Central Venous Catheters In Children Research Articles

About the Usage and Usability of Central Venous Catheters in Children with TPN: the Parents' Viewpoint.

Medical devices are important components of medical care. Therefore, they must be safe and useful for patients. This study aimed to analyze the situation of children with central venous catheters (CVCs) for long-term parenteral nutrition from the parents' perspective with respect to patient safety and usefulness. An online cross-sectional survey was conducted using a quantitative research approach, with a German patient support group for children with chronic intestinal failure. 61 responses were collected between November 202 and January 2021. Concerning the usability of the CVCs, the caregivers assessed overall satisfaction, patient safety, usability, learnability of handling, "self-explanatory ability, " and mental load. Furthermore, various suggestions for improvements have been documented. Although CVCs can cause a variety of complications in the context of long-term use, the usage for parents in everyday life is feasible. Insufficient fixation and protection outside of the body have been identified as unmet clinical needs. In addition to the underlying disease of chronic intestinal failure, the catheter adds an extra mental burden to families' lives. Furthermore, parents articulated the need for further information and training.

Guidewire replacement of tunneled central venous catheters in children reusing the same subcutaneous route.

Tunneled centrally inserted central venous catheters (CICCs) are a type of catheters used especially in cancer pediatric patients or affected from short bowel disease and malabsorption. Recently, thanks to biomedical research progresses, polyurethane catheters have resulted in high surgical performances with a low caliber but extremely fast infusion rate. Sometimes the replacement procedure over a Seldinger guidewire could be an appreciable technique especially reusing the same vein and the same tunnel of the previous catheter, with local anesthesia. The aim of this article was to explain our replacement technique over guidewire of tunneled CICCs on pediatric patients. The casuistry presented was evaluated at the Unit of Vascular Access of ASST Spedali Civili in Brescia, Italy. The study involved 7 successful catheter replacement over guidewire, meanwhile cases where patients presented sepsis, exit site infection or catheter damage were premeditatedly excluded. Three of them were tunneled and cuffed. Five catheters were in brachiocephalic vein and 2 in internal jugular vein. Every procedure was ended without complications. Of seven patients, five of them underwent to the procedure only with local anesthesia and 2 patients require premedication with Midazolam. No one required general anesthesia. The maneuver was always conducted following the same procedure without noticing particular complications associated with CICC insertion. Indeed, the operation was quick, feasible and safe. Septic, thromboembolic, or hemorrhagic complications also related to patients presenting dysfunctional coagulation cascade were not encountered. Our experience regarding the replacement technique of tunneled catheters over guidewire was considered feasible, accurate and efficient for all patients treated, even in those presenting thrombocytopenia or dysfunctional coagulation cascade.

Tunnelled external versus implanted port central venous catheters in paediatric oncology: a systematic review and meta-analysis

ObjectiveTo evaluate and compare the complications associated with tunnelled external and implanted port (PORT) central venous catheters (CVCs) in children with cancer.DesignA systematic review in accordance with PRISMA (Preferred Reporting...

Elaboration and development of a realistic 3D printed model for training in ultrasound-guided placement of peripheral central venous catheter in children.

Simulation for training is becoming a trend topic worldwide, even if its applications are commonly limited to adulthood. Ultrasound-guided procedures require practice and experience-especially in the pediatric field, where the small size of the involved anatomical structures poses major problems. In this context, a realistic 3D printed pediatric phantom for training of the ultrasound-guided placement of peripheral central venous catheters in children was developed. Starting from Computed Tomography scans of an 8 years-old girl, her left arm was virtually reconstructed-including bones, arteries, and veins-through a semi-automatic segmentation process. According to preliminary results, the most suitable 3D printing technologies to reproduce the different anatomical structures of interest were selected, considering both direct and indirect 3D printing techniques. Experienced operators were asked to evaluate the efficacy of the final model through a dedicated questionnaire. Vessels produced through indirect 3D printing latex dipping technique exhibited the best echogenicity, thickness, and mechanical properties to mimic real children's venous vessels, while arteries-not treated and/or punctured during the procedure-were directly 3D printed through Material Jetting technology. An external mold-mimicking the arm skin-was 3D printed and a silicone-based mixture was poured to reproduce real patient's soft tissues. Twenty expert specialists were asked to perform the final model's validation. The phantom was rated as highly realistic in terms of morphology and functionality for the overall simulation, especially for what concerns vessels and soft tissues' response to puncturing. On the other hand, the involved structures' US appearance showed the lower score. The present work shows the feasibility of a patient-specific 3D printed phantom for simulation and training in pediatric ultrasound-guided procedures.

Double-lumen catheter is a risk factor for complications of peripherally inserted central venous catheters in children

BackgroundAlthough peripherally inserted central venous catheters (PICCs) are useful for children because of the high burden of vascular puncture, no guidelines exist for PICC in terms of insertion site, blood vessel, and type of catheter. We investigated the risk factors of complications during PICC placement in pediatric patients. MethodsWe analyzed the medical records of children who were admitted to the Tokyo Medical and Dental University Hospital and had PICCs inserted between January 2016 and December 2020. A total of 92 patients with 141 PICCs (age at insertion: 0–18 years, average PICC per patient: 1.48) were analyzed. The median duration of indwelling catheter use was 49 days (interquartile range: 24–80 days). Exposures are patient characteristics (age, weight, primary disease) and variables that the surgeons have choices for during the clinical procedure, such as inserted vessel, inserted part, catheter diameter, catheter lumen, and catheter type (open or closed end). Multilevel logistic regression, considering the correlation among multiple PICCS within a patient, was performed. ResultsForty-four PICCs (31%) were removed because of catheter-related complications (18 suspected infections, 9 occlusions, 7 breakages, 6 dislodgements, and 4 phlebitis). Double-lumen catheters were significantly positively associated with complications (odds ratio: 3.91; 95% confidence interval: 1.03, 14.9) after adjusting for all covariates. The other factors were not significantly associated with the occurrence of complications. ConclusionsDouble-lumen PICCs were associated with complications. The double lumen is useful for the simultaneous administration of multiple drugs, but cases should be carefully monitored.

Significance of ultrasound navigation during central venous catheterization in children with scoliotic spinal deformity: a prospective observational single-centre study

BACKGROUND: Surgeries to correct scoliotic spinal deformity (posterior corrective transpediculocorporal fusion) are classified as highly traumatic, are accompanied by significant blood loss, and require reliable venous access. Central vein catheterization is an important part of patient management and is a successful and safe procedure.
 AIM: To evaluate the effectiveness of ultrasound navigation during central venous catheterization in patients with severe and super-severe scoliotic spinal deformity.
 MATERIALS AND METHODS: A single-center prospective study included 52 patients aged 6 to 18 (median age 13.2) years undergoing surgical treatment to correct grade IV scoliotic spinal deformity. Patients underwent catheterization of the internal jugular vein under ultrasound navigation using an ultrasound scanner with a linear sensor and a frequency of 713 MHz. The procedures were performed by one operator. The following were assessed: anatomy of the neurovascular bundle, relative position of the vessels relative to each other, size of the internal jugular vein in a horizontal and Trendelenburg positions, frequency and time of the procedure, and complications during puncture and catheterization.
 RESULTS: In patients with severe scoliotic deformity of the spine, an atypical location of neck vessels was noted in every fifth patient (13.46%). The peculiarity of the location of the vessels was associated with congenital developmental anomalies. The most common anomaly in the location of the vessels relative to each other was the medial location of the internal jugular vein relative to the carotid artery. In one patient, the passage of the internal jugular vein at a considerable distance from the carotid artery was revealed, which made it impossible to puncture according to anatomical landmarks. The average diameter of the internal jugular vein in the horizontal position was 6.20.9 mm. In the Trendelenburg position, the diameter was 9.081.5 mm. The average duration of the procedure was 92 seconds (70). Taking into account the use of ultrasound navigation during catheterization of the internal jugular vein, no early and late complications occurred.
 CONCLUSION: The use of ultrasound navigation for central venous catheterization during surgical treatment of severe and super-severe scoliotic deformities of the spine is a safe and essential method. The Trendelenburg position allows for better visualization of the jugular vein and facilitates its puncture and catheterization. The use of ultrasonography during invasive vascular manipulations allows for minimizing the number of failed catheterizations and avoiding complications, which improves the efficiency of medical care and increases the level of comfort and safety for the patient.

Vaskularni pristupi kod dece - tehnike i komplikacije centralnih venskih katetera

The installation of central venous catheters in children becomes more complex the smaller the patients are. This is less due to the anatomy itself than to the dimensioning of the anatomical structures and the associated vulnerability. While the puncture based on anatomical landmarks CVC (Central Venous Catheter), should not be forgotten, especially for dealing with emergencies, the use of sonography in newborns, infants, and children has become indispensable in everyday clinical practice. While it is important to master the techniques of puncture and placement, one should always keep in mind the special considerations for children, especially younger ones, and be aware of potential undiagnosed anatomical variations. If these points are heeded, the installation of central venous catheters in children can be carried out safely, easily, and with few complications.

Construction and validity of an online course for nurses on central venous catheters in children at home

Resumo Objetivo construir um curso online e autoinstrucional para enfermeiros que realizam assistência às crianças em uso de cateter venoso central no domicílio e validar o conteúdo do curso por especialistas. Método estudo metodológico, alicerçado no Design Instrucional pelo modelo ADDIE, desenvolvido em duas etapas entre setembro de 2019 e maio de 2020: construção do curso; e validação do conteúdo por um comitê de oito especialistas, recrutados pelo método bola de neve por meio eletrônico. Utilizou-se o Instrumento de Validação de Conteúdo Educativo em Saúde, com ponto de corte ≥0,8 para a validação de conteúdo. Resultado s: elaboram-se 25 produtos tecnológicos para a produção final do curso: quatro planos de ação pedagógica, seis storyboards, nove recursos educativos em vídeo e 6 módulos do curso em formato Sharable Content Object Reference Model, aplicável em diferentes plataformas. Todos os módulos apresentaram Índice de Validade de Conteúdo ≥0,80 em todos os domínios e na avaliação global. Conclusão e implicações para a prática o conteúdo de todos os módulos foi validado pelos especialistas. O curso contribui para a prática assistencial, permitindo atualização com base em conteúdo atual e validado cientificamente. Ele pode ser utilizado em outras propostas pedagógicas, desde que atendidas as premissas da Licença Creative Commons 4.0 Internacional.

Comparison of Open and Ultrasound-Guided Placement of Central Venous Catheter in Children Weighing Less Than Five Kilograms; A Randomized Clinical Trial

Ultrasound is currently utilized to locate the internal jugular vein (IJV), reduce the complications of catheter placement, and increase the likelihood of accessing IJV. Therefore, the aim of the present study was to evaluate the effectiveness of ultrasound in reducing complications during catheter placement in children weighing less than 5 kg. The current randomized clinical trial was performed on 111 children weighing less than 5 kg who required a central venous catheter (CVC). Children were divided into two groups: in the first group (Seldinger group; n=55), a CVC was inserted using the Seldinger wire method under ultrasound guidance, and in the second group (open surgical cutdown (OSC); n=56), the catheter was inserted via the open method. Two weeks after catheter placement, patients were evaluated for thrombosis, catheter occlusion, catheter tip migration, infection, catheter removal, and catheter dysfunction. The success rate of catheter placement in the ultrasound-guided method was 85.5%. The incidence of thrombosis (3.6% vs. 5.4%), infection (1.8% vs. 7.4%), and bleeding (zero vs. 3.6%) was lower in the Seldinger group, but the difference was not significant (p ˃ 0.05). Hematoma (7.3% vs. 3.6%) occurred less frequently in the patients of the OSC group (p=0.33). Hemothorax, pneumothorax, catheter migration, and occlusion did not occur in any of the patients. In the OSC group, two deaths (3.6%) occurred due to underlying diseases. When ultrasound is used to insert a CVC in children weighing less than 5 kg, the incidence of complications is not significantly different compared to when the open method is employed.

Additionally using transthoracic echocardiography during ultrasound-guided jugular central venous catheter placement and the odds of catheter misplacement in children: A before-and-after study.

Central venous catheter (CVC) misplacement is a major complication.1 To avoid CVC misplacement, real-time ultrasound (US) guidance is recommended for CVC placement in children.2, 3 Transthoracic echocardiography (TTE) can be additionally used to confirm correct CVC tip position.4, 5 Whether additionally using TTE during US-guided jugular CVC placement reduces the incidence of catheter misplacement remains scarcely described. We thus sought to test the hypothesis that additionally using TTE during US-guided jugular CVC placement reduces the odds of CVC misplacement in children. After approval by the ethics committee with waiver of informed consent, we performed a retrospective before-and-after study in children aged 0–6 years who received a jugular CVC during anesthetic induction for congenital heart disease surgery at the University Medical Center Hamburg-Eppendorf (Hamburg, Germany) between March 2015 and April 2020. In our institution, jugular CVCs in children having cardiac surgery are routinely placed using real-time US guidance since 2013. In October 2017, routine use of additional TTE during US-guided jugular CVC placement was implemented. In the 31-month “before period” (March 2015 to September 2017), anesthesiologists did not use TTE but chose the CVC insertion depth considering patient height (no-TTE-group). In the 31-month “after period” (October 2017 to April 2020), additional TTE (subcostal long-axis view) was routinely used during US-guided jugular CVC placement to confirm the correct position of the guidewire and the CVC tip (rapid saline flush test) (TTE-group) (Figure S1). During both study periods, chest x-ray was used to confirm correct CVC tip position after surgery. We categorized CVCs as misplaced when the CVC tip ended above the level of the superior vena cava in a noncentral vein or deep in the right atrium (Figure S2). We investigated the associations between CVC misplacement and TTE use by logistic regression for all patients including age as covariate—and separately for patients aged <1 year and 1–6 years. We report the odds ratios (OR) with 95% confidence intervals. We included 373 patients (156 no-TTE-group and 217 TTE-group) (Table S1). CVC misplacement occurred in 15/156 no-TTE-group patients (9.6%) and in 5/217 TTE-group patients (2.3%). The odds for CVC misplacement were 371% lower when TTE was used compared to when it was not used (p = .004, OR = 0.21 [0.067–0.57]) (Figure 1). Of all 373 patients, 229 (61%) were younger than 1 year. In these patients, CVC misplacement occurred in 8/76 no-TTE-group patients (11%) and in 4/153 TTE-group patients (2.6%). The odds for CVC misplacement were 319% lower when TTE was used (p = .023, OR = 0.24 [0.062–0.79]). Of all 373 patients, 144 (39%) were between 1 and 6 years old. In these patients, CVC misplacement occurred in 7/80 no-TTE-group patients (8.8%) and in 1/64 TTE-group patients (1.6%). The odds for CVC misplacement were 480% lower when TTE was used (p = .107, OR = 0.17 [0.0090–1.0]). In our study, additionally using TTE during US-guided jugular CVC placement in children reduced the odds for CVC misplacement by more than 300%—which obviously is clinically meaningful. In only about 1% of children, the subcostal long-axis view could not be obtained—and TTE could thus not be used to confirm the CVC tip position. In general, children provide an excellent acoustic window for TTE examination of the right atrium and the superior vena cava. Nevertheless, TTE requires technical skills and operator experience. Our results need to be interpreted in light of the inherent limitations of retrospective before-and-after studies. Additionally, we only included children with congenital heart disease, whose anatomy may differ from healthy children. However, as we excluded patients with irregular venous conformations, we assume that our findings can be transferred to pediatric patients in general. Additionally using TTE during US-guided jugular CVC placement reduces the odds of CVC misplacement in children aged 0–6 years. Clinicians should consider additionally using TTE during US-guided jugular CVC placement to increase patient safety. This work was supported solely from institutional and/or department sources. There are no conflicts of interest to declare. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Supporting Information Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Ultrasound versus intracavitary electrocardiography for intraprocedural tip location during central venous catheterization in infants and children: A prospective clinical study.

Both intracavitary electrocardiography (IC-ECG) and ultrasound (US) have been proven to be safe and accurate for intraprocedural tip location during central venous catheterization, and both are known to be easily applicable and feasible in pediatric patients. Though, no prospective clinical study has directly compared the two methods as regards their applicability, feasibility, and procedural time. This study prospectively enrolled all children requiring a central venous access device in non-emergency situations, during a period of 1 year. All devices were inserted according to a well-defined insertion bundle including both IC-ECG and US-based tip location. The primary endpoint of the study was to compare the two methods in terms of applicability, feasibility and time required. This study included 100 consecutive central venous catheterizations in children of age ranging from 1 month to 18 years. The applicability of IC-ECG based tip location was 98% and its feasibility 100%; the time required for IC-ECG was 1.9 ± 2 min. The applicability of US-based tip location was 96% and its feasibility was 100%; the maneuver required 2.2 ± 3 min. US is an appropriate alternative method for intraprocedural tip location in children. The combined use of US and IC-ECG (both maneuvers being accurate, inexpensive, cost-effective, non-invasive, and equally fast to perform) should be recommended for tip location in pediatric patients, and it will avoid completely the use of fluoroscopy or of post-procedural x-ray.

Glucocorticosteroid and Silicone Gel During Patch Application Without Clinical Scar Improvement After Central Venous Catheter Removal: A Randomized Trial.

We studied whether glucocorticosteroid during patch occlusion has a beneficial effect on scar outcome in children and adolescents treated for cancer. A double-blinded placebo-controlled randomized clinical trial was performed. The main outcome was the Vancouver Scar Scale. Secondary outcomes were scar width and scar quality measured using the Patient and Observer Scar Assessment Scale. The patients were divided into an intervention groups and a control group. The intervention group was randomized into active and placebo group. The active treatment consisted of cream with glucocorticosteroid and fusidic acid. The placebo treatment consisted of cream with fusidic acid. Both groups received silicone gel patch after central venous catheter removal. The control group received no specific skin care. Assessment at 12 months showed that the intervention group had a significantly lower Vancouver Scar Scale and a smaller scar (0,1cm) compared with the control group ( P =0.00, P =0.02) but no benefit of glucocorticosteroid. The Patient and Observer Scar Assessment Scale showed no significant difference between the intervention and control groups ( P =0.84, P =0.36). Silicone gel sheet alone or in combination with application of glucocorticosteroid during sheet occlusion does not clinically improve scar outcome after removal of central venous catheter in children treated for neoplastic diseases.

Management of Central Venous Catheters in Children and Adults on Home Parenteral Nutrition: A French Survey of Current Practice.

Although central venous catheter (CVC)-related thrombosis (CRT) is a severe complication of home parenteral nutrition (HPN), the amount and quality of data in the diagnosis and management of CRT remain low. We aimed to describe current practices regarding CVC management in French adult and pediatric HPN centers, with a focus on CVC obstruction and CRT. Current practices regarding CVC management in patients on HPN were collected by an online-based cross-sectional survey sent to expert physicians of French HPN centers. We compared these practices to published guidelines and searched for differences between pediatric and adult HPN centers’ practices. Finally, we examined the heterogeneity of practices in both pediatric and adult HPN centers. The survey was completed by 34 centers, including 21 pediatric and 13 adult centers. We found a considerable heterogeneity, especially in the responses of pediatric centers. On some points, the centers’ responses differed from the current guidelines. We also found significant differences between practices in adult and pediatric centers. We conclude that the management of CVC and CRT in patients on HPN is a serious and complex situation for which there is significant heterogeneity between HPN centers. These findings highlight the need for more well-designed clinical trials in this field.

521 Maintaining Central Line Patency in Burned Children

IntroductionChildren with major burn injury frequently require prolonged central venous access to assure appropriate fluid management and pain control. Central venous catheters in children frequently develop clots that prevent drug administration, requiring administration of tissue plasminogen activator (TPA). The purpose of this study was to identify the frequency and efficacy of TPA use in burned children with central venous catheters (CVC).MethodsThis retrospective chart review evaluated all children requiring CVC admitted to our tertiary pediatric burn center from 2018-2019. Data collected included patient demographics (age, burn size, hospital length of stay (LOS)), catheter-related data (number of central lines, lines replaced due to clotting), TPA administration (number of times administered, successful TPA administrations, how often repeated), and line clotting data (time from insertion to clot, interval between TPA order and administration).ResultsIn 2018, 116 lines were place in 49 children with mean age of 8.4 years and mean burn size of 29%, intensive care unit LOS was 24 days. TPA was infused in 20% of lines to relieve obstruction and was successful in relieving the clot in 21% (5/23). The interval between identification of the obstructed line to TPA order was 191 minutes, with the administration of TPA 83 minutes after order placement. The average time from identification of obstruction to TPA administration was 257 minutes. In 2019, 150 lines were place in 65 children with mean age of 5.2 years and mean burn size of 25%, LOS was 13 days in the PICU. TPA was infused in 5% of lines to relieve obstruction and was successful in relieving the clot in 0 % (0/8). The interval between identification of the obstructed line to TPA order was 117 minutes, with the administration of TPA 49 minutes after order placement. The average time from identification of obstruction to TPA administration was 158 minutes.ConclusionsThe incidence of obstruction in pediatric central venous catheters in our unit decreased from 26% in 2018 to 3% in 2019. TPA was successful in clot resolution in only 5% (2018), and 0% (2019) . Based on our results, we targeted areas for improvement including: Standing order for TPA; staff education on TPA use; decreasing our average time to identify, order, and administer TPA; and standardizing the frequency of flushing unused central venous catheter lumens with heparinized saline flush.

A survival analysis of cuffed tunneled silicon central venous catheters in children affected by short bowel syndrome: A lesson from the past.

Tunneled central venous catheters (CVC) are crucial in the management of children affected by short bowel syndrome (SBS). This work aims to investigate the outcomes of tunneled CVC and to identify factors influencing their survival. All the children diagnosed with SBS and undergone a procedure of insertion of a tunneled CVC from 2010 to 2019 were included. Demographic data and surgical information about the procedures were collected. Regression models and Kaplan-Meier analysis were performed to estimate the survival. Eighteen patients, eight males (44%), with a median length of residual bowel measuring 72 cm (IQR 50-102 cm), were enrolled. Thirty-nine Broviac CVCs were inserted with a mean number of 2.2 CVCs per patient and 13365 line-days. The overall incidence of complications was 3.2/1000 line-days, and the incidence of central line associated bloodstream infections (CLABSI) was 1.1/1000 line-days. No episode of catheter thrombosis was reported. The median survival was 269 days (IQR 82-1814 days). The survival was negatively influenced by a younger age at insertion (R2 = 0.29; p < 0.001), 2.7 Fr diameter (median survival 76 days; p < 0.001) and the occurrence of complications (median survival 169 days; p = 0.002). The length of residual bowel was a mild risk factor for anticipated removal (OR 1.1; CI95 1.0-1.1; p = 0.05). CVC-related complications negatively influenced the survival of the line. An elder age at insertion together with a larger CVC diameter increased the survival of the line, while a shorter residual bowel was associated with an anticipated removal due to complications.

A prospective study on safety and outcomes of ultrasound guided tunneled central venous catheter in children with cancers from low middle income country

A prospective study on safety and outcomes of ultrasound guided tunneled central venous catheter in children with cancers from low middle income country

Central venous catheter in children with cancer: Are we optimal? - Retrospective audit from a tertiary cancer care centre in India

Central venous catheter in children with cancer: Are we optimal? - Retrospective audit from a tertiary cancer care centre in India

Mechanical complications of central venous catheters in children: A cohort study.

Despite the numerous advantages of central venous catheters (CVCs), they have been associated with a variety of complications. Surveillance for mechanical complications of CVCs is not routine, so the true incidence and impact of this adverse patient outcome remains unclear. Prospectively collected CVC data on mechanical complications were reviewed from a centralized database for all in-hospital patient days at our tertiary-care hospital from January 2001 to June 2016 in patients aged <19 years. Patient demographics, CVC characteristics, and rates of mechanical complications per 1,000 days of catheter use were described. In total, 8,747 CVCs were placed in 5,743 patients during the study period, which captured 780,448 catheter days. The overall mechanical complication rate was 6.1 per 1,000 catheter days (95% confidence interval [CI], 5.9-6.3). The highest complication rates were in nontunneled lines; this was consistent throughout the 15-year study period. Also, 521 CVCs (∼6%) were removed due to mechanical complications before therapy termination. Catheters with tip location in the superior vena cava or right atrium had the fewest complications. Mechanical complications of CVCs are a common and significant event in the pediatric population. We propose that CVC-associated mechanical complications become a routinely reported patient safety outcome.

Secondary Anticoagulation Prophylaxis for Catheter-Related Thrombosis in Pediatric Intestinal Failure: Comparison of Short- Vs Long-Term Treatment Protocols.

Catheter-related thrombosis (CRT) is a devastating complication of central venous catheters in children with intestinal failure (IF), but the optimal preventive therapy of CRT is unknown. This study assessed the efficacy and safety of 2 protocols of secondary anticoagulation prophylaxis with low-molecular-weight heparin (LMWH). This is a comparative cohort study of children from 2 IF programs who received secondary anticoagulation prophylaxis with LMWH for CRT. The short-term protocol group (N = 13) received therapeutic dosing until thrombus resolution or ≤3 months. In the long-term protocol group (N = 26), prophylactic dosing continued until line removal. Patients underwent routine annual vascular ultrasound and were followed for ≥1 year. The primary outcome was development of secondary thrombosis; post hoc analysis assessed rates of secondary thrombosis at 12 months. Patient demographics were similar between groups. Secondary thrombosis occurred in 8 of 13 (62%) patients in the short-term group and in 9 of 26 (35%) in the long-term protocol group (P = .019) in a median time of 144.5 and 689 days, respectively (P = .01). Secondary thrombosis within 12 months occurred in 7 of 13 (54%, short term) and 2 of 26 (8%, long term) patients (P = .001). Secondary thrombosis was associated with catheter replacements (23.5 vs 5.5 catheters per 1000 catheter days; P = .016) and longer daily parenteral nutrition (PN) infusion (24 vs 15.25 hours; P = .044). Compliance was good (>80% of doses) in 92% of patients. Long-term secondary anticoagulation prophylaxis with LMWH reduces the incidence of secondary thrombosis and should be considered in children with CRT that require PN for prolonged periods of time.

Asymptomatic central line-associated bloodstream infections in children leading to right-sided infective endocarditis

Background: Indwelling central venous catheters (CVC) are used to provide long term hemodialysis (LT-HD). The commonest and the severe complication of CVC is the central line-associated bloodstream infection (CLABSI). This study was done to assess the etiology and infectious complications of CVC in children on LT-HD. Methods and materials: Children newly undergoing hemodialysis and having indwelling CVC were included. They were followed up to a period of 2 y to assess infectious complications. Catheter bundle care approach was employed to prevent infections and other complications. Automated culture from the CVC and peripheral vein and 2D-echocardiography were done in each hemodialysis. Serial procalcitonin (PCT) was measured. Differential time of positivity (DTP) was used to detect CLABSI. Following discharge, weekly telephone conversations were done to assess features of infection, and whenever having, we have asked to admit to the tertiary care unit. Logistic regression was performed, and the significant outcome variable was considered as risk factors. Results: Blood cultures were positive in 1090 (74.5%) out of 1462 children. According to DTP, 410 (28%) were having CLABSI, while 520 (35.6%) were having bacteremia without CLABSI. Out of 410 CLABSI patients, 175 (42.7%) were asymptomatic. Coagulase-negative Staphylococcus sp. (CoNS) bacteremia was significantly associated with asymptomatic CLABSI. Right-sided infective endocarditis (RS-IE) was significantly associated with asymptomatic CLABSI and asymptomatic bacteremia without CLABSI. CoNS was associated significantly in RS-IE following asymptomatic CLABSI and asymptomatic bacteremia. PCT was in asymptomatic CLABSI was 1.8 ± 0.9 ng/mL while in symptomatic CLABSI was 11.3 ± 2.5 ng/ml (p = 0.02). CoNS bloodstream infection, tunneled CVC, peripherally inserted central catheter, femoral site, the number of line days > 90, receipt of vancomycin, meropenem, or linezolid in the 5 d before CLABSI diagnosis and recurrent bacteremia were risk factors for asymptomatic CLABSI. Conclusion: Asymptomatic CLABSI could be a rare occurrence. CoNS was predominantly isolated in patients with asymptomatic CLABSI. RS- IE is a well-known complication in long term indwelling CVC. CoNS was significantly associated with RS-IE following asymptomatic CLABSI. Regular procalcitonin, microbiological, and imaging studies would be essential to detect infectious complications in both symptomatic and asymptomatic patients implanted with long term indwelling CVCs.