S. Rao, A. Alladi, K. Das, A.J.D. Cruz

From the Department of Pediatric Surgery, St. John’s Medical College Hospital, Bangalore, India.

Correspondence to: Dr. Ashley D, Cruz, Department of Pediatric Surgery, St. John’s Medical College Hospital, Bangalore 560 034, India.E-mail: [email protected]

Manuscript received: February 11, 2002; Initial review completed: March 22, 2002; Revision accepted: September 4, 2002.

 

From September 2000 to August 2001, 104 central venous access devices (CVAD) were inserted in 91 children, governed by a uniform protocol. Thirty catheters were inserted in neonates, 29 in infants, 37 in children and 8 in adolescents. Fifty-one were planned insertions in the operating suite and 53 were emergencies - often by the bedside. There were 12 insertion related complications-all of which were minor. Neonatal age and bedside introduction had a higher risk of insertion related problems. The incidence of non-infectious complications was 20% (rate of 13.7/1000 line days) and was influenced by the child’s age and insertion site. Femoral route was the safest. Incidence of catheter associated infections (CAI) was 15.4% (rate of 11/1000 line days). Only 2 children had catheter associated bloodstream infection. Neonates were at higher risk of catheter related infections. Age, insertion site and occurence of insertion complications influenced duration of catheterization (median 7.5 days, range 2-243 days) There was no major complication, though more than 50% insertions were in neonates and infants. In our practice, use of CVAD is feasible and safe, especially in neonates and infants.

Key words: Catheter associated infection, Central venous access.

Reliable venous access is a challenging and important aspect of pediatric and neonatal intensive care. Though central venous access devices (CVAD) have been in use for several years in the West for prolonged venous access, published experience from India is lacking. This paper audits our initial experience with long and medium term central venous access in children at a tertiary referral center.

One hundred and four consecutive CVAD’s (central venous access devices) inserted over a 12 month period from September 2000 to August 2001 in 91 children were studied. The common types of catheters used included Leaderflex 22G (Vygon), Arrow 20G, Broviac catheters (Bard), Mahurkar hemodialysis cathethers (Quinton), and Epicutaneo-Cavo Cath (Vygon)(23G sialastic long line). The type of catheter inserted depended on the indication and projected duration of requirements.

All lines were inserted by consultant staff, either in the operating theatre or by the bedside if the child was too sick to be moved. A uniform protocol was followed for dressings, care and infection surveillance. This included daily flushing of the lines with 10 u/mL of heparin, twice weekly dressings with betadine ointment, transparent dressings and weekly blood cultures. A nurse certified in the care of these devices supervised use of the lines. Tips of all lines were cultured on removal. Center for Disease Control definitions for catheter related infections were used(1).

Of the 104 catheters, 30 were inserted in neonates, 29 in infants, 37 in children(1-12 years) and 8 in adolescents (all for hemodialysis). There were 68 boys and 36 girls. Fifty-one (48%) lines were inserted in the operating theatre and 53 (52%) by the bedside. The indications for the lines are summarized in Table I. Seventy-One lines (68%) were inserted in the presence of other foci of infection, other invasive devices (e.g. endotracheal tubes, previous central lines) and immunocompromised states (e.g. prematurity, renal failure).

Table I__Indication for Insertion of Central Venous Access Devices.

Indication

Number of Patients

(n=104)

Difficult peripheral veins

41

Prolonged access required

39

Hemodialysis

15

TPN

6

Prolonged antibiotics

2

Chemotherapy (cancer)

1

Routes of insertion included femoral vein (41), internal jugular (27), subclavian (21), saphenous (6), external jugular (5), antecubital (3) and other upper limb veins (1). The complications related to the line and various factors influencing them are summarized in Table II. There were no major complications at insertion. A single attempt at puncture was successful in more than 90% of cases. On 6 occasions, percutaneous insertion failed and a venesection was required. The risk of insertion related complications doubled in neonates and in bedside insertions. The site of insertion and type of catheter used did not influence the occurrence of complications at insertion. Non-infectious complications were influenced by the age and insertion site. Femoral site was the safest. All complications were minor and of a mechanical nature like catheter blocks etc.

Table II__Line Related Complications, Cannulation Days and Factors
	 

* catheter associated infection; **catheter associated blood stream infection; *** in 1 of these 52, line was removed due to death/discontinuation of treatment from serious nature of primary disease and not due to line related problems.

Coagulase negative staphylococcus (CoNS) caused both catheter associated blood stream infections (CABSI). Organisms causing line colonisation (line tip cultures) included CoNS(4), gram negative bacilli(3), enterobacter(2), citrobacter(1) and gram positive cocci(1). All these children were asymptomatic and blood cultures repeated after line removal were sterile and no further treatment was offered. The only factor influencing catheter infection was neonatal age; this group being at 1.7 times risk. All other factors such as insertion setting, insertion site, pre-insertion positive cultures and presence of other foci of infection had no bearing on the occurrence of catheter infection.

Eighty percent of catheters functioned well until removal when no longer required. The median duration of catheterisation was 7.5 days (2 to 243 days) and a mean of 12.5 days. Details are summarized in Table II. Days of cannulations was influenced by age, site of insertion and occurrence of complications at insertion and not by insertion setting, pre-insertion positive cultures, presence of other foci of infection and presence of line infection.

Sixty-six of the 104 catheters inserted were in neonates and infants, the commonest indications being non-availability of suitable peripheral veins and need for prolonged venous access. Despite 70% of the catheters being inserted in critically ill children there were no major insertion related complications. Neonates, due to their smaller veins, had 2 times greater risk of problems at insertion. Insertions by the bedside also had 2 times greater risk-lack of adequate immobilisation, suitable positioning and workspace could be the contributory causes. However, use of sedation/anesthesia and insertion in an operating theatre setting reduces the risk of insertion related complications and improves success. The rate of non-infectious complications in this group is comparable to other reported series(2,3). Securing of non-tunneled lines on a wriggly and active baby is a problem. Also, the smaller catheter lumen makes them more prone to blocks and rupture.

The femoral access route was the most useful in our practice, being easier and safer to introduce, especially by the bedside. It was also easier to secure the line to thigh. Suboptimal surface for fixation resulted in both jugular and subclavian lines having a higher chance of slipping out or kinking under the dressings. Venkataraman et al(3) in a meta-analysis also found the femoral access route to be safe in children. This has also been the experience of several other authors(4,5). We recommend the femoral route as first preference, especially when line is being inserted by the bedside, in neonates or in children with coagulopathy.

The incidence and rates of catheter associated blood stream infections (CABSI) and catheter associated infection (CAI) are within contemporary standards(2,4,5,6). CoNS was isolated from both children with CABSI and both responded promply to removal of catheter and antibiotics. This experience is shared by other groups too(2,4,6). Of the 11 colonized lines, 6 had enterogenic organisms. Five of these 6 children had intestinal surgery and 1 child had surgery for a low spina bifida; fecal contamination of the myelomeningocele sac could be the route of infection in this child. Page et al(7) have also reported a higher incidence of CAI with gram negative organisms in children after gastrointestinal surgery. As complications at line insertion significantly affected the life of the catheter, extreme care must be exercised during insertion, especially in neonates. When possible these lines should be inserted in the operating suite under proper anesthesia/sedation.

Contributors: SR is the principle investigator and guarantor for the study. AA, KD, and AJD have contributed at all stages of design, data collection and analysis and drafting of the article.

Funding: None

Competing interests: None stated

1. Pearson ML. Guideline for prevention of intravascular device-related infections. Am J Infect Control 1996; 24: 262-293.

2. Chua MC, Chan IL. Use of central venous lines in pediatrics-a local experience. Ann Acad Med Singapore 1998; 27: 358-362.

3. Venkataraman ST, Thompson AE, Orr RA. Femoral vascular catheterization in critically ill infants and children. Clin Pediatr 1997; 36: 311-319.

4. Goh AY, Lum LC, Chan PW Roziah M. Percutaneous central venous catheterisation in critically ill children. Med J Malaysia 1998; 53: 413-416.

5. Luyt DK, Mathivha LR, Litmanovitch M, Dance MD, Brown JM. Confirmation of the safety of central venous catheterisation in critically ill infants and children - the Baragwanath experience. S Afr Med J 1996; 86 (Suppl): 603-660.

6. Salzman MB, Rubin LG. Intravenous-catheter related infections. Adv Pediatr Infect Dis 1995; 10: 337-368.

7. Page S, Abel G, Stringer MD, Puntis JW. Management of septicemic infants during long-term parenteral nutrition. Int J Clin Pract 2000; 54: 147-150.