Central Venous Catheters In Children Research Articles

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.

Insertion of central venous catheters in children undergoing bone marrow transplantation: is there a platelet level for a safe procedure?

BackgroundBone marrow transplantation (BMT) is a therapeutic procedure for the management of several hematological diseases and malignancies in pediatric population. Central venous catheters (CVCs) play a pivotal role during the process of BMT. The aim of this study was to compare the complications of CVCs placements in children undergoing BMT with platelet levels above and below 50,000/μL and also to detect if there is a platelet count for a safe insertion. This prospective study included all children who had placements of tunneled CVCs during BMT at our hospital between March 2017 and March 2020. Procedures were divided into two groups accordingly to preoperative platelet counts (above and below 50,000/μL). Data were compared between both groups regarding postoperative complications including bleeding or catheter-related blood stream infections (CRBSIs).ResultsForty-six CVC insertions were performed in 40 patients. There were 20 procedures below 50,000/μL (median 27,500; range 5000–42,000) inserted with perioperative platelet transfusions, and their postoperative levels were median 59,500/μL, range 18,000–88,000. Allogeneic BMT was adopted in 39 patients (97.5%). Beta thalassemia major was the commonest indication (21/40, 52.5%), followed by acute lymphocytic leukemia in six patients (15%). There were nine postoperative complications (bleeding n = 2 and CRBSIs n = 7) encountered in all placements. Four of them occurred in insertions below 50,000/μL (two bleeding complications that managed conservatively, and two CRBSIs). Post-procedural morbidities regarding bleeding or CRBSIs did not differ significantly between both groups (p value = 0.099 and 0.695, respectively).ConclusionsPostponement of CVC insertions in thrombocytopenic children due to the fear of potential complications seems unwarranted, as it has no significant impact on the morbidity. Placements of such catheters can be safe under cover of perioperative platelet transfusions irrespective of the preoperative platelet count.

Asymptomatic central line-associated bloodstream infections in children implanted with long term indwelling central venous catheters in a teaching hospital, Sri Lanka

BackgroundIndwelling central venous catheters (CVC) are used to provide long term hemodialysis. 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 long term hemodialysis.MethodsChildren newly undergoing hemodialysis and having indwelling CVC were included. They were followed up to a period of 2-years to assess infectious complications. Catheter bundle care approach was employed to prevent infections and other complications. Automated culture from the central catheter 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. During homestay in 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 following multivariable analysis as a risk factor.ResultsBlood 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, 79 (19.2%) were asymptomatic. Coagulase-negative Staphylococcus spp. (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 days before CLABSI diagnosis and recurrent bacteremia were risk factors for asymptomatic CLABSI.ConclusionsAsymptomatic 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.

Rates of Venous Thromboembolism and Central Line-Associated Bloodstream Infections Among Types of Central Venous Access Devices in Critically Ill Children.

Central venous access devices, including peripherally inserted central catheters and central venous catheters, are often needed in critically ill patients, but also are associated with complications, including central-line associated bloodstream infections and venous thromboembolism. We compared different central venous access device types and these complications in the PICU. Multicenter, cohort study. One hundred forty-eight participating Virtual PICU Systems, LLC, hospital PICU sites. Pediatric patients with central venous access placed from January 1, 2010, to December 31, 2015. None. Patient and central venous access device variables postulated to be associated with central-line associated bloodstream infection and venous thromboembolism were included. Data were analyzed using Pearson chi-square test or Fisher exact test for categorical variables, Mann-Whitney U test for continuous variables, and logistic regression and classification trees for multivariable analysis that examined significant predictors of venous thromboembolism or central-line associated bloodstream infection. Analysis included 74,196 first lines including 4,493 peripherally inserted central catheters and 66,194 central venous catheters. An increased rate of venous thromboembolism (peripherally inserted central catheter: 0.93%, central venous catheter: 0.52%; p = 0.001) (peripherally inserted central catheter: 8.65/1,000 line days, central venous catheter: 6.29/1,000 line days) and central-line associated bloodstream infection (peripherally inserted central catheter: 0.73%, central venous catheter: 0.24%; p = 0.001) (peripherally inserted central catheter: 10.82/1,000 line days, central venous catheter: 4.97/1,000 line days) occurred in peripherally inserted central catheters. In multivariable analysis, central venous catheters had decreased association with central-line associated bloodstream infection (odds ratio, 0.505; 95% CI, 0.336-0.759; p = 0.001) and venous thromboembolism (odds ratio, 0.569; 95% CI, 0.330-0.982; p = 0.043) compared with peripherally inserted central catheters. Peripherally inserted central catheters are associated with higher rates of central-line associated bloodstream infection and venous thromboembolism than central venous catheters in children admitted to the PICU.

Accuracy of electrocardiography guidance for depth of insertion of central venous catheters in children: A prospective observational study

Context: Central venous catheters (CVCs) have become integral in the pediatric intensive care setting as well as in the operating room (OR). In the OR, these lines are usually used without prior confirmation of correct position, and a chest radiograph is performed postoperatively, several hours later. Hence, it is desirable to confirm the correct CVC position immediately after placement. Aim: This observational study was designed to evaluate the accuracy of electrocardiography (ECG) guidance on correct CVC positioning in pediatric population. Settings and Design: This was a prospective observational study. Subjects and Methods: Patients till 12 years of age were included in the study. Ultrasound was used to guide initial cannulation of the vessel. Certodyn® universal adaptor was connected to the guidewire via a sterile alligator clip. The CVC along with the guidewire was advanced till it lies in the right atrium which was seen by an increase in the amplitude of P-wave on the intracardiac ECG. The CVC was then withdrawn slowly until the P-wave morphology returned to normal or preprocedural configuration. Statistical Analysis Used: Data were expressed as percentage. Results: Out of the 68 patients, the percentage of patients having appropriate position of CVC tip was 95.5% (65 patients). Out of the three patients with incorrect tip position, in two patients, the tip was distal to the appropriate position and in one case, the ECG changes could not be appreciated. Conclusions: ECG-guided CVC placement has high accuracy of correct positioning in infants and children.

Risk factors for central line–associated bloodstream infections in children with tunneled central venous catheters

Central line-associated bloodstream infections (CLABSIs) are among the most common complications of central venous catheters (CVCs). The aim of this study was to examine the epidemiology of CLABSIs in tunneled CVCs and analyze their risk factors in a general pediatric population. Children with a tunneled CVC inserted at the University Children's Hospital Zürich between January 2009 and December 2015 were eligible for the study. The influence of CVC dwell time on the risk of CLABSI was examined using life tables. Hazard ratios (HRs) for CLABSIs were analyzed using Cox regression for age and diagnosis with cluster robust standard errors. Fifty-five CLABSIs were observed in 193 patients with 284 tunneled CVCs. Overall, CVCs in children with gastrointestinal disorders and in children 2 to 5 years of age showed the highest incidence rates of 6.06 and 5.85 CLABSIs per 1,000 catheter days, respectively, during the first 90 days after placement. Gastrointestinal disease (HR, 3.89; 95% CI, 2.19-6.90; P < .001) and age 2 to 5 years (HR, 2.48; 95% CI, 1.45-4.22; P = .001) were identified as independent risk factors for CLABSI. In children without gastrointestinal disease, tunneled CVCs showed an increasing risk of CLABSI after a dwell time of 90 days. The need for tunneled CVCs requires the evaluation of targeted CLABSI prevention measures, especially in young children with underlying gastrointestinal disease.

Should you pick the PICC? Prolonged use of peripherally inserted central venous catheters in children with intestinal failure

PurposeProlonged central vascular access is a source of significant morbidity in children with intestinal failure (IF). In an effort to decrease morbidity, our multidisciplinary IF team has primarily used peripherally inserted central catheters (PICCs) for these patients. We compared outcomes of PICCs to Broviacs®. MethodsA review of children with IF (2006–2018) at an academic children's hospital was conducted. Inclusion criteria: total parenteral nutrition duration >42 days or small bowel length < 25% of total for gestational age. Complications/1000 catheter days were extracted, and a Poisson model was used to compare complications between PICCs and Broviacs®. ResultsThirty-seven patients with IF were included, accounting for 19,452 catheter days. There were 209 PICCs (1.2–4F) and 39 Broviacs® (2.7–7F). The median duration of overall PICC access/patient was 166 days (range: 35 days–8 years). Incidences of central line associated blood stream infection and venous thrombosis were 3.95 and 0.55 per 1000 catheter days, respectively. There were no significant differences in complication rates per line per catheter day between PICCs and Broviacs® on multivariate analysis. Broviacs® showed a trend towards increased of catheter-related hospital admissions when compared to PICCs. ConclusionsPICCs in children with intestinal failure have similar complication rates to Broviacs® but may reduce catheter-related hospital admissions. Use of tunneled PICCs and increasing experience with this vascular access method may allow it to realize its potential advantages. Level of evidenceRetrospective study, level III.

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.

Ultrasound guidance improves safety and efficiency of central line placements

BackgroundUse of ultrasound-guidance for central venous access in adults is the standard of care. There is, however, less clarity in the role of routine ultrasound use in obtaining venous access in children. We sought to evaluate safety and efficiency of the placement of central lines utilizing an ultrasound-guided approach compared to the traditional, landmark approach in pediatric patients. Study designA single-institution retrospective chart review, using CPT codes, was performed for all tunneled central venous catheters in children between 2005 and 2017 by the same pediatric surgery group. During the study period, a practice change occurred from exclusively landmark-based line placement to ultrasound-guided line placement. Groups were divided into three phases: a traditional/landmark era (Phase 1), transitional period (Phase 2), and the ultrasound era (Phase 3). The primary outcomes analyzed were postoperative chest tube insertions and operative time. ResultsA total of 2010 tunneled central lines were included for analysis: Phase 1 (N = 930), Phase 2 (N = 313) and Phase 3 (N = 767). Venous access for chemotherapy was the most common indication (29%). Phase 1 had a chest tube placement rate of 9.7/1000 procedures, while Phase 2 had a rate of 6.4/1000 procedures, and Phase 3 had no chest tube insertions (p = 0.009). Phase 1 had longer OR times compared to Phase 2 (57 vs. 49, p = 0.0026) and Phase 3 (57 vs. 46 min, p < 0.001). ConclusionsThis study represents the largest analysis of ultrasound-guided access for children. A complete practice transition to the ultrasound-guided approach was feasible within a two-year period. The ultrasound-guided approach had a shorter operative time and less chest tube insertions than the traditional, landmark technique in children.Level III evidence.

Ultrasound versus anatomical landmarks: Immediate complications in the central venous catheterization in children under 18 years of age

Abstract Introduction The insertion of a central venous line in children and adolescents is technically more difficult, due to the smaller size of the structures. This can lead to an increase in immediate complications, which can be reduced when using ultrasound. In our institution, the percentage of these complications and the use of ultrasound are unknown. Objective To describe the frequency of immediate complications of central venous catheterisation guided by the ultrasound in a general university hospital, compared to the anatomical landmarks technique in children less than 18 years of age. Materials and methods Observational, retrospective, and analytical study, comparing the frequency of complications with two central venous catheterisation techniques: anatomical landmarks and ultrasound, according to the clinical records of procedures performed from June to November 2016. Results A total of 201 procedural records were analysed, of which 71% were with landmarks, and 29% with ultrasound. The overall incidence of immediate complications was 18.4%, with 12% using ultrasound and 21% using landmarks (OR: 0.5; 95 CI: 0.2–1.2). Children under 5 years of age presented with 90% of the complications, the most frequent being the impossibility of passing the guide (29.7%) and multiple punctures (24.3%). There was no arterial puncture with use of ultrasound. Ultrasound was used by 13.4% of paediatric surgeons, by 32.4% of paediatricians, and 46.4% of anaesthetists, with complications of 25%, 19%, and 7%, respectively. The main indication for catheterisation was the need for vasoactive agents (74%), with the procedure being more complicated in patients with no peripheral venous accesses (46%). The success rate with anatomical landmarks was 77.6%, compared to 91.4% with ultrasound. Conclusion Central venous catheterisation with ultrasound guidance in children under 18 reduces immediate complications by 42.8% and improves the success rate by 13.8%.

A case report of infective endocarditis in a 10-year-old girl.

Infective endocarditis is a rare disease in children, and it can result in significant morbidity and mortality. The epidemiology of infective endocarditis in children has shifted in recent years with less rheumatic heart disease, more congenital heart disease survival, and increased use of central venous catheters in children with chronic illness. Less commonly, infective endocarditis occurs in children with no preexisting cardiac disease or other known risk factors. We present a "case of" 10 year-old girl with no known cardiac disease or any other risk factors who was diagnosed with infective endocarditis according to modified Duke criteria. Blood cultures grew haemophilus parainfluenza. She had prolonged fever for 2 weeks after starting antibiotics, even though her blood culture became sterile 48 hours after treatment. We emphasize the importance of maintaining high index of suspicion for endocarditis in febrile children, even those without cardiac anomalies or other apparent risk factors.

Bloodstream infection and occlusion of central venous catheters in children

One in ten children with a central venous catheter (CVC) develops a central line-associated bloodstream infection (CLABSI),1 which is a life-threatening complication and harmful distraction from time-sensitive treatment. However, across CVC types (figure), device occlusion is also troublesome and might increase CLABSI risk, presumably through the complementary interactions of fibrin, thrombus, and biofilms.2 The question arises as to what antimicrobial, antithrombotic, or other solution can be periodically instilled (known as locked) within the CVC to prevent one, or preferably both, of these complications. Furthermore, which solutions could effectively treat such complications, should they arise, without needing to remove the CVC? Few high-quality randomised controlled trials have addressed these questions, and it is difficult to find two health-care institutions that share identical policies for lock solution type, concentration, frequency, or duration of dwell. This situation has probably resulted in preventable injuries in children who rely on CVCs to administer treatment.

Abstract P-379: EFFECT OF ANTIBIOTIC IMPREGNATED CENTRAL VENOUS CATHETERS ON SERIOUS THROMBOSIS IN THE PEDIATRIC INTENSIVE CARE SETTING

Aims & Objectives: The CATCH clinical trial found antibiotic impregnated central venous catheters (CVCs) reduced bloodstream infections compared to heparin bonded or standard CVCs in paediatric intensive care units (PICUs), but evidence is lacking on the effect of antibiotic impregnation on clinical signs of serious thrombosis, resulting in CVC removal. Methods 1859 children (<16 years) admitted to 14 English PICUs between December 2010 and November 2012 who required a CVC for ≥3 days were randomised to receive, antibiotic impregnated, heparin bonded, or standard CVC. Consent was obtained for analysis of 1485 CVCs. Signs of two episodes of difficulty withdrawing blood or flushing, swollen limb, positive ultrasound and CVC removal due to thrombosis were documented. Observational analysis was used to create a clinically significant thrombosis definition based on what signs were predictive of CVC removal (serious thrombosis). Cox proportional hazard regression was used for three-ways comparisons between CVC types, adjusting for significant risk factors: age, cardiovascular admission, femoral insertion, anticoagulant use and systemic infection. Results Swollen limb was an early sign of thrombosis (median 2.5 days from insertion) and occurred in 40.6% (41/101) of CVC removals. Serious thrombosis was defined by one report of swollen limb or CVC removal. Significant risk factors were femoral insertion and systemic infection. No difference was found between antibiotic impregnated versus standard CVCs (Hazard ratio:1.32:95% confidence interval;0.91,1.93) nor antibiotic impregnated versus heparin bonded CVCs(HR:0.98;0.68,1.40) in time to serious thrombosis. Conclusions Antibiotic impregnated CVCs do not increase risk of serious thrombosis compared to heparin bonded or standard CVCs in children.

Increased Risk of Thrombosis Associated with Peripherally Inserted Central Catheters Compared with Conventional Central Venous Catheters in Children with Leukemia

To study the risk of catheter-associated thrombosis (CAT) between peripherally inserted central catheters (PICCs) and tunneled central venous catheters in children with leukemia. We analyzed all PICCs and conventional tunneled catheters placed in patients aged <18 years and admitted to our institute for leukemia treatment between February 2008 and April 2014. Cases of symptomatic CAT were confirmed by ultrasound and treated with low-molecular-weight heparin. During the study period, 157 PICCs and 138 conventional tunneled catheters were placed in 192 patients with leukemia. CAT incidence was 1.5% (n = 2) in the conventional tunneled catheter group and 10.2% (n = 16) in the PICC group. The OR for CAT occurrence after PICC vs conventional tunneled catheter placement was 5.6 (95% CI, 1.2-26.5). Our results suggest that the use of PICCs in children with leukemia increases the risk of CAT in comparison with the use of conventional tunneled catheters. Further randomized controlled studies are needed to characterize this risk and to better define indications.

392 The Effect of Impregnated Central Venous Catheters in Children

392 The Effect of Impregnated Central Venous Catheters in Children

Central venous access in children: indications, devices, and risks.

Central venous catheters (CVCs) have a prominent role in the diagnostic and therapy of neonates and children. Herein, we describe the multiple indications for CVC use and the different devices available for central venous access. Given the prevalent use of CVCs, healthcare systems are focused on reducing complications from their use, particularly central line-associated bloodstream infections (CLABSIs). The most up-to-date information available sheds light on best practices and future areas of investigation. Large systematic reviews of randomized trials suggest that ultrasound guidance for placement of CVCs in children is safer than using blind technique, at least for internal jugular vein access. Appropriate catheter tip placement is associated with decreased complications. Furthermore, the prophylactic use of ethanol lock between cycles of parenteral nutrition administration has reduced the rates of CLABSI. A recent randomized trial in pediatric CVCs showed a benefit with antibiotic-coated CVCs. Based on the available evidence, multiple techniques for CVC placement are still valid, including the landmark technique based on practitioner experience, but ultrasound guidance has been shown to decrease complications from line placement. Adherence to CVC care protocols is essential in reducing infectious complications.

Hybrid interventions for catheter placement in pediatric intestinal rehabilitation patients with end-stage venous access

PurposeThe purpose of this study is to analyze the combined approach of endovascular and open surgical procedures for insertion of permanent central venous catheters in children with intestinal failure and end-stage venous access. MethodsData of 14 children (16 interventions) with intestinal failure and end-stage venous access, treated within the pediatric intestinal rehabilitation program at our institution between September 2011 and November 2016, were retrospectively reviewed. The patients underwent hybrid endovascular/open surgical approaches for insertion of central venous catheters. Access to central veins was established through endovascular intervention; catheter placement was achieved with combined interventional and surgical measures depending on the individual vascular conditions. ResultsMedian age at intervention was 47months (interquartile range (IQR),29–74), median time for interventions was 66min (IQR,42–111). Catheter placement was successfully achieved in all patients. The median dose of irradiation during angiography was 0.2Gy*cm2 (IQR, 0.2–0.6), no complications occurred during or after interventions. ConclusionsHybrid endovascular/open surgical procedures can be successfully applied for restoring or maintaining permanent central venous catheters in children with intestinal failure and end-stage venous access. These approaches are a valuable contribution in intestinal rehabilitation programs contributing to a further decrease of the need for intestinal transplantation in affected patients. Type of studyTreatment Study. Level of evidenceLevel IV.

Tunneled central venous catheters in children with malignant and chronic diseases: A comparison of open vs. percutaneous implantation

PurposeTunneled central venous catheters (tCVCs) are routinely used for long-term venous access in children with cancer and chronic diseases. They may be inserted by surgical venous cut-down or percutaneously. The aim of this study was to compare the operative times and intraoperative complications of both techniques. MethodsThis study compared group A (surgical venous cut-down, years 2002–2006) with group B (percutaneous, years 2008–2012). Patient characteristics, operative times, and intraoperative complications were obtained from surgical reports. (IRB review and approval, number 6/15). Both Hickman/Broviac and Portacath catheters were included. Results343 patients in group A and 321 patients in group B were studied. Ages at implantation and underlying diagnoses were similar. Operative time was significantly shorter in group B. Only 60% of primarily dissected veins were suitable for surgical implantation, whereas successful vessel puncture was possible in 96% (87% on the first attempt, 9% on the second). Bleeding occurred in 2% of patients in group A, and pneumothorax occurred in 1.8% of patients in group B. Early catheter dislodgement was similar in both groups. ConclusionPercutaneous tCVC implantation is safe, less invasive, and faster than surgical implantation. Both techniques are feasible, and complication rates are low. Level of evidenceLevel III

小児における鎖骨下静脈カテーテル完全断裂例 2 例の経験

小児における鎖骨下静脈カテーテル完全断裂例 2 例の経験