Outcome of tunnelled central venous catheters used for haemodialysis in children weighing less than 15 kg

Purpose

Central venous catheters (CVC) are frequently used for haemodialysis (HD) in children. However, there is paucity of information on the outcomes of CVCs when used for HD in very young patients. Our objective is to report the success, safety and complication rates of CVCs used for HD in children weighing less than 15 kg.

Materials and methods

This is a single-center retrospective study of all patients with end-stage renal disease (ESRD) weighing < 15kg, who underwent a tunneled CVC placement for HD, between July 2006 and June 2012 at our institution. Analysed data included clinical background, age and weight at initiation of HD, outcome of HD, CVC vein insertion site, reason for removal, and catheter survival (in days).

Results

Thirty-one CVC were placed in 11 patients weighing < 15 kg, 8 males and 3 females. The main causes of ESRD were renal dysplasia and congenital nephrotic syndrome. At the beginning of HD, mean age was 27.5 (range 5–60) months and mean weight was 10.4 kg (4.5–13 kg). The preferred insertion site was the right internal jugular vein (90%). Mean duration of HD was 312 days. Mechanical factors were the main reason for catheter removal (39%). Mean catheter survival was 110 days/catheter.

Conclusions

We believe our study provides relevant information and encouraging data to support the use of CVC for HD in this cohort of infants; however, further improvement in prevention of catheter thrombosis and management of infections needs to be achieved.     

Image-guided placement of long-term central venous catheters reduces complications and cost

Background

The goals of this study were to evaluate the complication rate for intraoperative placement of a long-term central venous catheter (CVC) using intraoperative ultrasound (US) and fluoroscopy and to examine the feasibility for eliminating routine postprocedure chest X-ray.

Methods

Retrospective data pertaining to operative insertion of long-term CVC were collected and the rate of procedural complications was determined.

Results

From January 2008 to August 2013, 351 CVCs were placed via the internal jugular vein using US. Of these, 93% had a single, successful internal jugular vein insertion. The complications included 4 arterial sticks (1.14%). Starting in October 2012, postprocedure chest radiography (CXR) was eliminated in 170 cases, with no complications. A total of $29,750 in charges were deferred by CXR elimination.

Conclusions

This review supports the use of US for CVC placement with fluoroscopy in reducing the rate of procedural complications. Additionally, with fluoroscopic imaging, postprocedural CXR can be eliminated with associated healthcare savings.     

Sichere Platzierung von zentralen Venenkathetern im Kindesalter

Background

Correct positioning of a central venous catheter (CVC) tip in pediatric patients is very important. Malpositioning may lead to direct complications, such as arrhythmia and increase the risk of thrombosis, infections, valve failures or pericardial tamponade.

Objective

The aim of this review was to identify and summarize published formulae for the correct positioning of the CVC tip in children and to discuss the benefits of these formulae for the daily routine.

Material and methods

A systematic and standardized search in Medline and PubMed was performed to identify published formulae. Formulae for insertion depth of the CVC tip over the right internal jugular vein are discussed. The keywords “pediatric” or “pediatric”, “children”, “central venous catheter”, “CVC”, “central venous”, “length”, “insertion”, “optimal”, “formula”, “depth”, “correct position” and “right position”, “internal jugular vein” were used to identify the formulae.

Results

A total of 854 publications were found and 127 publications were analyzed. The publications were subsequently assessed and classified independently by a specialist in anesthesiology and a specialist in pediatrics. A total of six publications described different body height-based formulae for calculation of a CVC insertion depth. No prospective evaluation of these formulae was performed to show if it is possible to place a CVC tip at the optimal position.

Conclusion

The benefit of a formula for daily practice is very limited due to the problem of choosing the right insertion point. The recommended insertion depth should be considered as an indicator and a verification of the CVC tip position should be done using an imaging technique.

     

Central venous catheter-related bacteraemia: prospective study in a Moroccan medical intensive care unit

Objective

To determine the incidence of catheter-related bacteremia (CRB) in a Moroccan medical intensive care unit, the microbiological profile of this infection and risk factors associated with its occurrence.

Study design

Prospective observational study.

Methods

Over a period of 8 months, patients who required central venous catheter (CVC) placement for a duration greater than 48 h were included in the study. The CRB has been defined by the criteria of the SRLF Consensus Conference. The proportions of colonization and CRB were expressed as incidence density (ID). Risk factors for colonization were studied in univariate analysis.

Results

One hundred and two CVC were inserted in 70 patients. The average age was 54 ± 20 years with an APACHE II of 28 ± 10. The ID of colonization and CRB were respectively 34 for 1000 days of CVC use and 8 for 1000 days of CVC use. The isolated microorganisms were Gram-negative bacilli in 73 %, Gram-positive cocci in 22 % and finally yeast in 5 %. A prolonged duration of catheterization and the absence of systemic antibiotic therapy before catheterization were the main risk factors for colonization.

Conclusion

The incidence of CRB was high. These results impose a reflection of the care team to improve protocols for prevention of such nosocomial infections.     

High incidence of catheter-associated venous thromboembolic events in patients with long gap esophageal atresia treated with the Foker process

Purpose

To determine the incidence of catheter-associated venous thromboembolic events (VTE) in long gap esophageal atresia (LGEA) patients treated at Boston Children's Hospital (BCH) and to identify possible risk factors associated with their development.

Methods

We performed a retrospective analysis of LGEA patients from 2005 to 2012. Symptomatic VTEs with radiographic confirmation were defined as events. Potential risk factors were assessed by univariate analysis and multivariate logistic regression. Covariates included age, weight, initial gap length, cumulative days of pharmacologic paralysis and paralytic episodes, number and type of central venous catheters (CVCs), and number of operations.

Results

Forty-four LGEA patients were identified. The incidence of CVC associated VTE was 34%. Univariate analysis identified age at Foker 1 (P = .03), paralysis duration (P = .01), episodes of paralysis (P = .001), cumulative number of CVC (P = .007) and length of stay (P = .03) as significant. Multivariate logistic regression identified the number of paralytic episodes as the only significant independent risk factor for VTE (P < .0001).

Conclusions

The incidence of symptomatic VTE was 34%, significantly higher than the VTE incidence of 4.5% reported for our other hospitalized children. These data have led to multidisciplinary discussions regarding thromboprophylaxis and development of a consensus-driven protocol. Since the initiation of this protocol, no VTEs have been identified.     

Laparoscopic Approach for Artificial Urinary Sphincter Implantation in Women with Intrinsic Sphincter Deficiency Incontinence: A Single-Centre Preliminary Experience

Background

Implantation of an artificial urinary sphincter (AUS) is used as a last resort in women with stress urinary incontinence (SUI).

Objective

To assess the early functional outcome after laparoscopic placement of an AUS in women.

Design, setting, and participants

Twelve women with type 3 SUI underwent a laparoscopic AUS placement between 2006 and 2008. Eleven (92%) had previously undergone anti-incontinence procedures.

Intervention

The AUS was implanted with laparoscopic access either preperitoneally or intraperitoneally. The cuff was placed around the bladder neck between the periurethral fascia and the vagina.

Measurements

Perioperative complications were reviewed. To assess resolution of urinary incontinence, all patients were seen at 1, 3, 6, and 12 mo after the surgery and yearly thereafter.

Results and limitations

The mean age of subjects was 56.7 ± 12 yr (33–78). The mean body mass index was 24 ± 2.3 (20–25). The mean preoperative closure pressure was 22 ± 10.9 cmH₂O (4–35). The mean operative time was 181 ± 39 min [110–240]. Intraoperative complications occurred in three women (25%), with bladder (n = 2) and vaginal (n = 2) injuries. These complications required open conversion. AUS implantation was postponed in one case. The mean hospital stay was 7 ± 2.3 d (3–11). The bladder catheter was removed after a mean time of 10 ± 8 d (2–30). Urinary retention was observed in five cases (45%) after bladder catheter removal. AUS activation was done 4–14 wk after implantation. Mean follow-up was 12.1 ± 8 mo (5.2–27). Incontinence was completely resolved in eight women (88%) who underwent complete laparoscopic procedure. The main limitation of the study was the limited length of follow-up.

Conclusions

AUS implantation can be successfully achieved by laparoscopy. It appears to be technically feasible. These results are still preliminary, and further studies of larger populations with longer follow-up are needed to make any statement regarding surgical strategy.     

Obesity Has Minimal Impact on Clinical Outcomes in Children with Inflammatory Bowel Disease

Purpose

Childhood obesity is an increasing problem in affluent societies throughout the world. We sought to identify the impact of obesity on the outcome of inflammatory bowel disease (IBD) and determine differences (if any) between ulcerative colitis (UC) and Crohn’s disease (CD).

Methods

The 2009 Kids’ Inpatient Database was explored for all children (≤ 20 years) admitted with IBD. ICD-9 codes were used to identify obesity and complications, including hemorrhage, perforation, and complex fistulas. Logistic regression analysis accounting for demographics, underlying disease, surgical procedures, and obesity was performed to identify factors associated with complication development. Data are expressed as odds ratios (OR) and a 95% confidence interval (CI). A P value of 0.05 was regarded as significant.

Results

From 12,465 admissions, 164 children were obese (1.3%), with no difference between CD and UC (1.3% vs. 1.4%; P = 0.60). Girls had a two-fold increase in obesity (OR: 2.06, CI: 1.48–2.86; P < 0.01). Obesity had no effect on elective/emergent admission rate (OR: 0.85, CI: 0.54–1.35; P = 0.49), perforation (OR: 0.76, CI: 0.13–4.46; P = 0.76), hemorrhage (OR: 0.64,CI: 0.34–1.21; P = 0.17), complex fistula (OR: 1.19, CI: 0.45–3.17; P = 0.72), or requirement for surgery (OR: 0.80, CI: 0.48–1.31; P = 0.37). While the overall clinical morbidity rate was 10.7%, obesity was not associated with the development of overall complications (OR 1.20, CI: 0.75–1.93; P = 0.45) or length of stay (6.36 vs. 6.10 days; P = 0.61). Obesity increased the rate of central venous catheter (CVC) infections (OR: 10.98, CI: 2.50–48.20; P < 0.01).

Conclusions

Obesity was more prevalent in girls with IBD. While obesity did not alter disease severity, rate of surgical intervention, or hospital length of stay, it was associated with higher CVC infections.     

Assessment of the health status in Brazilian burn victims five to seven months after hospital discharge

Purpose

To evaluate health status, impact of event, anxiety, and depression in burn victims at five-to-seven months after hospital discharge, and to explore the association between those variables with age, body surface area burn (BSA), sex, and marital status.

Methods

Cross-sectional study involving 73 adults who were interviewed for general health status (BSHS-R), impact of event (IES), and anxiety and depression (HADS).

Results

Participants were mostly men (68.5%), with mean age 38.4 years (SD = 14.5), and mean hospital length of stay (LOS) 24.5 days (SD = 25.3). Mean scores were: 128.1 (SD = 18.9) for BSHS-R, 62.1(SD = 35.8) for IES, 5.5 (SD = 4.1) for anxiety, and 3.9 (SD = 3.9) for depression. Health status was highly and inversely correlated with impact of event, depression, anxiety, LOS, number of surgeries, and BSA. Men and women differed in the BSHS-R affect and body image domains, and depression. Individuals with larger BSA reported worse scores for BSHS-R (work domain).

Conclusion

Burn victims reported good health status on average, which was negatively correlated with reported depression, anxiety, impact of event, LOS, number of operations, and BSA. These findings suggest that general health might be improved by interventions that target modifiable behavioral factors, such as support groups and cognitive behavioral therapies.     

Proper catheter selection for needle thoracostomy: A height and weight-based criteria

Background

Obesity increases the incidence of mortality in trauma patients. Current Advanced Trauma Life Support guidelines recommend using a 5-cm catheter at the second intercostal (ICS) space in the mid-clavicular line to treat tension pneumothoraces. Our study purpose was to determine whether body mass index (BMI) predicted the catheter length needed for needle thoracostomy.

Methods

We retrospectively reviewed trauma patients undergoing chest computed tomography scans January 2004 through September 2006. A BMI was calculated for each patient, and the chest wall thickness (CWT) at the second ICS in the mid-clavicular line was measured bilaterally. Patients were grouped by BMI as underweight (≤18.5 kg/m2), normal weight (18.6–24.9 kg/m²), overweight (25–29.9 kg/m²), or obese (≥30 kg/m²).

Results

Three hundred twenty-six patients were included in the study; 70% were male. Ninety-four percent of patients experienced blunt trauma. Sixty-three percent of patients were involved in a motor vehicle collision. The average BMI was 29 [SD 7.8]. The average CWT was 6.2 [SD 1.9] cm on the right and 6.3 [SD 1.9] cm on the left. As BMI increased, a statistically significant (p < 0.0001) CWT increase was observed in all BMI groups. There were no significant differences in ISS, ventilator days, ICU length of stay, or overall length of stay among the groups.

Conclusion

As BMI increases, there is a direct correlation to increasing CWT. This information could be used to quickly select an appropriate needle length for needle thoracostomy. The average patient in our study would require a catheter length of 6–6.5 cm to successfully decompress a tension pneumothorax. There are not enough regionally available data to define the needle lengths needed for needle thoracostomy. Further study is required to assess the feasibility and safety of using varying catheter lengths.     

Catheter malplacement during central venous cannulation through arm veins in pediatric patients

For successful catheter placement, central venous cannulation (CVC) through internal jugular vein and subclavian vein has been recommended in both adult and pediatric patients. But it carries a risk of serious complications, such as pneumothorax, carotid, or subclavian artery puncture, which can be life-threatening, particularly in critically ill children. So a prospective study was carried out to determine the success rate of correct catheter tip placement during CVC through antecubital veins in pediatric neurosurgical patients. A total of 200 pediatric patients (age 1-15 years) of either sex were studied. Basilic or cephalic veins of either arm were selected. All the patients were cannulated in the operation room under general anesthesia. Single lumen, proper size catheters (with stillete) were used for cannulation. The catheter was inserted in supine position with the arm abducted at right angle to the body and neck turned ipsilaterally. The length of insertion was determined from cubital fossa to the right second intercostal space. The exact position of the tip of the catheter was confirmed radiologically in ICU. Correct catheter tip placement was achieved in 98 (49%) patients. Multivariate logistic regression analysis of data shows that there was no statistically significant difference among correct and incorrect catheter tip placement in relation to factors including sex, side of cannulation (left or right), and type of vein (basilic or cephalic). The analysis of correct catheter tip placement in relation to age showed that the highest success rate was achieved in children of age group 6 to 10 years (60.2%) followed by 30.6% in the 11 to 15 year group. The lowest success rate of tip placement of only 9.2% was observed in younger children of age 1 to 5 years, which is statistically significant (P = 0.001). Of 102 incorrect placements reported, 37% were in 1 to 5 year age group versus 9.2% correct tip placements. The most common unsatisfactory placements were either in the ipsilateral internal jugular vein (N = 38, 37.2%) or in the ipsilateral subclavian vein (N = 27, 26.4%). In 10 patients the catheter crossed over to the opposite subclavian vein, in 16 patients the catheter tips were found in the axillary vein, and in 10 patients each the catheter tip was observed in right atrium and right ventricle. No major complication during and following CVC was observed. To conclude, CVC using single orifice catheter through arm veins in pediatric patients is easy to perform, but the proper catheter tip placement is highly unreliable, particularly in younger children 1 to 5 years of age.     

Safety and yield of muscle biopsy in pediatric patients in the modern era

Background

Muscle and skin biopsies are commonly used diagnostic procedures in the evaluation of pediatric neuromuscular and genetic disorders. However, few modern reports have documented their diagnostic yield and clinical utility. We reviewed our experience at a tertiary care center.

Methods

We retrospectively studied consecutive pediatric patients who underwent muscle biopsy at our institution between January 2008 and April 2012.

Results

Of 169 patients, 97 (57%) were male, and the median (range) age was 7 years (9 days to 18 years). In 101 patients (60%), a pathologic diagnosis was made. Histologic results of biopsy were completely normal in 45 patients (27%). Minimal abnormalities not sufficient to make a definitive pathologic diagnosis were reported in 23 patients (14%). Sensitivity and specificity of preoperative electromyography in detecting muscle pathology were 58% and 56%, respectively. No complications occurred from the use of general anesthesia. The only complication was a right femoral vein laceration when the right vastus medialis muscle was chosen as a biopsy site.

Conclusion

Muscle biopsy in children is safe and useful in establishing the best management plan for patients with suspected neuromuscular disorders. This finding contradicts those of previous studies.     

Average chest wall thickness at two anatomic locations in trauma patients

Background

Needle thoracostomy is the emergent treatment for tension pneumothorax. This procedure is commonly done using a 4.5 cm catheter, and the optimal site for chest wall puncture is controversial. We hypothesize that needle thoracostomy cannot be performed using this catheter length irrespective of the site chosen in either gender.

Methods

A retrospective review of all chest computed tomography (CT) scans obtained on trauma patients from January 1, 2011 to December 31, 2011 was performed. Patients aged 18 and 80 years were included and patients whose chest wall thickness exceeded the boundary of the images acquired were excluded. Chest wall thickness was measured at the 2nd intercostal (ICS), midclavicular line (MCL) and the 5th ICS, anterior axillary line (AAL). Injury severity score (ISS), chest wall thickness, and body mass index (BMI) were analyzed.

Results

201 patients were included, 54% male. Average (SD) BMI was 26 (7) kg/m². The average chest wall thickness in the overall cohort was 4.08 (1.4) cm at the 2nd ICS/MCL and 4.55 (1.7) cm at the 5th ICS/AAL. 29% of the overall cohort (27 male and 32 female) had a chest wall thickness greater than 4.5 cm at the 2nd ICS/MCL and 45% (54 male and 36 female) had a chest wall thickness greater than 4.5 cm at the 5th ICS/AAL. There was no significant interaction between gender and chest wall thickness at either site. BMI was positively associated with chest wall thickness at both the 2nd and 5th ICS/AAL.

Conclusion

A 4.5 cm catheter is inadequate for needle thoracostomy in most patients regardless of puncture site or gender.     

Spleno-adrenal shunt: A novel alternative for portosystemic decompression in children with portal vein cavernous transformation

Purpose

Children with portal vein cavernous transformation (PVCT) can develop life-threatening variceal hemorrhage from progressive portal hypertension. While spleno-renal shunt ± splenectomy is the most common portosystemic decompression surgery performed in children, we have adopted a modified spleno-adrenal (SA) shunt for complicated PVCT. We describe our 10 year experience focusing on technique evolution and treatment efficacy.

Methods

Between 2001 and 2011, 15 children (9 girls and 6 boys, ages 3–11 years, median: 6 years) with PVCT, portal hypertension, and hypersplenism were treated with SA shunt with splenectomy in Shanghai Children's Medical Center. All children in the study had endoscopy proven active esophageal variceal bleeding requiring multiple transfusions (mean: 4.2 units) with failed sclerotherapy (mean: 2.6 times). Greater omental vein pressure (GVP) approximating portal venous pressure was measured pre- and post-SA shunt. Pre- and post-operative ammonia levels were obtained. Follow-up ranged from 6 months to 10 years (mean: 4.2 ± 2 years).

Results

Intra-operative adrenal vein diameter and length ranged from 0.7 to 1.8 cm and 2 to 3 cm, respectively. Intra-operative GVPs pre-and post-SA shunt were (30 ± 11) and (22 ± 7) mmHg, respectively (p < 0.01). On follow-up, there have been no recurrences of GI bleeding. Liver function tests remained normal in all children with the exception of elevated post-operative mean blood ammonia levels [Pre (18 ± 7) mmol/L, post (60 ± 17) mmol/L (p < 0.05)] in all children. Ammonia levels normalized in all cases on outpatient follow-up. There have been no cases of hepatic encephalopathy, and all have normal age appropriate neurodevelopment (Bayley's assessment). Barium swallow and/or upper endoscopy showed interval resolution of esophageal varices in all children, and vascular ultrasound showed patent shunt anastomosis without stricture in 14 (93%).

Conclusions

The left adrenal vein is a viable conduit for effective selective portosystemic decompression. Similar to the more traditional spleno-renal shunt, SA appears also to have the advantage of preventing hepatic encephalopathy preserving neurodevelopment, although the rise in post-operative ammonia levels was unexpected. Longer follow-up is needed to look for late signs of encephalopathy assessing neurodevelopment long term.     

Magnetic gastrointestinal anastomosis in pediatric patients

Background/Purpose

To describe 17 patients who underwent magnetic, non-surgical gastrointestinal (GI) anastomoses.

Methods

Patients with GI obstruction, stenosis, or atresia were treated with image-guided and/or endoscopically placed discoid magnet pairs or catheter-based bullet-shaped magnet pairs.

Results

Anastomosis was achieved in 7 days in an 11-year-old with gastric outlet obstruction due to metastatic colon cancer. Anastomosis was achieved in 8 and 10 days in 2 patients (age 2.0 years and 3.4 years) who had rectocolonic stenosis. Re-anastomosis was achieved in an average of 6 days (range 3 to 7 days) in 5 patients (age 6 months to 5.9 years) with severe recurrent postsurgical esophageal stenosis refractory to dilatation. Primary esophageal anastomosis was achieved in an average of 4.2 days (range 3 to 6 days) in 9 patients with esophageal atresia (Type A or Type C surgically converted to Type A) with a gap length of 4 cm or less. The average age of these esophageal atresia patients was 3 months (range 23 days to 5 months).

Conclusion

Minimally invasive magnet placement was feasible and achieved anastomosis in all patients.     

Are routine chest radiographs needed after fluoroscopically guided percutaneous insertion of central venous catheters in children?

Current guidelines for children still mandate routine postprocedural chest x-ray to confirm placement and detect complications. This is in spite of the risk of unnecessary exposure to radiation, the additional stress to children and their parents, and the cost of this practice. We studied the impact and cost-effectiveness of this practice on the management of children after percutaneous fluoroscopically guided central venous catheter (CVC) insertions.

Methods

A retrospective review of children who underwent percutaneous fluoroscopically guided CVC insertions between January 2000 and December 2005. Only patients with reported postprocedural radiographs in the electronic database were included, and we referred to the medical notes when the report indicated a complication.

Results

Two hundred eighty consecutive patients aged between 4 and 16 years were identified. Two hundred seventy-eight (99.3%) of the reports indicated absence of complications, whereas only 2 reports (0.7%) indicated any form of complications. Of the 2 complications detected, 1 was an asymptomatic pneumothorax, and the other was a slight kink in the line; on review of the medical notes, both lines were fully functional and neither required treatment.

Conclusion

After percutaneous fluoroscopically guided CVC insertions and in the absence of clinical indications, the use of routine postprocedural radiographs in children cannot be justified and is not cost-effective.     

Burden of complications from needle penetration of plastic ports in children

Background

Complications of totally implanted venous access ports are well documented. A concerning mechanical complication we have encountered is posterior penetration of plastic ports with the access needle. The purpose of this study is to investigate the burden of posterior penetrations.

Methods

We performed a retrospective review of all ports placed between November 2007 and December 2011 at a single institution.

Results

There were 247 children who received a port. 117 children (47%) received a port with a plastic posterior wall, 95 children (38%) received a port with a metal posterior wall, and 35 children (14%) had ports that were unable to be identified as plastic or metal. Posterior port penetrations occurred 8 times (3.2% overall, 6.8% of plastic ports). All perforations occurred in plastic ports of a single brand and product code. Average time from port insertion to penetration was 11.2 ± 21.3 months (range 0.3 to 63.4 months). Other complications included catheter malfunction (14), infection (9), pain (2), inability to draw/aspirate (4), leak (3), port migration (2), and malfunctioning not otherwise specified (15).

Conclusions

There is an unacceptably high risk of needle penetration of the posterior wall of plastic ports. We recommend utilizing ports with metal backing to avoid this complication.     

Percutaneous central access in patients younger than 5 years: size does matter

Purpose

The purpose of this study was to determine, in a pediatric population less than 5 years of age, which size catheter is ideal for central venous access via the subclavian and internal jugular vein based on the children’s age, weight, and height.

Methods

This was a retrospective chart review of children less than 5 years of age at The Children’s Hospital in Denver, Colorado who underwent subclavian or internal jugular central venous catheter placement from January 1, 1998 through December 31, 2001. Age, height, weight, primary disease, access site, type of central venous catheter, size of central venous catheter, and complications were recorded. Age, weight, and height were stratified and compared with catheter size to determine any correlation between age, weight, height, and complications.

Results

There were 430 central venous catheters placed via the subclavian or internal jugular vein in 331 patients less than 5 years old. One hundred ninety-five catheters (45.4%) were less than 6F in size, and 235 (54.6%) catheters were ≥6F in size. Children, who were between 0.5 and 0.99 years old, 5 to 7.49 kg in weight, 7.5 to 9.99 kg in weight, and 60 to 74.9 cm in height had higher complication rates (P < .05) when catheters ≥6F were inserted. Children who were greater than 1 year of age, greater than 10 kg in weight, and longer than 75 cm in height did not experience a significant difference (P > .05) in complications versus catheter size.

Conclusions

The choice of central venous catheter size should be predicated, not only on the primary disease, but also on the child’s age, weight, and height. Insertion of central venous catheters larger than 6F in children less than 1 year of age, less than 10 kg in weight, or less than 75 cm in height, was associated with higher complications compared with other settings.     

The use of retrievable fully covered self-expanding metal stent in refractory postoperative restenosis of benign esophageal stricture in children

Purpose

This study analyzes the efficacy and safety of a retrievable, fully covered self-expanding metal stent (cSEMS) in the treatment of refractory benign esophageal restenosis in children.

Methods

This is a retrospective analysis of the application of a newly designed cSEMS in treating refractory benign postoperative restenosis in five children with ages ranging from 16 months to 8 years. Efficacy and safety were evaluated during the follow-up period.

Results

cSEMS with or without an antireflux valve at the distal end were successfully placed and removed in five children. These five patients were followed up for 4–12 months after stent removal. Among the five patients, ulcerative stricture was observed in two patients because of reflux esophagitis, while three patients showed no signs of stricture recurrence. Stent migration was observed in three patients, two of which required the stent to be reset. The narrow esophagus was successfully expended to a diameter of 12–13 mm. Besides the observation of mild granulation tissue growth in one case, no severe complications were observed during surgery and after stent placement.

Conclusion

Our study suggests that a retrievable, fully covered SEMS is safe and partially effective for treating refractory benign postoperative esophageal restenosis in children during short-term observation.     

Laparoscopy utilization and outcomes for appendicitis in small children

Purpose

To examine the trends in laparoscopic appendectomy (LA) utilization and outcomes for children 5 years or younger.

Methods

We studied 16,028 inpatient admissions for children 5 years of age or less undergoing an appendectomy for acute appendicitis in 2000, 2003, and 2006 using the Kids' Inpatient Database (KID). Laparoscopy frequency, hospital length of stay, and complications were reviewed.

Results

In 2000, 2003 and 2006 appendectomies were done laparoscopically 11.4%, 18.7% and 31.3% of the time, respectively. Children were more likely to undergo LA at a children's hospital (P < 0.001). LA complications were less likely overall (OR: 0.80, CI: 0.70–0.92, P = 0.002) and in perforated cases (OR: 0.78, CI: 0.67-0.91, P = 0.001). LA decreased hospital length of stay by 0.54 days for all patients and 0.70 days for perforated cases (P < 0.001).

Conclusions

Open appendectomy has historically been the standard in children 5 years of age and younger. Laparoscopic appendectomy has slowly gained acceptance for the treatment of appendicitis in smaller children. The use of laparoscopy has increased significantly at all facilities. Furthermore, laparoscopic appendectomy in this age group has a comparatively low complication rate and short hospital length of stay, and is safe in complicated perforated appendicitis cases.