Venous Catheters In Pediatric Patients Research Articles

Adverse Events from Fluoroscopic versus Portable Placement of Peripherally Inserted Central Catheters and Central Venous Catheters in Pediatric Patients

PurposeTo compare the outcomes of fluoroscopic versus portable placement of peripherally inserted central catheters (PICCs) and central venous catheters (CVCs) in pediatric patients. Materials and MethodsThis is a single-center, retrospective review of 346 upper-extremity PICC placements (286 fluoroscopic and 60 portable; mean age, 9.83 years [SD ± 5.58]; 49.1% female) and 138 tunneled femoral CVC placements (56 fluoroscopic and 82 portable; mean age, 0.23 years [SD ± 0.36]; 57.0% female). Portable placements used mobile plain-film radiography. All lines were placed by board-certified interventional radiologists. ResultsFluoroscopic PICC placements had a lower procedure time (43.9 vs 57.9 minutes; P < .001), radiation dosage (342 vs 590 mGy·cm2; P < .001), incidence of technical failure (0% vs 3.3%; P = .029), and incidence of catheter malfunction (1.7% vs 12.1%; P < .001) compared with portable PICC placements. Fluoroscopic CVC placements had a lower procedure time (42.6 vs 54.8 minutes; P < .001) and radiation dosage (63.8 vs 405 mGy·cm2; P < .001) compared with portable CVC placements. No technical failures were found in either CVC groups and the difference was nonsignificant for catheter malfunction (0% vs 7.3%; P = .081). Fluoroscopic placements of PICCs and CVCs had a lower incidence rate of central line–associated bloodstream infection compared with portable placements (0.71 vs 2.22 cases per 1,000 line-days; P = .046). Overall, fluoroscopic placements of PICCs and CVCs had fewer adverse events compared with portable placements (3.2% vs 14.8%; P < .001). Portable procedure setting was the only significant factor associated with adverse events (odds ratio, 33.77; 95% CI, 4.56–757.01). ConclusionsFluoroscopic placements of PICCs and CVCs are associated with lower procedure time, radiation dose, and risk of adverse events compared with portable placements in pediatric patients.

Results of a long-term, prospective study on complications of central venous catheter in pediatric patients with hematologic-oncologic diseases.

Central venous catheter (CVC)-related complications remain a significant cause of morbidity in pediatric hematology-oncology. We prospectively surveyed the incidence of CVC-related complications in children with hematologic-oncologic diseases. Five-hundred-eighty-one CVCs were inserted in 421 patients from January 2010 to June 2022 (153,731 CVC days observation; follow-up data up to December 31, 2022). Overall, 671 complications were recorded (4.365/1000 CVC days): 49.7% malfunctions (1.88/1000 CVC days, 4.8% of CVC early removals), 23.9% bacteremia (0.90/1000, 15.1%), 19.6% mechanical complications (0.74/1000, 70.2%), 20.1% localized infections (0.76/1000, 17.1%), 0.5% thrombosis (0.02/1000, 33.3%). At multivariate analysis, risk factors for malfunction were Broviac-Hickman type of CVC (hazard ratio [HR] 2.5) or Port-a-cath (HR 3.4) or Proline (HR 4.3), p<.0001; for bacteremia double-lumen CVC (HR 3.2, p<.0001); for mechanical complications age at CVC insertion under median (HR 4.5, p<.0001) and Broviac-Hickman (HR 1.6) or Proline (HR 2.7), p=.01; finally for localized infections Broviac-Hickman (HR 2.9) or Proline (HR 4.4), p=.0001. The 2-year cumulative incidence of premature removal was 23.5%, and risk factors were age at CVC insertion under median (HR 2.4, p<.0001), Broviac-Hickman (HR 2.3) or Proline (HR 4.2), p<.0001. Premature removal occurs in approximately 20%-25% of long-term CVCs. A surveillance program has a fundamental role in identifying the risk factors for CVC complications and the areas of intervention to improve CVC management.

Heparin Versus Normal Saline: Flushing Effectiveness in Managing Central Venous Catheters in Pediatric Patients With Cancer.

There is insufficient evidence of the effects of intermittent flushing with normal saline versus heparin to prevent occlusion or increased alteplase use in pediatric patients with central venous catheters. The primary objective was to evaluate the effectiveness of a new standard flushing practice in the management of central venous access devices in pediatric patients with cancer. A secondary objective was to assess the cost of heparin flushing supplies to patients and financial impact. New flushing guidelines included tunneled lines flushed with saline in the push-pause method twice daily in the inpatient setting. The outpatient setting required saline lock while receiving care and heparin lock on discharge. Alteplase usage was monitored for five months in all pediatric patients with cancer who had tunneled central lines. There was no statistically significant difference in alteplase usage rate pre- to postimplementation. A formal flushing guideline was recommended using saline and lower heparin concentrations for tunneled catheters.

Retrospective Assessment of Patient and Catheter Characteristics Associated With Malpositioned Central Venous Catheters in Pediatric Patients.

The primary objective was to determine the prevalence and characteristics associated with malpositioned temporary, nontunneled central venous catheters (CVCs) placed via the internal jugular (IJ) and subclavian (SC) veins in pediatric patients. Single-center retrospective cohort study. Quaternary academic PICU. Children greater than 1 month to less than 18 years who had a CVC placed between January 2014 and December 2018. None. The primary outcome was the CVC tip position located on the first postprocedural radiograph. CVC tip was defined as follows: "recommended" (tip location between the carina and two vertebral bodies inferior to the carina), "high" (tip location between one and four vertebral bodies superior to the carina), "low" (tip position three or more vertebral bodies inferior to the carina), and "other" (tip grossly malpositioned). Seven hundred eighty-one CVCs were included: 481 (61.6%) were in "recommended" position, 157 (20.1%) were "high," 131 (16.8%) were "low," and 12 (1.5%) were "other." Multiple multinomial regression (referenced to "recommended" position) showed that left-sided catheters (adjusted odds ratio [aOR], 2.00, 95% CI 1.17-3.40) were associated with "high" CVC tip positions, whereas weight greater than or equal to 40 kg had decreased odds of having a "high" CVC tip compared with the reference (aOR, 0.45; 95% CI, 0.24-0.83). Further, weight category 20-40 kg (aOR, 2.42; 95% CI, 1.38-4.23) and females (aOR, 1.51; 95% CI, 1.01-2.26) were associated with "low" CVC tip positions. There was no difference in rates of central line-associated blood stream infection, venous thromboembolism, or tissue plasminogen activator usage or dose between the CVCs with tips outside and those within the recommended location. The prevalence of IJ and SC CVC tips outside of the recommended location was high. Left-sided catheters, patient weight, and sex were associated with malposition. Malpositioned catheters were not associated with increased harm.

A retrospective analysis of the real-time ultrasound-guided supraclavicular approach for the insertion of a tunneled central venous catheter in pediatric patients.

Tunneled central venous catheter (tCVC) placement plays an important role in the management of pediatric patients. We adopted a real-time ultrasound (US)-guided supraclavicular approach to brachiocephalic vein cannulation. We evaluated the outcomes of tCVC placement via a US-guided supraclavicular approach. A retrospective study was performed for patients who underwent US-guided central venous catheterization of the internal jugular vein (IJV group) and brachiocephalic vein (BCV group) in our institution. The background information and outcomes were reviewed using medical records. We evaluated 85 tCVC placements (IJV group: n = 59, BCV group: n = 26). Postoperative complications were recognized in 19 patients in the IJV group (catheter-related bloodstream infection (CRBSI), n = 14 (1.53 per 1000 catheter days); occlusion, n = 1 (1.7%, 1.09 per 1000 catheter days); accidental removal, n = 3 (5.2%, 0.33 per 1000 catheter days); and other, n = 1 (1.7%, 1.09 per 1000 catheter days)) and five patients in the BCV group (CRBSI, n = 2 (0.33 per 1000 catheter days); catheter damage, n = 1 (3.8%, 1.67 per 1000 catheter days); and accidental removal, n = 2 (7.7%, 0.33 per 1000 catheter days)). In the BCV group, despite that, the incidence of postoperative complications was lower (p = 0.205) and the period of placement was significantly longer in comparison to the IJV group (p = 0.024). US-guided placement of tunneled CVC though the BCV results in a low rate of postoperative complications despite longer CVC indwelling times compared to IJV insertion. Our results suggest that BCV insertion of tunneled CVC in children may offer advantages in terms of device performance and patient safety.

Occlusions in peripherally inserted central venous catheters in pediatric patients in antineoplastic chemotherapy.

To analyze the occurrence of occlusions in peripherally inserted central venous catheters in pediatric patients in antineoplastic chemotherapy. Retrospective cohort, with 156 medical records of patients aged 0-19 years who underwent outpatient chemotherapy between 2013 and 2017 by this catheter, in a hospital in the city of Rio de Janeiro. Descriptive and inferential statistics were applied. 219 catheters were registered. Occlusion occurred in 141 (64.4%) catheters; 63 (44.7%) were removed because of occlusion, either alone or associated with another factor. Total occlusion alone led to the removal of 27 (12.3%) catheters. Occlusion was associated with: catheter dwell time, cyclophosphamide, neuroblastoma, bone metastasis and number of chemotherapy sessions. Occlusion is an important complication because it occurred in more than half of the catheters and was one of the main reasons for withdrawal. The identified risk factors may guide the care to prevent this complication.

Long-Axis In-Plane Approach Versus Short-Axis Out-of-Plane Approach for Ultrasound-Guided Central Venous Catheterization in Pediatric Patients: A Randomized Controlled Trial.

The aim of this study was to compare the occurrence of posterior wall puncture between the long-axis in-plane and the short-axis out-of-plane approaches in a randomized controlled trial of pediatric patients who underwent cardiovascular surgery under general anesthesia. Prospective randomized controlled trial. Operating room of Osaka Women's and Children's Hospital. Pediatric patients less than 5 years old who underwent cardiovascular surgery. Ultrasound-guided central venous catheterization using the long-axis in-plane approach and short-axis out-of-plane approach. The occurrence of posterior wall puncture was compared between the long-axis in-plane and short-axis out-of-plane approaches for ultrasound-guided central venous catheterization. Patients were randomly allocated to a long-axis group or a short-axis group and underwent ultrasound-guided central venous catheterization in the internal jugular vein using either the long-axis in-plane approach (long-axis group) or the short-axis out-of-plane approach (short-axis group). After exclusion, 97 patients were allocated to the long-axis (n = 49) or short-axis (n = 48) groups. Posterior wall puncture rates were 8.2% (4/49) and 39.6% (19/48) in the long-axis and short-axis groups, respectively (relative risk, 0.21; 95% CI, 0.076-0.56; p = 0.0003). First attempt success rates were 67.3% (33/49) and 64.6% (31/48) in the long-axis and short-axis groups, respectively (relative risk, 1.04; 95% CI, 0.78-1.39; p = 0.77). Overall success rates within 20 minutes were 93.9% (46/49) and 93.8% (45/48) in the long-axis and short-axis groups, respectively (relative risk, 0.99; 95% CI, 0.90-1.11; p = 0.98). The long-axis in-plane approach for ultrasound-guided central venous catheterization is a useful technique for avoiding posterior wall puncture in pediatric patients, compared with the short-axis out-of-plane approach.

Comparison of Hickman Versus Proline Central Venous Catheters in Pediatric Patients Undergoing Hematopoietic Stem Cell Transplant

Introduction Central venous catheter (CVC) access is an essential component of pediatric hematopoietic stem cell transplant (HSCT). Long-term CVC access is associated with an increased risk of infection and device dysfunction. Studies have shown that one in four CVC devices in the pediatric population require removal prior to completion of treatment due to infectious or mechanical complications. A retrospective analysis evaluated CVC-related complications in Hickman versus Proline catheters among pediatric HSCT recipients. Methods We performed a detailed retrospective chart review of CVC related complications among pediatric patients who underwent HSCT between June 2016 and October 2019. During the study period there was a change in the standard CVC access device from Hickman to Proline catheter. We compared the complications related to Hickman Catheter (Cohort 1) to Proline line (Cohort 2). All patients received antibacterial prophylaxis with cefepime. Results Thirty- two patients with a median age 7 years (range 0.75-19) underwent HSCT for malignant (N=16) or nonmalignant (N=16) disease. The majority underwent allogeneic HSCT (N=29). CVC complications requiring line removal occurred in 3 out of 15 (20%) HSCTs in Cohort 1 in comparison to 2 out of 18 (11%) in Cohort 2. Of the 3 complications in Cohort 1, 2 (66%) were related to infection and 1 (33%) due to device malfunction. Both line removals in Cohort 2 were due to device malfunction. There was one documented central line infection in Cohort 2 that did not require line removal. Conclusion Results of this small pilot study suggests that Proline catheters for long-term access in pediatric HSCT recipients may lead to a decrease incidence of complications requiring line removal in comparison Hickman catheters. Further research is indicated in order to provide recommendations for the optimal CVC for long-term access in pediatric HSCT.

Interventions for Occluded Central Venous Catheters: A Meta-analysis.

Thrombotic occlusion is 1 of the most frequent complications in catheters implanted in children. To identify the interventions used to treat thrombotic events in long-term central venous catheters in pediatric patients with cancer. Electronic searches were performed in the Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Latin American and Caribbean Health Sciences Literature, LIVIVO, PubMed, Scopus, Web of Science, Google Scholar, OpenGrey, and ProQuest databases. There were no restrictions on language or publication period. This systematic review was performed in 2 phases and included clinical trials and observational studies on drugs used to treat thrombotic catheter events in pediatric patients with cancer. The review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis checklist, and the protocol was registered at PROSPERO (identifier CRD42018083555). The authors evaluated the quality of included studies using the Methodological Index for Nonrandomized Studies and Grading of Recommendations Assessment, Development and Evaluation methods. The meta-analysis was performed by using Stata software. Ten studies were included. The drugs used to restore catheter function were alteplase, urokinase, and streptokinase. A meta-analysis of 6 studies revealed an overall restoration rate of 88% for alteplase. Reference studies were excluded when it was not possible to reliably extract data that met the inclusion criteria of this review. Sampling issues (absence of randomization, blinding, or a control group) were the main methodologic concerns for the included articles. On the basis of the evidence obtained, thrombolysis is effective and potentially safe in this population.

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.

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.

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.

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.

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.

The changing profile of safe techniques for the insertion of a central venous catheter in pediatric patients – improvement in the outcome with the experiences of 500 insertions in a single institution

BackgroundThe ability to safely insert a central venous catheter (CVC) is critical to avoid associated complications. The aim of this study was to explore appropriate technique to maintain the safety of pediatric patients during CVC. MethodsWe reviewed the surgical records of CVC insertion techniques and associated complications of 503 tunneled CVC insertions performed from 2000 to 2015. ResultsTwo hundred thirty CVCs (45.7%) were inserted into the subclavian vein using the landmark technique for 10years (first period). Only two pneumothoraxes (0.9%) were experienced. In 2009, we adopted ultrasound-guided venous catheterization from the internal jugular vein, and 103 CVCs (20.5%) were inserted (second period). This procedure led to penetration into the innominate vein (1.0%) by dilater sheath. Patient underwent repair of the penetrated vessel. After this serious complication, 170 CVCs (33.8%) were inserted using the venous cutdown procedure except two catheters. We had two cases whose accessible veins were occluded because of frequent catheterization using venous cutdown technique. No mechanical complications were experienced. ConclusionsThe venous cutdown method is the safest technique for inserting a tunneled CVC in pediatric patients. However, multiple vein occlusions because of repeated catheterizaion by venous cutdown lead to the exhaustion of accessible vessels. Level of evidenceTreatment Study – Level IV

Proper tip position of central venous catheter in pediatric patients.

In this study, we analyzed the thin-section pulmonary computed tomographic (CT) angiogram scans of pediatric patients to determine the normative length of superior vena cava (SVC) and the distance between carina and cephalad of SVC or cavocatrial junction. Consecutive child patients, under 13 years of age in whom the central catheters were inserted under ultrasound guidance from December 2004 to April 2005 were evaluated retrospectively. In the 14 cases, the mean age was 7.2 ± 4.21 years. The mean length and diameter of the SVC in the pediatric patients were 45.6 ± 23.03 and 13.7 ± 3.62 mm, respectively. The distance from the carina to the cavoatrial junction was 22.0 ± 9.98 mm. The mean distance from the superior margin of the SVC to the carina was 23.7 ± 16.70 mm. The mean distance from the carina to the catheter tip was 38.9 ± 18.60 mm. In no case was the cavoatrial junction cephalad with respect to the carina. Carina to cavoatrial junction junction was significantly associated with age, height, and weight, respecitively (r = 0.750; p = 0.005, r = 0.763; p = 0.004; r = 0.777; p = 0.003). The carina is a good landmark for the upper border of the cavoatrial junction. Length of carina to cavoaterial juction was associated with age. The rates of malposition and re-intervention and the patient's exposure to radiation can be reduced by using ultrasound during the catheter insertion.

The Effect of Simulation Teaching on Baccalaureate Nursing Students' Self-confidence Related to Peripheral Venous Catheterization in Children: A Randomized Trial.

In recent decades, nursing instructors have tended to use simulation rather than traditional methods due to benefits such as increased self-confidence. However, little academic literature is available to verify this claim. The procedure of establishing peripheral venous catheterization in pediatric patients is of great importance. Therefore, the researchers attempted to review the effect of the simulation teaching method on nursing students' self-confidence related to peripheral venous catheterization in pediatric patients. In this trial, 45 students in the 5(th) and 6(th) semester of nursing school in the first half of school year 2012 from the Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Iran, were randomly assigned to three groups (a control group, and two intervention groups). They were trained in establishing peripheral venous catheterization in pediatric patients through simulation teaching method and practical training. The students' self-confidence was assessed by C-Scale before and after the intervention. The students' self-confidence score showed a significant increase in the simulation group after the intervention in comparison to other groups (p = 0.03). RESULTS revealed a significant increase in self-confidence of nursing students related to peripheral venous catheterization in pediatric patients by simulation. This substantiates the assertion that simulation can improve self-confidence. Due to the low sample size, further studies with larger population are suggested.

Ultrasound-guided subclavian catheterization in pediatric patients with a linear probe: a case series

Central venous catheterization (CVC) can be difficult, especially with pediatric patients in critical care. Accessing the subclavian vein (SCV) can cause serious complications, including pneumothorax, arterial puncture, and hemothorax. Recently, the ultrasonographic (USG) technique has gained popularity, but its efficiency is not yet confirmed. Subclavian venous catheterization (SCVC) through the supraclavicular approach (SCA) with USG or accessing the brachiocephalic vein through the infraclavicular approach (ICA) has been reported in the past. A useful technique is reported that involves the use of a 40 mm probe rather than the usual 25 mm probe in order to confirm the location of the needle while successfully performing subclavian venous catheterization in pediatric patients weighing 1.1 kg to 15.0 kg.

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Introduction: Alteplase (recombinant tissue plasminogen activator) is the primary therapeutic option to noninvasively salvage an occluded catheter due to thrombus. The use of alteplase as a local instillation (dwell) for clearing partial occlusions in central venous catheters is well documented in the literature; however, there is a paucity of information published regarding the use of continuous infusions. The purpose of this study was to evaluate the efficacy and safety of continuous low-dose alteplase infusions to clear partially occluded catheters. Hypothesis: The authors hypothesized that the use of continuous low-dose alteplase infusions was both effective and safe for clearance of partially occluded central venous catheters in pediatric patients. Methods: The medical record of pediatric intensive care unit patients who received a low-dose alteplase infusion as the primary treatment for a partial catheter occlusion was retrospectively reviewed for efficacy and safety. All types of pediatric central venous catheters were included. The typical alteplase regimen was to administer 0.1 mg/kg (max 2 mg) of alteplase in 25 mL of 0.9% sodium chloride over 3 hours. Efficacy was defined as documentation of positive blood return from the catheter at the conclusion of the alteplase infusion. Physician, nursing, and radiology documentation and laboratory values were reviewed to assess for bleeding events. Results: 85 low-dose alteplase continuous infusions were used throughout the study time period. 71 of 85 (84%) alteplase infusions resulted in an initial positive blood return from the catheter. Only 1 catheter that initially failed to resolve was re-dosed with alteplase within 24 hours of the first dose, resulting in positive blood return (combined efficacy of 85%). No bleeding events were attributed to the alteplase infusion. Conclusions: Overall, 72 central venous catheter lumens with partial occlusions were salvaged with low-dose alteplase infusions, supporting the efficacy of this practice. No adverse events due to alteplase were identified, supporting the safety of this practice. The use of an infusion may be of benefit to avoid a bolus of alteplase if the dwell is unsuccessful and offer potential cost savings.