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Cunningham AJ, McClellan KV, Dewey E, Krishnaswami S, Butler MW, Nolt D, Fialkowski E, Haag MC, Hamilton NA. Perioperative neutropenia is not an independent risk factor for infectious complications of central venous line placement in children: A propensity score-matched analysis. J Pediatr Surg 2020; 55:1339-1343. [PMID: 31515110 DOI: 10.1016/j.jpedsurg.2019.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/08/2019] [Accepted: 08/07/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The infectious risk of central venous line (CVL) placement in children with neutropenia (absolute neutrophil count [ANC] <500/mm3) is not well defined. This study aims to investigate the early (≤30 days) and late (>30 days) infectious complications of CVLs placed in pediatric patients with and without neutropenia. METHODS A retrospective review was conducted of all CVLs placed by pediatric surgeons at two institutions from 2010 to 2017. Multivariable logistic regression was performed to identify risk factors for line infection. Propensity score-matched cohorts of patients with and without neutropenia were compared in a 1:1 ratio. Wilcoxon rank-sum, Chi-square, Fisher's exact, and log-rank tests were also performed. RESULTS Review identified 1,102 CVLs placed in 937 patients. Fifty-four patients were neutropenic at the time of placement. Multivariable analysis demonstrated tunneled catheters and subclavian access as associated with line infection. The propensity score-matched cohort included 94 patients, 47 from each group. Demographic and preoperative data were similar between the groups (p > 0.05). Patients with neutropenia were no more likely to develop early (4.3% vs. 2.1%, p = 1.000) or late (19.1% vs. 17.0%, p = 1.000) infectious complications than patients without neutropenia, with similar median time to infection (141 vs. 222 days, p = 0.370). CONCLUSION A policy of selective CVL placement in neutropenic patients with standardized postoperative line maintenance is safe. Future directions include defining criteria by which neutropenic patients could be prospectively selected for safe CVL placement. LEVEL OF EVIDENCE II - Retrospective cohort study.
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Affiliation(s)
- Aaron J Cunningham
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA.
| | | | - Elizabeth Dewey
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Sanjay Krishnaswami
- Division of Pediatric Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Marilyn W Butler
- Division of Pediatric Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Dawn Nolt
- Division of Pediatric Infectious Diseases, Oregon Health & Science University, Portland, OR, USA
| | - Elizabeth Fialkowski
- Division of Pediatric Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Meredith C Haag
- School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Nicholas A Hamilton
- Division of Pediatric Surgery, Oregon Health & Science University, Portland, OR, USA
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Bedoya MA, Raffini L, Durand R, Acord MR, Srinivasan A, Krishnamurthy G, Vatsky S, Escobar F, Cahill AM. Implantable venous access devices in children with severe hemophilia: a tertiary pediatric institutional experience. Pediatr Radiol 2020; 50:1148-1155. [PMID: 32390060 DOI: 10.1007/s00247-020-04668-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 02/25/2020] [Accepted: 03/26/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Clotting factor replacement forms the pillar of treatment for children with hemophilia. Most children can be treated using peripheral venipuncture, but very young children and children with poor venous access might require a central venous catheter. Short-term and long-term complications of implantable venous access device placement (also known as port placement) can result in important morbidity and mortality in children with hemophilia. OBJECTIVE The purpose of this study is to describe our experience with port placement in children and adolescents with severe hemophilia (<1% of the Factors VIII or IX). MATERIALS AND METHODS We performed a retrospective review over a 10-year period to identify port placement in pediatric patients with severe hemophilia. We reviewed demographic and procedural information, access frequency, mechanical complications, and central-line-associated bloodstream infections (CLABSI). Eighteen males were included, with median age at insertion of 3.9 years (0.7-22.7 years). Fifteen of the 18 patients had hemophilia Type A and 3/18 had Type B. Thirteen had high neutralizing inhibitor titers. RESULTS Technical success in port placement was achieved in 26/27 (96.3%) patients, with 1 port failure caused by venous occlusion from prior catheter placement. Port catheter size ranged from 5 French (Fr) to 7.5 Fr. All were single-lumen and placed via right (76.9%) or left (23.1%) internal jugular vein; 59.3% were placed during general anesthesia, and all had factor replacement prophylaxis. A peripherally inserted central catheter (PICC) was placed concurrently in 69.2% of the cases; per hospital policy, the port was only accessed 15 days post-placement to reduce the risk of site hematoma. Two patients were lost to follow-up. The total catheter days was 15,893. Ports were removed in 14/24 cases, most commonly because of CLABSI (7/24; 29.2%) and transition to peripheral infusion (3/24; 12.5%). Bleeding was the most common complication in the first 30 days after placement. There were nine CLABSI events (0.57 per 1,000 catheter days), all in patients with high neutralizing inhibitor titers. A higher frequency of port access (more or equal to daily vs. less than daily) correlated with higher infection rates (P=0.02). Median time from port insertion to first infection was 348 days (range 167-1,055 days). There were four fibrin-sheath-related catheter occlusions (0.25 per 1,000 catheter days): three catheters were salvaged with intra-catheter tissue plasminogen activator (tPA) instillation resulting in a salvage of an additional 1,214 catheter days, and one catheter was removed after tPA failure (0.06 per 1,000 catheter days). CONCLUSION Port maintenance in boys with severe hemophilia is challenging given the need for long-term frequent device access that is associated with catheter-related infections. The rate of bleeding or infection did not differ in patients whether the device was accessed immediately or 15 days post placement. With appropriate pre- and post-procedural factor replacement, immediate and early term severe complications are not common.
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Affiliation(s)
- Maria A Bedoya
- Department of Radiology, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA.
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Leslie Raffini
- Department of Radiology, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Rachelle Durand
- Department of Radiology, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael R Acord
- Department of Radiology, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Abhay Srinivasan
- Department of Radiology, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ganesh Krishnamurthy
- Department of Radiology, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Seth Vatsky
- Department of Radiology, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Fernando Escobar
- Department of Radiology, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anne Marie Cahill
- Department of Radiology, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Khair K, Ranta S, Thomas A, Lindvall K. The impact of clinical practice on the outcome of central venous access devices in children with haemophilia. Haemophilia 2017; 23:e276-e281. [DOI: 10.1111/hae.13241] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2017] [Indexed: 11/28/2022]
Affiliation(s)
- K. Khair
- Great Ormond Street Hospital for Children NHS Foundation Trust; London UK
| | - S. Ranta
- Karolinska University Hospital; Stockholm Sweden
| | - A. Thomas
- Royal Hospital for Sick Children; Edinburgh UK
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Shin M, Park SG, Oh BC, Kim K, Jo S, Lee MS, Oh SS, Hong SH, Shin EC, Kim KS, Kang SW, Lee H. Complete prevention of blood loss with self-sealing haemostatic needles. NATURE MATERIALS 2017; 16:147-152. [PMID: 27698353 DOI: 10.1038/nmat4758] [Citation(s) in RCA: 172] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 08/23/2016] [Indexed: 06/06/2023]
Abstract
Bleeding is largely unavoidable following syringe needle puncture of biological tissues and, while inconvenient, this typically causes little or no harm in healthy individuals. However, there are certain circumstances where syringe injections can have more significant side effects, such as uncontrolled bleeding in those with haemophilia, coagulopathy, or the transmission of infectious diseases through contaminated blood. Herein, we present a haemostatic hypodermic needle able to prevent bleeding following tissue puncture. The surface of the needle is coated with partially crosslinked catechol-functionalized chitosan that undergoes a solid-to-gel phase transition in situ to seal punctured tissues. Testing the capabilities of these haemostatic needles, we report complete prevention of blood loss following intravenous and intramuscular injections in animal models, and 100% survival in haemophiliac mice following syringe puncture of the jugular vein. Such self-sealing haemostatic needles and adhesive coatings may therefore help to prevent complications associated with bleeding in more clinical settings.
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Affiliation(s)
- Mikyung Shin
- The Graduate School of Nanoscience and Technology, Korea Advanced Institute of Science and Technology (KAIST), Daejeon 34141, Republic of Korea
| | - Sung-Gurl Park
- Predictive Model Research Center, Korea Institute of Toxicology (KIT), Daejeon 34114, Republic of Korea
| | - Byung-Chang Oh
- Department of Chemistry, Korea Advanced Institute of Science and Technology (KAIST), Daejeon 34141, Republic of Korea
| | - Keumyeon Kim
- R&D Center, InnoTherapy Inc., Seoul 07327, Republic of Korea
| | - Seongyeon Jo
- R&D Center, InnoTherapy Inc., Seoul 07327, Republic of Korea
| | - Moon Sue Lee
- R&D Center, InnoTherapy Inc., Seoul 07327, Republic of Korea
| | - Seok Song Oh
- Meta-Biomed Co., Cheongju, Chungbuk 28161, Republic of Korea
| | - Seon-Hui Hong
- Laboratory of Immunology and Infectious Diseases, Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon 34141, Republic of Korea
| | - Eui-Cheol Shin
- Laboratory of Immunology and Infectious Diseases, Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon 34141, Republic of Korea
| | - Ki-Suk Kim
- Predictive Model Research Center, Korea Institute of Toxicology (KIT), Daejeon 34114, Republic of Korea
- Department of Human and Environmental Toxicology, University of Science and Technology, Daejeon 34113, Republic of Korea
| | - Sun-Woong Kang
- Predictive Model Research Center, Korea Institute of Toxicology (KIT), Daejeon 34114, Republic of Korea
- Department of Human and Environmental Toxicology, University of Science and Technology, Daejeon 34113, Republic of Korea
| | - Haeshin Lee
- The Graduate School of Nanoscience and Technology, Korea Advanced Institute of Science and Technology (KAIST), Daejeon 34141, Republic of Korea
- Department of Chemistry, Korea Advanced Institute of Science and Technology (KAIST), Daejeon 34141, Republic of Korea
- R&D Center, InnoTherapy Inc., Seoul 07327, Republic of Korea
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5
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Smitherman AB, Alexander T, Connelly M, Snavely AC, Weston BW, Liles EA, Steiner MJ. The incidence of catheter-associated venous thrombosis in noncritically ill children. Hosp Pediatr 2015; 5:59-66. [PMID: 25646197 DOI: 10.1542/hpeds.2014-0041] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Previous studies estimated the incidence of catheter-associated venous thrombosis to be between 2% and 81%. Our goals were to define the incidence rate of catheter-related thrombosis in a hospitalized, noncritically ill, pediatric population and to determine modifiable factors that alter the risk of thrombosis. METHODS A retrospective cohort study was performed at the North Carolina Children's Hospital from 2009 to 2012. Chart review was performed with extraction of patient characteristics and line-related variables. Presence of symptomatic catheter-associated venous thrombosis was the primary outcome. Bivariable analysis and multivariable logistic regression were used to explore associations between line-related variables and thrombosis. RESULTS A total of 1135 lines were placed in 815 patients for 118,023 catheter-days. Thirty-six were complicated by venous thrombosis (3.2%) yielding a rate of 0.3 events per 1000 catheter-days. In multivariable analysis, increasing age (odds ratio [OR] 1.08, 95% confidence interval [CI] 1.03-1.13; P=.002), renal dialysis (OR 3.2, 95% CI 1.09-9.66; P=.035), and a diagnosis of inflammatory bowel disease or short bowel syndrome (OR 4.3, 95% CI 1.2-15.0; P=.02) were associated with increased risk of thrombosis. Modifiable risk factors, such as line site, size, and lumens, were not significantly associated with thrombosis. No thromboembolic events were observed. CONCLUSIONS We observed a lower incidence rate of catheter-associated venous thrombosis than in most previous reports. No modifiable characteristics altered the risk of thrombosis. Additional investigation of measures to prevent thrombosis is warranted in higher-risk populations, such as patients undergoing dialysis or patients with inflammatory bowel disease.
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Affiliation(s)
- Andrew B Smitherman
- Division of Pediatric Hematology Oncology, UNC Lineberger Comprehensive Cancer Center, North Carolina Cancer Hospital, Chapel Hill, North Carolina; and
| | - Thomas Alexander
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, and Department of Internal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Mark Connelly
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, and
| | - Anna C Snavely
- UNC Lineberger Comprehensive Cancer Center, North Carolina Cancer Hospital, Chapel Hill, North Carolina; and Department of Internal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Brent W Weston
- Division of Pediatric Hematology Oncology, UNC Lineberger Comprehensive Cancer Center, North Carolina Cancer Hospital, Chapel Hill, North Carolina; and UNC Hemophilia and Thrombosis Center, Chapel Hill, North Carolina
| | - Edmund A Liles
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, and Department of Internal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Michael J Steiner
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, and
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6
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Experience with central venous access devices (CVADs) in the Canadian hemophilia primary prophylaxis study (CHPS). Haemophilia 2015; 21:469-76. [DOI: 10.1111/hae.12713] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2015] [Indexed: 11/26/2022]
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7
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Harroche A, Merckx J, Salvi N, Faivre J, Jacqmarcq O, Dazet D, Makhloufi M, Clairicia M, Torchet MF, Aouba A, Rothschild C. Long-term follow-up of children with haemophilia - low incidence of infections with central venous access devices. Haemophilia 2015; 21:465-8. [DOI: 10.1111/hae.12638] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2014] [Indexed: 11/29/2022]
Affiliation(s)
- A. Harroche
- Department of Haematology; Haemophilia Care Centre; Universitaire Necker-Enfants Malades; Paris France
| | - J. Merckx
- Department of Anaesthesia; Universitaire Necker-Enfants Malades; Paris France
| | - N. Salvi
- Department of Anaesthesia; Universitaire Necker-Enfants Malades; Paris France
| | - J. Faivre
- Department of Anaesthesia; Universitaire Necker-Enfants Malades; Paris France
| | - O. Jacqmarcq
- Department of Anaesthesia; Universitaire Necker-Enfants Malades; Paris France
| | - D. Dazet
- Department of Haematology; Haemophilia Care Centre; Universitaire Necker-Enfants Malades; Paris France
| | - M. Makhloufi
- Department of Haematology; Haemophilia Care Centre; Universitaire Necker-Enfants Malades; Paris France
| | - M. Clairicia
- Home Care Education Centre for Children; Universitaire Necker-Enfants Malades; Paris France
| | - M.-F. Torchet
- Department of Haematology; Haemophilia Care Centre; Universitaire Necker-Enfants Malades; Paris France
| | - A. Aouba
- Department of Haematology; Haemophilia Care Centre; Universitaire Necker-Enfants Malades; Paris France
| | - C. Rothschild
- Department of Haematology; Haemophilia Care Centre; Universitaire Necker-Enfants Malades; Paris France
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8
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Affiliation(s)
- Rolf C. R. Ljung
- Lund University, Departments of Paediatrics and Malmö Centre for Thrombosis and Haemostasis; Skåne University Hospital; Malmö; Sweden
| | - Karin Knobe
- Lund University, Departments of Paediatrics and Malmö Centre for Thrombosis and Haemostasis; Skåne University Hospital; Malmö; Sweden
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9
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RANTA S, KALAJOKI-HELMIÖ T, POUTTU J, MÄKIPERNAA A. MRI after removal of central venous access device reveals a high number of asymptomatic thromboses in children with haemophilia. Haemophilia 2011; 18:521-6. [DOI: 10.1111/j.1365-2516.2011.02719.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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10
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Di Carlo I, Pulvirenti E, Mannino M, Toro A. Increased use of percutaneous technique for totally implantable venous access devices. Is it real progress? A 27-year comprehensive review on early complications. Ann Surg Oncol 2010; 17:1649-56. [PMID: 20204533 DOI: 10.1245/s10434-010-1005-4] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Indexed: 12/15/2022]
Abstract
BACKGROUND First implantation of a totally implantable venous access device (TIVAD) was performed in 1982 with surgical technique. Since then, these devices have permitted infusion of total parenteral nutrition, antibiotics, blood products, and, above all, they have definitively changed the quality of life of patients with cancer. However, with the increase of percutaneous procedures, we have assisted with a concomitant raise of immediate postprocedural life-threatening complications. The aim of this study was to review the literature during a 27-year period, with regard to the changes of incidence of immediate complications after percutaneous or surgical cutdown for TIVAD's implant. MATERIALS AND METHODS An extensive search of relevant literature was carried out by using MEDLINE (PubMed) and Google Scholar. We gathered articles from 1982 to 2009 that quoted patient's number, type of pathology, specialist involved, number of devices implanted, site and technique of implantation (surgical cutdown or percutaneous technique), and immediate complications occurrence. RESULTS A total of 952 reports were screened, and finally only 45 articles addressing all inclusion criteria were used for the present study. A total of 11,430 TIVADs implanted in 11,381 patients were analyzed. Pneumothorax, hemothorax, arterial puncture, and hemoptysis developed only after percutaneous procedures. Atrial fibrillation, hematomas, and malpositioning were more frequent after percutaneous approach. The total amount of immediate complications in patients submitted to percutaneous implant was 4.5%, compared with 0.9% subsequent to cutdown technique. CONCLUSIONS Despite the increased use of percutaneous technique for TIVADs' implantation, surgical cutdown, because of its safety, remains the best approach to avoid possible fatal immediate complications.
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Affiliation(s)
- Isidoro Di Carlo
- Department of Surgical Sciences, Organ Transplantation, and Advanced Technologies, University of Catania, Catania, Italy,
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11
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Jauch KW, Schregel W, Stanga Z, Bischoff SC, Brass P, Hartl W, Muehlebach S, Pscheidl E, Thul P, Volk O. Access technique and its problems in parenteral nutrition - Guidelines on Parenteral Nutrition, Chapter 9. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2009; 7:Doc19. [PMID: 20049083 PMCID: PMC2795383 DOI: 10.3205/000078] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2009] [Indexed: 02/08/2023]
Abstract
Catheter type, access technique, and the catheter position should be selected considering to the anticipated duration of PN aiming at the lowest complication risks (infectious and non-infectious). Long-term (>7-10 days) parenteral nutrition (PN) requires central venous access whereas for PN <3 weeks percutaneously inserted catheters and for PN >3 weeks subcutaneous tunnelled catheters or port systems are appropriate. CVC (central venous catheter) should be flushed with isotonic NaCl solution before and after PN application and during CVC occlusions. Strict indications are required for central venous access placement and the catheter should be removed as soon as possible if not required any more. Blood samples should not to be taken from the CVC. If catheter infection is suspected, peripheral blood-culture samples and culture samples from each catheter lumen should be taken simultaneously. Removal of the CVC should be carried out immediately if there are pronounced signs of local infection at the insertion site and/or clinical suspicion of catheter-induced sepsis. In case PN is indicated for a short period (max. 7-10 days), a peripheral venous access can be used if no hyperosmolar solutions (>800 mosm/L) or solutions with a high titration acidity or alkalinity are used. A peripheral venous catheter (PVC) can remain in situ for as long as it is clinically required unless there are signs of inflammation at the insertion site.
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Affiliation(s)
- K W Jauch
- Dept. Surgery Grosshadern, University Hospital, Munich, Germany
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12
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JENG MR, O’BRIEN M, WONG W, ZOLAND J, LEA J, TANG N, GLADER B. Monthly recombinant tissue plasminogen activator administration to implantable central venous access devices decreases infections in children with haemophilia. Haemophilia 2009; 15:1272-80. [DOI: 10.1111/j.1365-2516.2009.02063.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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13
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Titapiwatanakun R, Moir C, Pruthi RK, Stavlo PL, Schmidt KA, Rodriguez V. Central venous access devices for paediatric patients with haemophilia: a single-institution experience. Haemophilia 2009; 15:168-74. [PMID: 19149849 DOI: 10.1111/j.1365-2516.2008.01906.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Use of a central venous access device (CVAD) can facilitate early introduction of home-based infusion of factor concentrate for long-term prophylaxis or immune tolerance therapy in children with bleeding disorders. The aim was to review outcomes associated with use of CVAD. Retrospective review of paediatric patients with bleeding disorders was observed at the Mayo Clinic Comprehensive Hemophilia Center. Thirty-seven CVAD were placed in 18 patients (haemophilia A [n = 15], type 3 von Willebrand disease [n = 2] and haemophilia B [n = 1]). Follow-up was for 45 952 CVAD days, and median time that CVAD remained in place was 1361 days per device. Factor VIII (FVIII) inhibitors were present in 4 of the 15 patients. Ten CVAD-related infections occurred (median, 672 days; range, 72-1941 days), of which six were in one patient with FVIII inhibitors. Overall infection rate was 0.22 (95% confidence interval [CI], 0.10-0.40) per 1000 CVAD days, with 0.11 infections in patients without FVIII inhibitors compared with a pooled incidence of 0.66 (95% CI, 0.44-0.97) reported in the literature. Indications for removal of 27 CVAD were blockage, change to peripheral venous access, catheter displacement, infection, leak in the port septum, short catheter and skin erosion. No clinically apparent thrombosis or sequelae of thrombosis were observed. Infection is the most common complication associated with CVAD use and is increased in patients who have inhibitors. The low rate of clinically apparent thrombosis reflects our practice of not screening for thrombosis. The low infection rate reflects our practice of using and reinforcing the aseptic technique.
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Affiliation(s)
- R Titapiwatanakun
- Division of Pediatric Hematology and Oncology, Mayo Clinic, Rochester, Minnesota, USA.
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14
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Optimal treatment for children with haemophilia: a review. Acta Med Litu 2009. [DOI: 10.2478/v10140-009-0003-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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15
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HERMANS C, ALTISENT C, BATOROVA A, CHAMBOST H, DE MOERLOOSE P, KARAFOULIDOU A, KLAMROTH R, RICHARDS M, WHITE B, DOLAN G. Replacement therapy for invasive procedures in patients with haemophilia: literature review, European survey and recommendations. Haemophilia 2009; 15:639-58. [DOI: 10.1111/j.1365-2516.2008.01950.x] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Abstract
Surgery in infants and young children with haemophilia, when preceded by accurate diagnosis and accompanied by safe and effective factor prophylaxis, is not associated with a significant risk of haemorrhage. Haemophilic newborns undergoing circumcision or major surgery prior to diagnosis and in the absence of appropriate haemostatic prophylaxis remain as a concern. Inhibitor development has replaced haemorrhage as the major surgical complication in the developed world, largely because of the intensity of treatment used to secure haemostasis. For that reason only, essential surgery should be performed. Intracranial haemorrhage (ICH) during the neonatal period affects 3.5-4.0% of all haemophilia boys in countries with a good standard of health care, which is considerably (40-80 times) higher than expected in the normal population. Because of the high frequency of sporadic cases, ICH in the neonatal period can only be partially prevented by improved carrier diagnosis and counselling. Infections and thrombosis are the major serious complications of central venous lines. Large differences are seen in the frequency of these complications, the most plausible explanations are probably related to the protocol used for device care, the quality of education and the compliance of the users, an issue addressed in an on-going study.
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Affiliation(s)
- R Ljung
- Departments of Paediatric, Lund University, University Hospital, Malmö, Sweden.
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Risebrough N, Oh P, Blanchette V, Curtin J, Hitzler J, Feldman BM. Cost-utility analysis of Canadian tailored prophylaxis, primary prophylaxis and on-demand therapy in young children with severe haemophilia A. Haemophilia 2008; 14:743-52. [PMID: 18422610 DOI: 10.1111/j.1365-2516.2008.01664.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Primary prophylaxis is the emerging standard treatment for boys with severe haemophilia. Tailored (escalating-dose) prophylaxis (EscDose), beginning at a low frequency and escalating with repeated bleeding may prevent arthropathy at a lower cost than standard prophylaxis (SP). From a societal perspective, we compared the incremental cost per joint-haemorrhage that is avoided and quality-adjusted-life-year (QALY) gained of SP and EscDose to on-demand (Demand) therapy in severe haemophilia A boys treated to age 6 using a decision analytic model. Costs included factor VIII (FVIII), professional visits and tests, central venous placement/complications, hospitalization, home programmes and parents' lost work-days. Resource utilization was estimated by surveying 17 Canadian clinics. The natural history of bleeding and other probabilities were determined from a longitudinal chart review (n = 24) and published literature. EscDose costs an additional $3192 per joint-haemorrhage that was avoided compared with Demand whereas SP costs an additional $9046 per joint-haemorrhage that was avoided compared with EscDose. Clinic costs and lost wages were reduced by 60-80% for EscDose and SP compared with Demand. EscDose attained more QALYs than SP and Demand on account of less bleeding than Demand and lower need for ports than SP. The incremental cost per QALY for EscDose vs. Demand was $542 938. EscDose was less expensive with similar QALYs compared to SP. Sensitivity analysis was performed on all probability- and cost-estimates, and showed the model was sensitive to the cost of FVIII and the SP and target joint utilities. In conclusion, prophylaxis will substantially improve clinical outcomes and quality of life compared to Demand treatment, but with substantial cost.
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Affiliation(s)
- N Risebrough
- HOPE Research Centre, Division of Clinical Pharmacology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario, Canada.
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18
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NEUNERT CE, MILLER KL, JOURNEYCAKE JM, BUCHANAN GR. Implantable central venous access device procedures in haemophilia patients without an inhibitor: systematic review of the literature and institutional experience. Haemophilia 2008; 14:260-70. [DOI: 10.1111/j.1365-2516.2007.01605.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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19
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Abstract
It has been proven that early prophylactic therapy can prevent bleeding and arthropathy. Numerous retrospective non-randomized cohort studies have demonstrated that prophylaxis, if started early in life, is associated with a considerable reduction of the mean number of joint bleeds and the rate of joint deterioration. It is quite extraordinary that despite the considerable evidence base it has been considered necessary by investigators to pursue the ideal of the controlled randomized trial and expose children to the risk of cerebral bleed. This questionable ethical approach is driven by the reluctance of the 'willingness to pay' but it is important that patients are not subjected to unnecessary investigation at either the behest of the Cochrane Database or those who control the financing of haemophilia care.
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Affiliation(s)
- C A Lee
- University of London, Oxford Haemophilia Centre, Oxford, UK.
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20
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Abstract
Haemophilia is often characterized by acute haemarthrosis and synovitis arising from spontaneous bleeding episodes, particularly in the muscles and joints of the elbows, knees and ankles. Current treatment for patients with severe haemophilia involves coagulation factor concentrate (CFC) replacement therapy given on demand at the time of bleeding or through long-term prophylaxis aimed at preventing future bleeds and joint disease. Although prophylaxis has many advantages over on-demand therapy (particularly if started before age 2 and prior to any signs of joint disease), its practice varies widely even among developed countries because of several barriers. Such barriers include CFC costs and availability; patient perceptions, lifestyles and bleeding patterns; difficulties and complications arising from the use of intravenous access devices (IVADs); the development of inhibitors; and the lack of randomized clinical trials. These barriers can be overcome by tailoring treatment regimens according to individual patient bleeding patterns and CFC pharmacokinetic profiles, using IVADs selectively and judiciously, helping patients maintain normal weight and physical exercise and providing the families of patients with continuous support from healthcare providers.
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Affiliation(s)
- P Petrini
- Karolinska University Hospital, Stockholm, Sweden.
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21
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Ragni MV, Journeycake JM, Brambilla DJ. Tissue plasminogen activator to prevent central venous access device infections: a systematic review of central venous access catheter thrombosis, infection and thromboprophylaxis. Haemophilia 2007; 14:30-8. [PMID: 18005145 DOI: 10.1111/j.1365-2516.2007.01599.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The recent unequivocal demonstration that prophylaxis, three to four weekly factor infusions, is effective in preventing joint disease in children with haemophilia, has provided impetus to initiate prophylaxis early in such children. Yet, nearly a quarter (22%) of the 83% who required central venous access devices for factor infusion developed central venous access catheter (CVAD)-related infection. This limitation of CVAD use prevents many families from initiating prophylaxis. The frequent occurrence of local thrombosis accompanying CVAD-related infection in surgical patients and autopsy cases, the thrombogenic plastic CVAD surfaces, and local clot formation at the insertion site, suggest the potential role of thrombolytic agents in preventing these infections. Yet, correlation between CVAD-related infection and local thrombosis in children with haemophilia are lacking, and thromboprophylaxis to prevent CVAD-related infection is controversial. Tissue plasminogen activator (t-PA), a recombinant serine protease glycoprotein that lyses plasmin-bound fibrin and is safe and effective in the treatment of occluded catheters, has not been evaluated in the prevention of these infections. We performed a literature review of CVAD-related infection, CVAD-related thrombosis, and thromboprophylaxis studies to evaluate the role of t-PA in the prevention of these infections in children with haemophilia. Metanalysis of published thromboprophylaxis trials demonstrate current prophylaxis regimens do not prevent CVAD infection, and further, that thrombosis and infection do not necessarily occur simultaneously. Pilot data demonstrate CVAD infection reduction in haemophilic children by monthly t-PA in 18 haemophilic children, suggesting the potential role of t-PA in CVAD infection prevention. Clinical trials to evaluate t-PA in CVAD infection prevention are justified.
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Affiliation(s)
- M V Ragni
- Division Hematology/Oncology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15213-4306, USA.
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22
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Abstract
Infections are the most frequent complications associated with the use of central venous lines (CVLs) in children with haemophilia. Several retrospective studies that include data from a substantial number of patients have reported approximately 0.2-0.3 infections per 1000 catheter-days (mainly Port-A-Cath). Some studies have shown a much higher frequency of infections, 1-2/1000 catheter-days. The most plausible explanations, for the difference seen in frequency of infections with Port-A-Caths, are probably related to the protocol used for the device care and the quality of education and the compliance of the users, whether these are parents or health-care professionals. The figures are low for clinically apparent thrombosis in the larger series on record, but routine venograms were not performed in most of these series. In studies, where this has been performed, a high frequency of abnormalities (>50%) on venograms have been seen in some series but not in others. Despite obvious potential risks with CVLs, they are useful in many cases and facilitate the treatment of a serious disorder. With careful guidelines and surveillance protocols, the risk of complications should be reduced in the future.
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Affiliation(s)
- Rolf Ljung
- Departments of Paediatrics and Coagulation Disorders, Lund University, University Hospital, Malmö, Sweden.
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23
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Chambost H, Meunier S. [Relevance of early paediatric care for boys with severe haemophilia]. Arch Pediatr 2006; 13:1423-30. [PMID: 16928435 DOI: 10.1016/j.arcped.2006.06.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2006] [Accepted: 06/23/2006] [Indexed: 11/19/2022]
Abstract
Major molecular and genetic findings over the last decades and subsequent applications for diagnosis and therapeutic concerns have dramatically improved the evolution of severe haemophilia in countries with high economic resources. Another major factor of progress consisted in the setting of comprehensive care centres coordinating the care at a regional level. The early involvement of paediatricians for this rare and potentially serious chronic disease, which may be symptomatic from birth, is relevant in this context. Indeed, the early diagnosis of severe haemophilia and the involvement of expert caregivers in a multidisciplinary approach, are essential to make the acceptance of the disease easier. The diagnosis announcement should go together with a therapeutic project, which is nowadays based on long-term prophylaxis. Awaiting for likely curative treatments in the future, such as gene therapy, early implementation of prophylaxis and observance of this gold standard treatment during all the period of growth are critical to prevent the haemophilic arthropathy, to favour the future social and work-related integration and overall to improve the quality of life. The occurrence of an inhibitor represents the major residual complication of replacement therapy, especially for young children with severe haemophilia A. Even though new therapeutic resources brought substantial improvements for inhibitor patients, a better understanding of risk factors is a key issue since more accurate replacement regimen might induce tolerance during the first exposures and subsequently might prevent this complication. Prophylaxis and inhibitors that represent major concerns in paediatric care of severe haemophilia are included as main research objectives for the national registry " FranceCoag Network".
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Affiliation(s)
- H Chambost
- service de pédiatrie et d'hématologie pédiatrique, centre régional de traitement de l'hémophilie, CHU hôpital d'enfants La Timone, université de la Méditerranée, 13385 Marseille cedex 5, France.
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24
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Dunn AL, Abshire TC. Current issues in prophylactic therapy for persons with hemophilia. Acta Haematol 2006; 115:162-71. [PMID: 16549891 DOI: 10.1159/000090930] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Factor VIII or IX replacement in a prophylactic manner is utilized for many patients with moderate to severe hemophilia A or B. Studies have shown it to be effective in reducing or preventing degenerative joint disease in many but not all patients. However, many unanswered questions still exist and optimization of this expensive treatment regimen is needed. This paper recounts the current products that are available for use and explores the literature regarding different treatment regimens. It explores age at initiation, dose, interval between infusions, joint health outcomes, barriers to compliance and age at discontinuation of prophylaxis. Individualized treatment is recommended. Collaborative efforts are needed to improve outcomes for all persons with hemophilia.
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Affiliation(s)
- Amy L Dunn
- AFLAC Cancer Center and Blood Disorders Service, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, GA 30322, USA.
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25
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Abstract
Central venous catheters (CVC) are frequently used in children with haemophilia to deliver factor infusions for the treatment or prophylaxis of bleeding. Complications of CVCs in patients with haemophilia include thrombosis and infection. We report a young boy with severe haemophilia A and an inhibitor who developed disseminated Staphylococcus aureus infection most likely related to a CVC. To our knowledge, this is the first reported case of fatal sepsis secondary to a CVC in a patient with haemophilia.
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Affiliation(s)
- S E Crary
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, University of Texas Southwestern Medical Center at Dallas, Dallas, TX 75390-9063, USA
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26
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Dunn AL, Abshire TC. Recent advances in the management of the child who has hemophilia. Hematol Oncol Clin North Am 2004; 18:1249-76, viii. [PMID: 15511615 DOI: 10.1016/j.hoc.2004.06.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This article discusses recent advances in the management of the child who has hemophilia.
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Affiliation(s)
- Amy L Dunn
- AFLAC Cancer Center and Blood Disorders Service, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, 2040 Ridgewood Drive NE, Suite 100, Atlanta, GA 30322, USA.
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27
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Hengartner H, Berger C, Nadal D, Niggli FK, Grotzer MA. Port-A-Cath infections in children with cancer. Eur J Cancer 2004; 40:2452-8. [PMID: 15519519 DOI: 10.1016/j.ejca.2004.07.017] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2004] [Revised: 07/12/2004] [Accepted: 07/16/2004] [Indexed: 10/26/2022]
Abstract
Implanted subcutaneous (s.c.) central venous port accesses including Port-A-Cath (PAC) facilitate the administration of chemotherapy or blood products and are frequently used in children with cancer. The incidence of PAC-related infections was determined in 155 consecutive paediatric cancer patients with PAC followed for a total of 134,773 days (median, 738; range, 25-2080). Overall, 48 bloodstream infections occurred in 26 patients. 12 (25%) of these infections and 3 local infections at the insertion site were treatment-resistant and demanded removal of the PAC. Coagulase-negative staphylococci were involved in 12 of these 15 episodes. The rate of clearly PAC-related infections in this so far largest reported series was 0.11 episodes per 1000 PAC days, one of the lowest in the literature. Although catheter-related infections demanded PAC removal in 8% of our patients, the long periods PAC were in use and their benefits argue for continued PAC use in the paediatric cancer population.
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Affiliation(s)
- H Hengartner
- Division of Oncology, University Children's Hospital of Zurich, Steinwiesstrasse 75, Zurich 8032, Switzerland
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28
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Ewenstein BM, Valentino LA, Journeycake JM, Tarantino MD, Shapiro AD, Blanchette VS, Hoots WK, Buchanan GR, Manco-Johnson MJ, Rivard GE, Miller KL, Geraghty S, Maahs JA, Stuart R, Dunham T, Navickis RJ. Consensus recommendations for use of central venous access devices in haemophilia. Haemophilia 2004; 10:629-48. [PMID: 15357790 DOI: 10.1111/j.1365-2516.2004.00943.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Venous access is essential for delivery of haemophilia factor concentrate. Wherever possible, peripheral veins remain the route of choice, and the use of central venous access devices (CVADs) should be limited to cases of clear need in patients with caregivers able to exercise diligence in CVAD care and should continue no longer than necessary. CVADs are of recognized value for repeated administration of coagulation factors in haemophilia, particularly for prophylaxis and immune tolerance therapy and in young children. Evidence to guide best practices has been fragmentary, and standardized methods for CVAD usage have yet to be established. We have developed management recommendations based upon available published evidence as well as extensive clinical experience. These recommendations address patient and CVAD selection; CVAD placement, care and removal; caregiver/patient guidance; and complications, including infection and thrombosis. In the absence of inhibitors, ports are recommended, primarily because of fewer associated infections than with external catheters. For patients with inhibitors, ports also appear to be associated with fewer infections. Infection is the most frequent complication, and recommendations to prevent and treat infections are supported by extensive clinical data and experience. Strict adherence to handwashing and aseptic technique are essential elements of catheter care. Evidence-based data regarding the detection and treatment of CVAD-related thrombotic complications are limited. Caregiver education is an integral part of CVAD use and the procedural practices of users should be regularly re-assessed. These recommendations provide a basis for sound current CVAD practice and are expected to undergo further refinements as new evidence is compiled and clinical experience is gained.
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Affiliation(s)
- B M Ewenstein
- Baxter BioScience, Westlake Village, California 91362, USA.
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29
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Abstract
Infections, thrombosis and technical problems are the most frequent complications when using implantable central venous access devices in patients with haemophilia. There seem to be two major experiences concerning infections in non-inhibitor patients, one is approx. 0.2 infections per 1000 days and the other approx. 1.0(0.7-1.6)/1000 days. Infections are more frequent in inhibitor patients and one can expect approx. one infection per 6-12 months of use. The figures are low for clinically apparent thrombosis in the larger series on record, but routine venograms were not done in most of these series. In studies where this has been done, a high frequency of abnormalities on venograms have been seen in some but not in others. The final decision to use a central line has to be a compromise between the medical goal, the patient's bleeding tendency, the social situation and the expected risk of complications at the particular haemophilia center. Some of the complications may be reduced by adequate aseptic measures both during implantation and in the subsequent use and clear basic routines for surveillance of the systems and repeated education of the users.
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Affiliation(s)
- Rolf Ljung
- Department of Paediatrics, Lund University, University Hospital, SE-205 02 Malmö, Sweden.
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30
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Price VE, Carcao M, Connolly B, Chait P, Daneman A, Temple M, Stain AM, Sung L, Al-Tralbosi H, Blanchette VS. A prospective, longitudinal study of central venous catheter-related deep venous thrombosis in boys with hemophilia. J Thromb Haemost 2004; 2:737-42. [PMID: 15099279 DOI: 10.1111/j.1538-7836.2004.00653.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Central venous catheters (CVCs) are often inserted into boys with hemophilia to secure venous access for factor prophylaxis and immune tolerance induction therapy. Complications associated with CVCs include catheter-related infections, local hemorrhage, and mechanical failure. Less frequently reported is CVC-related deep venous thrombosis (DVT). We conducted a prospective study to determine the frequency and outcome of this complication. METHODS All boys (n = 16) with congenital hemophilia A or B with a CVC in place who were registered in the pediatric comprehensive care program at the Hospital for Sick Children, Toronto, were included in the study. They were prospectively assessed by imaging studies and clinical examinations for CVC-related DVT at two time-points, 2 years apart. Each boy was evaluated for inherited hypercoagulability. RESULTS Eleven (69%) of the 16 boys had radiological evidence of DVT at the first evaluation and 13/16 (81%) at the second evaluation. In two boys there was improvement in the venogram findings at the second evaluation. None of the CVC-related DVTs completely resolved. Median age at the time of initial insertion of a CVC was 1.0 years (range 0.02-6.7 years). Median duration of CVC placement was 6.4 years (range 3.3-15.5 years). Only 4/13 boys with DVTs had clinical evidence of upper venous system obstruction. Only one boy, who did not develop a DVT, had a low protein C level. CONCLUSIONS CVC-related DVTs occur in the majority of boys with hemophilia who have CVCs inserted for a prolonged period of time. Annual screening with imaging is recommended for boys with CVCs in place for >/= 3 years. Consideration should be given to removing CVCs as soon as peripheral venous access is feasible.
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Affiliation(s)
- V E Price
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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31
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Abstract
The demonstrated benefits of home care for haemophilia include improved quality of life, less pain and disability, fewer hospitalizations, and less time lost from work or school. Although reduced mortality has not been demonstrated, the substantial increase in longevity since the early 1980s correlates with the introduction of home treatment and prophylaxis programmes. These programmes must be designed and monitored by haemophilia treatment centres (HTC), which are staffed with professionals with broad and complementary expertise in the disease and its complications. In return, patients and their families must be willing to accept the reciprocal responsibilities that come from administering blood products or their recombinant equivalents at home. Patients with inhibitors to factors VIII or IX pose special challenges, but these complications do not obviate participation in home care programmes. Home care was an essential prerequisite to the introduction of effective prophylactic factor replacement therapy. Prophylaxis offers significant improvements in quality of life, but requires a substantial commitment. The use of implantable venous access devices can eliminate some of the difficulty and discomfort of peripheral venous access in small children, but brings additional risks. The future holds the promise of factor concentrates for home use that have longer half-lives, or can be administered by alternate routes. Knowledge of patient genotypes may allow treatments tailored to avoid complications such as inhibitor development. Gene therapy trials, which are currently ongoing, will ultimately lead to gene-based treatments as a complement to traditional protein-based therapy.
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Affiliation(s)
- J M Teitel
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
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32
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Abstract
Central venous access devices (CVADs) can facilitate repeated and/or urgent administration of coagulation factors in haemophilic patients. We conducted a systematic review and meta-analysis of complication rates and risk factors for poor outcome. Forty-eight studies with a total of 2704 patients and 2973 CVADs were included. The primary indications for CVADs were immune tolerance therapy (34.9% of patients), difficult venous access (31.8%) and prophylaxis (29.1%). Fully implanted CVADs were employed in 77.4% of cases and external CVADs in 22.6%. A total of 1190 infections were reported, and the pooled incidence of infection was 0.66 per 1000 CVAD days [confidence interval (CI), 0.44-0.97 per 1000 CVAD days]. Among patients developing infection, the pooled time to first infection was 295 days (CI, 181-479 days). Presence of inhibitors was an independent risk factor for infection with an incidence rate ratio (IRR) of 1.67 (CI, 1.15-2.43). Infection was less likely in patients >6 years of age (IRR, 0.46; CI, 0.27-0.79) and recipients of fully implanted CVADs (IRR, 0.31; CI, 0.12-0.86). Available information on thrombosis was limited, with only 55 cases being reported. Eventually, 31.3% of CVADs were removed, and infection was the reason for removal in 69.9% of cases and thrombosis in 4.1%. The pooled time period CVADs remained indwelling prior to removal or the expiration of the study observation period was 578 days per CVAD (CI, 456-733 days per CVAD). CVADs can confer major benefits in patients with haemophilia requiring long-term venous access, and serious complications are rare.
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Affiliation(s)
- L A Valentino
- RUSH Hemophilia and Thrombophilia Center, RUSH University and RUSH Children's Hospital, Chicago, IL 60612-3833, USA.
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33
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Tarantino MD, Lail A, Donfield SM, Lynn H, Peddle L, Hunsberger S, Shapiro AD. Surveillance of infectious complications associated with central venous access devices in children with haemophilia. Haemophilia 2003; 9:588-92. [PMID: 14511299 DOI: 10.1046/j.1365-2516.2003.00793.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To analyse the risk factors for infection associated with central venous access device (CVAD) use in children with haemophilia. METHODS Risk factors for CVAD infection among patients with congenital haemophilia who had had a CVAD implanted at a single institution were evaluated utilizing the following variables: age at CVAD placement, age at end of study, number of days with a CVAD, percentage of lifetime with a CVAD, and history of inhibitor. RESULTS Fifty-nine patients had a total of 97,936 (median 1768 days per patient) CVAD days in the study period. The median age at CVAD placement was 2.7 years (range 0-14.0). Twenty-six (44%) patients reported CVAD infections during the study period from January 1993 to October 2000. Twenty-four patients had their CVAD replaced, 17 (71%) of whom reported having infections and seven (29%) of whom had a history of inhibitor. The strongest predictor for having any infections was inhibitor status (P=0.16), although none of the risk factors had statistically significant effects. Among the 26 patients reporting infections, 42% had more than one CVAD-related infection. Seven patients had multiple infections involving the same organism. The mean rate of infection was 0.45 per 1000 catheter days, with a 95% confidence interval of 0.33-0.60. Those with a history of inhibitor had an infection rate of 0.66 compared with 0.38 per 1000 catheter days (P=0.09) for those without a history of inhibitor. Patients who were older (greater than the median age of 2.7) at CVAD placement had a lower rate of infection (0.29 vs. 0.65, P<0.01) compared with those < or =2.7 years. Adjustment for inhibitor status had little impact on these results. For the group as a whole, the median time to first infection was 1977 days from CVAD placement. Patients who were older at CVAD placement or study exit had lower relative hazards of infection (P=0.05 and P=0.09 respectively), while those who had inhibitors had a higher but not statistically significant relative hazard of 1.88 (P=0.13). CONCLUSIONS These data reveal that while considerable numbers of patients develop CVAD-related infection, the interval between catheter placement and infection can be quite long. In addition, the earlier in life a CVAD is placed, the higher the risk of infectious complications, as evidenced by the tendency towards a higher infection rate. Measures to prevent CVAD-related infection might be focused on very young patients who appear to be at higher risk.
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Affiliation(s)
- M D Tarantino
- Comprehensive Bleeding Disorders Center, University of Illinois College of Medicine at Peoria, Peoria IL 61614, USA.
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34
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Butler RB, McClure W, Wulff K. Practice patterns in haemophilia A therapy - a survey of treatment centres in the United States. Haemophilia 2003; 9:549-54. [PMID: 14511293 DOI: 10.1046/j.1365-2516.2003.00792.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A survey was conducted to ascertain practice patterns for haemophilia A therapy in the United States. Questionnaire data were supplied by 52 haemophilia centres with a total of 4129 patients under treatment. Most participating centres were affiliated with academic/teaching hospitals or institutions. Patients below 5 years comprised 17% of the study population, 6-18 years 41% and >18 years 42%, and the apportionment across severity categories was 53% severe, 17% moderate and 30% mild. Among patients with severe haemophilia, 49% were receiving on-demand treatment, while 44% were receiving some form of prophylaxis (13% primary, 20% secondary and 11% tertiary). Primary prophylaxis was the most common type in children below 5 years of age, accounting for 25% of this age group. In children 6-18 years old, 58% were on some type of prophylactic regimen, while on-demand treatment was most frequent among adults. Difficulties of venous access were the most frequently cited barrier to instituting prophylaxis. Catheters were in use among 37% of the patients under primary prophylaxis and 14% of those on secondary prophylaxis. No major differences were observed in forms of therapy used between larger and smaller centres. These observations provide an extensive characterization of haemophilia A practice patterns in the United States.
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Affiliation(s)
- Regina B Butler
- The Children's Hospital of Philadelphia, Philadelphia, PA 19104-4399, USA.
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35
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Abstract
Use of central venous catheters has become standard in the treatment of many chronic conditions during childhood and for the acute treatment of critically ill infants and children. However, these catheters can be associated with numerous complications, including thrombosis at the tip or in the lumen causing difficulty with its overall function. Even more concerning is the occlusion of large veins into which the catheter is placed, which could predispose patients to pulmonary embolism or postthrombotic syndrome. Recent research has focused on identifying risk factors for catheter-related thrombosis in children and determining methods for diagnosing deep venous thrombosis associated with a catheter in the upper extremities. Evidence now exists that as many as 50% of children with catheters develop deep venous thrombosis; however, most events are clinically silent. Few clinical trials have studied prevention of catheter-related thrombosis in pediatric patients. Data regarding incidence, treatment, and long-term outcome of catheter-related thrombosis in children are limited. Although central venous catheters are extremely important in the supportive care of sick children, concerns remain about their immediate and long-term safety.
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Affiliation(s)
- Janna M Journeycake
- Department of Pediatrics, Division of Hematology/Oncology, 5323 Harry Hines Blvd., Dallas, TX 75390-9063, USA.
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36
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Abstract
Infections and technical problems are the most frequent complications when using implantable central venous access devices in patients with haemophilia. There are two major experiences reported concerning infections in noninhibitor patients: one is approximately 0.2 infections per 1000 days and the other approximately 1.0 (0.7-1.6) per 1000 days. Infections are more frequent in inhibitor patients and approximately one infection per 6-12 months of use can be expected. The figures are low for clinically apparent thrombosis in the larger series on record, but routine venograms were not carried out in most of these series. In studies where this has been done, a high frequency of abnormalities on venograms has been seen in some but not in others. The final decision to use a central line has to take into account the medical goal, the patient's bleeding tendency, the social situation and the expected risk of complications at the particular haemophilia centre. Some of the complications may be reduced by adequate aseptic measures both during implantation and in subsequent use, and by clear basic routines for surveillance of the systems and repeated education of the users.
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Affiliation(s)
- R Ljung
- Department of Paediatrics, Lund University, University Hospital, Malmö, Sweden.
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Berntorp E, Piitulainen E, Lethagen S, Mattson E, Tengborn L, Mätzsch T. Experience with a new percutaneous port system, Percuseal, for intravenous injection in patients with haemophilia, von Willebrand disease and severe alpha1-antitrypsin deficiency. Haemophilia 2003; 9:173-8. [PMID: 12614368 DOI: 10.1046/j.1365-2516.2003.00724.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We have implanted a new port system (Percuseal) in altogether 13 patients with haemophilia A, B, von Willebrand disease and alpha1-antitrypsin deficiency in order to facilitate venous access. The Percuseal system differs from subcutaneous ports, such as Port-a-Cath, in that the upper part of the device protrudes above the skin. In this way, the patient can easily puncture the port membrane under the guidance of his eyes without penetrating the skin. In the present study cohort, a number of complications occurred. These were mainly caused by repeated local infections (in five patients), which made it necessary to replace the ports in three of the patients and to permanently remove the ports as the first option in two of the patients. In one patient, the port was removed because of inconvenience when doing physical exercise. In one additional patient, a severe systemic infection occurred, causing spondylitis. Despite the high infection rate, most patients considered the device very convenient to use. Because of the side-effects seen in our study, the Percuseal port in its present form is not to be recommended for regular use. A reconstruction of the port, making it smaller and giving it an antibacteriostatic cap, may possibly make this kind of port system a feasible alternative to use in order to improve pharmacoeconomics in the prophylactic treatment of haemophilia and patients with alpha1-antitrypsin deficiency.
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Affiliation(s)
- E Berntorp
- Department for Coagulation Disorders, Lund University, Malmö University Hospital, Malmö, Sweden.
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Domm JA, Hudson MG, Janco RL. Complications of central venous access devices in paediatric haemophilia patients. Haemophilia 2003; 9:50-6. [PMID: 12558778 DOI: 10.1046/j.1365-2516.2003.00692.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We conducted a retrospective survey of our experience with central venous access devices (CVADs) implanted in children with haemophilia seen at the Vanderbilt Hemostasis-Thrombosis Clinic from 1986 to 2000. Following discussion with parents on the merits and risks associated with the use of CVADs for immune tolerance induction or factor prophylaxis, catheters were inserted under sterile technique in the operating room. One nurse provided demonstration and teaching about catheter care and access. Thirty central venous catheters were inserted in 22 children. Our survey revealed that the two most common complications associated with central venous catheters were bacteraemia and thrombosis. We found a sepsis rate of 0.30/1000 catheter-days or one episode of bacteraemia for every 3346 days of catheter use. The thrombosis rate of our cohort was 0.13/1000 catheter-days or one episode of thrombosis for every 7529 days of catheter use. Uncomplicated venous access is essential in children with severe haemophilia who require prophylaxis or immune tolerance induction. While infection was the most common complication observed in our series, we experienced a lower overall infection rate than several reported series. Catheter thrombosis and subsequent obstruction may occur as a result of intraluminal fibrin deposits. We conclude that the use of implantable central venous catheters is an effective method for accessing children with haemophilia. We accept that the benefits of CVADs in the treatment of paediatric haemophilia patients outweigh the previously documented risks. Future prospective studies should be designed to define all associated risks and to determine effective strategies to reduce them.
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Affiliation(s)
- J A Domm
- Vanderbilt Hemostasis-Thrombosis Clinic, Vanderbilt University Medical Center, Nashville, TN 37232, USA
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Manco-Johnson MJ, Nuss R, Lear J, Wiedel J, Geraghty SJ, Hacker MR, Funk S, Kilcoyne RF, Murphy J. 32P Radiosynoviorthesis in children with hemophilia. J Pediatr Hematol Oncol 2002; 24:534-9. [PMID: 12368689 DOI: 10.1097/00043426-200210000-00007] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND This study was performed to prospectively evaluate the safety, efficacy, and cost of injecting P-colloid into joints of children with hemophilia and synovitis to decrease the rate of joint bleeding. PATIENTS AND METHODS Eligibility included a diagnosis of hemophilia, history of more than six hemorrhages into a joint within a 6-month period, and evidence of synovitis by objective imaging. With written, informed consent, 0.25 to 1.0 mCi of P-colloid was injected into the problem joints. Safety was monitored by external beta-scanning and physical assessment. Efficacy was determined by analysis of the change in joint hemorrhage frequency from 6 months before and up to 96 months after the injection using a signed-rank test. Physical assessment and pain assessment were analyzed similarly using values obtained within 1 week before and 6 months after the radiosynoviorthesis. Cost was modeled using charges from the authors' institution in relation to existing alternative therapies. RESULTS One hundred injections were given into 91 joints in 59 children. Seven children had high-titer neutralizing antibodies to factor VIII or IX. Nine children were infected with HIV. Joints injected included 44 ankles, 19 knees, 27 elbows, and 1 shoulder. Nine joints required reinjection. All children showed a significant decrease in bleeding rate (P < 0.0001) and pain (P = 0.03), with improved physical function (P = 0.02). In one child acute lymphocytic leukemia developed, but it was judged unrelated to the two P injections that he had received 3 and 10 months before the leukemia diagnosis. There were no cases of bleeding, infection, or inflammation caused by the injection. Cost was substantially less than medical and surgical alternatives. CONCLUSIONS Radiosynoviorthesis is effective in limiting the frequency of joint hemorrhage, decreasing pain and improving function in children with hemophilia. However, long-term safety studies are needed.
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Abstract
OBJECTIVE To review clinical information related to the use of continuous infusion factor products in patients with hemophilia. Specifically, case reports and open-label trials are summarized involving the use of factor VIII and recombinant factor VIIa for a variety of indications including surgical prophylaxis, acute bleeding, primary prevention, and management of inhibitors. In addition, issues surrounding the use of continuous infusion of factor products such as pharmacokinetic rationale, stability/sterility, and cost are reviewed. DATA SOURCES Primary and review articles were identified through a MEDLINE search (1990-June 2001) and through secondary sources. STUDY SELECTION AND DATA EXTRACTION All articles identified from the data sources were evaluated, and all information deemed relevant was included in this review. DATA SYNTHESIS Data concerning the administration of factor products are primarily detailed in open-label trials and case reports. Comparisons between intermittent bolus injections and continuous infusion of factor products are limited and primarily compare continuous infusion regimens with historical controls. The rationale behind the continuous-infusion approach is linked to the pharmacokinetics of factor products administered via this route. Pharmacokinetic data reveal that, with continuous infusion of factor products, a reduction in clearance and a maintenance of factor serum concentrations are noted. CONCLUSIONS Administration of factor products (factor VIII and recombinant factor VIIa) via continuous infusion has produced favorable hemostatic effects compared with intermittent bolus injections. The advantages of continuous infusion include maintenance of a constant factor concentration, thereby reducing risk of bleeding from excessively low trough concentrations, and a decrease in factor consumption related to a reduction in factor clearance with constant infusion. Manufacturers recommend using reconstituted factor products either immediately or within 1-3 hours after reconstitution; however, several studies have found the products to be stable and sterile for longer periods.
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Affiliation(s)
- Joan M Stachnik
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, 833 S. Wood Street (M/C 886), Rm. 164, Chicago, IL 60612-7230, USA.
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Abstract
The significant progress made in recent years in the safety and efficacy of both plasma-derived and recombinant factor concentrates has allowed treatment programmes to be developed that go beyond the simply curative or the treatment of the consequences of the disease (episodic or on-demand treatment), enabling the criteria of preventative medicine to be applied to congenital bleeding disorders. The aim of these programmes is to achieve constant, minimum levels of factor in patients above 1 or 2%, thereby converting severe haemophilia into moderate haemophilia.
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Affiliation(s)
- J Tusell
- Hospital Vall d'Hebron, Barcelona, Spain, Academia Nacional de Medicina, Buenos Aires, Argentina.
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Abstract
Haemophilia care and treatment products have greatly improved over the past 2 decades. Transitions in treatment produced by these changes were accompanied by the emergence of unexpected risks and new complications. In order to provide the best comprehensive care to patients with haemophilia, healthcare providers periodically need to re-evaluate and adjust their management and therapeutic products to prevent or minimize the effects produced by the emerging issues. For example, reducing the effects of infectious agents remains the highest priority for the haemophilia community because of the high level of morbidity and mortality that has resulted from earlier therapeutic agents. In many countries, the goal has been to achieve absolute zero risk for infectious agents. In some instances, the screening procedures to achieve these goals reduced the availability of plasma needed for manufactured derivatives and produced another emerging risk, shortages of clotting factor preparations. Similarly, better diagnostic methods identified other potential agents that were not inactivated by current technology. Likewise, immune tolerance regimens and the prophylactic management of haemophilia introduced different therapeutic delivery systems with their own risks. The drugs used to manage diseases such as human immunodeficiency virus (HIV), which were transmitted by products manufactured before mid-1980, create their own set of risks for this community. Topical emerging risks of treatment, including variant Creutzfeldt-Jakob disease, an assessment of its risks and impact, the complications of using indwelling catheters, and the role of protease inhibitors used to treat HIV may have on bleeding complications of haemophilia are discussed.
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Affiliation(s)
- B L Evatt
- Hematologic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA
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Abstract
The paediatric care of children with haemophilia in developed countries should focus on the health of the child, not on the disorder. Gene therapy offers the hope of an ultimate 'cure' for the disorder, but until this is a viable proposition, patients should be given more control over their treatment, and the focus should be on 'self-monitored and self-adjusted' prophylaxis. New instruments for measuring joint function and radiographic changes, and quality of life are valuable tools in improving the treatment of paediatric care for children with haemophilia.
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Affiliation(s)
- R Ljung
- Department of Paediatric and Coagulation Disorders, Lund University, University Hospital, Sweden.
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Abstract
Prophylactic treatment of haemophilia has been gaining acceptance as the optimal therapeutic option in an increasing number of haemophilia centres in the developed world in recent years. This paper focus on three aspects of prophylactic therapy: when to start treatment, venous access and the dose/dose interval. Evidence is in favour of prophylactic treatment to be started at an early age using either a peripheral vein with 1-2 injections per week and a successive increase in the frequency depending on the child and the veins, or, using a Port-A-Cath which allows a better prophylactic coverage by infusions preferably every second day in haemophilia A and every third day in haemophilia B.
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Affiliation(s)
- R C R Ljung
- Department of Paediatrics, Lund University, University Hospital, Malmö, Sweden.
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Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr 2002. [PMID: 11841046 DOI: 10.1177/0148607102026001011] [Citation(s) in RCA: 468] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Miners AH, Sabin CA, Tolley KH, Lee CA. Cost-utility analysis of primary prophylaxis versus treatment on-demand for individuals with severe haemophilia. PHARMACOECONOMICS 2002; 20:759-774. [PMID: 12201795 DOI: 10.2165/00019053-200220110-00005] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
OBJECTIVE To assess the cost effectiveness of primary prophylaxis with clotting factor instead of treatment following a bleed (on-demand) for individuals with severe haemophilia. DESIGN Different data sources on the clinical effects and costs of treatments were combined using a Markov model. SETTING English treatment centres. PERSPECTIVE UK societal. PARTICIPANTS Hypothetical cohorts of 100 individuals with severe haemophilia A or B or severe von Willebrands disease. INTERVENTIONS Primary prophylaxis treatment on-demand with clotting factor. OUTCOME MEASURES Costs, quality-adjusted life-years (QALYs) and incremental cost per QALY in UK pounds ( pound, 1999/2000 values). RESULTS The baseline results showed that treating individuals with severe haemophilia A/severe von Willebrands disease or severe haemophilia B with primary prophylaxis instead of treatment on-demand cost an additional pound 46500 and pound 8600 per QALY gained, respectively. However, the results were extremely sensitive to a number of factors including the clotting factor unit cost, the time between prophylactic doses and the discount rate. CONCLUSIONS Despite the high costs of treatment, primary prophylaxis was cost effective compared with treatment on-demand in some scenarios. Primary prophylaxis is more likely to be cost effective for individuals with severe haemophilia B compared with individuals with severe haemophilia A/severe von Willebrands disease. Further research is required to assess the relationship between methods of clotting factor infusion and health-related quality-of-life.
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Affiliation(s)
- Alexander H Miners
- Health Economics Research Group, Brunel University, Uxbridge, United Kingdom.
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Journeycake JM, Quinn CT, Miller KL, Zajac JL, Buchanan GR. Catheter-related deep venous thrombosis in children with hemophilia. Blood 2001; 98:1727-31. [PMID: 11535504 DOI: 10.1182/blood.v98.6.1727] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Central venous catheters (CVCs) are a common adjunct to hemophilia therapy, but the risk of CVC-related deep venous thrombosis (DVT) in hemophiliacs is not well defined. In a previous study, 13 patients with CVCs had no radiographic evidence of DVT. However, recent abstracts and case studies demonstrate that DVT does occur. Therefore, this study sought to determine the frequency of DVT in children with hemophilia and long-term CVCs and to correlate venographic findings with clinical features. All hemophilia patients with tunneled subclavian CVCs in place for 12 months or more were candidates for evaluation. Patients were examined for physical signs of DVT and questioned about catheter dysfunction. Contrast venograms were obtained to identify DVT. Fifteen boys with severe hemophilia were evaluated, including 9 from the initially studied group of 13. Eight patients had evidence of DVT, 5 of whom previously had normal venograms. Five of 15 patients had clinical problems related to the CVC, all of whom had DVT. Four of 15 patients had suggestive physical signs; 3 had DVT. The mean duration of catheter placement for all patients was 57.5 months (range, 12-102 months). For patients with DVT, the mean duration was 66.6 +/- 7.5 months, compared to 49.5 +/- 7.2 months for patients without DVT (P =.06). No patient whose CVC was in place fewer than 48 months had an abnormal venogram. Many hemophilia patients with CVCs develop DVT of the upper venous system, and the risk increases with duration of catheter placement.
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Affiliation(s)
- J M Journeycake
- Division of Hematology-Oncology, Department of Pediatrics, The University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA
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Ljung R, Aronis-Vournas S, Kurnik-Auberger K, van den Berg M, Chambost H, Claeyssens S, van Geet C, Glomstein A, Hann I, Hill F, Kobelt R, Kreuz W, Mancuso G, Muntean W, Petrini P, Rosado L, Scheibel E, Siimes M, Smith O, Tusell J. Treatment of children with haemophilia in Europe: a survey of 20 centres in 16 countries. Haemophilia 2000; 6:619-24. [PMID: 11122385 DOI: 10.1046/j.1365-2516.2000.00427.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A survey was made of the current status of treatment of haemophilic boys at 20 centres in 16 European countries and includes approximately 1500 of the estimated 6500 haemophiliacs in the participating countries. Many mild haemophiliacs are not seen, or seen infrequently, at haemophilia centres and this requires study. Nine of 18 centres provide continuous prophylaxis to 80-100% of their patients, five centres provide it to 55-80% and the remaining four centres to 15-40% of the boys. The median dose given was 6240 U kg-1 year-1 (range 3120-7800). Four centres administered only recombinant concentrates to children with severe haemophilia A, while seven centres administered recombinant concentrates to 75-90% and the remaining centres to less than 50% of the boys (two centres < 10%). When asked for the choice of concentrate for a newly diagnosed boy with severe haemophilia A, all but one centre preferred recombinant concentrate. Most boys below 6 years received concentrates via a peripheral vein but three centres preferred a central venous line for 80-100% of the boys. Thirteen of 18 centres applied home treatment to 84-100% of the boys and the remaining five centres to 57-77% of the boys.
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Affiliation(s)
- R Ljung
- Department of Paediatrics, University Hospital, SE-205 02 Malmö, Sweden.
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Damiano ML, Hutter JJ. Immune tolerance for haemophilia patients with inhibitors: analysis of the western United States experience. The Tri-Regional Nursing Group. Haemophilia 2000; 6:526-32. [PMID: 11012697 DOI: 10.1046/j.1365-2516.2000.00412.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The experience with immune tolerance (IT) induction therapy for haemophilia patients with inhibitors, instituted during 1990-97 at 17 haemophilia treatment centres in the western United States, was reviewed. IT was instituted in 104 of 139 (75%) of all identified haemophilia A and haemophilia B patients with inhibitors. Doses and schedules for IT varied but most patients were treated with a daily administration of 25-200 units kg-1 day-1. Successful immune tolerance (defined as Bethesda Unit titres < 1.0) was achieved in 57 of 81 (78%) patients who completed therapy. IT success was significantly greater for those patients with historic titres < 100 BU (P < 0.0003) and those with titres of < 10 BU at initiation of IT (P < 0.0001). IT success was uniformly achieved in 16 patients with low to moderate responding inhibitors. IT in infants < 2 years of age was problematic due to the presence of high titre inhibitors and complications of venous access. Frequent complications of IT included increased bleeding during intravenous access device insertion (20%) and infections associated with venous access devices (64%). IT is widely accepted as a treatment modality for haemophilia patients with inhibitors. Patient participation in IT regimens and management during therapy is facilitated greatly by the efforts of treatment centre nurse coordinators who are knowledgeable about haemophilia and its complications. Additional clinical trials will be necessary to define better initial dose, schedule, dose adjustment and success/failure criteria for IT.
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Affiliation(s)
- M L Damiano
- Hemophilia Treatment Center, University of Arizona, Tucson, AZ 85724, USA
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Abstract
A case is reported of septic arthritis in a child with human immunodeficiency virus-negative hemophilia A associated with a Staphylococcus aureus catheter-associated septicemia. The infection occurred in relation to the use of a totally implantable central venous catheter. The organism was eventually eradicated with antibiotics injected via the catheter. With increasing use of such catheters in the hemophilic population, clinicians should be alerted to the possibility of septic arthritis for prompt diagnosis and treatment.
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Affiliation(s)
- C H Li
- Department of Paediatrics, Tuen Mun Hospital, New Territories, Hong Kong, China
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