Efficacy of subcutaneous tunneling for prevention of bacterial colonization of femoral central venous catheters in critically ill children

BACKGROUND: Blood stream infections are a common and serious complication of central venous catheters (CVCs). To decrease catheter colonization, some authors advocate tunneling the catheter in the subcutaneous tissue during insertion. This technique has proved effective in adults, but there are no data on its safety and efficacy in critically ill children. Our objective was to evaluate the efficacy and safety of subcutaneous tunneling of short term, noncuffed CVCs for the prevention of CVC-related infections in critically ill children. METHODS: A prospective randomized controlled trial was performed at a tertiary children's medical center in Israel and included children ages 0 to 18 years admitted to the pediatric intensive care unit or the pediatric cardiac intensive care unit from September 2000 to April 2001 who required placement of a femoral central venous catheter for >48 h. The children were randomized for tunneled or nontunneled insertion. The main outcome measures were bacterial colonization of proximal and distal catheter segments tested by semiquantitative technique and infectious or noninfectious complications of the CVC. RESULTS: Of 98 eligible children, 49 received tunneled catheters and 49 received nontunneled catheters. Patients' age ranged from 1 month to 16.5 years (mean, 3.07 +/- 2.48 years). There were no significant differences between the groups in age, sex, disease severity [Pediatric Risk of Mortality III (PRISM) score], duration of catheterization and underlying diseases. Bacterial colonization was found in 11 (22.4%) catheters in the nontunneled group compared with 3 (6.1%) in the tunneled group (P = 0.004). Proximal segment colonization occurred in 7 (14.2%) nontunneled catheters and 2 (4.8%) tunneled catheters (P = 0.07), and distal segment colonization occurred in 3 (6.1%) and 9(18.3%) tunneled and nontunneled catheters, respectively (P = 0.053). The main pathogens were coagulase-negative staphylococci, Pseudomonas spp. and Klebsiella spp. There was no statistically significant difference between the groups in the rate of bloodstream infection (2 in the tunneled group, 3 in the nontunneled). Except for 1 case of subcutaneous hematoma, which resolved, there were no immediate or late complications of the tunneling procedure. CONCLUSION: Subcutaneous tunneling of CVCs in the femoral site is a safe procedure and decreases significantly the rate of CVC colonization in critically ill children.     

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.     

Use of central venous catheters implanted subcutaneously in children with neoplasms

The use of totally implantable right atrial catheters was evaluated in pediatric oncology patients. From September 15, 1987 to March 31, 1989, 26 catheters were inserted in patients (1 year to 20 years of age) with the following diagnosis: acute leukemia (6), osteosarcoma (5), lymphoma (4), central nervous system tumors (6), osteosarcoma (5), lymphoma (4), central nervous system tumors (6) and other solid tumors (5). Total number of catheter days was 5,475. The catheters were maintained for a mean of 210 days (range 10-534). Complications included: documented local infection in 1 patient, successfully treated with antibiotics without removing the catheter and transient obstructions resolved with injection of heparin or urokinase in other children. The use of these right atrial catheters has been widely accepted by patients and families as well as by the health team. Complications have been minimal. Our experience confirms that these catheters contribute to improving quality of life in pediatric patients with neoplasms.     

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.     

Right atrial thrombus formation screening using two-dimensional echocardiograms in neonates with central venous catheters

Two-dimensional echocardiograms were used to prospectively screen 49 patients with 56 central venous catheters for right atrial thromboses from October 1985 to May 1986. All but four patients received a two-dimensional echocardiogram prior to insertion of the catheter. Once the catheters were in place, two-dimensional echocardiograms were performed no later than 3 weeks after insertion and then every 14 days until the catheter was removed. A single thrombus was detected 79 days after catheter placement (an incidence of 1.8%). Previous recommendations for weekly screening with two-dimensional echocardiogram were based on case reports alone. The 95% confidence limits for a negative two-dimensional echocardiogram result suggest that the initial two-dimensional echocardiogram screen for thrombus be obtained no sooner than 3 weeks after catheter insertion. In addition, significant gastrointestinal disease requiring operative intervention was present in 10 of 11 previous case reports as well as in our patient. Further studies with larger sample sizes are needed to determine whether subgroups of infants exist who are at a relatively higher risk for right atrial thrombus formation.     

Experience with the Hickman catheter in bone marrow transplantation and intensive cytostatic chemotherapy

Long-Term indwelling right atrial (Hickman) catheters were placed in 37 patients undergoing bone marrow transplantation or intensive chemotherapy for acute leukemia and other malignancies. Blood sampling, application of blood products or intravenous drugs and parenteral nutrition were impressively facilitated. Parents were easily trained for catheter care at home. The median duration of function has been 85 (2-312) days. 7 catheters had to be changed because of dislocation - especially in smaller children - or fluid leakage. In 6 severely neutropenic patients bacteremia was observed which resolved without catheter removal. The cause of death in 9 children with functioning catheter was due to the underlying disease (graft rejection, relapse). The use of Hickman-catheters improved venous access and supportive care in children with acute leukemia or other malignancies at an acceptable complication rate.     

Bacterial colonization of indwelling vascular catheters in newborn infants

Objective : To determine the incidence of bacterial colonization of intravascular catheters, to compare the incidence of colonization of intra-arterial (IA), intravenous (IV) and central venous catheters (CVC), and to determine the association, if any, between catheter withdrawal and bacterial sepsis.
Methodology : A prospective observational study was carried out at the neonatal intensive care unit of a university-affiliated regional referral centre. A total of 155 catheters (45 IA, 54 IV and 56 CVC) were obtained from 96 infants admitted to the unit and the distal 0.75 cm studied under the scanning electron microscope. The adjoining 0.75 cm was cultured for bacteria.
Results : Scanning electron microscopy revealed that 46% of catheters had bacteria on the internal surface and 13% had bacteria on the outer surface. Greater numbers of CVC were colonized with bacteria compared to IA and IV catheters ( P < 0.01). Bacterial colonization of intravascular catheters was not significantly associated with the duration the catheter remained in situ or local reaction at the site of entry of the catheter. Colonization of the external surface of the catheter was significantly associated with bacterial septicaemia ( P = 0.0466). Eighty-three per cent of 155 catheters studied had coagulum on the inner or outer surface. Only 53% of these were colonized with bacteria. Bacterial colonization occurred in the absence of a coagulum in only three instances. Catheter withdrawal was not associated with bacterial sepsis. Lack of coagulum on the internal surface of the catheter was strongly associated with septicaemia during the 7 days after catheter withdrawal.
Conclusions : Although significant numbers of intravascular catheters were colonized with bacteria, only colonization with the external surface was associated with catheter-related sepsis.     

Percutaneous central venous catheter colonization with Malassezia furfur: incidence and clinical significance

Malassezia furfur colonization of central venous catheters has been implicated in the pathogenesis of systemic infections with this lipid-dependent yeast. To determine the incidence of catheter colonization in our neonatal intensive care unit (NICU), 25 consecutively removed percutaneous central venous catheters were examined by rinsing the lumen with saline and plating the rinse fluid on Sabouraud dextrose agar overlaid with olive oil. M furfur grew from the lumina of eight catheters (32%). Surveillance skin cultures were performed in the NICU on two occasions to determine the prevalence of skin colonization with M furfur. M furfur was found on the skin of 64% of the infants. In contrast, only 3% (1/33) of healthy, nonhospitalized infants 2 to 8 weeks of age had skin colonized with M furfur. During the 5-month study period, two NICU infants had evidence of systemic infection with M furfur. We conclude that M furfur frequently colonizes both the skin and percutaneous central venous catheters in NICU infants. Further studies are needed to determine the relationship between skin colonization and catheter colonization, and the factors contributing to systemic disease with this organism.     

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.     

Efficacy of thromboresistant umbilical artery catheters in reducing aortic thrombosis and related complications

Previous in vitro and in vivo reports suggest that catheters constructed of polyurethane with heparin bonded to the surface (HB-PU) are less thrombogenic than catheters made of polyvinyl chloride (PVC). A randomized trial sufficiently large (power 80%) to detect a reduction in the incidence of umbilical artery (UA) catheter complications, including aortic thrombus formation, from 45% to 20% was conducted in 125 infants. The infants were monitored for complications possibly related to the use of a UA catheter, such as systemic hypertension and abnormalities of lower extremity perfusion. The presence of aortic thrombi was assessed by ultrasound study 3.5 +/- 1.2 (SD) days and 11.1 +/- 2.3 days after insertion of the catheter. The use of HB-PU umbilical catheters did not lead to a significant reduction in the incidence of complications and aortic thrombi compared with the use of PVC catheters. The lack of reduction may have been related to the prolonged duration of catheter use in both groups. A much larger study would have been required to detect a smaller, but perhaps clinically significant, reduction in catheter-associated complications.     

Central venous lines in neonates: a study of 2186 catheters

OBJECTIVE: To describe the use of percutaneously inserted silicone central venous lines (CVLs) in neonates at the Royal Brisbane and Women's Hospital, Australia. DESIGN: Data for all infants admitted from 1 January 1984 until 31 December 2002 who had a CVL were examined in the neonatal database, completed from paper records and patient charts where necessary. Autopsy reports of all babies who died with a catheter in place were reviewed. RESULTS: There were 18,761 admissions, 2186 catheters in 1862 babies for a total of 35,159 days (median 14 days, range 1-99 days). The tip was in the right atrium for 1282 (58.6%) of the catheters. A total of 142 babies (7.6%) died with a CVL in place, 89 (4.8%) with the catheter tip in the right atrium. Thirty two of these 89 babies had an autopsy. No autopsies reported tension in the pericardium or milky fluid resembling intralipid. One case (0.05% of catheters) of non-lethal pericardial effusion occurred in a baby whose catheter was inappropriately left coiled in the right atrium. There were no cases of pleural effusion related to CVL use. Most (1523, 69.7%) were removed electively. Septicaemia occurred during the life of 116 catheters (5.3%). CONCLUSION: This is the largest series of percutaneously inserted silicone central venous catheters reported. It illustrates the safety of these catheters in this context. It highlights the value of keeping prospective records on such catheters. Catheters with their tips in the right atrium and not coiled did not cause pericardial effusion. Strict insertion and management principles for CVLs should be adhered to.     

Fetal lamb ventricles respond differently to filling and arterial pressures and to in utero ventilation

Right and left ventricular function were investigated in 12 fetal lambs (127-140 days gestation) instrumented with electromagnetic flow sensors on the ascending aorta and the main pulmonary artery, and with vascular catheters. Nine fetuses were equipped with a postductal aortic occluder and the trachea was cannulated in eight. Control arterial blood values were pH 7.36 +/- 0.02 (SD), PCO2 49.3 +/- 2.3 torr, PO2 18.4 +/- 1.7 torr, and hematocrit 37.3 +/- 4.4%. Biventricular function curves relating stroke volume to mean right and left atrial pressure were generated by rapid withdrawal and reinfusion of fetal blood. Both function curves were composed of steep ascending and plateau limbs that intersected at a breakpoint. Stroke volumes at the breakpoints were 0.94 +/- 0.19 ml.kg-1 and 0.63 +/- 0.15 ml.kg-1 for right and left ventricle, respectively (p less than 0.001). During postductal aortic occlusion, arterial pressure increased by 19.3 +/- 7.9 torr while right ventricular stroke volume decreased by approximately 48% and left ventricular stroke volume decreased by approximately 9%. In utero ventilation increased arterial pressure, heart rate, PO2, and oxygen content. Right atrial pressure increased from 3.9 +/- 1.3 to 5.8 +/- 2.9 torr (p less than 0.05); left atrial pressure from 3.5 +/- 1.5 to 10.0 +/- 4.4 torr (p less than 0.05). Aortic flow nearly doubled (112 +/- 29 to 211 +/- 35 ml.min-1.kg-1) (p less than 0.05), and the left ventricular function curve shifted upward. The right ventricular function curve was shifted downward during ventilation. We conclude that the fetal ventricles differ significantly in their outputs, response to changes in arterial pressure, and to the onset of in utero ventilation.     

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.     

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.     

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.     

Tunneled central venous catheter for neonates: A simple technique for prolonged indwelling central catheters in intensive care.

OBJECTIVE: To describe and evaluate a new technique to insert a 24-gauge Silastic catheter in a central vein with a subcutaneous tunneled catheter in newborns after peripherally inserted central catheter (PICC) insertion failure. DESIGN: Retrospective chart review. SETTING: Pediatric and neonatal intensive care unit. PATIENTS: Twenty-nine newborns in whom a new technique was used to insert a prolonged indwelling jugular, femoral, or subclavian Silastic tunneled central catheter. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: This new technique was used in 29 newborns between January 1, 2004, and December 31, 2005. The mean gestational age was 34 +/- 5 wks with a mean weight of 2440 +/- 1101 g. Thirty-four insertion attempts were carried out. Access sites were internal jugular (28 of 34), femoral (three of 34) or subclavian (three of 34) vein. In five cases, catheter insertion failed. Pneumothorax occurred two times, and no other serious complication were observed. CONCLUSIONS: This technique is an interesting alternative when PICC insertion is not possible.     

Central venous catheters and catheter locks in children with cancer: A prospective randomized trial of taurolidine versus heparin

Background

To determine if the catheter lock taurolidine can reduce the number of catheter‐related bloodstream infections (CRBSI) in pediatric cancer patients with tunneled central venous catheters (CVC).

Procedure

During a study period of 34 months, 129 newly placed tunneled CVCs in 112 patients were randomly assigned to standard lock with heparin solution or experimental lock with a taurolidine solution ( ClinicalTrials.gov Identifier NCT00735813).

Results

Sixty‐five CVCs were included in the standard group and 64 CVCs in the experimental group. The groups were comparable regarding patients' characteristics. A total number of 72 bloodstream infections of which 33 were CRBSIs were observed during 39,127 CVC‐days. A lower rate of CRBSI (0.4 per 1,000 CVC‐days) was observed in the experimental arm compared with the standard arm (1.4 per 1,000 CVC‐days, incidence rate ratio (IRR) = 0.26; 95% confidence interval (CI) 0.09–0.61; P = 0.001). A lower rate of total bloodstream infections (1.2 per 1,000 CVC‐days) was also observed in the experimental arm compared with the standard arm (2.5 per 1,000 CVC‐days, IRR = 0.49; 95% CI 0.29–0.82; P = 0.004). Median interval from catheter insertion until first CRBSI was significantly lower in the standard group (156 days, range 12–602) compared with the experimental group (300 days, range 12–1,176; P = 0.02). Premature removal of the CVC due to infection and overall CVC survival were similar in the two study groups.

Conclusion

Locking of long‐term tunneled CVC with taurolidine significantly reduces catheter‐related bloodstream infections in children with cancer. Pediatr Blood Cancer 2013;60:1292–1298. © 2013 Wiley Periodicals, Inc.     

Reduction of catheter-associated bloodstream infections in pediatric patients: experimentation and reality.

OBJECTIVE: Few data exist on successes at reducing pediatric catheter-associated bloodstream infections (CA-BSI). The objective was to eradicate CA-BSI with a multifaceted pediatric-relevant intervention proven effective in adult patients. DESIGN: Prospective cohort of pediatric intensive care (PICU) patients with historical controls. SETTING: Multidisciplinary PICU. PATIENTS/PARTICIPANTS: PICU patients with intervention targeting PICU providers. INTERVENTIONS: Multifaceted intervention involving preintervention staff surveys, provider educational program, creation of central catheter procedure cart, guideline-supported central catheter insertion checklist, nursing staff empowerment to stop procedures that breached guidelines, and real-time data feedback to PICU leadership. MEASUREMENTS AND MAIN RESULTS: We measured rate of CA-BSI per 1000 catheter days from August 2001 through September 2006. Reliable use of evidence-based best practices for insertion of central catheters in our PICU was associated with a statistically and clinically significant decrease in our CA-BSI rate for 24 months postintervention (p < .05). During a portion of this postintervention period, we experienced a dramatic increase in our CA-BSI rate that was ultimately found to be due to the introduction of a new positive displacement mechanical valve intravenous port in April 2004. After removal of this positive displacement mechanical valve, our CA-BSI rate dropped from 5.2 +/- 4.5 CA-BSI per 1000 central catheter days to a rate of 3.0 +/- 1.9 CA-BSI per 1000 central catheter days. Chart review of postintervention CA-BSI cases revealed that these patients acquired CA-BSI weeks after both PICU admission and after insertion of the most recent central catheter. CONCLUSIONS: Our data show that improving practices for insertion of central catheters leads to a reduction of CA-BSI among pediatric patients but not elimination of CA-BSI. More research is needed to identify best practices for maintenance of central catheters for children. In addition, our experience shows that even despite good interventions to control CA-BSI, institutions must remain vigilant to factors such as new technology with apparent advantages but short track records of use.     

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.     

A technique for re-utilizing catheter insertion sites in children with difficult central venous access

Maintenance of central venous access in patients with chronic medical conditions such as short bowel syndrome demands forethought and ingenuity. We describe an innovative technique for re-utilizing central venous access sites in patients who have chronic central venous access needs. Records of patients undergoing this technique were reviewed between August 2012 and December 2015. The technique involves “cutting-down” to the sterile fibrous tunnel that naturally forms around tunneled catheters. The fibrous sheath is then isolated and controlled much as would be done for a venous “cut-down.” A separate exit site is then created for the new catheter and it is tunneled to the “cut-down” site per routine. The non-functioning catheter is then removed from the surgical field. The proximal fibrous sheath is finally cannulated either directly with the new catheter or with a wire/dilator system. This technique effectively re-uses the same venous access point while allowing for a complete change of the physical line and external site. Twenty attempts at this technique were made in twelve patients; six patients underwent the site re-utilization procedure multiple times. Re-using the fibrous tunnel to re-cycle the internal catheter site was successful in seventeen of twenty attempts. All patients had chronic conditions leading to difficult long-term central venous access [short bowel syndrome (6), hemophilia (2), cystic fibrosis (1), chronic need for central IV access (3)]. Indications for catheter replacement included catheter occlusion/mechanical failure/breakage (9), dislodgement (6), infection (1), and inadequate catheter length due to patient growth (4). Broviac/Hickman catheter sites were most commonly re-used (13; one failure); re-using a portcath site was successful in 5 of 7 attempts. There were no short term infections or mechanical complications. We describe a novel technique for salvaging tunneled central venous catheter access sites. This technique is well suited for patients with difficult and long-term central venous access needs, particularly those with chronic conditions such as intestinal failure. It is specifically useful when tunneled lines are broken, precipitated or clotted and unamenable to wiring.