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A totally implantable venous access system for long-term chemotherapy in children
A Totally Implantable Venous Access System for Long-Term Chemotherapy in Children By Bruce McGovern, Robert Solenberger, and Kenneth Reed San Antonio, Texas 9 A totally implantable venous access system consisting of a subcutaneously placed stainless steel portal with a silicone diaphragm attached to a Silastic elastomer central venous catheter was inserted in 39 children with poor venous access. The devices were utilized for blood drawing and the administration of antineoplastic drugs, parenteral nutritional fluids, antibiotics, and blood products. Cumulative duration of access was 6,724 days (range 5 - 4 9 1 , median 172 days). Major complications necessitating removal of the device included catheter sepsis or pocket abscess (7%), catheter clot not responsive to enzyme declotting (5%), and catheter occlusion by too tight a ligature (2%). The system provided easy venous access and permitted full physical activity. 9 1985 by Grune & Stratton, Inc. INDEX WORDS: Venous access; central venous catheterization; leukemia.
EPEATED and prolonged venous access to deliver
R antineoplastic drugs, parenteral nutritional fluids, and blood products is a necessity for aggressive
chemotherapy of childhood leukemias and solid tumors. Not infrequently, peripheral veins become exhausted because of repeated use for hyperosmolar or vesicant solutions. Right atrial catheters (Hickman, Broviac) exit through the skin and provide an avenue for skin bacteria to travel and enter the bloodstream. In this groups of debilitated and severely neutropenic children, right atrial catheters become infected in 25% of our patients. We have recent experience with a central venous catheter attached to a totally implanted, subcutaneously placed, venous portal with a self-sealing diaphragm for hypodermic needle entry (Port-A-Cath; Pharmacia Laboratories, Piscataway, N J). MATERIALS AND METHODS The system consists of a stainless steel injection reservoir or portal with a silicone rubber diaphragm. The portal is connected to a Silastic catheter by a slip ring. The catheters are available in two sizes, in infant size (outer diameter, 2.03 mm; inner diameter, 0.51 mm) and a child size (outer diameter, 2.79 mm; inner diameter, 1.02 mm). The base of the portal has four stainless steel fixation rings. Before implantation, a coagulation profile was obtained on all patients. Attempts were made to correct major derangements before operation but this was not always possible due to far advanced disease, patient debility, and circulating platelet antibodies. Each patient was started on a 3-day course of an anti-Staphylococcal antibiotic beginning the night before operation. General anesthesia was used in all patients. Central venous access was obtained through cutdown on the common facial vein in children (Fig 1). In infants the catheter was inserted in the internal jugular vein through a purse-
Journal of PediatricSurgery, Vo120, No 6 (December), 1985: pp 725-727
string suture. In children with extensive cervical adenopathy, the greater saphenous vein at the fossa ovalis was used for central access. A 5 cm incision was made over the second rib lateral to the sternum staying well away from the breast bud. A pocket with a thick flap was developed over the second and third ribs (Fig 2). A tonsil clamp was used to develop a subcutaneous tunnel between the neck and chest incisions and the catheter was drawn through the tunnel to the chest incision (Fig 3). The catheter was trimmed to the proper length and attached to the venous portal (which was prefilled with saline) using the metal slip ring. The portal was planted in the pocket and 4-0 silk was used to suture the two cephalad fixation rings to the pectoral fascia (Fig 4). Using a syringe and Huber needle (solid tip with side hole opening so no core would be cut out of the silicone diaphragm), the portal was aspirated to assure blood return, flushed with sterile saline, and heparin locked with 0.5 ml of heparin (1000 I.U. per mL). Both incisions were closed with 4-0 chromic to Scarpa's fascia and a running subcuticular 44) Vicryl to the skin. Steristrips (3M Corporation, St Paul, Minn) and collodion completed the dressing. The system was ready for use immediately. Access was achieved by percutaneous puncture through Betadine prepped skin using Huber point needles. Blood drawing was done using a straight Huber needle, an extension tubing with pinchcock, and 10 cc syringe. A preliminary 3 mL of blood was drawn and discarded. Following use, the Port-A-Cath was flushed with 20 cc of sterile saline and heparin locked with 5 cc of heparin (100 I.U. per mL). Continuous infusions were given using a right angle Huber needle that was stabilized by a 2 x 2 gauze under the hub and covered with plastic adhesive dressing (Op-site; Acme United Corporation, Bridgeport, Conn). Needle and puncture site were changed every 14 days. When catheter obstruction by clot occurred, enzymolysis was accomplished by injecting 0.5 cc of urokinase (5000 I.U. per 1 mL vial) (Abbokinaise; Abbott Laboratories, North Chicago, Ill) using a tuberculin syringe. If aspiration of the clot was not possible after 1 hour, the injection was repeated and aspiration attempted 8 hours later. RESULTS T h i r t y - n i n e p a t i e n t s ( a g e 3 m o s to 12 y r ) w i t h p o o r v e n o u s a c c e s s h a v e h a d a P o r t - A - C a t h i n s e r t e d to permit blood sampling and chemotherapy administration. T h e c u m u l a t i v e d u r a t i o n o f a c c e s s w a s 6 , 7 2 4 d a y s ( r a n g e , 5 - 4 9 1 ; m e d i a n , 172). B l o o d s a m p l i n g w a s p o s s i b l e in 7 0 % o f t h e u n i t s all t h e t i m e a n d i n t e r m i t t e n t l y p o s s i b l e in 20%. I n 10% o f t h e u n i t s b l o o d
From Santa Rosa Children's Hospital and Brooke Army Medical Center, San Antonio, Tex. Presented before the 16th Annual Meeting o f the American Pediatric Surgical Association, Kohala Coast, Hawaii, May l-4, 1985. Address reprint requests to Bruce McGovern, MD, 7711 Louis Pasteur Dr, San Antonio, TX 78227. 9 1985 by Grune & Stratton, Inc. 0022-3468/85/2006-0032503.00/0
725
726
McGOVERN ET AL
~i'g,'~icA,. ~A ( bluntneedle
wit#
Syringe
sampling n ue to the position of the catheter tip. Major complications requiring removal of the device included catheter
Fig 3.
Cathetertunnelledsubcutaneously
to c h e s t incision.
sepsis or pocket abscess in 3 (7%), catheter clot not responsive to enzyme declotting in 2 (5%), and catheter occlusion by a too tight ligature in 1 (2%). Minor
f-
2oo.,. ~
Fig 2. ribs.
f
~"
'c~-
~
Subcutaneous pocket developed over second and third Fig 4.
Position of catheter tip in atrium verified by x-ray.
A TOTALLY IMPLANTABLE VENOUS ACCESS SYSTEM
complications not requiring removal include temporary catheter clot relieved by enzymolysis in 5 (12%) and pocket hematoma that resorbed in 4 (9%). Twelve children have died of their disease during the period of follow-up. No deaths have been directly attributed to
727
the Port-A-Cath. Activity of the children was not hindered by the device. Easy venous access greatly eases the emotional stress of prolonged aggressive chemotherapy in childhood malignancies.
EPEATED and prolonged venous access to deliver
R antineoplastic drugs, parenteral nutritional fluids, and blood products is a necessity for aggressive
chemotherapy of childhood leukemias and solid tumors. Not infrequently, peripheral veins become exhausted because of repeated use for hyperosmolar or vesicant solutions. Right atrial catheters (Hickman, Broviac) exit through the skin and provide an avenue for skin bacteria to travel and enter the bloodstream. In this groups of debilitated and severely neutropenic children, right atrial catheters become infected in 25% of our patients. We have recent experience with a central venous catheter attached to a totally implanted, subcutaneously placed, venous portal with a self-sealing diaphragm for hypodermic needle entry (Port-A-Cath; Pharmacia Laboratories, Piscataway, N J). MATERIALS AND METHODS The system consists of a stainless steel injection reservoir or portal with a silicone rubber diaphragm. The portal is connected to a Silastic catheter by a slip ring. The catheters are available in two sizes, in infant size (outer diameter, 2.03 mm; inner diameter, 0.51 mm) and a child size (outer diameter, 2.79 mm; inner diameter, 1.02 mm). The base of the portal has four stainless steel fixation rings. Before implantation, a coagulation profile was obtained on all patients. Attempts were made to correct major derangements before operation but this was not always possible due to far advanced disease, patient debility, and circulating platelet antibodies. Each patient was started on a 3-day course of an anti-Staphylococcal antibiotic beginning the night before operation. General anesthesia was used in all patients. Central venous access was obtained through cutdown on the common facial vein in children (Fig 1). In infants the catheter was inserted in the internal jugular vein through a purse-
Journal of PediatricSurgery, Vo120, No 6 (December), 1985: pp 725-727
string suture. In children with extensive cervical adenopathy, the greater saphenous vein at the fossa ovalis was used for central access. A 5 cm incision was made over the second rib lateral to the sternum staying well away from the breast bud. A pocket with a thick flap was developed over the second and third ribs (Fig 2). A tonsil clamp was used to develop a subcutaneous tunnel between the neck and chest incisions and the catheter was drawn through the tunnel to the chest incision (Fig 3). The catheter was trimmed to the proper length and attached to the venous portal (which was prefilled with saline) using the metal slip ring. The portal was planted in the pocket and 4-0 silk was used to suture the two cephalad fixation rings to the pectoral fascia (Fig 4). Using a syringe and Huber needle (solid tip with side hole opening so no core would be cut out of the silicone diaphragm), the portal was aspirated to assure blood return, flushed with sterile saline, and heparin locked with 0.5 ml of heparin (1000 I.U. per mL). Both incisions were closed with 4-0 chromic to Scarpa's fascia and a running subcuticular 44) Vicryl to the skin. Steristrips (3M Corporation, St Paul, Minn) and collodion completed the dressing. The system was ready for use immediately. Access was achieved by percutaneous puncture through Betadine prepped skin using Huber point needles. Blood drawing was done using a straight Huber needle, an extension tubing with pinchcock, and 10 cc syringe. A preliminary 3 mL of blood was drawn and discarded. Following use, the Port-A-Cath was flushed with 20 cc of sterile saline and heparin locked with 5 cc of heparin (100 I.U. per mL). Continuous infusions were given using a right angle Huber needle that was stabilized by a 2 x 2 gauze under the hub and covered with plastic adhesive dressing (Op-site; Acme United Corporation, Bridgeport, Conn). Needle and puncture site were changed every 14 days. When catheter obstruction by clot occurred, enzymolysis was accomplished by injecting 0.5 cc of urokinase (5000 I.U. per 1 mL vial) (Abbokinaise; Abbott Laboratories, North Chicago, Ill) using a tuberculin syringe. If aspiration of the clot was not possible after 1 hour, the injection was repeated and aspiration attempted 8 hours later. RESULTS T h i r t y - n i n e p a t i e n t s ( a g e 3 m o s to 12 y r ) w i t h p o o r v e n o u s a c c e s s h a v e h a d a P o r t - A - C a t h i n s e r t e d to permit blood sampling and chemotherapy administration. T h e c u m u l a t i v e d u r a t i o n o f a c c e s s w a s 6 , 7 2 4 d a y s ( r a n g e , 5 - 4 9 1 ; m e d i a n , 172). B l o o d s a m p l i n g w a s p o s s i b l e in 7 0 % o f t h e u n i t s all t h e t i m e a n d i n t e r m i t t e n t l y p o s s i b l e in 20%. I n 10% o f t h e u n i t s b l o o d
From Santa Rosa Children's Hospital and Brooke Army Medical Center, San Antonio, Tex. Presented before the 16th Annual Meeting o f the American Pediatric Surgical Association, Kohala Coast, Hawaii, May l-4, 1985. Address reprint requests to Bruce McGovern, MD, 7711 Louis Pasteur Dr, San Antonio, TX 78227. 9 1985 by Grune & Stratton, Inc. 0022-3468/85/2006-0032503.00/0
725
726
McGOVERN ET AL
~i'g,'~icA,. ~A ( bluntneedle
wit#
Syringe
sampling n ue to the position of the catheter tip. Major complications requiring removal of the device included catheter
Fig 3.
Cathetertunnelledsubcutaneously
to c h e s t incision.
sepsis or pocket abscess in 3 (7%), catheter clot not responsive to enzyme declotting in 2 (5%), and catheter occlusion by a too tight ligature in 1 (2%). Minor
f-
2oo.,. ~
Fig 2. ribs.
f
~"
'c~-
~
Subcutaneous pocket developed over second and third Fig 4.
Position of catheter tip in atrium verified by x-ray.
A TOTALLY IMPLANTABLE VENOUS ACCESS SYSTEM
complications not requiring removal include temporary catheter clot relieved by enzymolysis in 5 (12%) and pocket hematoma that resorbed in 4 (9%). Twelve children have died of their disease during the period of follow-up. No deaths have been directly attributed to
727
the Port-A-Cath. Activity of the children was not hindered by the device. Easy venous access greatly eases the emotional stress of prolonged aggressive chemotherapy in childhood malignancies.