Central venous catheter use in the pediatric patient: Mechanical and infectious complications

Abstract

CVC-related complications in pediatric patients are closely linked to age, body size, and age-related immune status. In older children, many complications are similar to those encountered in adult patients. Because of ongoing growth and body changes, a cutoff point beyond which children can be regarded as "young adults" is difficult to define; many of our recommendations are therefore age-related. More frequently than in adults, an implanted port may be the first choice in pediatric patients when long indwelling times are expected. The optimal site of insertion also depends on factors such as the patients' age as well as the need for sedation and analgesia during the insertion procedure. In contrast to guidelines in adult patients, we recommend that a radiograph always be made following CVC insertion to check the position of the catheter. Regarding prevention of infectious complications, we recommend full sterile barrier precautions during CVC insertion and strict protocols for catheter care. CVCs should be removed as soon as possible when they are no longer needed, but there is no place for elective CVC replacement on a routine basis. New developments such as the use of impregnated catheters might help reduce infection rates; however, additional research will be required to provide more evidence of benefit in the pediatric population.

Radiographic confirmation following pediatric femoral venous cannulation

“…These include: difficulty in advancing the guidewire, difficulty or inability to aspirate blood through the catheter, lateral deviation of the catheter at the L4 and L5 levels on abdominal plain films, a catheter path directly overlying the vertebral column, signs of unexplained acute respiratory distress or seizure, and neurological deficits in children receiving parental nutrition via the catheter. [2][3][4] Despite the absence of warning signs during the described procedure, the catheter was clearly misplaced. Only the abdominal x-ray demonstrated the incorrect ascending lumbar venous cannulation.…”

“…[1][2][3] The greatest reported experience with the GVL is in adult patients. 1,3 We recently used the neonatal model GVL in five neonates presenting for elective nasotracheal intubation (NTI). Demographics are reported in the Table. Nasotracheal intubation was performed by two pediatric residents supervised by an expert neonatologist.…”

“…2 A second limitation specific to the neonatal population relates to the special curvature of the GVL blade that appears to cause resistance to the advancement of the TT. 3 In case 1, this difficulty was overcome by repositioning the blade inside the mouth. In the smaller neonates, this procedure was not possible because the blade in which the camera was installed was blocked by the small size of the mouth.…”

Interventions to reduce central venous catheter-associated infections in children: which ones are beneficial?

“…First, the case mix is different with a higher number of children who are immunocompromised and have congenital abnormalities. Secondly, children have small veins, which are susceptible to thrombosis, thus increasing bacterial adhesion [13,14]. Thirdly, although femoral venous catheterization is associated with a greater risk of infective and thrombotic complications [15,16], the femoral vein is safer and more commonly used as a site for CVCs in children.…”

“…For the same reason, CVCs are more precious in children than in adults and less likely to be replaced unless blocked or clearly infected. Fifth, children are more likely than adults to receive total parenteral nutrition, which increases the risk of CA-BSI [12][13][14]17].…”