Substantial harm associated with failure of chronic paediatric central venous access devices

Abstract

Central venous access devices (CVADs) form an important component of modern paediatric healthcare, especially for children with chronic health conditions such as cancer or gastrointestinal disorders. However device failure and complications rates are high.Over 2½ years, a child requiring parenteral nutrition and associated vascular access dependency due to 'short gut syndrome' (intestinal failure secondary to gastroschisis and resultant significant bowel resection) had ten CVADs inserted, with ninesubsequently failing. This resulted in multiple anaesthetics, invasive procedures, injuries, vascular depletion, interrupted nutrition, delayed treatment and substantial healthcare costs. A conservative estimate of the institutional costs for each insertion, or rewiring, of her tunnelled CVAD was $A10 253 (2016 Australian dollars).These complications and device failures had significant negative impact on the child and her family. Considering the commonality of conditions requiring prolonged vascular access, these failures also have a significant impact on international health service costs.

The Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics: miniMAGIC

“…These devices are required across a continuum of age and acute, subacute, and home care settings. 2 Although vital for treatment, VADs have well recognized insertion morbidity risks (eg, pneumothorax), are costly, 3 and can lead to lethal complications such as thrombosis and bloodstream infection. 4 Even minor VADassociated adverse events, such as occlusion or dislodgement, can have significant negative sequelae and lead to delays in treatment during acute and chronic illness.…”

Development of a paediatric central venous access device database: A retrospective cohort study of practice evolution and risk factors for device failure

“…The Healthcare Cost and Utilization Project data estimate a mean increase in costs of US$50 621 per device failure . The patient costs of CVAD failure include multiple and painful reinsertion procedures, extended inpatient stays and long‐term vessel insufficiency …”

“…4,5 The patient costs of CVAD failure include multiple and painful reinsertion procedures, extended inpatient stays and long-term vessel insufficiency. 6 There is growing body of evidence on which we should base our CVAD practices to reduce failure rates and associated patient harm. This includes the incorporation of enhanced decontamination products (including chlorhexidine gluconate (CHG)), 7 novel catheter materials and designs, 8 ultrasound guidance (USG), 9 interventional radiology techniques 10 and alternative sites.…”

Building a Global, Pediatric Vascular Access Registry: A Scoping Review of Trial Outcomes and Quality Indicators to Inform Evidence‐Based Practice

“…Approximately one third of included registries and trials collected VAD insertion data; however, there was a noticeable disconnect between insertion practices and the long‐term VA outcomes. A recent case report of a 2‐year‐old child with gastroschisis (Ullman et al., ) describes the journey of a young child who required 10 CVAD insertions due to recurrent device failure. For clinicians, reinsertion VA assessment and planning should strongly influence choice of VAD type; however, we found no trial or registry focussed on vein assessment tools or inserter decision making frameworks, nor measuring the effect of VADs on long‐term vessel health.…”

“…However, whilst the ability to obtain and maintain reliable VA in pediatrics is forefront when dealing with an individual patient, quality data to monitor VA safety are rarely available at the institutional level. VA management in pediatrics is further complicated since VA insertion, care, and management of complications are largely decentralized throughout specialties, so the lifetime care of a child's VA is not reported or managed with a comprehensive, long‐term focus (Ullman, Kleidon, Cooke, & Rickard, ). The health sector and families need increased access to data for tracking each patient's VA journey, and measuring associated outcomes so as to maximize institutional safety and performance, and ensure intact vasculature into adulthood.…”