Insertion, management, and complications associated with arterial catheters in paediatric intensive care: A clinical audit

Safety and Sustainability of Axillary Versus Radial Arterial Catheters in Critically Ill Children: A Retrospective Comparative Study

BACKGROUND

Arterial catheters are commonly used for hemodynamic monitoring and blood sampling in critically ill children, with the radial artery being the typical site. When radial cannulation is not feasible, alternative sites like the axillary artery may be utilized. However, the safety and sustainability of axillary arterial catheters compared to radial catheters in this population remain unclear.

AIMS

This study aims to assess the safety and sustainability of axillary arterial catheters compared to radial arterial catheters in pediatric intensive care unit patients.

METHODS

We conducted a retrospective, case-control study at a university-affiliated tertiary care pediatric intensive care unit. Patients aged 18 years or younger with axillary arterial catheters from January 2007 to December 2023 were compared to patients of similar ages with radial catheters.

RESULTS

A computerized chart review identified 306 patients with axillary catheters, compared to 306 randomly selected patients with radial catheters. The rate of catheter site replacement was identical in both groups (40 out of 306). The median duration of axillary catheter use was 34 h longer (95% CI: 24-48; p < 0.001). Only one patient in the axillary group (0.33%) experienced a vascular complication, recovering fully after intervention. Patients with axillary catheters were characterized by a higher Pediatric Index of Mortality 3 scores, Vasoactive-Inotropic Scores, and PICU mortality rates.

CONCLUSIONS

In this critically ill pediatric cohort, axillary arterial catheters were used longer and in a more severely ill population than radial catheters. Despite these differences, both catheter types demonstrated comparable safety and sustainability profiles.

Peripheral arterial catheter securement and catheter survival in the pediatric intensive care unit

BACKGROUND

Peripheral arterial catheters (PACs), and their associated complications, are common in the pediatric intensive care unit (PICU). Accidental catheter displacement and non-functional PACs are the most common complications, and this may be related to inadequate catheter securement. There is mixed guidance on the best way to secure PACs to prevent complications. The authors hypothesized that sutures would not be associated with a decreased risk of malfunction or accidental removal.

METHODS

This was a single center retrospective cohort study at a quaternary-care PICU. PICU patients with a peripheral arterial catheter placed in the PICU from 7/2020 to 1/2023 were included. The primary outcome was unplanned PAC removal. A univariate and multivariate Cox proportional hazards regression analysis was performed, using patient weight, sedation, paralytic, and role of the proceduralist as covariates. The secondary outcome was survival probability. A log-rank test was used to compare survival curves.

RESULTS

Of 761 PACs that met inclusion criteria in 437 unique patients, 599 were sutured (78.7%) and 162 were un-sutured (21.3%). In 257 cases (33.8%), the PAC had an unplanned removal. Among all PACs, the median duration of PAC placement was 5.3 days (IQR 2.1-10.5 days). There was an unplanned removal rate of 42.2% (68) in the un-sutured group and 31.4% (188) in the sutured group (p < 0.001). In multivariable analysis, sutured PACs were also associated with a lower rate of unplanned removal (hazard ratio, 0.59; 95% CI, 0.44-0.78). Use of continuous sedation was also associated with an increased risk of unplanned removal of PACs (hazard ratio, 1.54; 95% CI, 1.10-2.16). There was a 50% survival probability at 13.3 days for un-sutured PACs and 23.7 days for sutured PACs.

CONCLUSIONS

Suturing is associated with fewer unplanned removals and longer catheter survival, compared to un-sutured PACs in pediatric patients.

Guidelines for Performing Ultrasound-Guided Vascular Cannulation: Recommendations of the American Society of Echocardiography

Vascular access is a commonly performed procedure to facilitate patient care. This document provides expert consensus from diverse specialists on best practices and techniques for incorporating ultrasound (US) into vascular access procedures. This update replaces the 2011 American Society of Echocardiography guidelines for US-guided vascular cannulation. It includes recommendations for US-guided access to central and peripheral veins and arteries in adult and pediatric patients based on the strength of the scientific evidence present in the literature. The major roles of US during vascular access include (1) precannulation vessel assessment, (2) dynamic US guidance during cannulation, and (3) identification of local complications. This document discusses the general aspects of anatomic and US imaging of vessels, US-guided vascular cannulation techniques, and the identification of local vascular cannulation complications. Proper training should impart the cognitive knowledge and technical skills necessary to perform US-guided cannulation. There is an increasing body of literature indicating that US-guided vascular access improves success rates and reduces complications, although the quality of the evidence to date remains weak. A gap remains between the existing evidence and guidelines for the use of US in clinical practice. The availability of US equipment and clinical proficiency will more likely influence the role of US-guided vascular access as a standard of care than will future research studies.

Dressings and securement devices to prevent complications for peripheral arterial catheters

BACKGROUND

Peripheral arterial catheters (ACs) are used in anaesthesia and intensive care settings for blood sampling and monitoring. Despite their importance, ACs often fail, requiring reinsertion. Dressings and securement devices maintain AC function and prevent complications such as infection.

OBJECTIVES

To evaluate the effectiveness of peripheral AC dressing and securement devices to prevent failure and complications in hospitalised people.

SEARCH METHODS

We searched the Cochrane Wounds Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL Plus up to 16 May 2023. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform up to 16 May 2023.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing different dressing and securement devices for the stabilisation of ACs in hospitalised people.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, extracted data, and assessed risk of bias using Cochrane's RoB 1 tool. We resolved disagreements by discussion, or by consulting a third review author when necessary. We assessed the certainty of evidence using GRADE.

MAIN RESULTS

We included five RCTs with 1228 participants and 1228 ACs. All included studies had high risk of bias in one or more domains. We present the following four comparisons, with the remaining comparisons reported in the main review. Standard polyurethane (SPU) plus tissue adhesive (TA) compared with SPU: we are very uncertain whether use of SPU plus TA impacts rates of AC failure (risk ratio (RR) 0.44, 95% confidence interval (CI) 0.20 to 0.98; I² = 0%; 2 studies, 165 participants; very low-certainty evidence). Neither study (165 participants) reported catheter-related bloodstream infections (CRBSI), thus we are very uncertain whether SPU plus TA impacts on the incidence of CRBSI (very low-certainty evidence). It is very uncertain whether use of SPU plus TA impacts AC dislodgement risk (RR 0.54, 95% CI 0.03 to 9.62; I² = 44%; 2 studies, 165 participants; very low-certainty evidence). We are very uncertain whether use of SPU plus TA impacts AC occlusion rates (RR 1.20, 95% CI 0.37 to 3.91; I² = 3%; 2 studies, 165 participants; very low-certainty evidence). We are very uncertain whether use of SPU plus TA impacts rates of adverse events with few reported events across groups (RR 0.89, 95% CI 0.09 to 8.33; I² = 0%; 2 studies, 165 participants; very low-certainty evidence). Bordered polyurethane (BPU) compared to SPU: we are very uncertain whether use of BPU impacts rates of AC failure (RR 0.67, 95% CI 0.21 to 2.13; 1 study, 60 participants; very low-certainty evidence). BPU may make little or no difference to CRBSI compared to SPU (RR 3.05, 95% CI 0.12 to 74.45; I² = not applicable as 1 study (60 participants) reported 0 events; 2 studies, 572 participants; low-certainty evidence). BPU may make little or no difference to the risk of AC dislodgement compared with SPU (RR 0.75, 95% CI 0.17 to 3.22; I² = 0%; 2 studies, 572 participants; low-certainty evidence). BPU may make little or no difference to occlusion risk compared with SPU (RR 0.80, 95% CI 0.60 to 1.07; I² = 0%; 2 studies, 572 participants; low-certainty evidence). It is very uncertain whether BPU impacts on the risk of adverse events compared with SPU (RR 0.33, 95% CI 0.01 to 7.87; 1 study, 60 participants; very low-certainty evidence). SPU plus sutureless securement devices (SSD) compared to SPU: we are very uncertain whether SPU plus SSD impacts risk of AC failure compared with SPU (RR 0.78, 95% CI 0.40 to 1.52; I² = 0%; 2 studies, 157 participants; very low-certainty evidence). We are very uncertain if SPU plus SSD impacts CRBSI incidence rate with no events in both groups (2 studies, 157 participants; very low-certainty evidence). It is very uncertain whether SPU plus SSD impacts risk of dislodgement (RR 0.14, 95% CI 0.01 to 2.57; I² = not applicable as 1 study (96 participants) reported 0 events; 2 studies, 157 participants; very low-certainty evidence). It is very uncertain whether SPU plus SSD impacts risk of AC occlusion (RR 1.94, 95% CI 0.50 to 7.48; I² = 38%; 2 studies, 157 participants; very low-certainty evidence). We are very uncertain whether SPU plus SSD impacts on the risk of adverse events (RR 1.94, 95% CI 0.19 to 20.24; I² = not applicable as 1 study (96 participants) reported 0 events; 2 studies, 157 participants; very low-certainty evidence). Integrated securement dressings compared to SPU: integrated securement dressings may result in little or no difference in risk of AC failure compared with SPU (RR 1.96, 95% CI 0.80 to 4.84; 1 study, 105 participants; low-certainty evidence); may result in little or no difference in CRBSI incidence with no events reported (1 study, 105 participants; low-certainty evidence); may result in little or no difference in the risk of dislodgement (RR 0.33, 95% CI 0.04 to 3.04; 1 study, 105 participants; low-certainty evidence), may result in little or no difference in occlusion rates with no events reported (1 study, 105 participants; low-certainty evidence), and may result in little or no difference in the risk of adverse events (RR 0.35, 95% CI 0.01 to 8.45; 1 study, 105 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

There is currently limited rigorous RCT evidence available about the relative clinical effectiveness of AC dressing and securement products. Limitations of current evidence include small sample size, infrequent events, and heterogeneous outcome measurements. We found no clear difference in the incidence of AC failure, CRBSI, or adverse events across AC dressing or securement products including SPU, BPU, SSD, TA, and integrated securement products. The limitations of current evidence means further rigorous RCTs are needed to reduce uncertainty around the use of dressing and securement devices for ACs.

Topical glyceryl trinitrate to increase radial artery diameter in neonates: study protocol for a randomized controlled trial

BACKGROUND

Newborn infants admitted to the neonatal intensive care unit require arterial cannulation for hemodynamic monitoring and blood sampling. Arterial access is achieved through catheterization of umbilical or peripheral arteries. Peripheral artery cannulation is performed in critically ill newborns, but artery localization and cannulation is often challenging and unsuccessful. Therefore, increasing the internal diameter and preventing vasospasm are important for successful peripheral artery cannulation in neonates. Topical glyceryl trinitrate has the potential to increase cannulation success by relaxing arterial smooth muscles and thus increasing the internal diameter. We aim to conduct a pilot randomized controlled trial to evaluate the efficacy and safety of topycal glyceryl trinitrate in increasing the diameter of the radial artery in neonates.

METHODS/DESIGN

This study will be a single-center, observer-blind, randomized, placebo-controlled trial conducted in the neonatal intensive care unit of Perth Children's Hospital, Western Australia. A total of 60 infants born at >34 weeks of gestation who are admitted for elective surgery or medical reasons and for whom a peripheral arterial line is needed for sampling or blood pressure monitoring will be recruited after informed parental consent is obtained. The primary outcome will be the change in radial arterial diameter from baseline to postintervention. Secondary outcomes will be the absolute and percentage change from baseline in the radial arterial diameter in both limbs and safety (hypotension and methemoglobinemia).

DISCUSSION

This will be the first randomized controlled trial evaluating the use of topical glyceryl trinitrate to facilitate peripheral artery cannulation in neonates. If our pilot randomized controlled trial confirms the benefits of glyceryl trinitrate patches, it will pave the way for large multicenter randomized controlled trials in this field.

Risk factors for arterial catheter failure and complications during critical care hospitalisation: a secondary analysis of a multisite, randomised trial

OBJECTIVES

Arterial catheters (ACs) are critical for haemodynamic monitoring and blood sampling but are prone to complications. We investigated the incidence and risk factors of AC failure.

METHODS

Secondary analysis of a multi-centre randomised controlled trial (ACTRN 12610000505000). Analysis included a subset of adult intensive care unit patients with an AC. The primary outcome was all-cause device failure. Secondary outcomes were catheter associated bloodstream infection (CABSI), suspected CABSI, occlusion, thrombosis, accidental removal, pain, and line fracture. Risk factors associated with AC failure were investigated using Cox proportional hazards and competing-risk models.

RESULTS

Of 664 patients, 173 (26%) experienced AC failure (incidence rate [IR] 37/1000 catheter days). Suspected CABSI was the most common failure type (11%; IR 15.3/1000 catheter days), followed by occlusion (8%; IR 11.9/1,000 catheter days), and accidental removal (4%; IR 5.5/1000 catheter days). CABSI occurred in 16 (2%) patients. All-cause failure and occlusion were reduced with ultrasound-assisted insertion (failure: adjusted hazard ratio [HR] 0.43, 95% CI 0.25, 0.76; occlusion: sub-HR 0.11, 95% CI 0.03, 0.43). Increased age was associated with less AC failure (60-74 years HR 0.63, 95% CI 0.44 to 0.89; 75 + years HR 0.36, 95% CI 0.20, 0.64; referent 15-59 years). Females experienced more occlusion (adjusted sub-HR 2.53, 95% CI 1.49, 4.29), while patients with diabetes had less (SHR 0.15, 95% CI 0.04, 0.63). Suspected CABSI was associated with an abnormal insertion site appearance (SHR 2.71, 95% CI 1.48, 4.99).

CONCLUSIONS

AC failure is common with ultrasound-guided insertion associated with lower failure rates. Trial registration Australian New Zealand Clinical Trial Registry (ACTRN 12610000505000); date registered: 18 June 2010.

Patient and Technical Factors Associated with Difficult Arterial Access and Ultrasound Use in the Operating Room

Arterial catheterization enables continuous hemodynamic monitoring but has been shown to cause severe complications, especially when multiple attempts are required. The aim of this study was to explore what factors were associated with multiple attempts and ultrasound use in the operating room. We performed a retrospective analysis of patients who had arterial catheters inserted at a tertiary care children's hospital from January 2018 to March 2022, identifying clinical factors that were associated with both outcomes. A total of 3946 successful arterial catheter insertions were included. Multivariable analysis showed multiple attempts were associated with noncardiac surgery: pediatric (OR: 1.79, 95% CI: 1.30-2.51), neurologic (OR: 2.63, 95% CI: 1.89-3.57), orthopedic (OR: 3.23, 95% CI: 2.27-4.55), and non-radial artery placement (OR: 5.00, 95% CI: 3.33-7.14) (all p < 0.001). Multivariable analysis showed ultrasound use was associated with neonates (OR: 9.6, 95% CI: 4.1-22.5), infants (OR: 6.98, 95% CI: 4.67-10.42), toddlers (OR: 6.10, 95% CI: 3.8-9.8), and children (OR: 2.0, 95% CI: 1.7-2.5) compared to teenagers, with cardiac surgery being relative to other specialties-pediatric (OR: 0.48, 95% CI: 0.3-0.7), neurologic (OR: 0.27, 95% CI: 0.18-0.40), and orthopedic (OR: 0.38, 95% CI: 0.25-0.58) (all p < 0.001). In our exploratory analysis, increased odds of first-attempt arterial catheter insertion success were associated with cardiac surgery, palpation technique, and radial artery placement. Younger patient age category, ASA III and IV status, cardiac surgery, and anesthesiologist placement were associated with increased odds of ultrasound use.

Neonatal Vascular Access Practice and Complications: An Observational Study of 1,375 Catheter Days

Vascular access devices play vital roles within neonatal care. We aimed to identify neonatal vascular access device insertion and management practices, and describe the incidence and risk factors for complication development. This is a prospective cohort study of neonates requiring vascular access devices over 3 months in an Australian quaternary-referral neonatal intensive care unit. In addition to describing current practices, primary outcomes were device failure, complications, and skin complications. Results are reported using descriptive statistics and with risk factors calculated via Cox proportional hazards regression. A total of 104 neonates required 302 vascular access devices, over 1375 catheter days. Peripheral intravenous catheters (PIVCs) were most used (n = 186; 62%), followed by umbilical venous catheters (n = 52; 17%). Insertion attempts were often undocumented; but for those recorded, 5% of devices (n = 15) required 4 attempts or more. Device failure occurred in 28% (n = 82), at an incidence rate of 62.5 per 1000 catheter days (95% confidence interval [CI] 49.7-75.9). Failure was most frequent in PIVCs (37%; n = 68), peripheral arterial catheters (33%; n = 2), and peripherally inserted central catheters (20%; n = 6). Infiltration and extravasation were the most frequent cause of PIVC failure (12%; n = 35). A birth weight less than 1500 g was associated with a significant decrease in PIVC failure (hazard ratio 0.58; 95% CI 0.34-0.99).

Ultrasound-guided arterial cannulation in the paediatric population

BACKGROUND

In arterial line cannulation in children and adolescents, traditional methods of locating the artery include palpation and Doppler auditory assistance. It is unclear whether ultrasound guidance is superior to these methods. This is an update of a review originally published in 2016.

OBJECTIVES

To evaluate the benefits and harms of ultrasound guidance compared with traditional techniques (palpation, Doppler auditory assistance) for assisting arterial line placement at all potential sites in children and adolescents.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and Web of Science from inception to 30 October 2022. We also searched four trials registers for ongoing trials, and we checked the reference lists of included studies and relevant reviews for other potentially eligible trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing ultrasound guidance versus other techniques (palpation or Doppler auditory assistance) to guide arterial line cannulation in children and adolescents (aged under 18 years). We planned to include quasi-RCTs and cluster-RCTs. For RCTs with both adult and paediatric populations, we planned to include only the paediatric population data.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the risk of bias of included trials and extracted data. We used standard Cochrane meta-analytical procedures, and we applied the GRADE method to assess the certainty of evidence.

MAIN RESULTS

We included nine RCTs reporting 748 arterial cannulations in children and adolescents (under 18 years of age) undergoing different surgical procedures. Eight RCTs compared ultrasound with palpation, and one compared ultrasound with Doppler auditory assistance. Five studies reported the incidence of haematomas. Seven involved radial artery cannulation and two involved femoral artery cannulation. The people performing arterial cannulation were physicians with different levels of experience. The risk of bias varied across studies, with some studies lacking details of allocation concealment. It was not possible to blind practitioners in any case; this adds a performance bias that is inherent to the type of intervention studied in our review. Compared to traditional methods, ultrasound guidance probably causes a large increase in first-attempt success rates (risk ratio (RR) 2.01, 95% confidence interval (CI) 1.64 to 2.46; 8 RCTs, 708 participants; moderate-certainty evidence) and probably causes a large reduction in the risk of complications such as haematoma formation (RR 0.26, 95% CI 0.14 to 0.47; 5 RCTs, 420 participants; moderate-certainty evidence). No studies reported data about ischaemic damage. Ultrasound guidance probably improves success rates within two attempts (RR 1.78, 95% CI 1.25 to 2.51; 2 RCTs, 134 participants; moderate-certainty evidence) and overall rate of successful cannulation (RR 1.32, 95% CI 1.10 to 1.59; 6 RCTs, 374 participants; moderate-certainty evidence). In addition, ultrasound guidance probably reduces the number of attempts to successful cannulation (mean difference (MD) -0.99 attempts, 95% CI -1.15 to -0.83; 5 RCTs, 368 participants; moderate-certainty evidence) and duration of the cannulation procedure (MD -98.77 seconds, 95% CI -150.02 to -47.52, 5 RCTs, 402 participants; moderate-certainty evidence). More studies are needed to confirm whether the improvement in first-attempt success rates is more pronounced in neonates and younger children compared to older children and adolescents.

AUTHORS' CONCLUSIONS

We identified moderate-certainty evidence that ultrasound guidance for arterial cannulation compared with palpation or Doppler auditory assistance improves first-attempt success rate, second-attempt success rate and overall success rate. We also found moderate-certainty evidence that ultrasound guidance reduces the incidence of complications, the number of attempts to successful cannulation and the duration of the cannulation procedure.

Local nitroglycerin to facilitate peripheral arterial cannulation in children: systematic review and meta-analysis

BACKGROUND

Neonates and children admitted to intensive care units require peripheral arterial cannulation to monitor their blood pressures and for blood sampling, but many times it is unsuccessful.

OBJECTIVE

To conduct a systematic review and meta-analysis to evaluate the efficacy and safety of local nitroglycerin (NTG) to facilitate peripheral artery cannulation in neonates and children.

REVIEW METHODS

PubMed, EMBASE, CINAHL, Emcare and Cochrane library were searched till August 2021. Grey literature was searched through Mednar. Data were extracted by two reviewers independently using a prespecified form and the risk of bias was assessed. Meta-analysis was conducted using a random-effects model. The I2 statistic was used to quantify statistical heterogeneity. Certainty of evidence was assessed using the criteria of inconsistency, imprecision, indirectness, publication bias and size of effect as per the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) guidelines.

RESULTS

Two randomised controlled trials (RCTs) were included in this meta-analysis (n=153). One was conducted in children 2-8 years of age and the other was in children <2 years. Both trials found increased success rates with the use of local NTG. Pooling of the two studies found that the first-attempt success rate was significantly higher in the NTG group (risk difference: 0.44, 95% CI 0.05 to 0.83; I2=89%). Overall procedure time was significantly lower in the NTG group (mean difference: -100.28 s, 95% CI -136.74 to -63.82; I2=0%). No major complications secondary to the use of NTG were noted. The GRADE of evidence was very low.

CONCLUSION

Local NTG may be useful in facilitating peripheral arterial cannulation in children. Adequately powered RCTs are needed to confirm these findings.

Iatrogenic vascular trauma and complications of vascular access in children

Vascular access is frequently a critical component of the diagnostic and therapeutic procedures required to manage childhood illnesses, including many emergent conditions and critical illnesses. Vascular access in the pediatric population presents unique challenges, and many clinical and technical factors must be considered to avoid complications that can occur with vascular access procedures. This article reviews various aspects of vascular access and associated iatrogenic trauma in children, including risk factors, management of complications, and preventive measures to avoid complications. It is only with a comprehensive understanding of the topic that vascular access in children can be performed safely, effectively, and efficiently.