Percutaneous Central Venous Catheter Placement in Children

Abstract and Introduction

Abstract

Objectives: To summarize existing knowledge regarding the prevalence of complications associated with temporary percutaneous central venous catheters placed in critically ill children, and to review evolving strategies to minimize the prevalence of these complications.

Data Sources: Literature review was performed: PubMed and EBSCOhost were searched using the terms central venous catheter, children, ultrasound, infection, thrombosis, and thromboembolism in various combinations. Citations of interest from identified articles were also reviewed.

Study Selection: The review focused primarily on pediatric literature relevant to the topic of interest.

Data Extraction and Synthesis: Randomized clinical trials and other prospective studies were discussed in greater detail than retrospective, single-center investigations.

Conclusions: Complications during percutaneous central venous catheter placement in children are not rare and may be in part attributable to abnormalities in vascular anatomy. Thromboses in children with central venous catheters are increasingly recognized as an important problem for which evidence-based preventive measures are lacking. Catheter-associated bloodstream infection rates in critically ill children have markedly decreased over the last decade, associated with an increased emphasis on staff education and the use of insertion and maintenance bundles. Available evidence tends to support the use of two-dimensional ultrasound to augment the landmark technique for catheter placement, but more studies are needed.

Introduction

Percutaneous central venous catheters (CVC) are placed in children for a variety of reasons, including repeated blood sampling, hemodynamic monitoring, difficult peripheral access, and administration of vasoactive medications and parenteral nutrition. CVC placement is more difficult in children than in adults, and neonates and infants are particularly challenging.^[1–7] In recent years, a variety of strategies have been used in an effort to minimize the occurrence of complications associated with percutaneous CVC placement. This review summarizes contemporary complications associated with percutaneous CVCs and recent developments relevant to their prevention. Basic descriptions of normal vascular anatomy and the standard Seldinger technique used during CVC insertion may be found in a number of textbooks, and these issues are not discussed in detail.^[8,9] Although selected concepts discussed in this article may be relevant to the placement and management of peripherally inserted central catheters, umbilical venous catheters, or surgically or fluoroscopically placed central catheters, these devices will not be specifically addressed.^[10]

Table 1. Rates of Selected Complications Related to Central Venous Catheter Insertion in a PICU or Emergency Department Setting
Study	Subclavian	Internal Jugular	Femoral
Arterial puncture
Casado-Flores et al (11)	7/322	2.2%	—	—	—	—
Casado-Flores et al (12)	12/235	5.1%	0/10	0%	4/63	6.3%
Karapinar and Cura (6)	17/119	14.3%	6/84	7.1%	10/166	6.0%
Citak et al (13)	19/148	12.8%	—	—	—	—
Venkataraman et al (7)	4/100	4.0%	—	—	—	—
Venkataraman et al (5)	—	—	—	—	13/89	14.6%
Combined estimate (95% confidence interval)^a		4.0% (2.7% to 5.2%)^b		6.7% (1.7% to 11.7%)		7.4% (4.5% to 10.3%)
Malposition
Casado-Flores et al (11)	19/322	5.9%	—	—	—	—
Casado-Flores et al (12)	38/235	16.2%	2/10	20.0%	3/63	4.8%
Karapinar and Cura (6)	19/119	16.0%	2/84	2.4%	6/166	3.6%
Citak et al (13)	3/148	2.0%	—	—	—	—
Venkataraman et al (7)	12/100	12.0%	—	—	—	—
Combined estimate (95% confidence interval)^a		6.1% (4.6% to 7.6%)^b		2.7% (0.0% to 5.9%)		3.9% (1.4% to 6.4%)
Pneumothorax
Casado-Flores et al (11)	6/322	1.9%	—	—
Casado-Flores et al (12)	6/235	2.6%	0/8	0%
Karapinar and Cura (6)	3/119	2.5%	0/84	0%
Citak et al (13)	2/148	1.4%	—	—
Venkataraman et al (7)	4/100	4.0%	—	—
Stenzel et al (15)	0/95	0%	0/115	0%
Combined estimate (95% confidence interval)^a		1.6% (0.9% to 2.4%)		0.5% (0.0% to 1.5%)
Hemothorax
Casado-Flores et al (11)	2/322	0.6%	—	—
Casado-Flores et al (12)	3/235	1.3%	0/10	0%
Venkataraman et al (7)	0/100	0%	—	—
Combined estimate (95% confidence interval)^a		0.7% (0.1% to 1.4%)		0.5% (0.0% to 16.9%)

Table 1. Rates of Selected Complications Related to Central Venous Catheter Insertion in a PICU or Emergency Department Setting

Study

Subclavian

Internal Jugular

Femoral

Arterial puncture

Casado-Flores et al (11)

7/322

2.2%

—

Casado-Flores et al (12)

12/235

5.1%

0/10

4/63

6.3%

Karapinar and Cura (6)

17/119

14.3%

6/84

7.1%

10/166

6.0%

Citak et al (13)

19/148

12.8%

—

Venkataraman et al (7)

4/100

4.0%

—

Venkataraman et al (5)

—

13/89

14.6%

Combined estimate (95% confidence interval)^a

4.0% (2.7% to 5.2%)^b

6.7% (1.7% to 11.7%)

7.4% (4.5% to 10.3%)

Malposition

Casado-Flores et al (11)

19/322

5.9%

—

Casado-Flores et al (12)

38/235

16.2%

2/10

20.0%

3/63

4.8%

Karapinar and Cura (6)

19/119

16.0%

2/84

2.4%

6/166

3.6%

Citak et al (13)

3/148

2.0%

—

Venkataraman et al (7)

12/100

12.0%

—

Combined estimate (95% confidence interval)^a

6.1% (4.6% to 7.6%)^b

2.7% (0.0% to 5.9%)

3.9% (1.4% to 6.4%)

Pneumothorax

Casado-Flores et al (11)

6/322

1.9%

—

Casado-Flores et al (12)

6/235

2.6%

0/8

Karapinar and Cura (6)

3/119

2.5%

0/84

Citak et al (13)

2/148

1.4%

—

Venkataraman et al (7)

4/100

4.0%

—

Stenzel et al (15)

0/95

0/115

Combined estimate (95% confidence interval)^a

1.6% (0.9% to 2.4%)

0.5% (0.0% to 1.5%)

Hemothorax

Casado-Flores et al (11)

2/322

0.6%

—

Casado-Flores et al (12)

3/235

1.3%

0/10

Venkataraman et al (7)

0/100

—

Combined estimate (95% confidence interval)^a

0.7% (0.1% to 1.4%)

0.5% (0.0% to 16.9%)

Table 2. Summary of Selected, Key Recommendations for the Prevention of Catheter-Associated Bloodstream Infections
Recommendations	Category
General
Educate clinicians and periodically assess their knowledge regarding and compliance with guidelines for CVC insertion and maintenance, including appropriate measures to prevent catheter-associated infections	1A
Designate only trained personnel to insert and maintain CVCs	1A
Ensure appropriate nursing staffing levels in ICUs	1B
Perform hand hygiene before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter	1B
CVC insertion
Avoid using femoral vein for central venous access in adults	1A
Use a CVC with the minimum number of ports essential for patient management	1B
Use ultrasound guidance to place CVCs (if this technology is available and the operator has been trained) to reduce the number of cannulation attempts and mechanical complications	1B
Use maximal sterile barrier precautions (cap, mask, sterile gown, sterile gloves, and sterile full body drape) for insertion of CVCs or guidewire exchanges	1B
Unless contraindicated, prepare skin with more than 0.5% chlorhexidine preparation	1A
Antiseptics should be allowed to dry prior to CVC placement	1B
When adherence to aseptic insertion technique cannot be assured, remove the CVC as soon as possible (i.e., within 48 hr)	1B
CVC maintenance
Promptly remove any intravascular catheter that is no longer essential	1A
Wear either clean or sterile gloves when changing the dressing on intravascular catheters	1C
Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site	1A
Replace the catheter site dressing if it becomes damp, loosened, or visibly soiled	1B
Do not use topical antibiotic ointment or creams on insertion sites	1B
Replace dressings on temporary CVCs every 7 days for transparent dressings and every 2 days for gauze dressings	1B
Do not routinely replace CVCs or use guidewire exchanges to prevent catheter-related infections	1B
Replace administration sets that are continuously used every 4–7 days	1A
Replace tubing used to administer blood, blood products, or fat emulsions within 24 hours of initiating the infusion	1B
Minimize contamination risk of needleless intravascular catheter systems by scrubbing the access port with an appropriate antiseptic and accessing the port with only sterile devices	1A
Second-tier strategies if the central catheter–associated blood stream infection rate is not decreasing despite adherence to basic prevention measures
Use a chlorhexidine/silver sulfadiazine or minocycline/rifampin-impregnated CVC in patients whose catheter is expected to remain in place greater than 5 days	1A
Use a chlorhexidine-impregnated sponge dressing for CVCs in patients older than 2 months of age	1B

Table 2. Summary of Selected, Key Recommendations for the Prevention of Catheter-Associated Bloodstream Infections

Recommendations

Category

General

Educate clinicians and periodically assess their knowledge regarding and compliance with guidelines for CVC insertion and maintenance, including appropriate measures to prevent catheter-associated infections

Designate only trained personnel to insert and maintain CVCs

Ensure appropriate nursing staffing levels in ICUs

Perform hand hygiene before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter

CVC insertion

Avoid using femoral vein for central venous access in adults

Use a CVC with the minimum number of ports essential for patient management

Use ultrasound guidance to place CVCs (if this technology is available and the operator has been trained) to reduce the number of cannulation attempts and mechanical complications

Use maximal sterile barrier precautions (cap, mask, sterile gown, sterile gloves, and sterile full body drape) for insertion of CVCs or guidewire exchanges

Unless contraindicated, prepare skin with more than 0.5% chlorhexidine preparation

Antiseptics should be allowed to dry prior to CVC placement

When adherence to aseptic insertion technique cannot be assured, remove the CVC as soon as possible (i.e., within 48 hr)

CVC maintenance

Promptly remove any intravascular catheter that is no longer essential

Wear either clean or sterile gloves when changing the dressing on intravascular catheters

Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site

Replace the catheter site dressing if it becomes damp, loosened, or visibly soiled

Do not use topical antibiotic ointment or creams on insertion sites

Replace dressings on temporary CVCs every 7 days for transparent dressings and every 2 days for gauze dressings

Do not routinely replace CVCs or use guidewire exchanges to prevent catheter-related infections

Replace administration sets that are continuously used every 4–7 days

Replace tubing used to administer blood, blood products, or fat emulsions within 24 hours of initiating the infusion

Minimize contamination risk of needleless intravascular catheter systems by scrubbing the access port with an appropriate antiseptic and accessing the port with only sterile devices

Second-tier strategies if the central catheter–associated blood stream infection rate is not decreasing despite adherence to basic prevention measures

Use a chlorhexidine/silver sulfadiazine or minocycline/rifampin-impregnated CVC in patients whose catheter is expected to remain in place greater than 5 days

Use a chlorhexidine-impregnated sponge dressing for CVCs in patients older than 2 months of age

Study	Number Patients	Ultrasound Technique	Operator	Percent Central Venous Catheter		Success Arterial Puncture
Study	Number Patients	Ultrasound Technique	Operator	Landmark	Ultrasound	Landmark	Ultrasound
Alderson et al (52)	40	Prelocation	Cardiac anesthesia attending	80%	100%	6%	12%
Verghese et al (56)	95	Real time	Anesthesia fellow	77%	100%	25%	0%
Verghese et al (50)	32	Real time	Anesthesia fellow	81%	94%	19%	6%
Grebenik et al (57)	124	Real time	Cardiac anesthesia attending	89%	80%	6%	12%
Chaun et al (55)	62	Prelocation	Anesthesiologist	80%	100%	27%	3%

Minimizing Complications Associated With Percutaneous Central Venous Catheter Placement in Children

Recent Advances

Abstract and Introduction

Abstract

Introduction

Minimizing Complications Associated With Percutaneous Central Venous Catheter Placement in Children

Recent Advances

Abstract and Introduction

Abstract

Introduction

Tables

Tables

Tables

References

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Authors and Disclosures

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