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.     

Infections related to vascular catheters in a pediatric intensive care unit

We determined the rate and risk factors for colonization of 103 peripheral intravenous catheter and 32 central venous catheters. 52.5% peripheral catheters had colonization. Common organisms isolated were Pseudomonas (33.3%) and coagulase negative Staphylococci (29.6%). Colonization was higher in catheters inserted in the lower limb. Overall 62.5% of the central catheters were colonized, chiefly by coagulase negative Staphylococci, Pseudomonas and Candida. All central catheters in place for more than 11 days were colonized. Subclavian vein catheters had a higher rate (68.2%) of colonization in comparison to femoral vein insertions (40%). We conclude that upper limb placements are preferable to lower limbs when using peripheral lines. Changing peripheral intravenous catheters every 48 hours and central venous catheters every 10 days may decrease the rate of colonization.     

Survival times and complications of catheters used for outpatient parenteral antibiotic therapy in children

Outpatient parenteral antibiotic therapy is routinely used in pediatrics, but few data are available on catheter-associated complications and survival times. Catheter-associated complications, defined as mechanical or nonmechanical, and survival times in peripherally inserted central catheters and central venous catheters used for outpatient parenteral antibiotic therapy in childhood were compared. The life test procedure was performed to determine survival time. Cox proportional hazards model was used to compare the independent effect of variables such as age and gender on catheter survival. There were 104 peripheral and 130 central venous catheters, of which 28 peripheral and 19 central catheters had mechanical complications, and 13 peripheral and 17 central catheters had nonmechanical complications. Peripheral catheters are more likely to develop mechanical complications and have a shorter survival time than central venous catheters. For outpatient parenteral antibiotic therapy longer than 6 weeks, central venous catheters appear to be a better choice.     

Selective placement of bronchial suction catheters in intubated neonates.

Flexible suction catheters were passed through the endotracheal tubes of infants undergoing mechanical ventilation, just before chest radiographic examination for clinical purposes. With the head straight, 7 of 10 straight catheters entered the right main bronchus but with the head turned, 17 of 20 straight catheters and 19 of 20 curved tip catheters entered the contralateral bronchus.     

Reduced thrombus formation with silicone elastomere (silastic) umbilical artery catheters.

This report describes clinical experience with a radiopaque silicone elastomere (Silastic) umbilical artery catheter. Twenty infants, ten with polyvinyl chloride (PVC) umbilical artery catheters and ten with Silastic umbilical artery catheters, all positioned at the aortic bifurcation, had aortograms performed at the time of catheter removal. Catheter-associated thrombus formation was observed in nine of the ten infants (90%) with PVC umbilical artery catheters and in one of the ten infants(10%) with Silastic catheters. The incidence of lower extremity vasospasm associated with the two catheters was not significantly different. Aortic pressure tracing recorded through Silastic catheters were accurate, but slightly damped. Autopsies were performed on five additional infants who died with indwelling Silastic umbilical artery catheters. None of the catheters, nor their surrounding tissues, showed evidence of thrombus formation on either gross or microscopic examination. It is our experience that radiopaque silicone elastomere tubing can be used as an umbilical artery catheter and appears to have the advantage of being less thrombogenic than the standard PVC tubing currently in general use.     

Prevention and management of pediatric catheter-related infections

Various catheters are used in providing care to children. Infection is a major complication related to use of these catheters because they bypass normal defenses and provide access to normally sterile sites. Treatment of catheter-related infections often is difficult and frequently requires removal of the device. Prevention of infection begins with limiting use of catheters. Other critical measures include using aseptic technique during insertion of catheters; meticulous care of catheters; limited manipulation of all catheters; maintaining sterile technique during preparation of fluids and medications; and preparing infusion hubs and ports before use. Education of patients and care providers is essential and effective. Copyright © 2001 by W.B. Saunders Company     

Percutaneous femoral venous catheterizations: a prospective study of complications

In a prospective, 45-month study, we compared the complication rates of percutaneously placed femoral and nonfemoral central venous catheters in critically ill pediatric patients. Forty-one percent of the 395 central venous catheters placed during this interval were femoral. Noninfectious complications were recognized for 2.5% of femoral catheters and 2.1% of nonfemoral catheters. Only three complications occurred with catheter insertion, all during nonfemoral attempts. Systemic infections that were possibly attributable to the central venous catheter were found in 3.7% of patients with femoral catheters and 7.3% of those with nonfemoral catheters. Femoral venous catheterization offers several practical advantages for central access over other sites. The low incidence of complications documented in this study suggests that the femoral vein is the preferred site in most critically ill children when central venous catheterization is indicated.     

Continuous infusion of low-dose urokinase in the treatment of central venous catheter thrombosis in infants and children

Thrombotic occlusion is a frequent complication associated with the use of central venous catheters. The purpose of this study was to evaluate the efficacy of a continuous infusion of low-dose urokinase (200 U/kg/h) in clearing catheters that had not cleared after two bolus doses of urokinase in a pediatric oncology population. Fifty-eight incidents of catheter-related occlusions (49 Hickman-type catheters/nine implantable ports) as documented by radiographic dye study occurred in 227 pediatric oncology patients with 254 central venous catheters during a 1-year period. Fourteen of 58 catheters failed to clear after two bolus instillations of urokinase (5,000 U and 10,000 U). Thirteen catheters were treated for 24 hours with urokinase, 200 U/kg/h, and one catheter with urokinase, 100 U/kg/h for 24 hours. Twelve catheters were used for study. Coagulation studies were monitored preinfusion, 12 hours into the infusion, and postinfusion. Patency was reestablished in 11/12 catheters (92%) with a mean infusion time of 28.7 hours. No coagulation abnormalities or clinical bleeding associated with the urokinase infusion occurred. Only one patient exhibited a prolonged partial thromboplastin time (greater than 150 seconds); this was associated with a heparin effect. These data indicate that low-dose urokinase may be a safe and effective means to clear occluded central venous catheters in children.     

Supportive care for children with cancer. Guidelines of the Childrens Cancer Study Group. Use of venous access lines

The use of central access lines in children with cancer may significantly improve the quality of life of these patients. Indwelling atrial catheters (Broviac and Hickman catheters) seem at present to be the best technique. These catheters are associated with complications, of which infection is the most feared. However, their use allows patients to undergo complex prolonged therapy with less discomfort. These indwelling catheters also provide venous access at all times, which may be lifesaving.     

The efficacy of heparinization in prolonging patency of arterial and central venous catheters in children: a randomized double-blind trial

This study evaluates the efficacy of heparinization in prolonging patency of arterial and central venous catheters in children. A randomized double-blind trial in a tertiary 10-bed pediatric intensive care unit was used to evaluate 300 children (age older than 4 weeks, younger than 18 years). Trial medication consisted of either NaCl 0.9% infusion or NaCl 0.9% infusion to which 1 IU of heparin per milliliter was added. The number of nonpatent arterial and central venous catheters and the duration of stay of patent arterial and central venous catheters were measured. There was a significant risk increase for nonpatency in the nonheparinized arterial catheters (relative risk [RR]: 3.54; 95% confidence interval [CI]: 1.01-12.42). No significant risk increase for nonpatency could be demonstrated for the nonheparinized central venous catheters (RR: 7.63; 95% CI: 0.40-145). The median duration of stay of the patent arterial and central venous catheters was similar for both treatment groups. These results indicate that the use of normal saline in arterial catheters is associated with an increased frequency of catheter nonpatency as compared with heparinized saline.     

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。     

Inferior vena cava thrombosis as a complication of femoral vein catheterisation.

Indwelling femoral venous catheters were prospectively studied by ultrasonography to define the frequency and evolution of inferior vena cava (IVC) thrombosis. IVC thrombosis was identified in six of 56 catheters (54 children). Only one patient with a positive ultrasound scan had clinical signs of thrombosis. All children with IVC thrombosis had had catheters in place for over six days. It is recommended that either the femoral central venous catheters are routinely changed at six days or ultrasound studies are routinely performed twice a week in all patients with catheters in situ for six or more days and that the catheter is removed immediately if evidence of thrombosis appears.     

Complications of central venous access in children

Central venous access has become a frequent requirement in the management of seriously ill or injured infants and children with a wide variety of conditions. This report evaluates the complications observed with the use of central venous catheters in 1,378 cases. Central venous catheters (n = 2,281) were placed in 1,378 children (728 boys:650 girls). There were 1,012 temporary catheters (noncuffed/percutaneously placed) while 1,268 were inserted operatively, including 37 portacaths and 1,231 with dacron cuffs (Hickman, Broviac) for long-term use. A single catheter was inserted in 542 cases and multiple catheters in 836. Indications for catheter insertion included emergency resuscitation or access (501), malignancy (462), and intestinal dysfunction (415). Catheter infection occurred in 430 cases (18.8%). Of 219 infected temporary access catheters, 123 were removed while 96 were changed over a guide wire. Of 211 infected permanent catheters, 18 were immediately removed while 193 were treated with i.v. (vancomycin, gentamicin) antibiotics. Forty-seven of 193 (24%) catheters were eventually removed because of persistent or recurrent infection (16 cases) or subsequent fungal sepsis due to Candida albicans (31 cases). Only 3 of 37 portacaths were removed because of infection. Bacterial isolates were single in 125 cases and multiple in 86. Organisms included Staphylococcus epidermidis in 104 cases, Staph. aureus in 65, Klebsiella pneumoniae in 51, Escherichia coli in 51, and others in 18. Catheter complications occurred in 107 (5%) cases, including symptomatic vessel thrombosis in 49, pneumothorax in 26, catheter migration in 25, vessel injury in 5, and catheter embolus in 2. Despite the relatively high complication rate there were no catheter-related deaths. Multiple-lumen catheters had twice the complication rate and infection rate of single lumen catheters (P < 0.05). Temporary percutaneous catheters had a complication/infection rate 1.5 times greater than permanent catheters (P < 0.05) that were operatively placed. Bacterial infection cleared with antibiotics in 76% of cases with catheter sepsis, however secondary fungal infection necessitated prompt catheter removal. These data indicate that percutaneously placed catheters and multilumen catheters are associated with significantly higher complication and infection rates. Surgeons should balance the risks of convenience vs. complications in their choice of catheters and methods of insertion.     

THE EFFICACY OF HEPARINIZATION IN PROLONGING PATENCY OF ARTERIAL AND CENTRAL VENOUS CATHETERS IN CHILDREN: A Randomized Double-Blind Trial

This study evaluates the efficacy of heparinization in prolonging patency of arterial and central venous catheters in children. A randomized double-blind trial in a tertiary 10-bed pediatric intensive care unit was used to evaluate 300 children (age older than 4 weeks, younger than 18 years). Trial medication consisted of either NaCl 0.9% infusion or NaCl 0.9% infusion to which 1 IU of heparin per milliliter was added. The number of nonpatent arterial and central venous catheters and the duration of stay of patent arterial and central venous catheters were measured. There was a significant risk increase for nonpatency in the nonheparinized arterial catheters (relative risk [RR]: 3.54; 95% confidence interval [CI]: 1.01-12.42). No significant risk increase for nonpatency could be demonstrated for the nonheparinized central venous catheters (RR: 7.63; 95% CI: 0.40-145). The median duration of stay of the patent arterial and central venous catheters was similar for both treatment groups. These results indicate that the use of normal saline in arterial catheters is associated with an increased frequency of catheter nonpatency as compared with heparinized saline.     

Intraurethral knot in a very-low-birth-weight infant: radiological recognition, surgical management and prevention

We report a case where a knot developed in a urinary catheter and became lodged within the urethra of a very-low-birth-weight (VLBW) preterm infant. The catheter was removed with the assistance of a urologist. We recommend using caution when placing urinary catheters in VLBW infants and question the appropriateness of feeding tubes as catheters. Recognition on radiographs of malpositioned bladder catheters is vital to the care of these patients. All staff involved in the insertion, maintenance or removal of these catheters should be suitably trained to minimize the risk of knots and related complications.     

Port-A-Cath in Children During Long-Term Chemotherapy: Complications and Outcome

Complications related to Port-A-Cath were studied prospectively during a period of 32 months in 31 patients, aged 1-18years, with leukemias and solid tumors. There were 34 Port-A-Cath inserted, and the cumulative time for these catheters kept in place was 5899 days. No complications occurred in 18 patients (19 catheters) kept in place for a cumulative time of 3998 days with an average duration of 210 days (12-550 days). In 13 patients (15 catheters) there were 14 events of systemic infections; seven events were treated successfully with antibiotics, four events necessitated the extraction of the catheter (in one patient a combination of systemic and local infection), and in three events the catheters were kept unused, as the patients were in terminal stages. Nonsystemic complications occurred with five catheters; two local infections, two obstructions (catheters removed), and one local bleeding (catheter kept unused). Appropriate antimicrobial treatment of systemic infections enables the immunocompromised child to keep the Port-A-Cath in place for a long time.     

Central venous silastic catheters in newborns: localization by sonography and radiology

The positioning of various central venous catheters in newborns including very thin silastic catheters has been checked by sonography. Even the very thin silastic catheters are easily detectable owing to their strong echoes. Diverse malpositions are presented, including non-central positioning detected by sonography. The frequency of control radiographs could be reduced.     

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.     

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.     

Heparinization of alimentation solutions administered through peripheral veins in premature infants: a controlled study

A randomized controlled study was done to determine whether the addition of heparin (1 U/mL) to peripheral intravenous alimentation solutions would affect the incidence of phlebitis and duration of patency of intravenous catheters in premature infants. Twenty-two-gauge Teflon catheters were uniformly used. One hundred five catheters infused with heparin were placed in 13 infants, and 122 catheters were placed in the control group of 13 infants. The time, nature, and incidence of complications were noted for each infusion site. Infusion of heparin was found to double the duration of patency of intravenous catheters and to reduce significantly the incidence of phlebitis. No complications related to the administration of heparin were noted. Heparinization of intravenous alimentation solutions should therefore be considered in premature infants as a means of reducing the work load and incidence of complications associated with peripheral lines.