Peripherally inserted central catheters in infants and children

2018 Infectious Diseases Society of America Clinical Practice Guideline for the Management of Outpatient Parenteral Antimicrobial Therapy

A panel of experts was convened by the Infectious Diseases Society of America (IDSA) to update the 2004 clinical practice guideline on outpatient parenteral antimicrobial therapy (OPAT) [1]. This guideline is intended to provide insight for healthcare professionals who prescribe and oversee the provision of OPAT. It considers various patient features, infusion catheter issues, monitoring questions, and antimicrobial stewardship concerns. It does not offer recommendations on the treatment of specific infections. The reader is referred to disease- or organism-specific guidelines for such support.

Equivalent success and complication rates of tunneled common femoral venous catheter placed in the interventional suite vs. at patient bedside

BACKGROUND

Femoral tunneled central line placement in the pediatric population offers an alternative means for intravenous (IV) access, but there is concern for higher complication and infection rates when placed at bedside.

OBJECTIVE

To describe the complications and infection outcomes of primary femoral tunneled central venous catheter placement in the interventional radiology suite compared to the portable bedside location at a single tertiary pediatric institution.

MATERIALS AND METHODS

We conducted a retrospective review comparing interventional radiology suites vs. bedside primary tunneled common femoral vein central line placement (January 2014 to December 2015). We identified 244 primary femoral placements in pediatric patients, ages 1 day to 18 years, using our electronic medical record and collected into a Research Electronic Data Capture. We compared categorical variables using the Fisher exact test. We compared continuous variables using the Wilcoxon rank test.

RESULTS

In total, 2,375 pediatric patients received peripherally inserted and central lines; 244 of these were primary femoral tunneled central venous catheters (in 140 boys and 104 girls). In 140 children (mean age: 206 days), lines were inserted in the interventional radiology (IR) suite (technical success of 100%), with 14 (10.0%) complications including infection (n=7), malposition (n=2), bleeding (n=0), thrombosis (n=1) and line occlusion (n=4). The infection rate was 2.1 per 1,000 line days. In 104 children (mean age: 231 days), lines were placed at bedside (technical success 100%) with 14 (13.3%) complications including infection (n=3), malposition (n=5), bleeding (n=0), thrombosis (n=2) and line occlusion (n=4). The infection rate was 0.78 per 1,000 line days. The total line days were 7,109, of which 3,258 were in the IR suite and 3,851 in the bedside group. There was no statistical significance for complication rate (P=0.55) or infection rate (P=0.57) between bedside and interventional suite placements.

CONCLUSION

In a cohort of children receiving primary femoral tunneled central venous catheters, the complication and infection rates in a bedside setting are not significantly increased compared to the lines placed in an IR suite. The perception of increased infection and complications from bedside-placed tunneled central venous catheters appears to be hyperbolized.

Massive pleural effusion on the contralateral side of a venous peripherally inserted central catheter

A preterm newborn infant, delivered at 30 weeks of gestation and 965 g birth weight, developed respiratory distress with resistant hypoxia after a central catheter line was inserted via the right venae brachialis on postnatal day 21. Left-sided massive pleural effusion, collapsed left lung with air bronchograms, and bidirectional shunting through reopened ductus arteriosus were detected by targeted neonatal echocardiography. Hydrothorax was drained under sonographic guidance, producing a milky-white fluid biochemically compatible with parenteral nutrition. We report this case of hydrothorax secondary to a misplaced central catheter on the contralateral side of its peripheral insertion. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 46:140-144, 2018.

Venous thrombosis and stenosis after peripherally inserted central catheter placement in children

BACKGROUND

Peripherally inserted central catheters (PICCs) can lead to development of venous thrombosis and/or stenosis. The presence of venous thrombosis and/or stenosis may preclude children with chronic medical conditions from receiving lifesaving therapies, from hemodialysis in end-stage renal disease to total parenteral nutrition in short bowel syndrome. Several adult studies have found an association between PICCs and venous thrombosis and/or stenosis, but none has evaluated for this association in children.

OBJECTIVE

To determine the incidence of venous thrombosis and/or stenosis after PICC placement and identify factors that increase the risk of venous thrombosis and/or stenosis after PICC placement in children.

MATERIALS AND METHODS

We conducted a retrospective review of children ages 1-18 years with a PICC placed between January 2010 and July 2013 at our center, and included those who had at least one vascular imaging study of the ipsilateral extremity (Doppler ultrasound, venogram or MR angiogram) after PICC placement. Logistic regression was applied to determine risk factors for development of venous thrombosis and/or stenosis.

RESULTS

One thousand, one hundred and ten upper extremity PICCs were placed, with 703 PICCs in the right and 407 PICCs in the left. Eight hundred fifty-one imaging studies (609 Doppler ultrasounds, 193 contrast venograms and 49 MR angiograms) were performed in 376 patients. The incidence of venous thrombosis and/or stenosis in the imaged cohort was 26.3%. PICC laterality, insertion site, duration, patient height to PICC diameter ratio, and number of PICCs per patient were not associated with development of venous thrombosis and/or stenosis. Additionally, primary diagnosis and symptoms at the time of imaging did not predict findings of venous thrombosis and/or stenosis. However, patients exposed to non-PICC central venous catheters (CVC) were more likely to develop venous thrombosis and/or stenosis (odds ratio 1.95, 1.10-3.45).

CONCLUSION

More than a quarter of the vascular imaging studies performed in this study cohort showed previously unknown venous thrombosis and/or stenosis, irrespective of PICC laterality, insertion site, duration and size and the number of PICCs. A history of CVC was associated with a nearly two-fold increase in risk of venous thrombosis and/or stenosis after PICC placement. We suggest that PICCs and CVCs should be placed judiciously in all children, but especially in those with lifelong medical conditions who are more likely to incur direct consequences from limited vascular access.

Incidence and risk factors of superficial and deep vein thrombosis associated with peripherally inserted central catheters in children

Essentials Pediatric studies on peripherally inserted central catheter (PICC)-related thrombosis are scarce. This study analyzes incidence and risk factors for PICC-related venous thrombosis in children. PICC-related thrombosis is a common, and nearly always, asymptomatic complication. Echo-guided insertion and a catheter to vein ratio < 0.33 may notably decrease this complication.

SUMMARY

Background Upper-extremity venous thrombosis is associated with the use of peripherally inserted central catheters (PICCs). Few pediatric studies have focused on this issue. Objectives To determine the incidence and risk factors for PICC-related superficial vein thrombosis (SVT) and deep vein thrombosis (DVT) in children. Patients/methods An observational follow-up cohort study was conducted at a single hospital between June 2012 and June 2015. All patients receiving a PICC were enrolled and followed up, with weekly Doppler ultrasound examination of the catheterized limb until PICC removal. Patient, procedural and follow-up data were analyzed. Results In the study period, 265 PICCs were inserted (median age of patients 6.5 years, interquartile range [IQR] 2.4-13 years; median weight 20 kg, IQR 11-38 kg; 54% males; 67.9% chronically ill), and patients were followed up for a total of 9743 days. The median indwelling time was 21 days (IQR 12-37 days). During follow-up, 88 (33.2% of insertions) PICC-related thromboses (incidence rate [IR] 9.03 per 1000 catheter-days) were diagnosed, 66 (24.9%) as isolated SVT, seven (2.6%) as isolated DVT, and 15 (5.7%) as SVT with associated DVT (IR 6.78, 0.71 and 1.54 per 1000 catheter-days, respectively). Only 9.9% of patients with SVT and 18.2% of those with DVT were symptomatic. The main risk factors for PICC-related SVT and DVT were a catheter/vein ratio of > 0.33 and thrombosis of the catheterized superficial vein, respectively. Conclusions PICC-related thrombosis is a common and nearly always asymptomatic complication in children, the SVT rate being approximately three times higher than the DVT rate. Optimal vein and catheter selection, yielding the lowest possible catheter/vein ratio, may decrease the rate of PICC-related thrombosis.

Risk of Infection Using Peripherally Inserted Central and Umbilical Catheters in Preterm Neonates

OBJECTIVE

To compare the rates of catheter-associated bloodstream infection (CABSI) in preterm infants born at <30 weeks' gestation who received a peripherally inserted central catheter (PICC) versus an umbilical venous catheter (UVC) immediately after birth as their primary venous access.

METHODS

This retrospective matched cohort study examined data from infants born at <30 weeks' gestation and admitted between January 2010 and December 2013 to neonatal units in the Canadian Neonatal Network. Eligible infants who received a PICC on the first day after birth (day 1) were matched with 2 additional groups of infants, those who received a UVC on day 1 and those who received a UVC on day 1 that was then changed for a PICC after 4 days or more. The primary outcome was number of infants with CABSI per 1000 catheter days, which was compared between the 3 groups using multivariable analyses.

RESULTS

Data from 540 eligible infants were reviewed (180 per group). There was no significant difference in infants with CABSI/1000 catheter days between the 3 groups (9.3 vs 7.8 vs 8.2/1000 catheter days, respectively; P > .05) despite lower rates of late onset sepsis in the group of infants who received only a UVC.

CONCLUSIONS

There was no significant difference in the incidence of CABSI between very preterm neonates who received a PICC, UVC, or UVC followed by PICC as the primary mode of venous access after birth. A prospective randomized controlled trial is justified to further guide practice regarding primary venous access and reduction of infection.

Introduction of the use of a pediatric PICC line in a French University Hospital: review of the first 91 procedures

PURPOSE

In order to assess the establishment of a pediatric PICC line service in a University Hospital after the first 91 consecutive procedures.

MATERIALS/PATIENTS AND METHODS

Retrospective study over a period of 24months. The criteria analysed were success or failure of the procedure, indication, age when inserted, type of PICC line, mean length of use and development of complications such as accidental removal, venous thrombosis or infection.

RESULTS

Ninety-one PICC lines were inserted in 74 patients between 4months and 25years old (sex-ratio: 1.1 girls/boys). The procedure was performed under general anaesthesia in four cases (4.4%) and under EMLA and MEOPA in 87 cases (95.6%). The insertion was ultrasound guided through the basilic (n=63, 70%), humeral (n=18, 20%) or cephalic (n=9, 10%) veins in the non-dominant arm (L in 62 cases, R in 28 cases). The insertion success rate was 99% (n=90). The main indications were starting antibiotic therapy (n=47, 52%), chemotherapy (n=34, 38%) and parenteral nutrition (n=5, 5%). The devices used were single lumen 3F (n=4, 4%), single lumen 4F (n=31, 34%), double lumen 4F (n=2, 2.2%), single lumen 5F (n=12, 13%), and double lumen 5F (n=41, 45%). The PICC line was used for an average period of 45days (14 to 300days). The complications found were accidental removal (n=2, 2.2%), catheter fracture (n=2; 2.2%), obstruction (n=5, 5.5%), suspected infection (n=1, 1.1%), and venous thrombosis and pulmonary embolism (n=3, 3.3%). The overall complication rate was 14.4% (n=13) including 4.4% serious complications (n=4).

CONCLUSION

PICC lines are a future solution in pediatrics. This technique is reliable and has a similar complication rate to studies carried out in adults, most of which can be prevented by careful catheter maintenance and informing the care staff.

Pharmacokinetics and pharmacodynamics of oral cephalexin in children with osteoarticular infections

BACKGROUND

Osteoarticular infections lead to significant morbidity in children. Cephalexin has in vitro activity against methicillin-susceptible Staphylococcus aureus, a predominant pathogen in osteoarticular infection. However, cephalexin pharmacokinetics (PK) and pharmacodynamics (PD) are poorly described in children. This study described cephalexin PK in children treated for osteoarticular infection and assessed the proportion of children achieving surrogate PK/PD target for efficacy in methicillin-susceptible S. aureus infection.

METHODS

Children with osteoarticular infection, 1 to 18 years of age, were eligible for this study if they were receiving oral cephalexin per standard of care. PK plasma samples were collected at specified times after multiple doses. PK parameters were estimated using noncompartmental analysis. PK/PD target for efficacy was calculated using the child's PK parameters, minimum inhibitory concentration (MIC) of the isolate when available and previously described MIC of 2 and 4 mg/L.

RESULTS

Twelve children were enrolled and PK profiles were obtained from 11 of them. Median age was 7 years, and median cephalexin dose was 40 mg/kg/dose every 8 hours. Median apparent oral clearance, apparent oral volume of distribution and elimination half-life (T1/2) were 0.29 L/h/kg, 0.44 L/kg and 1.1 h, respectively. Time above MIC (T>MIC) was greater than 40% of the dosing interval in 100%, 90% and 80% of the children when MICs were 0.25, 2 and 4 mg/L, respectively.

CONCLUSIONS

Oral cephalexin achieved optimal plasma exposure and was well tolerated in children with osteoarticular infection. Correlation between osteoarticular infection clinical outcome and PK/PD parameters needs further evaluation.

Peripherally inserted central catheters in infants and children - indications, techniques, complications and clinical recommendations

Venous access required both for blood sampling and for the delivery of medicines and nutrition is an integral element in the care of sick infants and children. Peripherally inserted central catheters (PICCs) have been shown to be a valuable alternative to traditional central venous devices in adults and neonates. However, the evidence may not extrapolate directly to older paediatric patients. In this study, we therefore review the indications, methods of insertion and complications of PICC lines for children beyond the neonatal age to provide clinical recommendations based on a search of the current literature. Although the literature is heterogeneous with few randomised studies, PICCs emerge as a safe and valuable option for intermediate- to long-term central venous access in children both in and out of hospital. Insertion can often be performed in light or no sedation, with little risk of perioperative complications. Assisted visualisation, preferably with ultrasound, yields high rates of insertion success. With good catheter care, rates of mechanical, infectious and thrombotic complications are low and compare favourably with those of traditional central venous catheters. Even in the case of occlusion or infection, fibrinolytics and antibiotic locks often allow the catheter to be retained.

Peripherally inserted central catheter placement in cancer patients with profound thrombocytopaenia: a prospective analysis

OBJECTIVE

No studies have specifically evaluated the safety of peripherally inserted central catheter (PICC) placement in patients with profound thrombocytopaenia. We prospectively determined the frequency of haemorrhagic complications of PICC placement in cancer patients with uncorrected profound thrombocytopaenia.

METHODS

Profound thrombocytopaenia was defined as a platelet count <50 × 10(9)/l. No patients received transfusions before or after the procedure. Three types of adverse effects were analysed: minor oozing, mild haematoma and major haemorrhage.

RESULTS

One hundred and forty-three PICC implantations in 101 cancer patients were prospectively included in the study: seven patients (7 %) had a solid tumour and 94 (93 %) a haematological malignancy. Among these 143 procedures in thrombocytopaenic patients, 93 (65 %) were performed with a platelet count 20-50 × 10(9)/l and 50 (35 %) had lower than 20 × 10(9)/l. No major haemorrhage was observed. Minor oozing was observed in six implantations (4 %) and mild haematoma in two (1.5 %), for a total of eight minor haemorrhagic adverse events (5.5 %). In patients with a platelet count <20 × 10(9)/l, 1/50 (2 %) had minor oozing and none had minor haematoma.

CONCLUSIONS

In cancer patients with uncorrected profound thrombocytopaenia, the incidence of adverse events after PICC implantation was low, and was limited to minor haemorrhagic adverse events.

KEY POINTS

• PICC placement has high technical success in profound thrombocytopaenic cancer patients. • Few adverse events are encountered after PICC placement, limited to minor haemorrhage. • PICC placement does not routinely require platelet transfusion in patients with thrombocytopaenia. • Such PICC placement still seems safe when the platelet count is <20 × 10 (9) /l.

Complications associated with outpatient parenteral antibiotic therapy in children

BACKGROUND

The authors sought to determine the prevalence, risk factors, and clinical impact of complications associated with outpatient parenteral antimicrobial therapy (OPAT) in children.

METHODS

A cohort of patients ≤18 years old with infections, who received OPAT were evaluated retrospectively. Antibiotic-associated complications (AACs), catheter-associated complications (CACs), and unplanned medical care visits were the main outcome measures.

RESULTS

Overall, 36 complications (25 CACs and 11 AACs) occurred in 32 of 98 patients. Mean age of patients, race, gender, and infecting organism did not differ between study groups. The use of OPAT for osteomyelitis was associated with complications (odds ratio = 2.69; 95% confidence interval = 0.99-7.35; P = .05). All patients, except for 4 who had complications, clinically improved by the end of OPAT. Unplanned medical visits occurred in 17 patients, 15 of which were because of CACs.

CONCLUSION

Complications occurred commonly in children receiving OPAT and resulted in unplanned medical visits.

Transcatheter Removal of Peripherally Inserted Central Catheter Adherent to the Ventricular Septum

We describe an unusual case of a young child with peripherally inserted central catheter (PICC) adherent to the ventricular septal wall 5 days following insertion. The impacted PICC was successfully retrieved using a transcatheter procedure. The technique describes the freeing of an intracardiac central line with closed ends.

The Use of Peripherally Inserted Central Catheters in Cancer Patients

From 2002 to 2006, 524 cancer patients who underwent PICC insertion by nursing staff were studied. 568 PICCs were in place for a total of 32068 days (mean duration: 56 days; range: 1 to 487 days). The complication rates were phlebitis – 24.07%, broken/leaking catheter – 12.33%, accidental removal – 7.44%, occlusion – 14.68%, and infection – 1.77%. Group A patients who underwent PICC insertion for the major purpose of receiving repeated chemotherapy had higher incidences of phlebitis, broken/leakage catheter and infection. Group B patients who underwent PICC insertion for the major purpose of hospice care had a higher incidence of accidental removal.

Survey of the long-term use of peripherally inserted central venous catheters in children with cancer: experience in a developing country

Peripherally inserted central catheters (PICCs) have been used for many years in developed countries, but few studies have been focused on children with cancer in developing countries. In this study, we assessed the feasibility of PICCs and determined the rate of PICC-related complications in children with cancer. We prospectively followed all children with cancer over 3 years of age who received chemotherapy and PICC placement in our cancer center between June 2003 and May 2007. The date of last follow-up was January 31, 2008. A total of 119 PICCs were inserted into 116 patients during the 48-month period. PICCs were placed in 113 of 119 attempts, yielding an insertion rate of 95.0%. The 113 PICCs were in place for a total 26,721 catheter days (median time, 246 d; range, 8 to 455 d). The 113 PICCs had 53 overall complications, for a rate of 1.98/1000 catheter days. Twenty-one (18.6%) PICCs were removed because of complication with a rate of 0.79/1000 catheter days. The most common reason for PICC removal was breakage/leakage. An infection requiring PICC removal occurred in 4 patients. This study demonstrated relatively low complication rate and long duration for PICCs in children with cancer over 3 years of age in our hospital.

Peripherally inserted central venous catheters are a good option for prolonged venous access in children with cancer

BACKGROUND

A long term venous access device is essential in children with malignancies for the safe administration of medication and to avoid repeated painful venipunctures. The advantage of peripherally inserted central venous catheters (PICC) over conventional central venous catheter (CVC) is easy bedside insertion without need for general anesthesia and theatre time. The purpose of this study was to evaluate our experience with PICCs particularly with regard to catheter life, reason for removal and complications in children suffering from various malignancies.

PROCEDURE

A retrospective analysis of all PICCs inserted in children with cancer was done with regard to the demographic data, catheter life, reason for removal, and complications. The latter two were evaluated in association with patient age, catheter days, and year of insertion.

RESULTS

Of 127 catheters inserted in 127 children, median catheter life was 161 days with a total of 18,955 catheter days (for 124 patients, 3 lost to follow-up). Elective removal occurred in 63/101 (62.4%) PICCs and removal due to complications resulted in a complication rate of 2.41 per 1,000 catheter days. The common reasons for catheter removal were suspected infection, breakage/leakage, dislodgement, phlebitis, and occlusion with rates of 1.27, 0.57, 0.31, 0.06, and 0.06 per 1,000 catheter days, respectively.

CONCLUSION

We found PICC to be a convenient, cheap, safe, and reliable device for long term intravenous access in children with malignancies. This was possible with the help of dedicated catheter care nurses.

The place of interventional radiology in Crohn disease in children

The interventional radiologist plays an important role in the treatment of complicated Crohn disease in children. Interventional radiology includes percutaneous drainage of abscesses and insertion of suitable intravenous lines. A multidisciplinary approach is mandatory for the management of these patients.

Incidence of deep vein thrombosis related to peripherally inserted central catheters in children and adolescents

BACKGROUND

Peripherally inserted central catheters (PICC) in children and adolescents are being used with increasing frequency. We sought to determine the incidence and characterize risk factors of deep vein thrombosis associated with peripherally inserted central catheters in a pediatric population.

METHODS

We conducted a prospective study involving consecutive patients referred to the radiology department of a tertiary care university-affiliated hospital for insertion of a peripherally inserted central catheter. We included patients aged 18 years or less who weighed more than 2.5 kg and had a peripherally inserted central catheter successfully inserted in his or her arm between June 2004 and November 2005. The primary outcome was the occurrence of partial or complete deep vein thrombosis evaluated by clinical examination, ultrasonography and venous angiography.

RESULTS

A total of 214 patients (101 girls, 113 boys) were included in the study. Partial or complete deep vein thrombosis occurred in 20 patients, for an incidence of 93.5 per 1000 patients and 3.85 per 1000 catheter-days. Only 1 of the cases was symptomatic. In the univariable analyses, the only variable significantly associated with deep vein thrombosis was the presence of factor II mutation G20210A (odds ratio 7.08, 95% confidence interval 1.11-45.15, p = 0.04), a genetic mutation that increases the risk of a blood clot and that was present in 5 (2.3%) of the 214 patients.

INTERPRETATION

The incidence of deep vein thrombosis related to peripherally inserted central catheters in our study was lower than the incidence related to centrally inserted venous catheters described in the pediatric literature (11%-50%).

Survey of the use of peripherally inserted central venous catheters in neonates with critical congenital cardiac disease

Neonates with congenital cardiac disease are a special population. They are often critically ill, and need prolonged intravenous access. To date, no study has evaluated the efficacy and safety of peripherally inserted central venous catheters placed in this unique population. Our goal was to evaluate the use of such catheters in neonates with critical congenital cardiac disease, and to study features such as duration of use, reasons for removal of catheters, and complications. We inserted a total of 124 catheters in 115 neonates with critical congenital cardiac disease who were admitted to the Intensive Care Unit at Texas Children's Hospital from August 2002 to August 2004. The patients had a mean age of 10 days, and a mean weight of 3.1 kilograms. The peripherally inserted catheters were in place for a mean of 22.3 days. Therapy was completed in 76.6% patients at the time of removal of the catheter. The incidence of occlusion, dislodgement, and thrombus was 4.0%, 2.4%, and 1.6%, respectively. The infection rate was 3.6 per 1000 catheter-days, with a median onset on 37 days after placement. We conclude that central venous catheters, when inserted peripherally, provide reliable and safe access for prolonged intravenous therapy in neonates with critical congenital cardiac disease.

Therapy Insight: venous-catheter-related thrombosis in cancer patients

Central venous catheters (CVCs) have improved the management of patients with cancer substantially, by facilitating chemotherapy and supportive therapy. The use of CVCs is associated with complications such as infection and upper-limb deep vein thrombosis (UL-DVT). The incidence of clinically overt UL-DVT related to the use of CVCs ranges between 2% and 4%. In the most recent study, the incidence of CVC-related thrombosis, as screened by venography, was approximately 18% in the absence of prophylaxis. In cancer patients with CVC-related UL-DVT, the incidence of clinically overt pulmonary embolism was between 15% and 25%, and the incidence of autopsy-proven pulmonary embolism was up to 50%. Pathogenic factors for CVC-related thrombosis include vessel injury caused by the CVC insertion procedure, venous stasis because of the indwelling CVC, and hypercoagulability associated with cancer. Recent studies have not confirmed a benefit for prophylaxis with antithrombotic agents for CVC-related thrombosis. The recommended treatment for CVC-related thrombosis is based on long-term anticoagulant therapy, with or without catheter removal.

Vascular access for home intravenous therapy in children

This review article describes the vascular access devices available for long-term vascular access in children, describes the procedures for implanting them and the sites available for this purpose, discusses the complications associated with catheter placement and how to avoid them, and compares the various catheter systems in terms of their advantages and disadvantages.

Pediatric vascular access

Pediatric interventional radiologists are ideally suited to provide vascular access services to children because of inherent safety advantages and higher success from using image-guided techniques. The performance of vascular access procedures has become routine at many adult interventional radiology practices, but this service is not as widely developed at pediatric institutions. Although interventional radiologists at some children's hospitals offer full-service vascular access, there is little or none at others. Developing and maintaining a pediatric vascular access service is a challenge. Interventionalists skilled in performing such procedures are limited at pediatric institutions, and institutional support from clerical staff, nursing staff, and technologists might not be sufficiently available to fulfill the needs of such a service. There must also be a strong commitment by all members of the team to support such a demanding service. There is a slippery slope of expected services that becomes steeper and steeper as the vascular access service grows. This review is intended primarily as general education for pediatric radiologists learning vascular access techniques. Additionally, the pediatric or adult interventional radiologist seeking to expand services might find helpful tips. The article also provides education for the diagnostic radiologist who routinely interprets radiographs containing vascular access devices.

Vascular access

Vascular access is the cornerstone of medical therapy in the pediatric population and presents unique challenges. The vessels are small, often exceedingly so, and gaining access may require considerable patience and skill. Peripheral IVs are difficult to place in children, both because of lack of patient cooperation and because of the very small size of many veins. In addition, repeated venipuncture has been identified as one of the greatest stresses in hospitalized children. In the recent past, all forms of central venous access were the preserve of surgeons and were placed in the operating room under general anesthesia. In recent years, pediatric interventional radiologists have described placing peripherally inserted central catheters (PICCs), subcutaneous venous access ports, hemodialysis catheters, and a variety of temporary and permanent central lines even in the smallest children. This has been achieved safely, reliably, and, by dispensing with general anesthesia and operating room time in most cases, at considerable cost savings to the entire health care system. In addition, new forms of reliable, stable access such as the PICC line have made possible outpatient treatment of a wide variety of conditions, particularly infectious, which previously necessitated hospital admission. This has resulted not only in considerable cost saving for the health care system but also improved quality of life for the patient and their family. In this section, I review the current state of pediatric vascular access with emphasis on those areas where pediatric differs from adult practice.

Peripherally inserted central venous catheters in preterm newborns: two unusual complications

This report describes the case of two newborns who suffered unusual complications after peripheral insertion of a central venous catheter. In one baby a fragment of the catheter tip became embolized in a peripheral branch of the left pulmonary artery. In the other baby, the catheter perforated a peripheral branch of the pulmonary artery, giving rise to chemical pneumonitis with extensive pleural effusion. The outcome was positive for both babies. A large clinical series is necessary to establish the complications of this procedure, their prevention and management.

Venous thromboembolism associated with long-term use of central venous catheters in cancer patients

Long-term central venous catheters (CVCs) have considerably improved the management of cancer patients because they facilitate chemotherapy, transfusions, parenteral nutrition, and blood sampling. However, the use of long-term CVCs, especially for chemotherapy, has been associated with the occurrence of upper-limb deep venous thrombosis (UL-DVT). The incidence of clinically overt UL-DVT related to CVCs has been reported to vary between 0.3% and 28.3%. The incidence of CVC-related UL-DVT screened by venography reportedly varies between 27% and 66%. The incidence of clinically overt pulmonary embolism (PE) in patients with CVC-related UL-DVT ranges from 15% to 25%, but an autopsy-proven PE rate of up to 50% has been reported. Vessel injury caused by the procedure of CVC insertion, venous stasis caused by the indwelling CVC, and cancer-related hypercoagulability are the main pathogenetic factors for CVC-related venous thromboembolism (VTE). Several studies have assessed the benefit of the prophylaxis of UL-DVT after CVC insertion in cancer patients. According to the results of these studies, prophylaxis with low molecular weight heparin or a low fixed dose of warfarin has been recently proposed. However, the limitations of the experimental design of the prophylactic studies do not allow definitive recommendations. The recommended therapy for UL-DVT associated with CVC is based on anticoagulant therapy with or without catheter removal. This review focuses on the epidemiology, pathogenesis, diagnosis, prevention, and treatment of VTE in cancer patients with long-term CVC.

Central venous catheter sepsis in surgical newborns

We examined central venous catheter (CVC) sepsis in newborn surgical patients, as this group appeared to have a higher incidence of this complication. During a 3-year period 79 patients on the surgical service required a tunneled, cuffed, Broviac CVC. Nineteen patients (24% or 9.9 episodes per 1000 catheter days) had proven sepsis and 8 (10% or 1.9/1000 catheter days) had suspected sepsis. An intestinal stoma was definitely related to CVC sepsis ( p<0.001). Other risk factors included lower gestational age, more operations, and younger age at first stoma. Temperature, white blood cell (WBC) count, and platelet count did not correlate with CVC sepsis. We found no better indicator of CVC sepsis than the presentation of an ill child. Certainly temperature, WBC, and platelet count are not reliable indicators. Surgeons have little control over the factors that were found to be related to CVC sepsis. It would appear reasonable from these results to maintain a high index of suspicion in the high-risk groups, to use peripherally inserted central catheters (PIC lines) as the first line of long-term vascular access, and to bring CVCs out of a nonabdominal site, perhaps the scalp, in patients with stomas.

The effect of a mediastinal mass on the initial positioning of a peripherally inserted central venous catheter

The purpose of this project was to assess if the presence of a mediastinal mass adversely influences peripherally inserted central catheter (PICC) positioning. A retrospective review of all PICC placements over an 18-month period in a pediatric oncology hospital was conducted in which patients were categorized by the presence or absence of a mediastinal mass. A much higher proportion of patients with a mediastinal mass (8 of 13) had a malpositioned catheter than those without a mass (3 of 38; P = .0002). A significant proportion of the malpositioned catheters in patients with a mediastinal mass terminated in the right heart chambers. These findings show that clinicians must be vigilant about checking for PICC malpositioning in this patient population.

Using evidence-based practice to create a venous access team: the Venous Access Task Force of the Children's Hospital of Denver

The following article is an example of evidence-based practice applied to an institutional Quality Improvement (QI) project. QI originated in the 1980s and is best associated with the work of W. Deming (1986). It is also known as Continuous Quality Improvement, because a major principle of this approach is constant improvement of services or products. This improvement process contains other critical components: scientific method, employee participation and teamwork, accountable leadership, appropriate training and ongoing education, and client focus (Demming, 1986). QI has been globally successful and has helped transform American industry, including health care services. The following clinically based project illustrates the application of QI concepts and evidence-based practice to enhance outcomes.

Complication rates among cancer patients with peripherally inserted central catheters

PURPOSE

Peripherally inserted central catheters (PICCs) are frequently used to deliver outpatient courses of intravenous therapy. However, the rates and risks of complication for this device have not been well-studied. Our objective was to determine the incidence and risk factors of PICC-related complications with a 1-year prospective observational study.

PATIENTS AND METHODS

All PICCs inserted in adult and pediatric patients at Memorial Sloan-Kettering Cancer Center (MSKCC) were followed prospectively. The device insertion team, inpatient nurses, and various home-care companies and outside institutions collected longitudinal data.

RESULTS

Three hundred fifty-one PICCs were inserted during the study period and followed for a total of 10,562 catheter-days (median placement, 15 days; range, 1 to 487 days). Two hundred five PICCs (58%) were managed by home-care companies and outside institutions, and 146 PICCs (42%) were managed exclusively at MSKCC. For these 205 PICCs, 131 nurses from 74 home-care companies and institutions were contacted for follow-up clinical information. In all, 115 (32.8%) of 351 PICCs were removed as a result of a complication, for a rate of 10.9 per 1,000 catheter-days. Patients with hematologic malignancy or bone marrow transplant were more likely to develop a complication, whereas those with metastatic disease were less likely.

CONCLUSION

Complications occur frequently among cancer patients with PICCs, and long-term follow-up is onerous. Despite a high complication rate, the ease of insertion and removal argues for continued PICC use in the cancer population.

Pediatric peripherally inserted central catheters: complication rates related to catheter tip location

OBJECTIVE

To compare complication rates between central venous catheter tip location and noncentral tip location after peripherally inserted central catheter (PICC) placement in children.

METHODS

Between 1994 and 1998, data from all children who underwent PICC placement were analyzed. Patient demographics, catheter characteristics, catheter duration, infusate composition, and catheter complications were entered prospectively into a computerized database. Catheter tip locations were determined by fluoroscopy and were defined as central if they resided in the superior vena cava, right atrium, or high inferior vena cava at or above the level of the diaphragm, and as noncentral if located elsewhere. Differences in complication rates between the central and noncentral groups were analyzed.

RESULTS

Data from a total of 1266 PICCs were analyzed from 1053 patients with a mean age of 6.49 +/-.2 years (range: 0-45.0 years). Of the 1266 PICCs, 1096 (87%) were central in tip location, and 170 (13%) were noncentral in tip location. The central group had 42 complications of 1096 catheters (3.8%), while the noncentral group had 49 complications of 170 catheters (28.8%). Controlling for patient age, catheter size, gender, and catheter duration with a logistic regression model, there remained a statistically significant increased likelihood of complication in the noncentral group versus the central group (adjusted odds ratio: 8.28; 95% confidence interval: 5.11-13.43).

CONCLUSIONS

Centrally placed catheter tips are associated with fewer complications than are noncentrally placed catheter tips. Clinicians should ensure that catheter tips reside centrally after PICC placement in infants and children.

Peripherally inserted central catheters: guidance with use of US versus venography in 2,650 patients

PURPOSE

To compare technical success and initial complication rates of peripherally inserted central catheters (PICCs) by interventional radiologists using ultrasound (US) or venographic guidance.

MATERIALS AND METHODS

With use of a computer database, the authors retrospectively reviewed 2,650 procedures, 2,126 of which were performed with US and 524 with venography. Technical success was defined as placement of a PICC. Initial complications were defined as development of a hematoma, inadvertent arterial puncture, or neuropathy. Statistical significance was assessed using the chi2 test.

RESULTS

During 33 consecutive months, 2,650 procedures were performed with a complication rate of 1.0%. The technical success rate was 95.8% for venography and 99.6% for US. The initial complication rate was 0.75% for venography and 1.08% for US. There was no statistically significant difference in immediate complication rates (P = .50); however, there is statistical significance in regard to technical success (P < .001).

CONCLUSION

There is no difference in initial complication rates when comparing US and venographic guidance for PICC insertion. The decision to use either method can be based on clinical grounds and/or physician preference, although US has a higher initial success rate.

Peripherally inserted central venous catheters: success of scalp-vein access in infants and newborns

The authors assessed the feasibility of placing peripherally inserted central venous catheters via scalp veins in infants and newborns. In 60 newborns and infants, aged 3 days to 10 months, placement of 62 2-F peripherally inserted central venous catheters was attempted with scalpvein access. The tip location was central in 30 of the 62 catheters (48%) and long peripheral intravenous in 17 (27%); access failed in 15 (24%). Scalp-vein access for peripherally inserted central venous catheters offers a safe and effective alternative route for gaining central venous access in infants and newborns.