Causes and Outcome of Central Venous Catheter Repair in Children with Intestinal Failure on Home Parenteral Nutrition

OBJECTIVES

Children requiring a central venous catheter (CVC) for long-term parenteral nutrition (PN) are at risk of CVC breakage. Modern intestinal failure (IF) management aims to preserve vascular access sites. CVC repair rather than removal is hence attempted for broken catheters. The aim of this study was to describe causes and outcomes of CVC repairs in home PN dependent children.

METHODS

All patients (ages 0-17 years) with CVC dependency enrolled in the IF rehabilitation program of a pediatric referral center were identified, and those who underwent a CVC repair between January 2019 and November 2020 included. Data on associated cause for breakage and incidence of central line-associated bloodstream infections (CLABSIs) post repair were documented retrospectively. Descriptive statistics including medians, percentages, and frequencies were used.

RESULTS

Forty children, 15 males (37%) and 25 females (63%), were identified. Fifteen of 40 (37.5%) patients underwent a total of 29 CVC repairs (0.1 repairs per 1000 catheter days); 8 of 15 (53%; 33% females) were <5 years of age. The most common reason for repair was CVC fracture by biting (41%) followed by catheter occlusion with intraluminal PN deposition (13.2%). Repair was successful in 100% cases. Only 1 patient had a confirmed CLABSI post repair (1/29 repairs; 3%) who presented 3 days late after the initial catheter breakage. Catheter salvage was successful with antibiotics.

CONCLUSION

CVC repair in our cohort was very successful and infection rate after repair minimal. CVC repair rather than removal is recommended to preserve central venous access.

Repair of central venous access devices in intestinal failure patients is safe and cost-effective: A retrospective single centre cohort study

INTRODUCTION

Patients with chronic intestinal failure (IF) require home parenteral nutrition (HPN). Central venous access is needed for prolonged use of PN, usually via a long term central venous access device (CVAD). Post insertion there may be mechanical complications with a CVAD such as catheter rupture or tear. Repair of damaged CVADs is possible to avoid risks associated with catheter replacement in patients with IF. However, catheter related blood stream infections (CRBSI) are a concern when CVAD's are accessed or manipulated.

AIMS

To investigate the success of repair of CVADs in patients with IF on HPN, related to repair longevity and incidence of CRBSI following repair.

METHOD

Nutrition team records of CVAD repairs carried out in patients with IF were reviewed retrospectively for the period April 2015 to March 2019.

RESULTS

Nutrition Clinical Nurse Specialists carried out 38 repairs in 27 patients. Male n = 5, female n = 22; mean age 55 years. Catheter longevity before first repair (n = 27): median 851 days, IQR 137-1484 days. 30/38 (78.9%) of repairs were successful lasting ≥30days. Hospital admission was avoided in 76% of cases. 4 patients in the failed repair group underwent catheter re-insertion where 4 had a further, subsequently successful, repair, an overall success rate of 89.4% (34/38). 30-day CRBSI rate was 0.09/1000 catheter days in repaired catheters. In comparing costs, there is a potential cost saving of 2766GBP for repair compared to replacement of damaged CVADs.

CONCLUSION

Repair of tunnelled CVADs in patients with IF is successful and safe with no increased risk of CRBSI. Significant cost savings may be made.

Repair of Central Venous Catheter in a Single-Center Adult Home Parenteral Nutrition Cohort

BACKGROUND

Patients with chronic intestinal failure who require long-term parenteral nutrition rely on central venous catheters (CVCs) for access to nutrition and hydration. With prolonged use, complications such as central line-associated bloodstream infection (CLABSI), damage to CVC, and central venous thrombosis (CVT) can threaten the availability of life-preserving access. Because of this, all efforts should be made to preserve CVCs with techniques such as catheter salvage in case of CLABSI and catheter repair when damaged. The present study was conducted to evaluate the effectiveness and safety of catheter repair in our patient population.

METHODS

Retrospective review in 1253 adult patients who received home parenteral nutrition at the Mayo Clinic between September 1, 1997, and April 30, 2018, was conducted to determine the incidence of CLABSI and CVT in patients who underwent CVC repair.

RESULTS

Fifty-five CVC repairs were performed in 36 patients (n = 23 female) with mean age of 57.05 ± 16.96 years. A total of 14 catheters (25.45%) were complicated with 24 episodes of CLABSI. CLABSI rate before and after repair was 0.23/1000 catheter days and 0.21/1000 catheter days, respectively. Most common indications for eventual catheter replacement were mechanical damage (32%), infection (32%), and switching to alternate mode of nutrition (24%). We had a 100% success rate of catheter repair procedure, and no post-procedural complications were present.

CONCLUSION

Catheter repair can increase the catheter survival without increasing the risk of CLABSI, providing not only socioeconomic benefit but also decreasing risk of compromising future vascular access.

Efficacy of management for obstruction caused by precipitated medication or lipids in central venous access devices: A systematic review and meta-analysis

At present, central venous access devices (CVADs) are widely used in clinical practice. The reasons for CVAD obstruction caused by precipitated medication or lipids are increasingly complex. However, there is no clear treatment program for CVAD obstruction caused by precipitated medication or lipids. The target of this study was to analyze data regarding obstruction caused by precipitated medication or lipids in CVADs and to calculate the efficacy of different treatment methods. A systematic review with meta-analysis was conducted in alignment with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. The PubMed, Web of Science, EMBASE, Cochrane Library, CINAHL, and China National Knowledge Internet databases were searched for original research published before 2018. There were 1356 publications initially screened, with one additional study identified through snowballing. Seven studies met the inclusion criteria. The reasons for obstruction, except for clot formation, primarily included the following: mechanical complications; lipid deposition; mineral deposition; or drug precipitation. Meta-analysis showed that sodium hydroxide resulted in the highest recanalization rate in lipid deposition, followed by ethanol, and the difference was significant. The efficacy analysis revealed that hydrochloric acid and l-cysteine have similar effects on mineral deposition and drug precipitation. According to this review, the most effective methodology was shown to be the intravenous perfusion of sodium hydroxide in several treatments when the obstruction is caused by lipid deposition. In contrast, mineral deposition and drug deposition are best treated with l-cysteine to recover the patency of central venous access devices.

Central venous catheter repair is highly successful in children with intestinal failure

PURPOSE

Damaged central venous catheters (CVCs) are commonly repaired to avoid line replacement and preserve vascular access. However, limited data suggest an increased risk for central line-associated bloodstream infections (CLABSIs) associated with the repair procedure. The purpose of this study was to describe outcomes of CVC repairs among parenteral nutrition (PN) dependent children with intestinal failure (IF).

METHODS

A 2-year retrospective review was performed on children with IF on home PN > 6 months. Outcomes of interest were repair success and postrepair CLABSI incidence. Descriptive statistics included medians and frequencies.

RESULTS

A total of 36 pediatric IF patients underwent 96 CVC repairs during the study period. The median CVC repair count was 1.5 repairs/patient (range, 1 to 16 repairs/patient) with >1 repair in half the patients. Ninety-four broken catheters (98%) were successfully repaired with restoration of function. Of the unsuccessful repairs (2%), the two catheters eventually required surgical removal and replacement. One repair (1%) was followed by a CLABSI with Enterococcus faecalis in an immunocompromised patient.

CONCLUSION

CVC repair is a highly successful procedure with a low risk for infection. Catheter repair should be considered whenever possible as it may extend the lifetime of the catheter and decrease the risk for vascular access loss.

LEVEL OF EVIDENCE

Treatment study; level IV.

Occult catheter rupture causing episodic symptoms in a patient treated with epoprostenol

Infection, thrombosis, and catheter dislodgment are well-recognized potential complications of chronic intravenous prostanoid therapy for pulmonary arterial hypertension. As long-term outcomes of pulmonary hypertension patients improve, novel adverse events are likely to arise. We describe the sudden development of unexplained hypotension and lightheadedness in a patient receiving intravenous epoprostenol for several years, ultimately determined to be due to an unusual catheter complication, not previously described in this population.