Impact of a Discharge-Focused Central Line Strategy on Reducing Line-Related Morbidity in Pediatric Allogeneic...

Central venous lines (CVLs) are essential during pediatric allogeneic hematopoietic cell transplantation (alloHCT) but carry risk for infection, thrombosis, and mechanical complications. Despite their widespread use, limited clinical outcomes data exist to guide CVL selection and timing of removal, and current practices remain largely non-standardized. In 2019, our center implemented a practice change prioritizing discharge without an external CVL when clinically feasible to attempt to reduce line related morbidity.

To characterize complications associated with different CVL strategies during pediatric alloHCT, evaluate the impact of discharge with versus without an external CVL, and assess contemporary institutional practices regarding CVL selection and removal.

We performed a retrospective cohort study of 185 pediatric alloHCT recipients transplanted between 2015 and 2025. Outcomes were analyzed by (1) initial transplant CVL type, (2) transplant era before (Cohort A, 2015-2018) and after (Cohort B, 2019-2025) implementation of the practice change, and (3) discharge status with or without an external CVL. Primary outcomes included sepsis, septic shock requiring pressors or intensive care support, line-related complications, and readmissions. An exploratory cross-sectional survey of pediatric alloHCT physicians was conducted to characterize institutional CVL practices.

Broviacs were the most commonly chosen line for transplant (51.3%), followed by port+PICC (31.9%) and PICC alone (16.8%). Rates of sepsis during transplant admission differed by initial CVL type (Broviac 23.2%, port+PICC 22.0%, PICC 48.4%; p=0.013), and unplanned line removal was higher with PICCs (p=0.03). Following implementation of the practice change, patients were significantly more likely to be discharged without an external CVL (84.0% vs 26.9%; p<.001). Across all years, discharge without an external CVL was associated with fewer readmissions for sepsis (12.7% vs 38.5%; P<.001), septic shock (6.9% vs 20.0%; p=.02), and line-related readmissions (25.5% vs 49.2%; P=.003), without increased transplant admission length of stay (p=.24) or all-cause readmissions during the first post-transplant year (P=1.0). Survey responses from pediatric alloHCT physicians (N=48) demonstrated substantial variability in both CVL selection and timing of removal, with most respondents favoring tunneled catheters and later removal (approximately day +100).

Initial CVL choice carries significantly different early infectious and mechanical risk. A discharge-focused strategy favoring venous ports or no external CVL after pediatric alloHCT was feasible and associated with fewer episodes of sepsis, septic shock, and line-related readmissions. These findings support efforts to reduce unnecessary external CVL exposure and suggest a practical approach to do so. Variation in CVL practices across institutions, coupled with limited outcomes data, highlights the need for prospective studies to inform standardized approaches to CVL management in pediatric alloHCT.