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Critical appraisal of surgical venous access in children
M A Hollyoak1, T H Ong, J F Leditschke
1Department of Paediatric Surgery, Royal Children's Hospital, Herston, Queensland, 4029 Australia.
Insights
Fully implanted central venous catheters (CVC) show fewer complications than exteriorized ones in children. Careful insertion techniques and placement are crucial for reducing CVC issues in pediatric patients.
Area of Science:
- Pediatric Surgery
- Vascular Access
- Infectious Disease Control
Background:
- Central venous catheters (CVCs) are vital for pediatric patient management.
- CVC use is linked to frequent complications, often requiring premature removal.
- Optimizing CVC insertion and management is essential to minimize adverse events.
Purpose of the Study:
- To evaluate insertion techniques and complications of surgically inserted CVCs in pediatric patients.
- To compare complication rates between fully implanted and exteriorized CVCs.
- To identify factors influencing CVC-related problems and removal.
Main Methods:
- Retrospective analysis of 295 consecutive surgically inserted CVCs (1987-1991).
- Categorization of CVCs into fully implanted and exteriorized types.
- Comparison of complication rates (infection, dislodgment, leaking, blockage, migration) and reasons for removal.
Main Results:
- Fully implanted CVCs had significantly lower removal rates (31%) versus exteriorized CVCs (58%).
- Infection was a primary reason for removal, with higher rates for saphenous vein insertions (43%) vs. internal jugular (11%).
- Fully implanted CVCs showed lower sepsis rates (1.1/1000 days) compared to exteriorized (3.7/1000 days).
Conclusions:
- Fully implanted CVCs offer a significant advantage in reducing complications in pediatric patients.
- Catheter tip position, insertion vein, and surgical technique critically impact CVC outcomes.
- Attention to these factors is necessary to improve CVC safety and efficacy in children.
Abstract:
Central venous catheters (CVC) have become an important adjunct to the overall management of paediatric patients, but their use is associated with frequent complications resulting in premature removal. This report evaluates the insertion techniques and complications of 295 consecutive surgically inserted CVC from 1987 to 1991 in a paediatric hospital. Fully implanted catheters had significantly less incidence of catheter-related problems necessitating removal (infection, dislodgment, leaking, blockage, or migration - 31%) compared to exteriorised catheters (58%). One-third of catheters were removed because of infection, one-third as they were no longer needed, and the remaining for multiple reasons. Infected (110+/-18 days), dislodged (18+/-4 days), or migrated (44+/-6 days) catheters were removed significantly earlier than those removed because they were no longer needed (195+/-24 days). Catheters became dislodged more frequently in the younger patients. Catheters with the tip in the subclavian vein (29%) migrated more frequently than those in the right atrium. There was a significantly increased incidence of infection in catheters inserted into the saphenous vein (43%) compared to those in the internal jugular vein (11%). Some episodes of catheter infection were managed with antibiotics, with short-term resolution of symptoms and signs. However, all 71 infected catheters ultimately required removal for further sepsis. Fully implanted catheters had 1.1 episodes of catheter-related sepsis per 1,000 catheter days compared to 3.7 for exteriorised catheters. The position of the catheter tip, vein used for insertion, training of young surgeons, and location of the subcutaneous tunnel need particular attention in order to reduce catheter complications.