الفهرس 
Review of LiteratureOnly 14 pages are availabe for public view
 |  | from | 203 |  |  |
| | | from | 203 | | |
Abstract
I
n the context of pediatric cancer patients, central venous catheter (CVC) complications refer to adverse events associated with the insertion and maintenance of a central venous catheter. These complications can encompass both early and late issues, ranging from infection and thrombosis to mechanical problems. The study aims to document the frequency and types of these complications in pediatric patients with hemato-oncologic malignancy, identifying potential risk factors for such CVC- related morbidities. Such information is crucial for enhancing the care and management of children with hematolo-oncologic malignancies who require central venous catheterization.
A cross sectional study including 141 children and adolescent less than 18 years with confirmed diagnosis of cancer, was conducted in Pediatric Hematology /Oncology unit, Children’s Hospital, Ain Shams University, Egypt.
A record form was designed for each patient including demographic data (name, age, gender and social class), disease characteristics (type, stage, status, and duration) and CVC insertion and follow up.
A total of 141 children and adolescents with cancer were recruited in the study, 80 (56.7%) were boys and 61 (43%) were girls and their median age at time of insertion of CVCs was 6.5 (4 -11) years. Most of them 56 (39.7%) were in the age group 5-10 years.
The majority suffered from hematological malignancy including acute leukemia and lymphoma (n =100, 70.9%) with 41 of acute lymphoblastic leukemia (ALL) of standard risk category. The most common types of solid malignancy were Neuroblastoma and Ewing sarcoma followed by Retinoblastoma.
During the study period, 382 indwelling central venous catheters were inserted; 375 (98.2%) non-tunnelled and 7 (1.8%) peripherally inserted central catheter (PICC). Of the 141 patients, 92 (65%) had more than one CVC inserted. All inserted CVCs were non-valved, of polyurethan material and 82.2% of them were with triple lumen.
The jugular vein was used in 375 (98.2 %) for insertion, while 7 (1.8%) catheters were inserted into the basilic vein. In 292 (76.4%) cases, the catheter was implanted on the right side of the chest and only in 90 (23.6%) cases the catheter was implanted on the left side. During placement, the correct position of the distal tip of the catheter (at the superior vena cava–right atrium junction) was checked by standard chest radiograph with the patient in the upright position which was always obtained immediately afterwards. All CVCs were inserted by intervention radiologist with ultrasound guidance. Maintenance procedures were always performed according to international recommendations, the maintenance of the CVCs in our unit was managed by specialised pediatric nurses.
The overall length of observation ranged between 2 and 210 days for a total of 5869 catheter days (5541 days for non-tunnelled and 328 for PICC), the median time without complications among the studied CVCs was found to be 40 days; the cumulative proportion of survival rate at 7 days was 91.9%, the 14 days rate was 83.4% and at 30 days was 50.2%. (The complicated catheters had longer indwelling time than uncomplicated one (p=0.005).
Overall, 128 complications were observed in 97 devices (25.4% of all devices) in 141 patients with a maximum of three complications in two CVCs (0.5%). Early complications (<7 days) were observed in 26 (26.8%) while late complications (>7 days) in 72(73.2%). In total of 128 complications developed of which 68 (53.1%) were infectious complications, 42 (32.8%) were vascular, 15 (11.7%) were mechanical and 3 (2.3%) were malfunction. The overall complication rate was 21.8 per 1000 catheter days, it was 11.5 (n = 68) for infectious complications, 7.2 (n = 42) for vascular complications and 2.5 (n = 15) for mechanical complications.
There was no statistically significant difference between patients with uncomplicated and complicated catheters regarding gender, age, age at diagnosis and disease interval. Subjects with ALL and Ewing’s sarcoma had significantly more complications than those with other tumours (p < 0.001 and 0.03 respectively). There were statistically significant increased complications in non-tunnelled catheters. Patients with complicated catheters were comparable to others as regards number of lumens, place of insertion, site and type of vein and type of anesthesia used (p-value >0.05).
Regarding laboratory parameters before insertion patients with complicated CVCs had low total leucocytic count, neutrophil count, lymphocytes count, and platelets count and D-dimer levels (p value < 0.001 in all).
Regarding complications, the most important factors associated with complications were ALL, indwelling days more than 12 in multivariate survival analysis (odds ratio of 3.022 (95%-CI: 1.495 – 6.109).
Regarding infectious complications, it was the most common CVC-related complication with an incidence rate of 11.5/1000 CVC days and appeared after a median of 20 days. In 60 patients, who had clinical signs of infection, a positive blood culture was detected and a diagnosis of catheter related BSI was thereby established. AML, D-Dimer >0.83 were the most associated factors with infected catheters.
Regarding vascular complications, out of 128 complications 42 (32.8%) vascular complication were developed, the majority (38/42, 90.4%) were thromboses that were detected by ultrasound. Anticoagulant therapy were received in (34 / 42, 81 %) and 4 (10.5%) were removed. Total leucocytic count ≤ 2.7 with an odds ratio of 4.036 (95%-CI: 1.765 - 9.230) and D-Dimer >1.2 with an odds ratio of 12.368 (95%-CI: 5.360 - 28.537) were the most associated factors with thrombosis of central venous catheters. The remaining 4 patients had got hematoma around the CVC which were managed only by compression. In one, the hematoma was extensive and the patient passed away.
Malfunction was least complication encountered (2.3%; 0047 per 1000 catheter days).
CONCLUSION
C
atheters provide safe administration of chemotherapy and other medication in pediatric oncology patients. However, there may be a high incidence of catheter-related complications, some of which may result in death of the patient. In the present cohort, the complication frequency was 25.4%, necessitating the removal of the catheter in 9.3% and the mortality related to CVC complications was 1.03%. Catheter-related infections accounted for 53.1% followed by vascular complications in 32.8%, then detachment in 7% and leakage in 4.7%. Malfunction of the catheter was least observed accounting to 2.3%.
RECOMMENDATIONS
1- Utilization of a CVC insertion checklist to minimize mistakes and ensure adherence to the proper care techniques.
2- Meticulous monitoring of CVC in high-risk malignancy who are liable to more complications.
3- Selection of the optimal insertion site to minimize infections and complications during central line placement, taking into consideration age, health status, medical history, expected duration of line and risk of infection.
4- Adherence to aseptic technique and maintenance bundle to decrease the rate of infection of inserted CVC.
5- A CVC should be continually assessed for necessity and removed immediately after it is no longer deemed necessary.
6- All health care professionals, including physicians and nurses, caring for children with CVCs should be aware of potential complications and should receive regular and continued education on CVC usage.