Critical appraisal of surgical venous access in children

Central venous catheters (CVC) have become an important adjunct to the overall management of paediatric patients, but their use is associated with frequent complications resulting in premature removal. This report evaluates the insertion techniques and complications of 295 consecutive surgically inserted CVC from 1987 to 1991 in a paediatric hospital. Fully implanted catheters had significantly less incidence of catheter-related problems necessitating removal (infection, dislodgment, leaking, blockage, or migration — 31%) compared to exteriorised catheters (58%). One-third of catheters were removed because of infection, one-third as they were no longer needed, and the remaining for multiple reasons. Infected (110±18 days), dislodged (18 ± 4 days), or migrated (44 ± 6 days) catheters were removed significantly earlier than those removed because they were no longer needed (195 ± 24 days). Catheters became dislodged more frequently in the younger patients. Catheters with the tip in the subclavian vein (29%) migrated more frequently than those in the right atrium. There was a significantly increased incidence of infection in catheters inserted into the saphenous vein (43%) compared to those in the internal jugular vein (11%). Some episodes of catheter infection were managed with antibiotics, with short-term resolution of symptoms and signs. However, all 71 infected catheters ultimately required removal for further sepsis. Fully implanted catheters had 1.1 episodes of catheter-related sepsis per 1,000 catheter days compared to 3.7 for exteriorised catheters. The position of the catheter tip, vein used for insertion, training of young surgeons, and location of the subcutaneous tunnel need particular attention in order to reduce catheter complications.     

27-gauge percutaneous catheters: use in nutritional management of very-low-birth-weight and severely premature newborns in a neonatal intensive care unit]

Percutaneous central venous catheterization for parenteral feeding is a permanent problem in the management of very low birth weight neonates. Usually, 23-gauge catheters (diameter: 0.6 mm) are used. In our unit, we have started to use 27-gauge catheters (diameter 0.35 mm) since 1995. The aim of this study was to report our experience with this materiel. SUBJECT AND METHODS: Between September 1, 1997 and January 30, 2000, 352 catheter implantations were performed using 27-gauge infusing sets in 200 premature infants (gestational age less than or equal to 33 weeks [mean 29.2], weight less than or equal to 1,500 g [mean: 1, 152.5 g]). Data were reviewed retrospectively with the view to determine the modality of use and complications. Peculiar insertion modalities were prospectively evaluated in the 50 last included infants (92 catheters). RESULTS: In 97% of cases, the physician needed no help to insert the catheter. In 99.5% of cases (199 neonates), the insertion was successful (the procedure failed in one case). The mean duration procedure was 26 min (range 10 to 85 min). The mean age at insertion of the first catheter was 29 hours (range 0 to 216). Mean catheter maintenance duration was 15 days (range 1 to 53). In 31 cases, documented sepsis related to the catheter were noted (8.8% or 5.8 infections for 1,000 catheter-days). Endocarditis was observed in one case. A pericardial effusion was diagnosed in two cases. No death related to the catheter was noted. CONCLUSION: In our experience, 27-gauge catheter implantation is an easy and safe procedure. We noted no major maintenance problems. Complications were not observed more frequently than those usually encountered with 23-gauge catheters. We conclude that 27-gauge catheter utilization is an attractive alternative for percutaneous central venous catheterization, in very low birth weight neonates.     

Prospective evaluation of percutaneous central venous silastic catheters in newborn infants with birth weights of 510 to 3,920 grams

With improved neonatal survival, especially of very low birth weight infants, our efforts should be directed toward reduction of morbidity. Sick preterm infants require total parenteral nutrition for prolonged periods of time due to extreme prematurity and feeding intolerance. However, the use of surgically placed Broviac catheters has been associated with a high complication rate. A prospective study of 53 percutaneous central venous Silastic catheterizations for administration of total parenteral nutrition was performed in 45 newborn infants. At the time of catheter insertion, 37 babies weighted less than 1,500 g and 19 weighed less than 1,000 g. Percutaneous central venous catheters were placed successfully the first time in 50 of 55 attempts. In three babies, insertion was successful on second attempt. The catheters remained in place for 25.4 +/- 16.7 days ([mean +/- SD] range two to 80 days). In babies weighing less than 1,000 g, the catheters remained in place for a longer period of time (34.0 +/- 18.0; range 12 to 80 days). Sixty-six percent of the catheters were removed electively. There were four cases of bacteremia (7.5%), and the overall incidence of mechanical complications was 26.4%. We conclude that percutaneous central venous catheters can be used safely and effectively in newborn infants for prolonged administration of total parenteral nutrition, especially in neonates weighing less than 1,000 g.     

Evaluation of a new catheter for total parenteral nutrition

Central venous catheters play an important role in the management of children with a variety of disorders. Desirable characteristics of such catheters include ease and reliability of placement, secure fixation, low rates of complication, and ease of removal. We describe our experience with a new form of catheter that displays all of these characteristics. One hundred twenty-nine catheters were inserted in 111 patients over a 2-year period for a total of 5,729 treatment days. This catheter is made of silicone rubber and is positioned by using P-wave changes seen during intraoperative electrocardiography. x-Ray confirmation is not routinely necessary. The catheter is fixed in position by use of a grommet, which is sutured in the neck at the site of the venotomy. This form of fixation allows the catheter to be easily removed by nonsurgical means while keeping it securely in position for the duration of use. Our experience with this catheter has been associated with a low incidence of septic (1.1-4.2 septic episodes per 1,000 patient days) and mechanical (2.3 episodes per 1,000 patient days) complications in a setting that includes both in-hospital and home total parenteral nutrition patients. It is felt that this new form of catheter and catheter fixation offers several advantages over other types of central venous catheters currently in use.     

Performance of percutaneous Silastic central venous feeding catheters in surgical neonates

In surgical neonates receiving total parenteral nutrition a prospective study was undertaken to assess the performance of fine-bore central venous Silastic catheters inserted percutaneously via a peripheral vein. During a 1-year period a total of 33 catheters was inserted into 28 neonates. The mean duration of catheter survival was 14.98.0 (range 4–34) days. No complications occurred with 22/33 (66%) catheters which were removed when redundant. Although there were no long-term sequelae, 11 (33%) catheters was removed because of complications, the commonest being sepsis, which occurred in 5 (15%) patients. No septic complications were detected in the 13 patients having a catheter for 10 days or less. Catheters positioned in the great veins peripheral to the superior vena cava and right atrium proved to be safe and reliable in the short term. Offprint requests to: M. D. Stringer     

Percutaneous Silastic catheters in newborn and premature infants. A report of experiences with 497 catheters in 5 years]

BACKGROUND AND METHODS. Central catheters are an important prerequisite for adequate parenteral nutrition in preterm infants. However, a variety of complications have been shown to be associated with central lines: septicemica, thrombotic complications, mechanical complications. In this retrospective analysis we summarize our recent experience with central silastic catheters. RESULTS. Within a five-year-period (1986-1990). 497 silastic-catheters were inserted in 366 high risk neonates (mean birthweight 1360 g; 1060-1740 g, 25.-75. percentile) treated at the NICU, Department of Pediatrics, University of G?ttingen. 451 catheters which were placed in a central position, were removed after an average duration of 11 days (mean; 8-18 days, 25.-75. percentile). During the observation period, 62.8 percent of the catheters were purposely removed. Making use of the Kaplan-Meier-curve, we calculated how long the catheter could stay without complications; 50% of all catheters could be expected to be in place for 25 days. The incidence of septicemia was 1.9%, bacterial contamination of the catheters was evident in 22% of all central lines. The most predominant microorganisms responsible for catheter-contamination were coagulase-negative staphylococci. In addition, catheters were removed because of signs of phlebitis or suspected thrombotic complications (11.1%), and mechanical complications (dislocation, occlusion; 11.7%). Due to malposition of the central catheter two preterm infants developed pericardial effusions. There was no correlation between the site where the catheter was inserted and these complications. CONCLUSION. Central silastic catheters wherever clinically indicated are a valuable adjunct in the parenteral nutrition on high risk neonates.     

Right atrial catheters in children with cancer: a decade of experience in the use of tunnelled, exteriorized devices at a single institution

In the period 1980-1988, data were collected (prospectively from 1985) on the clinical utilization of exteriorized, tunnelled, right atrial catheters in children with cancer undergoing treatment at a single institution. A total of 231 devices were placed in 180 patients. Individual catheters were in place for a median of 314 days, with a total experience of more than 83,000 days. This form of long-term venous access was used for the administration of antineoplastic agents and other drugs, blood products (especially platelet concentrates and packed red blood cells), parenteral nutrition and infusion of other fluids, obtaining samples of venous blood, and giving intravenous contrast media and radiolabeled substances for radiological investigations. Almost 80% of catheters were removed electively (on completion of scheduled therapy or at death), with the remainder requiring removal in the management of infection or device displacement. Infections were manifest in two-thirds of the children, most commonly (60%) at the catheter exit site on the anterior chest wall. "Clinically significant" infection occurred with a frequency of 2.1 episodes per 1,000 patient days, with Staphylococcal species predominating except for the circumstances of catheter colonization in which Gram-negative, waterborne organisms were most in evidence. Empirical, intravenous, combined antibiotic therapy was effective in approximately 90% of "clinically significant" episodes. Mechanical complications (traveling, leakage, or catheter occlusion) occurred less frequently and were managed by repairing or replacing the device, or clearing the block. Indwelling catheters, of the Broviac or Hickman types, offer major advantages with acceptable morbidity in the management of children with malignant diseases.     

Evaluation of percutaneously inserted peripheral silicone catheters for parenteral nutrition in infants and children

Delivery of long term parenteral nutrition (PN) to small infants and children by peripheral vein effectively reduces: he risk of serious cather-related complications which may occur with central vein delivery, but provides the practical difficulties of repeated vein puncture, limited vein access and the problems of phlebitis and extravasation. This study evaluates the use of percutaneous peripheral indwelling fine silicone catheters, compared with conventional methods of delivery in 20 patients (median age 0.2 years) requiring PN for 521 patient-days (average, 26). These catheters compared favourably with other peripheral insertions in terms of mean indwelling time (12,6 ± 2.0 vs 1.3 ± 0.2 days, p<0.001), frequency of insertions required (7.9 vs 75 insertions per 100 patient-days) and local complications (2.6 episodes per 100 days — mild phlebitis only — vs 65 per 100 days). Fewer serious complications were encountered than with the centrally placed catheters, the major complication rate of 0.3 per 100 patient-days being due to a single possible episode of sepsis. We conclude that this technique offers significant practical advantages over conventional PN delivery for small infants and children, by reducing the frequency of venipuncture, prolonging vein life and vein access, reducing work load, and eliminating extravasation, with a minimum of serious complications.     

250 central venous silastic catheters in premature infants less than 1.500 g. A clinical study of technique and complications]

250 central venous catheters were inserted percutaneously in premature infants weighing less than 1,500 g in a prospective study over a period of five years. The mean catheter life was 25 days. We noted 47 complications (= 1/134 days). The most common complication was phlebitis (9.2%). The risk of phlebitis was highest after inserting catheters through the saphenous vein (60%) and lowest after inserting them through the basilic vein (3.9%). Septicaemia was diagnosed in 15 infants (6%). The incidence of thrombosis was 1.2%. Two infants had cardiac perforation with a resultant pericardial effusion. There were no deaths related to any catheter complication. In 116 catheterizations the position of the catheter was checked by recording the intravascular ECG via catheter. The ECG-method proved to be very reliable.     

Percutaneous central venous catheterization via the great saphenous vein in neonates

In 44 neonates (mean birthweight 1207 g and mean gestational age 30.0 weeks), very small central venous catheters were percutaneously inserted via the great saphenous vein on 46 occasions. Catheter-related complications such as catheter blockages in 17 (37%), edema in a unilateral leg in three (6%), and mechanical disruption in two (4%) were noted. Although two of the neonates were found to have bacteremia and five neonates died, none were catheter related. The optimal length of catheter insertion (Y) from the great saphenous vein at the level of the medial maleollus to the inferior vena cava at T9 and L3 was calculated by regression equations utilizing total body length (X). Radiographs taken with extended and flexed leg postures revealed that the catheter tips were retracted with extension of the lower extremities and the degree of displacement ranged from 1 to 4 (mean 2.7) vertebral levels. Because this movement might cause migration into veins that connect to the inferior vena cava, the catheter tip should be located between T9 and L3, except at the renal vein junction. Percutaneous central venous catheterization via the great saphenous vein is safe and useful. Regression equations provided for rapid estimation of the optimal length of insertion.     

Use of a soft catheter for acute peritoneal dialysis in infants and children

Acute peritoneal dialysis in 49 infants and children is described comparing the use of the conventional hard Trocath catheter and the soft catheter. The mean age of the patients was 3.6 years (range 1 day--17 years). Sixteen were treated using the hard Trocath catheter and 33 were treated using a soft catheter. Overall mortality for the total patient population was 43%. Twenty-three neonates were included in the series with an overall mortality of 61%. Significantly less mortality was observed in the 26 patients older than two months of age (31%). Major complications of the dialysis procedure included viscus perforation in three neonatal patients and subcutaneous extravasation of dialysate in two older patients. These major complications occurred only with the use of the Trocath. Two episodes of peritonitis occurred in two adolescent patients and were associated with an interruption of the sterile system. Peritonitis was not specifically related to the type of catheter used. We conclude that major complications associated with the use of the hard catheter for peritoneal dialysis in neonates precludes its continued use in this population. The alternative use of a soft catheter is recommended in neonates. Elective use of a soft catheter for acute peritoneal dialysis in older patients would also seem to be indicated.     

RIGHT ATRIAL CATHETER-RELATED COMPLICATIONS IN PEDIATRIC ONCOLOGY PATIENTS: The Situation in a Developing Country

The complications of right atrial catheters (RACs) in pediatric oncology patients are unknown for centers in developing countries. This study examined the complications of RACs at Ankara University Medical School, Turkey. A total of 90 RACs were placed in 61 children for long-term chemotherapy with a total experience of 15,536 catheter days. The rate of catheter-related sepsis was 4.9 episodes per 1000 catheter days. Coagulase-negative staphylococci and Candida species were the most common organisms, accounting for 25.0 and 13.1% of all organisms, respectively. The most common reasons for the removal of the RACs were infection (42.4%) and dislodgement (32.2%). The rates of complications were significantly higher in this study than in western studies. This increase could be explained by the differences in catheter care practices in the Turkish center. In conclusion, the use of RACs in a developing country necessitates an appraisal of the benefits and risks for each patient and improvement of catheter care procedures.     

Variations in central venous catheter-related infection risks among Canadian neonatal intensive care units

BACKGROUND: The objective of this study was to examine central venous catheter (CVC)-related nosocomial blood stream infection risks of umbilical venous, percutaneous and Broviac catheters, as well as variations in CVC use and CVC-related risk for nosocomial blood stream infection in the neonatal intensive care unit (NICU). METHODS: A cohort study was performed based on 19,507 infants admitted to 17 NICUs in the Canadian Neonatal Network from January, 1996, through October, 1997. Information on these subjects was prospectively collected by trained abstractors. Incidence of infection was measured as infection episodes per 1000 patient days. The risk ratio (RR) of CVC use for nosocomial blood stream infection was calculated as the infection rate during catheter days divided by the infection rate during noncatheter days. Using a Poisson regression model we examined the adjusted RR of CVC use for nosocomial blood stream infection, controlling for patient characteristics and illness severity at admission. Interinstitutional variations in CVC-related infection risks were examined by stratified analyses. RESULTS: CVC were used in 22.5% of patients. The incidence of nosocomial blood stream infection was 2.9 per 1000 noncatheter days, 7.2 per 1000 umbilical venous catheter days, 13.1 per 1000 percutaneous catheter days and 12.1 per 1000 Broviac catheter days. The RR for nosocomial blood stream infection, adjusted for differences in patient characteristics and admission illness severity, was 2.5 for umbilical venous catheter, 4.6 for percutaneous catheter and 4.3 for Broviac catheter (P < 0.05). There were significant (P < 0.05) risk-adjusted variations in CVC-related infection risks among NICUs. CONCLUSIONS: CVC use increased the risk of nosocomial blood stream infection. The risk of nosocomial blood stream infection in percutaneous and Broviac catheters was 70 to 80% higher than in umbilical venous catheters. There was significant variation in CVC-related infection risks among Canadian NICUs.     

植入式中心静脉给药装置在儿童肿瘤应用中常见并发症的预防和处理

目的讨论植入式中心静脉给药装置（化疗泵）在恶性肿瘤患儿治疗中常见并发症的预防和处理。方法1999年6月～2004年6月，共计79例肿瘤患儿安装化疗泵并经泵化疗。60例经颈外静脉切开插管．导管头端置于上腔静脉；10例经颈内静脉插管；9例锁骨下静脉穿刺插管，泵体置于侧胸壁皮下。结果79例患儿平均带泵天数721d。其间10例发生导管阻塞，1例置泵1年后泵体处皮肤磨损。79例经泵抽血培养98次，其中有菌生长17次。结论全麻下经颈外静脉切开插管为安装化疗泵的首选方法。化疗泵安装和应用的规范化是减少和预防并发症发生的主要措施，并发症的预防和及时有效的处理是化疗泵安装得以全面推广的可靠保证。     

Frequency of infections associated with implanted systems vs cuffed, tunneled Silastic venous catheters in patients with acute leukemia.

A total of 75 central venous catheters were used for prolonged chemotherapy in 39 children with acute lymphocytic leukemia and 21 patients with acute myelocytic leukemia. Infection rates were 2.2 per 100 catheter days with the use of cuffed, tunneled, single-lumen Silastic catheters, 2.0 per 1000 catheter days with cuffed, tunneled, double-lumen Silastic catheters, and 0.5 per 1000 catheter days with the use of implanted venous access systems. Eighty-one percent of catheter sepsis episodes were successfully treated without removal of the catheter. All tunnel infections required withdrawal of the catheter for cure. The microorganisms were gram-positive bacteria in 15%, gram-negative bacteria in 7%, and fungi in 4%. Coagulase-negative staphylococci and Pseudomonas aeruginosa were the most commonly isolated organisms. Three of six fatal sepsis episodes were caused by disseminated fungal infections. We conclude that the use of intracorporeal venous catheter systems in patients with acute lymphocytic leukemia is associated with a lower infection rate than that with cuffed, tunneled Silastic single- or double-lumen catheters and that most septicemias can be cured with antimicrobial therapy without removal of the catheter.     

A comparative study of two different percutaneous venous catheters in newborn infants

Between 1985 and 1988 the use of percutaneous venous catheters in the intensive care of newborn infants was evaluated. A total of 140 polyurethane catheters used in 91 patients were compared with 143 silicone catheters in 121 neonates. Patients of both series were comparable regarding sex, weight, gestational age and severity of disease. Insertion technique, puncture site care and infusions remained the same for both observation periods. Peripheral insertion of silicone catheters required more venous cutdowns but threading them to a central vein or the right atrium was more often successful. Fewer local complications (i.e. reddening or swelling along the peripheral venous access) resulted in a longer catheter duration and a less frequent need for an additional venous access in the silicone group. On the other hand, silicone catheters caused more technical problems (i.e. rupture or obstruction). Upon removal, more silicone than polyurethane catheter tips were colonized with bacteria. This was independent of catheter duration and was never followed by clinical signs of infection. The silicone catheter gave better results, especially in very small newborn infants of low gestational age, but was associated with more technical problems.     

Use of double-lumen umbilical vein catheters in a neonatal intensive care unit]

BACKGROUND: The aim of the study was to compare the success/failure rate and complications of insertion into the umbilical vein, of either double-lumen catheters (Charrière diameter 04, length 13 and 30 cm) or single-lumen catheters (Charrière diameter 05, length 40 cm) in a population of neonates admitted to a neonatal intensive care unit. The numbers of insertions of additional peripheral venous catheters were also compared. PATIENTS AND METHODS: The population was divided into two groups according to the severity of the respiratory failure. Group 1 (n = 52): normal hemodynamic parameters and moderate respiratory failure (FiO2 < 0.6): only single-lumen catheters were used. Group 2 (n = 56): low systemic pressure requiring vascular filling and/or inotropic drugs infusion and/or severe respiratory failure (FiO2 > 0.6): in this group, either single-lumen catheters or double-lumen catheters were inserted. RESULTS: The success rate of insertion of double-lumen catheters and of single-lumen catheters were similar (61% vs 71%: P = 0.7). Nineteen double-lumen catheters were inserted in the group 2. The average duration of double-lumen umbilical catheterization was not significantly different from simple-lumen catheterization (4.9 +/- 2.2 vs 4.6 +/- 2.2 days). Complications relating to the umbilical venous catheterization were uncommon: three catheter obstructions (two with single-lumen catheter, one with double-lumen catheters), two nosocomial infections (both with single-lumen catheter), one hydropericardium (with single-lumen catheter). In group 2, more peripheral venous catheters were required during the first 72 hours of life after insertion of single-lumen catheter than after insertion of double-lumen catheters (average number of peripheral venous catheters per infant: 1.6 +/- 0.83 vs 1 +/- 0.35 respectively; P < 0.01). CONCLUSION: Feasibility and complication rate of umbilical double-lumen catheters were similar to those of single-lumen catheters. The use of umbilical double-lumen catheters reduces the need of peripheral venous catheters.     

Cathlink 20: a subcutaneous implanted central venous access device used in children with sickle cell disease on long-term erythrocytapheresis--a report of low complication rates

BACKGROUND: Experience with the use of central venous access device (CVAD) in children with sickle cell disease (SCD) on hypertransfusion is limited and published studies report wide variability in the rates of CVAD-associated complications. PROCEDURE: In this study, a total of 18 Cathlink 20 ports (Bard Access systems, Salt Lake City, UT) were implanted in 15 patients aged 7-20 years with SCD for 19, 230 catheter patient days. RESULTS: No peri-operative complications were observed. Three episodes of catheter occlusion requiring replacement occurred in two patients for an observed rate of 0.16 per 1,000 catheter patient days for thrombotic occlusion. One patient required port replacement and another patient required replacement twice. In 13 out of 15 patients, the median duration of port use was 45 months. No episode of catheter-associated bacteremia or catheter tunnel infections was observed. CONCLUSIONS: Comparing our results with other reported studies of CVAD-associated complications in patients with SCD, we observed a lower rate of complications with the use of Cathlink 20 ports. These findings may be partly related to the design of the port and partly to a dedicated group of nurses accessing the ports in a controlled environment in an apheresis unit.     

Prevention of indwelling central venous catheter sepsis

In an attempt to decrease the incidence of central venous catheter sepsis in children with cancer, we conducted a study to evaluate the benefit of adding broad-spectrum antibiotics to the catheter “flush solution.” In a prospective, placebo-controlled, double-blinded, randomized trial, 69 children with different types of malignancies were studied. The central venous catheters in these children were flushed with either the standard solution (normal saline + 100 U/ml of heparin) or the study solution (25 μg/ml of both amikacin and vancomycin added to the standard solution). At the conclusion of the study, 64 children with a total of 67 indwelling central venous lines were assessable. The total catheter days on study were 20,700 days, with a median of 323 catheter days per patient. We documented 10 events of catheter-related infections (0.49 events/1,000 catheter days at risk). Five of these events were catheter-related sepsis (0.24 sepses/1,000 catheter days): two were fungal and three were bacterial. Due to the low incidence of catheter-related sepsis in this study, no statement regarding the prophylactic use of antibiotics could be made. The extremely low rate of catheter-related sepsis reported herein may be retrospectively attributed to continuous staff education regarding aseptic techniques in handling these catheters. Staff education is essential, and probably the most effective factor in preventing catheter-related sepsis. © 1996 Wiley-Liss, Inc.     

Sonographic detection of internal jugular vein thrombosis after central venous catheterization in the newborn period

We sonographically investigated the internal jugular veins of 40 children who had undergone catheterization of the vein (group A: silastic catheter,n-24; group B: polyurethane catheter,n=16) in the neonatal period. The average age at catheter implantation was 43±73 days, the average birthweight 2414±1145 g, and the average gestational age 34.8±5.0 weeks. We performed follow-up longitudinal and transverse high resolution sonographic scans including routine examination of the contralateral jugular vein at a mean age of 3.7±1.5 years. In group A thrombotic alterations were detected in 8 aut of 24 patients. In three of these patients we found mild clinical symptoms. In group B thrombotic alterations were detected in 1 aut of 16 patients without clinical symptoms. Mean birthweight (1815 versus 3313 g) and mean gestational age (32.3 versus 38 weeks) were significantly lower and indwelling time of the catheters (18 versus 11 days) was significantly longer in group A. Our results indicate that jugular vein thrombosis is a frequent long-term complication in neonates after jugular vein catheterization. High resolution ultrasonography is an adequate method for detecting jugular vein thrombosis and should therefore routinely be performed for long-term follow-up.