tip positioning (DNTP) technique improved the success rate of ultrasound-guided radial artery catheterization in patients with a radial artery depth ≥4 mm compared with the conventional ultrasound-guided technique. Randomized controlled study. Single institution, Osaka Women's and Children's Hospital. Patients (n = 40; age <3 years) with artery depth ≥4 mm. Patients were divided randomly into 2 groups. The DNTP group received ultrasound-guided radial artery catheterization with DNTP; the conventional group received catheterization without DNTP. First-attempt success rates were 85% and 50% in the DNTP and conventional groups, respectively (p = 0.018; relative risk = 1.7; 95% CI: 1.06-2.73). Overall success rates within 10 minutes were 95% and 60% in the DNTP and conventional groups, respectively (p = 0.008; relative risk = 1.58; 95% CI: 1.09-2.3). Posterior wall puncture rates were 5% and 50% in the DNTP and conventional groups, respectively (p = 0.0014; relative risk = 0.1; 95% CI: 0.014-0.71). Significantly fewer attempts were made in the DNTP group (median = 1 v 1.5; p = 0.01). The median catheterization times were 38 seconds (34-55.5) and 149 seconds (49.5-600) in the DNTP and conventional groups, respectively (p = 0.0003). Dynamic needle tip positioning improved first-attempt and overall success rates of ultrasound-guided radial artery catheterization in pediatric patients with a radial artery depth ≥4 mm.

Comparison of Complication Rates of Central Venous Catheters Versus Peripherally Inserted Central Venous Catheters in Pediatric Patients*

The purpose of our study is to compare the rate of central line-associated blood stream infections and venous thromboembolism in central venous catheters versus peripherally inserted central catheters in hospitalized children. There is a growing body of literature in adults describing an increased rate of venous thromboembolisms and similar rates of central line-associated blood stream infection associated with peripherally inserted central catheters versus central venous catheters. It is not known if the rate of central line-associated blood stream infection and venous thromboembolism differs between peripherally inserted central catheters and central venous catheters in children. Based on current adult literature, we hypothesize that central line-associated blood stream infection rates for peripherally inserted central catheters and central venous catheters will be similar, and the rate of venous thromboembolism will be higher for peripherally inserted central catheters versus central venous catheters. This is a cohort study using retrospective review of medical records and prospectively collected hospital quality improvement databases. Quaternary-care pediatric hospital from October 2012 to March 2016. All patients age 1 day to 18 years old with central venous catheters and peripherally inserted central catheters placed during hospital admission over the study dates were included. Central venous catheters that were present upon hospital admission were excluded. The primary outcomes were rate of central line-associated blood stream infection and rate of venous thromboembolism. None. Of 2,709 catheters included in the study, 1,126 were peripherally inserted central catheters and 1,583 were central venous catheters. Peripherally inserted central catheters demonstrated a higher rate of both infection and venous thromboembolism than central venous catheters in all reported measures. In multivariable analysis, peripherally inserted central catheters had increased association with central line-associated blood stream infection (odds ratio of 3.15; 95% CI, 1.74-5.71; p = 0.0002) and increased association with venous thromboembolism (odds ratio of 2.71; 95% CI, 1.65-4.45; p < 0.0001) compared with central venous catheters. Rates of central line-associated blood stream infection and venous thromboembolism were higher in hospitalized pediatric patients with peripherally inserted central catheters as compared to central venous catheters. Our study confirms the need for further investigation into the safety of central access devices to assist in proper catheter selection.

Stereotactic Placement of Intratumoral Catheters for Continuous Infusion Delivery of Herpes Simplex Virus -1 G207 in Pediatric Malignant Supratentorial Brain Tumors

The engineered herpes simplex virus-1 G207, is a promising therapeutic option for central nervous system tumors. The first-ever pediatric phase 1 trial of continuous-infusion delivery of G207 via intratumoral catheters for recurrent or progressive malignant brain tumors is ongoing. In this article, we describe surgical techniques for the accurate placement of catheters in multiple supratentorial locations and perioperative complications associated with such procedures. A prospective study of G207 in children with recurrent malignant supratentorial tumors is ongoing. Preoperative stereotactic protocol magnetic resonance imaging was performed, and catheter trajectories planned using StealthStation planning software. Children underwent placement of 3-4 silastic catheters using a small incision burr hole and the Vertek system. Patients had a preinfusion computed tomography scan to confirm correct placement of catheters. Six children underwent implantation of 3-4 catheters. Locations of catheter placement included frontal, temporal, parietal, and occipital lobes, and the insula and thalamus. There were no clinically significant perioperative complications. Postoperative computed tomography scans coupled with preoperative MRI scans demonstrated accurate placement of 21 of 22 catheters, with 1 misplaced catheter pulled back to an optimal location at the bedside. One patient had hemorrhage along the catheter tract that was clinically asymptomatic. Another patient had cerebrospinal fluid leak from a biopsy incision 9 days after surgery that was oversewn without complication. The placement of multiple intratumoral catheters in pediatric patients with supratentorial tumors via frameless stereotactic techniques is feasible and safe. Intratumoral catheters provide a potentially effective route for the delivery of G207 and may be employed in other trials utilizing oncolytic virotherapy for brain tumors.

Anesthetic considerations for magnetic resonance imaging-guided right-heart catheterization in pediatric patients: A single institution experience.

Cardiac catheterization is an integral part of medical management for pediatric patients with congenital heart disease. Owing to age and lack of cooperation in children who need this procedure, general anesthesia is typically required. These patients have increased anesthesia risk secondary to cardiac pathology. Furthermore, multiple catheterization procedures result in exposure to harmful ionizing radiation. Magnetic resonance imaging-guided right-heart catheterization offers decreased radiation exposure and diagnostic imaging benefits over traditional fluoroscopy but potentially increases anesthetic complexity and risk. We describe our early experience with anesthetic techniques and challenges for pediatric magnetic resonance imaging-guided right-heart catheterization.

Retrospective analysis of cuffed-tunneled catheters in pediatric patients receiving maintenance hemodialysis

Objective: To summarize the characteristics of cuffed-tunneled catheters insertion and investigate the values of cuffed-tunneled catheters in pediatric patients. Methods: Between March 2015 and July 2017, all the pediatric patients who received maintenance hemodialysis at least 3 consecutive months in our center were included. Sixteen cuffed-tunneled hemodialysis catheters were inserted in patients for long-term hemodialysis access. The clinical manifestations and complications were retrospectively reviewed. Results: Fifteen pediatric patients with end stage ranal disease (ESRD) were included in this study and they received 16 cuffed-tunneled catheters for long-term vascular access, including 10 males and 5 females; median age at start of catheter insertion was 11.5 (4.2-14.5) years. Body weight was (27.8±8.0)kg (16.0-39.4 kg) . The size and the length of the catheters were based on the height of patients as follows: 28 cm for (115.6±10.6) cm (102.0-130.0 cm) ,36 cm for (148.6±9.9)cm (140.0-167.0 cm) . Cuffed-tunneled catheters outcome: 10 cuffed-tunneled catheters were still functional at the end of the study; 5 catheters were removed after successful kidney transplantation. Catheter failure occurred in 1 out of 16 cuffed-tunneled catheters due to catheter-related infections. The median catheter survival time was 11.9 months (range 3.5-21.3 months). Complications of cuffed-tunneled catheters: Catheter placements operation was successful in 15 cases using ultrasound guidance. No serious complications were observed in any patients receiving catheter inserting operation. The overall rate of catheter-related infections and thrombosis/malposition was 6.3% and 18.7%, respectively. Conclusions: Ultrasound guidance is suggested in pediatric patients during the catheters insertion. The size and the length of the catheters should be based on the height of patients. Cuffed-tunneled hemodialysis catheters could be effectively used for maintenance of hemodialysis vascular access for pediatric patients with ESRD.

Survey of a Practical Approach to Central Venous Catheterization in Pediatric Patients

Background Central venous catheter (CVC) is used for measuring hemodynamic variables, transfusion of blood, fluids and medications when peripheral vascular lack sufficiency. Unfortunately CVC is associated with many complications ranging from anxiety and discomfort for the patient to severe mechanical side effects such as arterial lacerations, pleural and pericardial injury as well as infection and thrombosis. This study aimed to survey of a practical approach to central venous catheterization in pediatric patients. Materials and Methods In this retrospective and descriptive study, rate of success and complications of central venous catheterization by the anesthesia team for the hospitalized children 0-15 years from 2009 to 2016 years at Mofid Children Hospital, Tehran-Iran, were investigated. Advancement of catheters tips in pleural space; peritoneal cavity and pericardium were recognized by rat tail blood flow as a practical approach which was proved by chest X- ray. Successful rate and complications of inserting CVC were collected by researchers using medical records of the patients. Results There were 2,385 (53%) female and 2,115 (47%) male patients. Patient’s age ranged from 1 month to 10 years, mean 12.25±6.45 months. About 4,500 patients who underwent central venous catheterization were investigated that 815 patients (18%) had improper catheterization in the internal jugular and 374 patients (8%) had accidental arterial injury and 160 patients (3%) had accidental pleural injury. Accidental pleural injury were recognized by rat tail blood flow in the liquid column connected to the catheter to the patient's bedside and all of them was proven by taking control image. Conclusion Using rat tail blood flow as a practical approach to central venous catheterization in pediatric patients can be associated with prevention of the plural injury and subsequent pneumothorax and hemothorax.

Arrhythmia during diagnostic cardiac catheterization in pediatric patients with congenital heart disease

Arrhythmia during diagnostic cardiac catheterization in pediatric patients with congenital heart disease

Determination of the optimal depth of a left internal jugular venous catheter in infants: A prospective observational study.

Few reports exist regarding the optimal depth of a left-sided central venous catheter in pediatric patients. We aimed to provide a guideline for the optimal depth of central venous catheters at the left internal jugular vein in infants, using anatomical landmarks, age, height, and weight. A two-stage study was conducted. In the first observational study, infants aged ≤1year and scheduled for elective surgery requiring a central venous catheter were enrolled. The tip of the central venous catheter was confirmed using transthoracic echocardiography. Linear regression modeling was performed to determine the association between the insertion depth of the central venous catheter and the I-A-B distance (I, the insertion point; A, the sternal head of the left clavicle; B, the midpoint of the perpendicular line drawn between the sternal head of the right clavicle and an imaginary line between the nipples), based on age, height, and weight. In the second study, the results of the first study were validated in another group of consecutive infants. In the first study, the data of 67 patients were analyzed. The infant's height and I-A-B distance were highly correlated with the level of the central venous catheter tip (R2 =0.763 and 0.772, respectively; all P<.01), using the regression equations 0.11× height (cm) + 0.19 and 1.02× I-A-B (cm) + 1.55, respectively. In the second study, height was also highly correlated with the insertion depth of the central venous catheter in another 42 infants (r=.938, P=<.001). In a Bland-Altman's analysis, the mean bias and precision of the actual insertion depth and predicted depth using height were 0.09 and 0.15cm, respectively. The limits of agreement were -0.19 and 0.38cm, respectively. In infants, the optimal depth of a central venous catheter at the left internal jugular vein can be determined with a simple formula using height.

Avalon catheters in pediatric patients requiring ECMO: Placement and migration problems

PurposeThe Avalon dual-lumen venovenous catheter has several advantages, but placement techniques and management have not been adequately addressed in the pediatric population. We assessed our institutional outcomes and complications using the Avalon catheter in children. MethodsWe reviewed all pediatric patients who had Avalon catheters placed for respiratory failure at our institution, excluding congenital heart disease patients, from April 2009 to March 2016. All patients were managed using our standard ECMO protocol, and cannula position was followed by daily chest x-ray and intermittent echocardiography (ECHO). Data included demographics, diagnosis, PRISM3 predicted mortality, ECMO duration, complications, and survival. The primary outcome was the need for catheter repositioning. ResultsTwenty-five patients were included, with mean age 8.3±6.9years and 15±22days of ECMO support. Overall survival was 68% (17/25). Fourteen patients (56%) underwent placement with fluoroscopy in addition to ultrasound and ECHO, primarily after 2013. Overall, thirteen patients (52%) had problems with cannula malposition. 9 of these (69%) required cannula repositioning. Three of 14 (21%) cannulas placed with fluoroscopy required repositioning, compared to 7/11 (64%) placed without fluoroscopy (p=0.05). ConclusionsComplications are common with the Avalon catheter in children. Safe percutaneous access requires ultrasound guidance, and use of intraoperative fluoroscopy in addition to echocardiography decreases malposition rates. Level of evidenceIV (Prognosis study).

Intra-procedural continuous dialysis to facilitate interventional catheterization in pediatric patients with severe renal failure.

Interventional catheterization procedures may be needed for patients with severe renal failure who are dependent on dialysis. To avoid the risk of fluid overload and electrolyte derangement during complex procedures in this oliguric/anuric patient population, we performed intra-procedural dialysis, either continuous renal replacement therapy (CRRT) or continous cycling peritoneal dialysis (CCPD). We performed a retrospective review of a cohort of pediatric patients, ages 0-18 years, with dialysis-dependent renal failure who received CRRT or CCPD during catheterization procedures from January 2013 to March 2016. Eight patients underwent a total of nine interventional catheterization procedures while receiving intra-procedural dialysis. Median age was 4.5 years (range 8 months to 17 years) and weight, 11.6 kg (11.2-62.6 kg). Six patients had end-stage renal disease (ESRD) and two patients had acute kidney injury (AKI), one due to hepatorenal syndrome and one due to multifactorial causes associated with congenital heart disease. The most common reason for catheterization was occlusive venous thrombosis requiring recanalization. CRRT was used during five cases and CCPD during four cases. Median procedure time was 337 min (95-651 min) and median contrast dose 4.2 mLkg-1 (1.2-8.2 mLkg-1 ). Euvolemia was maintained based on pre- and post-catheterizations weights, and no significant electrolyte abnormalities occurred based on lab monitoring during and post-procedure. Intra-procedural dialysis using CRRT or CCPD enables even small pediatric patients with severe renal failure to undergo long and complex interventional catheterizations by reducing the risk of fluid overload and electrolyte abnormalities. Collaboration between nephrology, cardiology, and dialysis teams is necessary for successful management of this challenging patient population.