Removal of embedded central venous catheters

Background/Purpose

Long-term central venous access devices (CVAD) play an integral role in the management of children who require nutritional support, chemotherapy, blood drawing, and transfusion of blood products. Infrequently, the CVAD may be difficult or impossible to remove with traction.

Patient Population

Four patients, with ages ranging from 6 to 13 years, had 4 CVAD in place for 431, 730, 2232, and 3285 days which could not be removed by manual traction and local exploration.

Results

With the use of technology developed for removal of embedded transvenous pacemaker catheters, each CVAD was successfully dislodged using a lead locking device (n = 3) or a lead locking device and an excimer laser (n = 1). There were no complications of the procedure in our series.

Conclusions

There is no consensus on optimal management of embedded CVADs. In this small series, devices used routinely to remove embedded transvenous pacemaker wires were used to extract 4 embedded CVADs without complication; however, use of this technology in pediatric surgical patients is controversial because a small percentage of adult cases have resulted in tamponade or hemothorax, potentially resulting in death. Selection of patients and use of the technology in the appropriate setting are important considerations in weighing the risks vs the benefits of extracting such catheters or leaving them in place.     

Factors influencing early failure of central venous catheters in children with cancer

Background

The authors report the results of a prospective, multicenter, multidisciplinary study of central venous catheters (CVCs) in pediatric oncology patients analyzing factors involved in early failure.

Methods

Information was collected from parent-held records on the fate of 824 devices inserted over a 20-month period, 415 of which were no longer in situ.

Results

Within the first 7 weeks after insertion, there were 66 failures, all occurring in external lines. Accidental dislodgement was the principal reason for CVC failure (44 of 66, 67%). Detailed analysis of the reason for failure of this large subgroup showed 11 factors individually associated with early dislodgement, of which, 4 were independently associated with failure by multivariate analysis. These 4 variables were the use of multilumen catheters, the absence of a skin exit site suture, platelet transfusion at the time of insertion, and patient age less than 2 years.

Conclusions

This study confirms the multiple influences on successful CVC usage. Our analysis supports the principle of only using multilumen lines when clinically essential. The findings also support the inception of randomized studies of fixation, particularly in infants.     

Transhepatic central venous catheter for long-term access in paediatric patients

Vascular access in paediatric patients with chronic and/or life-threatening illness is crucial to survival. Access is frequently lost in this group because of thrombosis, infection, or displacement, and vascular options can quickly be exhausted. The last resort access procedure is generally a direct atrial catheter inserted via a thoracotomy. A viable alternative is the percutaneous transhepatic Broviac catheter (Bard Access Systems, Salt Lake City, UT). We retrospectively reviewed the charts of 5 patients who underwent percutaneous transhepatic Broviac insertion for long-term access over a 4-year period in a single institution. Four of the patients (80%) had a significant cardiac abnormality, with 1 patient requiring long-term parenteral nutrition after complicated necrotizing enterocolitis. All patients had significant caval thrombosis, which precluded them having placement of a standard percutaneous or openly placed central catheter. Of the 5 patients, 2 (40%) died of cardiac-related illnesses. Of the 3 surviving patients, 2 had functioning catheters electively removed because they were no longer required. One catheter was removed at thoracotomy for right atrial perforation because of catheter erosion. Vascular access in paediatric patients with chronic and/or life-threatening illness is crucial to survival. Transhepatic central venous catheters are a feasible, reliable, and relatively easily placed form of central access in patients with multiple venous thromboses requiring long-term access. This route should be considered in paediatric patients requiring central access in preference to a thoracotomy.     

Long-term central venous catheters: size and location do matter

BACKGROUND: Right or left side of placement for subclavian vein catheterization for placement of long-term central catheters and size of the catheters has not been analyzed completely. METHODS: The records of 502 consecutive long-term central venous catheters placed in patients while in the operating room over a 1-year period were reviewed and 230 subclavian vein tunneled catheters were analyzed. Technical difficulties in placing the catheters were defined as arterial puncture, guidewire malposition, catheter malposition, need to switch site of access, sheath difficulty, and inability to place the catheter. RESULTS: Three complications were identified (1%) and technical difficulties occurred in 15% of the patients. More difficulty was associated with the insertion of larger triple-lumen catheters than smaller single-lumen catheters (31% vs. 11%, respectively; P < .009). Right subclavian placement was associated with a 24.4% technical difficulty rate versus a 10.4% technical difficulty rate for left subclavian placement (P < .005). CONCLUSIONS: This study supports placing the smallest catheter necessary via the left subclavian vein.     

Malposition of central venous catheter

Key words  central venous catheter - malposition     

Differences in the outcome of surgically placed long-term central venous catheters in neonates: neck vs groin placement

Background/Purpose

Long-term tunneled central venous catheters (CVC) are frequently used in the neonatal intensive care unit (NICU) babies. They are placed either in the neck or groin based primarily upon the surgeon's preference. There is meager published information available about the relative risks of these lines.

Methods

This is a retrospective analysis of all the tunneled central venous catheters placed in NICU babies at a children's hospital over a nearly 5-year period. Single lumen Broviac catheters were used in all cases.

Results

A total of 137 catheters were placed in 126 patients. There were 88 neck lines and 49 groin lines. Age, gestational maturity, and body weight were significantly lower for babies who underwent groin line placement. There was no significant difference in the number of days the catheters were live between the 2 groups. Total complication rates and catheter infection rates were significantly higher with neck lines. The accidental removal rate was higher with neck lines but did not reach statistical significance.

Conclusions

Broviac catheters placed in the groin of NICU babies are associated with significantly fewer complications compared with those placed in the neck.     

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.     

A loop technique for the safe,secure, and convenient fixation of subclavian central venous catheters to the chest wall

Central venous catheters are placed frequently at our institution. Residents are taught the technique of subclavian line placement starting in their first year of training. Frequently the teaching stops once the line is in the vein. We have developed a method of fixation for subclavian central venous catheters that provides a safe, secure, and convenient means of fixation to the chest wall. The central venous catheter can be inserted by that technique with which the physician is the most comfortable and familiar.     

Difficult extraction of long-term central venous catheters in children—case report

Although many publications address the complications associated with insertion of long-term, indwelling central venous catheters, there are only scattered reports of problems related to their removal. We report 4 cases of pediatric patients in whom the lines could not be pulled from the vein by standard methods, requiring 2 intraperiosteal clavicle resections with venorrhaphy, 1 femoral vein exploration and reconstruction, and 1 jugular venorrhaphy. Despite their relative biocompatibility, long-term silicone lines may become fixed in the vein. The rare and unpredictable occurrence of this problem may present the surgeon with unexpected intraoperative dilemmas. Before attempting localized extraction, surgeons should consider what venue, equipment, and anesthesia support may be required to successfully remove these catheters.     

Late symptomatic venous stenosis in three hemodialysis patients without previous central venous catheters

It is well known that catheters placed in the subclavian or internal jugular veins may develop stenosis in the vein in which the catheter lies. Because the arteriovenous fistula (AVF) relies on good venous outflow, patients with ipsilateral central venous stenosis are subject to the malfunctioning of AVF. Until now, no data were published on patients showing central vein stenosis (CVS) without a previous central venous catheter (CVC) or a pacemaker. In this article, we report on 3 hemodialysis patients manifesting CVS ipslateral to AVF. None of these patients previously had undergone CVC. The stenosis observed had characteristics and symptoms similar to those observed in stenoses consequent to CVC. We concluded that CVS also may occur in subclavian or axillary veins proximal to a working AVF in hemodialysis patients who have never had a CVC and in the absence of compressive phenomena.     

抗生素涂层中心静脉置管对导管相关深静脉血栓的影响

目的评价和比较抗生素涂层与普通中心静脉置管对导管相关深静脉血栓(catheterassociated deep venous thrombosis,CADVT)的影响。方法回顾分析2017年1~6月行颈内静脉、腋-锁骨下静脉或股静脉穿刺置管的择期手术患者1 359例,年龄26~82岁,ASAⅠ~Ⅲ级。采用倾向性评分法按1∶1匹配分为两组,即抗生素涂层中心静脉置管组(A组)和普通中心静脉置管组(B组)。匹配因素包括性别、年龄、ASA分级、术前血栓风险(Caprini评分)、中心静脉置管部位、手术部位、是否采用超声引导穿刺置管、是否接受抗凝治疗等。分析术后CADVT的风险和血栓程度,以及置管相关并发症。结果共938例患者匹配成功,共323例患者(34.4%)经床旁超声诊断为CADVT,其中A组172例(36.7%),B组151例(32.2%),两组CADVT发生率和血栓程度差异无统计学意义;亚组分析结果表明,高危血栓风险(Caprini评分≥5分)(OR 1.34,95%CI 1.01~1.78)、体表标志定位穿刺置管(OR 1.69,95%CI 1.04~2.74)和未接受抗凝治疗(OR 1.39,95%CI 1.01~1.92)的患者使用抗生素涂层中心静脉导管CADVT的风险高于普通中心静脉导管;A组患者导管相关感染发生率明显低于B组(0.9%vs 4.1%,P0.05);其余置管相关并发症发生率差异均无统计学意义。结论抗生素涂层中心静脉置管不增加CADVT的发生率。     

Modified central venous catheter for pneumothorax

Pneumothorax frequently requires drainage, and many thoracic surgeons continue to use the traditional rigid chest tubes. Traditional tube thoracostomy using a large-bore tube is an essential technique for thoracic surgeons, but it is associated with significant pain at the time of insertion and during continued drainage. We have found a new small-bore, flexible thoracostomy method using a modified central venous catheter that is simple, less painful, and safe.     

Pericardial effusion and cardiac tamponade associated with central venous catheters in children: an uncommon but serious and treatable condition

Purpose

Pericardial effusion (PCE) resulting in cardiac tamponade (CT) is a rare complication associated with central venous catheters (CVCs) in children. The goal of this study was to determine the demographics, presenting clinical picture and CVC characteristics in children developing CT as a result of a CVC.

Methods

An institutional review board-approved retrospective review of children treated at a tertiary-care pediatric hospital from 1998 to 2007 was conducted. Patients were identified through institutional database search for diagnostic codes of PCE and simultaneously assigned patient codes for the presence of CVC. Patients with incidentally discovered effusions, those with recent cardiac surgery, or those with causative factors other than a CVC were excluded.

Results

Over the 10-year study period, 463 patients were identified using the search criteria. Six cases of CVC-associated PCE causing CT were identified (1.3%). Corrected postgestational age at diagnosis ranged from 34 to 41 weeks with a median corrected postgestational age of 38.5 weeks (median, 38.5 weeks). The median time from CVC placement to diagnosis was 2.5 days (range, 0-6 days). Radiographs obtained before diagnosis demonstrated CVC tip to be overlying the cardiac silhouette in 5 patients (83%). Five (83%) of the 6 patients were receiving hyperalimentation via the CVC at the time of PCE. All patients presented with clinical signs of cardiorespiratory distress and/or cardiac arrest. Pericardiocentesis was performed in 5 patients (83%) and resulted in rapid stabilization. All CVCs were removed at diagnosis. There was 1 mortality (17%).

Conclusions

Pericardial effusion and CT associated with CVC is rare and is chiefly a concern among infants. Characteristics of CVCs including infusate and tip position may be associated with increased risk of PCE. This diagnosis should be considered in any infant with a CVC who experiences acute respiratory distress or cardiovascular collapse.     

重症急性胰腺炎病人中心静脉导管感染的特点

目的　分析重症急性胰腺炎 (SAP)病人中心静脉导管感染的特点。方法　回顾性分析1998年 1月至 2 0 0 2年 12月在肠外营养过程中发生中心静脉导管感染的SAP病人。结果　 189次中心静脉插管中有 5 1次导管尖端培养阳性 (2 6 9% ) ,共培养出致病菌 6 9株 ,其中革兰阴性菌 35株 ,占5 1% ;革兰阳性菌 2 8株 ,占 4 0 % ;真菌 6株 ,占 9%。多重导管感染 7例 ,占 13 7% ,多重导管感染病人的住院时间显著延长 [(2 8 9± 12 3)dvs (2 0 4± 10 6 )d ,P <0 0 5 ]。根据临床表现和药敏结果调整抗生素 ,5例加用抗真菌药物。治愈 4 8例 ,死亡 3例。结论　SAP病人中心静脉导管感染以革兰阴性菌最常见 ,需减少肠源性感染 ,合理使用预防性抗生素。     

中心静脉插管与直接动脉穿刺血透治疗比较

目的：观察中心静脉插管（CVC）和直接动脉穿刺（AP）的透析效率,可维持透析时间及并发症并进行比较。方法：50例血透病人,22例行CVC（双腔静脉导管）单针单泵透析;28例行AP透析,于透析前,透析后不同时间采血查肾功,电解质,HCO3^-浓度。结果：CVC及AP对BUN,血Ca^2 ,P^3-浓度的影响相似（P＞0．05）,而首次透析2h后血K^ ,HCK3^-浓度的变化似与其相应透析前浓度测定值的水平有关,Scr浓度变化（降低）,AP组大于CVC组（P＜0．05）,可能由于存在通路再循环的影响,CVC常见并发症为感染,细菌为表皮葡萄球菌,AP常见并发症仍为血肿或动脉瘤,结论：CVC与AP作为临时性血管通路的短期透析效率相似,但CVC有减少穿刺,保护血管的优点。     

Fractured pediatric central venous catheters — Repair or replace?

Introduction

Central venous catheter (CVC) fracture is a common complication. The aim of this study is to examine risk factors resulting in CVC fracture and compare outcomes of children undergoing CVC repair versus replacement.

Survey of permanent central venous catheters for haemodialysis in the UK

BACKGROUND: Venous catheter haemodialysis may be necessary in some patientswithout arterio venous fistulae on dialysis for end-stage renalfailure. We conducted a survey to compare management of thesecatheters in different units in the UK. METHODS: Postal questionnaires were sent to nurses in charge of 81 renalunits in the UK for a twelve month study period in 1994 to findout the type of catheter used, catheter after insertion care,the rate and management of exit site infections, and bacteraemia. RESULTS: (1) Total number of questionnaires returned 66 (81.5%). (2)63.6% of renal units used double lumen Permcath catheters, 16.7%single lumen (Francis/Kimal, Gambro or Vascath), 10.6% use bothdouble and single lumen catheters and 9.1% of renal units onlyuse temporary polyurethane catheters. (3) Catheter exit siteaseptic dressing technique was used in 84.8% of renal units,clean technique in 15.2%. 66.8% changed dressings at each dialysissession, 22.7% weekly. The majority of renal units (63.6%) hadone nurse to change the dressing, used Betadine as a cleaningagent and Mepore to cover the exit site. (4) 75.8% did not knowthe exact incidence of episodes of sepsis and/or exit site infections.Flucloxacillin was the antibiotic of choice for each catheterrelated sepsis episode. CONCLUSIONS: During this study period most renal units used Permcaths asfirst choice for long term catheter dialysis, the after insertioncare of which varied. The number of episodes of sepsis was unknown.We suggest UK collection of data for all long term cathetersand related problems for audit purposes.