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Morbidity using subcutaneous ports and efficacy of vancomycin flushing in cancer
H Rubie1, M Juricic, S Claeyssens
1Unit of Paediatric Haematology and Oncology, Hospital Purpan, Toulouse, France.
Insights
Totally implanted venous access systems (subcutaneous ports) are safe and effective for children with cancer, reducing complications and saving time compared to external catheters. Vancomycin use significantly decreased Staphylococcus epidermidis infections.
Area of Science:
- Pediatric Oncology
- Vascular Access Devices
- Cancer Treatment
Background:
- Totally implanted venous access systems are crucial for long-term chemotherapy delivery in pediatric cancer patients.
- Evaluating the safety, efficacy, and complications of these devices is essential for optimizing patient care.
Purpose of the Study:
- To evaluate the performance of totally implanted venous access systems (subcutaneous ports) in pediatric cancer patients.
- To assess complication rates, particularly infections and mechanical issues, and identify risk factors.
- To determine the impact of prophylactic vancomycin on infection rates.
Main Methods:
- Retrospective analysis of 180 subcutaneous ports inserted in 163 pediatric cancer patients between 1988 and 1994.
- Data collection included patient demographics, diagnosis, chemotherapy intensity, device dwell time, complications, and interventions.
- Infection rates before and after the introduction of vancomycin were compared using life table analysis.
Main Results:
- Subcutaneous ports provided a cumulative venous access of 55,770 patient days with a mean dwell time of 305 days.
- Mechanical complications occurred in 19 ports (10.5%), primarily clots (16/19), with 14 successfully treated with urokinase.
- Infectious episodes occurred in 47 ports (26.1%), with 47 septic episodes (31 due to Staphylococcus epidermidis). Catheter-related sepsis rate was 0.05/100 catheter days.
- Risk factors for infection included age under 4 years and longer device use.
- Prophylactic vancomycin significantly reduced Staphylococcus epidermidis infections (from 26/83 to 4/97 ports).
- Significant time savings (approx. 30 minutes/patient/week) were observed compared to external catheters.
Conclusions:
- Totally implanted venous access systems are reliable, safe, and durable for pediatric cancer patients requiring prolonged venous access.
- The implementation of vancomycin prophylaxis effectively reduced Staphylococcus epidermidis-related infections.
- Subcutaneous ports offer a valuable alternative to external catheters, improving treatment efficiency and patient management.
Abstract:
An evaluation of totally implanted venous access systems inserted in 163 consecutive children with cancer is reported. From 1988 to 1994, 180 subcutaneous ports were inserted in children more than 1 year old. Initial diagnosis was acute leukaemia (n = 79), non-Hodgkin's lymphoma (n = 33), and solid tumour (n = 51). Median age was 85 months. All venous procedures were performed through the device. Chemotherapy was either moderate (n = 13) or intensive (n = 119) or very intensive (n = 48), including 16 patients undergoing marrow transplantation. Cumulative venous access totalled 55,770 patient days with a mean of 305 days/subcutaneous port. The cause of device removal was, end of treatment (n = 111), death due to malignancy (n = 20), catheter related infection (n = 7), and occlusion of the system (n = 4). Mechanical complications occurred in 19 ports; 16 were due to clots, of which 14 were cleared with instillation of urokinase. Documented infectious episodes occurred in 47 ports, recurred once in 14, and twice in five cases. Among these infections, 47 were septicaemic; 31 due to Staphylococcus epidermidis. Twenty seven of initial septic episodes were considered to be catheter related; the rate was 15%/subcutaneous port or 0.05/100 catheter days. Risk factors for the development of a first infection were age below 4 years and the time of use. Since February 1993, vancomycin (50 micrograms/ml) has been given and this has reduced the rate of S epidermidis infection from 26/83 subcutaneous port to 4/97. Life table analysis showed that the infection free interval for staphylococcus was significantly better after this technique ws initiated (log rank rest=0.02). Time saved was approximately 30minutes/patient/week compared with external catheters, or 45 hours/month for the cohort of children treated. Subcutaneous ports in paediatric cancer patients are reliable, safe, and durable and may offer an attractive alternative to external catheters for prolonged venous access and intensive treatment.