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Avoiding postoperative malposition of upper body tunneled central venous catheters in children: Evaluating technique and depth of placement
Journal of Pediatric Surgery xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Avoiding postoperative malposition of upper body tunneled central venous catheters in children: Evaluating technique and depth of placement☆ Joshua Gish ⁎, Tiffany Wright, Samir Gadepalli, Marcus Jarboe Section of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI
a r t i c l e
i n f o
Article history: Received 28 August 2015 Received in revised form 12 January 2016 Accepted 13 January 2016 Available online xxxx Key words: Central venous line Malposition Reposition Reoperation Pediatric
a b s t r a c t Background: Suboptimal position of tunneled central venous catheters (Broviacs) decreases long-term catheter longevity, incurring morbidity and cost. We postulated that catheter malposition is related to patient's age, technique used, and initial catheter tip location (CTL). Methods: We performed a retrospective review with 1-year follow-up of Broviacs placed in patients at our children's hospital from 3/2010 to 10/2013. We defined malposition as a noncentral CTL that required replacement, excluding catheters physically dislodged. We used logistic regression to determine whether age, technique and CTL predicted malposition with p-value b 0.05 deemed significant. We analyzed line longevity for different insertion techniques by survival analysis. Results: Overall, 404 upper body Broviacs were placed in 282 children (median age = 1.4 years [IQR:0.45–5.35]). Thirty-six (8.9%) were replaced for malposition, at median of 84.5 days [IQR:36–159]. We found that older children were less likely to develop malposition (OR = 0.91,p = 0.002). Adjusting for patient age and placement technique, catheters placed ≥1.5 vertebral bodies below the carina were less likely to be malpositioned (OR = 0.37,p = 0.015). Cox-regression shows the lateral technique to have the lowest rate of malposition within 90 days (HR = 0.30,p = 0.03). Conclusion: Older patients and lines placed 1.5 vertebral bodies below the carina are less likely to become malpositioned. Using the lateral approach for insertion improves catheter longevity. © 2016 Elsevier Inc. All rights reserved.
Tunneled central line placement is a common procedure for pediatric patients that require long-term venous access. Catheter migration from a central position, however, can require replacement, incurring a risk of complications to the patient and increasing financial costs in materials and operating room time [1]. Prevention of catheter replacement can improve patient outcomes and decrease health-care costs. (See Tables 1–3.) Central venous catheter tip location can affect function of the catheter. If the catheter migrates to a peripheral location rather than a central one, then the catheter can clot or injure the vessel that it is positioned within [2]. Optimal location at placement is somewhat controversial [2,3]. The American Society of Anesthesiologists defines optimal tip location as within the great vessels including the brachiocephalic veins or vena cavae [4], whereas the National Kidney Foundation defines optimal long-term catheter tip position as within the right atrium (likely to allow for the greater flow necessary for dialysis) [5]. ☆ Disclosures: The authors have no relevant financial disclosures. ⁎ Corresponding author at: Section of Pediatric Surgery, University of Michigan, 1540 E. Hospital Dr., SPC 4211, Ann Arbor, MI 48109-0245. Tel.: +734 764 4151; fax: +734 232 8984. E-mail address: [email protected] (J. Gish).
The European Society for Clinical Nutrition and Metabolism (ESPEN) combines both approaches and defines optimal tip position as between the lower third of the SVC and the upper third of the RA [6]. There are advantages and disadvantages to placing catheter tips more proximally or distally. If the tip is placed in the vena cavae then there is less risk of tamponade, but more risk of complications arising from lower flow like thrombosis [2]. For lines placed for infusion as opposed to dialysis, the consensus seems to be that the lower third of the SVC is optimum with the target being the cavoatrial junction to provide the maximum flow with a decreased risk of tamponade [2]. Several methods have been described for positioning the tip at the cavoatrial junction. One method, using EKG leads to measure the atrial impulse, is cumbersome and requires specialized equipment [7,8]. Another method uses mathematical calculations (height in decimeters − 1 with an additional subtraction for taller patients [N 100 cm]), but did not look at replacement rates [9]. While several studies investigate postplacement interventions [10], we focus on interventions that can be performed at the time of line placement. We aimed to identify interventions that could reduce the chance that a catheter placed in the upper body would need to be replaced for malposition. We postulated that age of the patient, technique of insertion and depth of placement would affect the rate of malposition.
http://dx.doi.org/10.1016/j.jpedsurg.2016.01.010 0022-3468/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: Gish J, et al, Avoiding postoperative malposition of upper body tunneled central venous catheters in children: Evaluating technique and depth of ..., J Pediatr Surg (2016), http://dx.doi.org/10.1016/j.jpedsurg.2016.01.010
2
J. Gish et al. / Journal of Pediatric Surgery xxx (2016) xxx–xxx
Table 1 Categorical data.
Table 3 Cox proportional hazards regression of line longevity by insertion technique at 90 days. N
Gender Male Female Days old at line insertion by quintiles 0–120 121–336 341–802 803–2855 3066–8629 Line Insertion Technique Superior Lateral Subclavian Other Catheter Tip Location N 0.5 Vertebral Bodies Above Carina Within 0.5 Vertebral bodies of Carina 0.51–1.5 Vertebral bodies below carina N1.5 Vertebral bodies below Carina Reason for insertion Cancer Intestinal Failure Other Catheter age in days at replacement 0–26 27–65 67–109 110–215 221–783
Not malpositioned
Malpositioned
p-value 0.846
207 197
188 180
80 81 81 81 81
69 67 76 75 81
11 14 5 6 0
147 167 65 25
132 157 59 20
15 10 6 5
40
31
9
71
57
14
137
131
6
156
149
7
139 117 148
134 99 135
5 18 13
0.119
b0.001
0.004
b0.001 11 30 28 28 29
N
Hazard Ratio
95% confidence interval
p value
Superior Lateral
147 167
4.03 0.3
1.27–12.8 1.26–12.91
0.018 0.03
19 17 0.001
32 32 33 32 33
Technique
21 2 5 4 4
Central lines placed in older children may have greater longevity since the catheter can migrate a short distance and still be in an acceptable position. Second, we postulated that catheters placed using a lateral approach to the internal jugular vein would have increased longevity. The lateral technique provides a gentle curve in the catheter and the tunnel is made low on the clavicle avoiding the potentially disruptive force of neck movement. Finally, the depth to which the catheter was placed would have an effect on the rate of malposition. In order to standardize measurement of depth in a heterogenous group of children, we used vertebral body heights as our unit of measure and chose the carina as an easily recognizable radiographic marker.
1. Methods We performed retrospective review of all patients with tunneled, cuffed central venous lines placed at our hospital from March 2010 to October 2013 by pediatric surgery (See Table 1). We did not exclude patients based on age, since occasional older patients are part of a typical pediatric surgical practice. The study was approved by the institutional Table 2 Reasons for replacement. Reason
N
Infection Malposition Dysfunction Break in Catheter Dislodgment Exposed Cuff Other
54 36 18 17 16 15 6
review board. We performed a 1-year follow-up to account for early and late displacement of catheters. We excluded all femoral lines to identify only the lines placed on the neck or chest since femoral lines have different factors leading to malposition from those placed in the upper body. Each placement was regarded as a separate event. In addition to non-ultrasound-guided percutaneous subclavian vein cannulation (SCV), two ultrasound-guided techniques were used for placement of internal jugular vein (IJV) lines: superior (SUP) and lateral (LAT) approaches (Figs. 1 and 2). In SUP, the ultrasound probe is placed over the IJV and the needle is directed in a caudal direction in line with the vein. For LAT, the ultrasound probe is similarly placed over the IJV; however, the needle enters the skin lateral to the sternocleidomastoid muscle and is directed medially. Additionally, lines were also placed in the external jugular vein (EJV) using a cut-down technique. All lines were placed under the direct supervision of one of 12 attending pediatric surgeons, with the choice of approach left to their discretion. There was no prospectively defined standard tip location, and intraoperative acceptability was determined by the attending surgeon based on fluoroscopy. If the line was determined to be malpositioned while the patient was still in the operating room, and the catheter was unable to be manipulated into position, the standard procedure was to replace the line prior to completing the procedure. If a different approach was used for the final attempt, this attempt was the one used for analysis, since the purpose of this study is to analyze the factors leading to postoperative malposition. The authors retrospectively reviewed the original postoperative chest radiograph to determine CTL in terms of vertebral bodies above or below the carina (Fig. 3), similar to the method identified by Song and others [11]. We identified whether the catheter needed replacement within a year following placement, the length of time from original placement to replacement, and the reason for replacement. We specifically wanted to identify catheters displaced needing replacement in the first 3 months (90 days), since lines requiring replacement this early would be less likely to have migrated owing to normal growth of the child. We identified the catheters replaced specifically for malposition, and excluded those replaced for physical dislodgement, need for alternate line or infection (See Table 2). Statistical analysis was performed with Stata version 12.1 (StataCorpLP, College Station, TX). Demographics of the patient population are presented with median and interquartile range for nonparametric variables, with mean and standard deviation for variables in normal distribution, and with percentages for categorical variables. Normality was assessed using a Shapiro–Wilks test. Hierarchal logistic regression with a generalized estimating equation approach was performed for malposition using independent variables of patient age, technique used and CTL. We also analyzed using quintiles, but there was no difference in the outcomes. A survival analysis to determine line survival by technique of insertion was done using the Cox Proportional Hazards model. P-values less than 0.05 were considered significant. 2. Results A total of 404 upper body central venous lines were placed in 282 children ranging in age from 1 day old to 23 years old with a median age of 1.4 years (interquartile range 0.45–5.35 years). At our institution, ultrasound-guided internal jugular vein access was the most commonly used technique (71.28%). Ultrasound guidance was used in a total of 290 attempts (71.78%). The median initial CTL was 1.5 vertebral bodies
Please cite this article as: Gish J, et al, Avoiding postoperative malposition of upper body tunneled central venous catheters in children: Evaluating technique and depth of ..., J Pediatr Surg (2016), http://dx.doi.org/10.1016/j.jpedsurg.2016.01.010
J. Gish et al. / Journal of Pediatric Surgery xxx (2016) xxx–xxx
3
Fig. 1. Consort Diagram.
below the carina (interquartile range 0.5–2 vertebral bodies). Reasons for catheter placement are chemotherapy (34%), parental nutrition (29%), and chronic disease requiring venous access for hydration, transfusion, or medications including antibiotics and prostaglandins (37%). In our study, we did not have any major events such as atrial perforation, arrhythmia needing intervention or further monitoring, or pericardial tamponade. We had one pneumothorax that appeared one day after a non-ultrasound-guided subclavian line placement which was controlled with a pig-tail tube thoracostomy (0.25% of total number of lines placed).
Replacement within a year was required in 153 patients (37.9%). Malposition was the reason for replacement in 36 patients (23% of all replacements) at a median of 16.5 days (interquartile range 4.5–103.5 days). We found that older children were significantly less likely to develop malposition (OR = 0.91,p = 0.002). Adjusting for patient age and technique of placement, catheters placed ≥1.5 vertebral bodies below the carina were less likely to be malpositioned (OR = 0.37,p = 0.015). Cox proportional hazards (Fig. 4) show the lateral technique to have the lowest rate of malposition especially in the first 90 days (HR = 0.30,p = 0.03) (See Table 3). 3. Discussion
Fig. 2. The two approaches to ultrasound-guided access to the IJV: LAT (A) and SUP (B) (arrow points to patient's head).
Limiting replacement and repositioning of central lines decreases patient morbidity, complications and repeat operations. We have identified three factors at line insertion that increase catheter longevity: age, technique and depth. In our study, catheter longevity for tunneled central lines increased with patient age, use of the lateral technique for ultrasound-guided IJV access, and CTL below 1.5 vertebral bodies from the carina. Of these three factors, age is the least controllable; however, there are times in which one can allow the child to grow before placing a Broviac. Several factors may contribute to catheter malposition in younger children. First, the tunnel made in an infant has room for catheter migration when using standard tunneling methods. Next, this is amplified by the short distance separating good position from malpostion. Finally, younger highly active children may be more likely to dislodge and displace a catheter than an older child. This corroborates previous findings that younger children had more maintenance related complications [12]. The lateral technique is not a new technique and is described by various names [13]. With ultrasound guidance the technique affords a view of the lung, needle, IJV and carotid artery all at the same time (Fig. 5). It does require development of skills with the ultrasound but the technique allows safe placement, very close to the clavicle. Much like a subclavian line, the lateral technique permits a gentle curve of the catheter and keeps the catheter out of the neck, which eliminates the catheter migration caused by neck movement. Furthermore, the technique had improved rate of longevity when compared to subclavian approach for unclear reasons, though we suspect the curve over the clavicle has a similar effect of avoiding migration caused by chest and arm movement. Depth of line placement contributes to catheter longevity but measurement of depth has not been standardized. According to The European Society for Clinical Nutrition and Metabolism (ESPEN), the goal CTL is between the lower third of the SVC and the upper third of the RA [6]; however, there have been several different methods
Please cite this article as: Gish J, et al, Avoiding postoperative malposition of upper body tunneled central venous catheters in children: Evaluating technique and depth of ..., J Pediatr Surg (2016), http://dx.doi.org/10.1016/j.jpedsurg.2016.01.010
4
J. Gish et al. / Journal of Pediatric Surgery xxx (2016) xxx–xxx
Fig. 5. Ultrasound image of the internal jugular vein accessed using the lateral technique demonstrating the view of the lung, needle and major vessels.
Fig. 3. The measurement of distance from carina (red arrow) to the catheter tip (blue arrow) using vertebral body height (green line). In this picture the catheter tip is located at two vertebral body heights from the carina.
described to attain this ideal location. In our study, we use vertebral bodies as a measure to define depth. There have been several studies looking at the cavoatrial junction (CAJ) using computerized tomography, and comparing the CAJ to vertebral bodies below the carina [8]. The CAJ in adults appears to be approximately 2 vertebral bodies below the carina on an AP x-ray image [14]. Without an ultrasound or echocardiography, this method gives a reasonably accurate indication of the right atrial–SVC junction. Other methods described for locating the tip of the catheter like using intravascular EKG readings [7,8] and patient height corrections [9] lack data regarding longevity of the catheters. While postplacement interventions such as locking and flushing may prolong the usable catheter duration [10,15], we have focused on interventions that can be performed at the time of line placement. Placing lines deeper than 1.5 vertebral bodies below the carina discourages line migration in our study. At the same time, lines that are placed too deep can cause potentially fatal complications like cardiac arrhythmias, perforation or valvular damage [16], though we did not have any in our study, likely owing
to limited number of lines placed at that distance and the overall rarity of these events. Our study has several limitations secondary to the retrospective nature. First, there was no randomization and though we attempted to control for patient age and depth in our statistical analysis, only a prospective study could fully elucidate the role of the technique used in preventing malposition. Second, as the catheter placement was at a large referral pediatric hospital, the results may not be generalizable to other settings. Furthermore, many institutions do not regard ultrasound use for line placement as standard of care; however, the majority of lines are done using ultrasound at our center. Guidelines from international organizations recommend placement with ultrasound guidance [6,17]. Similarly, ultrasound is user and experience dependent, limiting the generalizability of our results. Next, we excluded port placement and nontunneled lines and looked only at Broviac placement but we feel that similar results could be expected for other central venous access modalities. Finally, as mentioned above, our study was underpowered to discover any increased risk of rare but potentially serious complications such as great vessel injury or tamponade, which we did not see in this population. Despite these limitations, our study suggests that, when possible, central lines placed in the chest or neck should be placed with the tip located 1.5–2 vertebral body heights below the carina via a lateral approach to the internal jugular vein to limit the need for replacement owing to malposition.
References
Fig. 4. Cox proportional hazard for the superior versus the lateral approach.
[1] de Jonge RCJ, Polderman KH, Gemke RJBJ. Central venous catheter use in the pediatric patient: mechanical and infectious complications. Pediatr Crit Care Med 2005; 6(3):329–39. [2] Perin G, Scarpa MG. Defining central venous line position in children: tips for the tip. J Vasc Access 2015;16(2):77–86. [3] Vesely TM. Central venous catheter tip position: a continuing controversy. J Vasc Interv Radiol 2003;14(5):527–34. [4] Rupp SM, Apfelbaum JL, Blitt C, et al. American Society of Anesthesiologists. [Online] 2012 [cited 2015 October 17. Available from:] http://www.asahq.org/~/media/Sites/ ASAHQ/Files/Public/Resources/standards-guidelines/practice-guidelines-for-central-venous-access.pdf. [5] National Kidney Foundation. Clinical practice guidelines and clinical practice recommendations 2006 updates. [Online] 2006 [cited 2015 Oct 19. Available from:] http:// www2.kidney.org/professionals/KDOQI/guideline_upHD_PD_VA/va_guide2.htm. [6] Pittiruti M, Hamilton H, Biffi R, et al. ESPEN guidelines on parenteral nutrition: central venous catheters (access, care, diagnosis and therapy of complications). Clin Nutr 2009;28(4):365–77. [7] Hoffman MA, Langer JC, Pearl RH, et al. Central venous catheters—no X-rays needed: a prospective study in 50 consecutive infants and children. J Pediatr Surg 1988; 23(12):1201–3.
Please cite this article as: Gish J, et al, Avoiding postoperative malposition of upper body tunneled central venous catheters in children: Evaluating technique and depth of ..., J Pediatr Surg (2016), http://dx.doi.org/10.1016/j.jpedsurg.2016.01.010
J. Gish et al. / Journal of Pediatric Surgery xxx (2016) xxx–xxx [8] Chu KS, Hsu JH, Wang SS, et al. Accurate central venous port-a catheter placement: intravenous electrocardiography and surface landmark techniques compared by using transesophageal echocardiography. Anesth Analg 2004;98(4):910–4. [9] Andropoulos DB, Bent ST, Skjonsby B, et al. The optimal length of insertion of central venous catheters for pediatric patients. Anesth Analg 2001;93(4):883–6. [10] Jones BA, Hull MA, Richardson DS, et al. Efficacy of ethanol locks in reducing central venous catheter infections in pediatric patients with intestinal failure. J Pediatr Surg 2010;45(6):1287–93. [11] Song YG, Byun JH, Hwang SY, et al. Use of vertebral body units to locate the cavoatrial junction for optimum central venous catheter tip positioning. Br J Anaesth 2015;115(2):252–7. [12] Casado-Flores J, Barja J, Martino R, et al. Complications of central venous catheterization in critically ill children. Pediatr Crit Care Med 2001;2(1):57–62.
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[13] Weiner MM, Geldard P, Mittnacht AJC. Ultrasound-guided vascular access: a comprehensive review. J Cardiothorac Vasc Anesth 2013;27(2):345–60. [14] Baskin KM, Jimenez RM, Cahill AM, et al. Cavoatrial junction and central venous anatomy: implications for central venous access tip position. J Vasc Interv Radiol 2008;19:359–65. [15] Davis MBH. Pediatric central venous catheter management: a review of current practice. J Assoc Vasc Access 2013;18(2):93–8. [16] Askegard-Giesmann JR, Caniano DA, Kenney BD. Rare but serious complications of central line insertion. Semin Pediatr Surg 2009;18(2):73–83. [17] Troianos CA, Hartman GS, Glas KE, et al. Guidelines for performing ultrasound guided vascular cannulation: recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr 2011;24(12):1291–318.
Please cite this article as: Gish J, et al, Avoiding postoperative malposition of upper body tunneled central venous catheters in children: Evaluating technique and depth of ..., J Pediatr Surg (2016), http://dx.doi.org/10.1016/j.jpedsurg.2016.01.010
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Avoiding postoperative malposition of upper body tunneled central venous catheters in children: Evaluating technique and depth of placement☆ Joshua Gish ⁎, Tiffany Wright, Samir Gadepalli, Marcus Jarboe Section of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI
a r t i c l e
i n f o
Article history: Received 28 August 2015 Received in revised form 12 January 2016 Accepted 13 January 2016 Available online xxxx Key words: Central venous line Malposition Reposition Reoperation Pediatric
a b s t r a c t Background: Suboptimal position of tunneled central venous catheters (Broviacs) decreases long-term catheter longevity, incurring morbidity and cost. We postulated that catheter malposition is related to patient's age, technique used, and initial catheter tip location (CTL). Methods: We performed a retrospective review with 1-year follow-up of Broviacs placed in patients at our children's hospital from 3/2010 to 10/2013. We defined malposition as a noncentral CTL that required replacement, excluding catheters physically dislodged. We used logistic regression to determine whether age, technique and CTL predicted malposition with p-value b 0.05 deemed significant. We analyzed line longevity for different insertion techniques by survival analysis. Results: Overall, 404 upper body Broviacs were placed in 282 children (median age = 1.4 years [IQR:0.45–5.35]). Thirty-six (8.9%) were replaced for malposition, at median of 84.5 days [IQR:36–159]. We found that older children were less likely to develop malposition (OR = 0.91,p = 0.002). Adjusting for patient age and placement technique, catheters placed ≥1.5 vertebral bodies below the carina were less likely to be malpositioned (OR = 0.37,p = 0.015). Cox-regression shows the lateral technique to have the lowest rate of malposition within 90 days (HR = 0.30,p = 0.03). Conclusion: Older patients and lines placed 1.5 vertebral bodies below the carina are less likely to become malpositioned. Using the lateral approach for insertion improves catheter longevity. © 2016 Elsevier Inc. All rights reserved.
Tunneled central line placement is a common procedure for pediatric patients that require long-term venous access. Catheter migration from a central position, however, can require replacement, incurring a risk of complications to the patient and increasing financial costs in materials and operating room time [1]. Prevention of catheter replacement can improve patient outcomes and decrease health-care costs. (See Tables 1–3.) Central venous catheter tip location can affect function of the catheter. If the catheter migrates to a peripheral location rather than a central one, then the catheter can clot or injure the vessel that it is positioned within [2]. Optimal location at placement is somewhat controversial [2,3]. The American Society of Anesthesiologists defines optimal tip location as within the great vessels including the brachiocephalic veins or vena cavae [4], whereas the National Kidney Foundation defines optimal long-term catheter tip position as within the right atrium (likely to allow for the greater flow necessary for dialysis) [5]. ☆ Disclosures: The authors have no relevant financial disclosures. ⁎ Corresponding author at: Section of Pediatric Surgery, University of Michigan, 1540 E. Hospital Dr., SPC 4211, Ann Arbor, MI 48109-0245. Tel.: +734 764 4151; fax: +734 232 8984. E-mail address: [email protected] (J. Gish).
The European Society for Clinical Nutrition and Metabolism (ESPEN) combines both approaches and defines optimal tip position as between the lower third of the SVC and the upper third of the RA [6]. There are advantages and disadvantages to placing catheter tips more proximally or distally. If the tip is placed in the vena cavae then there is less risk of tamponade, but more risk of complications arising from lower flow like thrombosis [2]. For lines placed for infusion as opposed to dialysis, the consensus seems to be that the lower third of the SVC is optimum with the target being the cavoatrial junction to provide the maximum flow with a decreased risk of tamponade [2]. Several methods have been described for positioning the tip at the cavoatrial junction. One method, using EKG leads to measure the atrial impulse, is cumbersome and requires specialized equipment [7,8]. Another method uses mathematical calculations (height in decimeters − 1 with an additional subtraction for taller patients [N 100 cm]), but did not look at replacement rates [9]. While several studies investigate postplacement interventions [10], we focus on interventions that can be performed at the time of line placement. We aimed to identify interventions that could reduce the chance that a catheter placed in the upper body would need to be replaced for malposition. We postulated that age of the patient, technique of insertion and depth of placement would affect the rate of malposition.
http://dx.doi.org/10.1016/j.jpedsurg.2016.01.010 0022-3468/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: Gish J, et al, Avoiding postoperative malposition of upper body tunneled central venous catheters in children: Evaluating technique and depth of ..., J Pediatr Surg (2016), http://dx.doi.org/10.1016/j.jpedsurg.2016.01.010
2
J. Gish et al. / Journal of Pediatric Surgery xxx (2016) xxx–xxx
Table 1 Categorical data.
Table 3 Cox proportional hazards regression of line longevity by insertion technique at 90 days. N
Gender Male Female Days old at line insertion by quintiles 0–120 121–336 341–802 803–2855 3066–8629 Line Insertion Technique Superior Lateral Subclavian Other Catheter Tip Location N 0.5 Vertebral Bodies Above Carina Within 0.5 Vertebral bodies of Carina 0.51–1.5 Vertebral bodies below carina N1.5 Vertebral bodies below Carina Reason for insertion Cancer Intestinal Failure Other Catheter age in days at replacement 0–26 27–65 67–109 110–215 221–783
Not malpositioned
Malpositioned
p-value 0.846
207 197
188 180
80 81 81 81 81
69 67 76 75 81
11 14 5 6 0
147 167 65 25
132 157 59 20
15 10 6 5
40
31
9
71
57
14
137
131
6
156
149
7
139 117 148
134 99 135
5 18 13
0.119
b0.001
0.004
b0.001 11 30 28 28 29
N
Hazard Ratio
95% confidence interval
p value
Superior Lateral
147 167
4.03 0.3
1.27–12.8 1.26–12.91
0.018 0.03
19 17 0.001
32 32 33 32 33
Technique
21 2 5 4 4
Central lines placed in older children may have greater longevity since the catheter can migrate a short distance and still be in an acceptable position. Second, we postulated that catheters placed using a lateral approach to the internal jugular vein would have increased longevity. The lateral technique provides a gentle curve in the catheter and the tunnel is made low on the clavicle avoiding the potentially disruptive force of neck movement. Finally, the depth to which the catheter was placed would have an effect on the rate of malposition. In order to standardize measurement of depth in a heterogenous group of children, we used vertebral body heights as our unit of measure and chose the carina as an easily recognizable radiographic marker.
1. Methods We performed retrospective review of all patients with tunneled, cuffed central venous lines placed at our hospital from March 2010 to October 2013 by pediatric surgery (See Table 1). We did not exclude patients based on age, since occasional older patients are part of a typical pediatric surgical practice. The study was approved by the institutional Table 2 Reasons for replacement. Reason
N
Infection Malposition Dysfunction Break in Catheter Dislodgment Exposed Cuff Other
54 36 18 17 16 15 6
review board. We performed a 1-year follow-up to account for early and late displacement of catheters. We excluded all femoral lines to identify only the lines placed on the neck or chest since femoral lines have different factors leading to malposition from those placed in the upper body. Each placement was regarded as a separate event. In addition to non-ultrasound-guided percutaneous subclavian vein cannulation (SCV), two ultrasound-guided techniques were used for placement of internal jugular vein (IJV) lines: superior (SUP) and lateral (LAT) approaches (Figs. 1 and 2). In SUP, the ultrasound probe is placed over the IJV and the needle is directed in a caudal direction in line with the vein. For LAT, the ultrasound probe is similarly placed over the IJV; however, the needle enters the skin lateral to the sternocleidomastoid muscle and is directed medially. Additionally, lines were also placed in the external jugular vein (EJV) using a cut-down technique. All lines were placed under the direct supervision of one of 12 attending pediatric surgeons, with the choice of approach left to their discretion. There was no prospectively defined standard tip location, and intraoperative acceptability was determined by the attending surgeon based on fluoroscopy. If the line was determined to be malpositioned while the patient was still in the operating room, and the catheter was unable to be manipulated into position, the standard procedure was to replace the line prior to completing the procedure. If a different approach was used for the final attempt, this attempt was the one used for analysis, since the purpose of this study is to analyze the factors leading to postoperative malposition. The authors retrospectively reviewed the original postoperative chest radiograph to determine CTL in terms of vertebral bodies above or below the carina (Fig. 3), similar to the method identified by Song and others [11]. We identified whether the catheter needed replacement within a year following placement, the length of time from original placement to replacement, and the reason for replacement. We specifically wanted to identify catheters displaced needing replacement in the first 3 months (90 days), since lines requiring replacement this early would be less likely to have migrated owing to normal growth of the child. We identified the catheters replaced specifically for malposition, and excluded those replaced for physical dislodgement, need for alternate line or infection (See Table 2). Statistical analysis was performed with Stata version 12.1 (StataCorpLP, College Station, TX). Demographics of the patient population are presented with median and interquartile range for nonparametric variables, with mean and standard deviation for variables in normal distribution, and with percentages for categorical variables. Normality was assessed using a Shapiro–Wilks test. Hierarchal logistic regression with a generalized estimating equation approach was performed for malposition using independent variables of patient age, technique used and CTL. We also analyzed using quintiles, but there was no difference in the outcomes. A survival analysis to determine line survival by technique of insertion was done using the Cox Proportional Hazards model. P-values less than 0.05 were considered significant. 2. Results A total of 404 upper body central venous lines were placed in 282 children ranging in age from 1 day old to 23 years old with a median age of 1.4 years (interquartile range 0.45–5.35 years). At our institution, ultrasound-guided internal jugular vein access was the most commonly used technique (71.28%). Ultrasound guidance was used in a total of 290 attempts (71.78%). The median initial CTL was 1.5 vertebral bodies
Please cite this article as: Gish J, et al, Avoiding postoperative malposition of upper body tunneled central venous catheters in children: Evaluating technique and depth of ..., J Pediatr Surg (2016), http://dx.doi.org/10.1016/j.jpedsurg.2016.01.010
J. Gish et al. / Journal of Pediatric Surgery xxx (2016) xxx–xxx
3
Fig. 1. Consort Diagram.
below the carina (interquartile range 0.5–2 vertebral bodies). Reasons for catheter placement are chemotherapy (34%), parental nutrition (29%), and chronic disease requiring venous access for hydration, transfusion, or medications including antibiotics and prostaglandins (37%). In our study, we did not have any major events such as atrial perforation, arrhythmia needing intervention or further monitoring, or pericardial tamponade. We had one pneumothorax that appeared one day after a non-ultrasound-guided subclavian line placement which was controlled with a pig-tail tube thoracostomy (0.25% of total number of lines placed).
Replacement within a year was required in 153 patients (37.9%). Malposition was the reason for replacement in 36 patients (23% of all replacements) at a median of 16.5 days (interquartile range 4.5–103.5 days). We found that older children were significantly less likely to develop malposition (OR = 0.91,p = 0.002). Adjusting for patient age and technique of placement, catheters placed ≥1.5 vertebral bodies below the carina were less likely to be malpositioned (OR = 0.37,p = 0.015). Cox proportional hazards (Fig. 4) show the lateral technique to have the lowest rate of malposition especially in the first 90 days (HR = 0.30,p = 0.03) (See Table 3). 3. Discussion
Fig. 2. The two approaches to ultrasound-guided access to the IJV: LAT (A) and SUP (B) (arrow points to patient's head).
Limiting replacement and repositioning of central lines decreases patient morbidity, complications and repeat operations. We have identified three factors at line insertion that increase catheter longevity: age, technique and depth. In our study, catheter longevity for tunneled central lines increased with patient age, use of the lateral technique for ultrasound-guided IJV access, and CTL below 1.5 vertebral bodies from the carina. Of these three factors, age is the least controllable; however, there are times in which one can allow the child to grow before placing a Broviac. Several factors may contribute to catheter malposition in younger children. First, the tunnel made in an infant has room for catheter migration when using standard tunneling methods. Next, this is amplified by the short distance separating good position from malpostion. Finally, younger highly active children may be more likely to dislodge and displace a catheter than an older child. This corroborates previous findings that younger children had more maintenance related complications [12]. The lateral technique is not a new technique and is described by various names [13]. With ultrasound guidance the technique affords a view of the lung, needle, IJV and carotid artery all at the same time (Fig. 5). It does require development of skills with the ultrasound but the technique allows safe placement, very close to the clavicle. Much like a subclavian line, the lateral technique permits a gentle curve of the catheter and keeps the catheter out of the neck, which eliminates the catheter migration caused by neck movement. Furthermore, the technique had improved rate of longevity when compared to subclavian approach for unclear reasons, though we suspect the curve over the clavicle has a similar effect of avoiding migration caused by chest and arm movement. Depth of line placement contributes to catheter longevity but measurement of depth has not been standardized. According to The European Society for Clinical Nutrition and Metabolism (ESPEN), the goal CTL is between the lower third of the SVC and the upper third of the RA [6]; however, there have been several different methods
Please cite this article as: Gish J, et al, Avoiding postoperative malposition of upper body tunneled central venous catheters in children: Evaluating technique and depth of ..., J Pediatr Surg (2016), http://dx.doi.org/10.1016/j.jpedsurg.2016.01.010
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J. Gish et al. / Journal of Pediatric Surgery xxx (2016) xxx–xxx
Fig. 5. Ultrasound image of the internal jugular vein accessed using the lateral technique demonstrating the view of the lung, needle and major vessels.
Fig. 3. The measurement of distance from carina (red arrow) to the catheter tip (blue arrow) using vertebral body height (green line). In this picture the catheter tip is located at two vertebral body heights from the carina.
described to attain this ideal location. In our study, we use vertebral bodies as a measure to define depth. There have been several studies looking at the cavoatrial junction (CAJ) using computerized tomography, and comparing the CAJ to vertebral bodies below the carina [8]. The CAJ in adults appears to be approximately 2 vertebral bodies below the carina on an AP x-ray image [14]. Without an ultrasound or echocardiography, this method gives a reasonably accurate indication of the right atrial–SVC junction. Other methods described for locating the tip of the catheter like using intravascular EKG readings [7,8] and patient height corrections [9] lack data regarding longevity of the catheters. While postplacement interventions such as locking and flushing may prolong the usable catheter duration [10,15], we have focused on interventions that can be performed at the time of line placement. Placing lines deeper than 1.5 vertebral bodies below the carina discourages line migration in our study. At the same time, lines that are placed too deep can cause potentially fatal complications like cardiac arrhythmias, perforation or valvular damage [16], though we did not have any in our study, likely owing
to limited number of lines placed at that distance and the overall rarity of these events. Our study has several limitations secondary to the retrospective nature. First, there was no randomization and though we attempted to control for patient age and depth in our statistical analysis, only a prospective study could fully elucidate the role of the technique used in preventing malposition. Second, as the catheter placement was at a large referral pediatric hospital, the results may not be generalizable to other settings. Furthermore, many institutions do not regard ultrasound use for line placement as standard of care; however, the majority of lines are done using ultrasound at our center. Guidelines from international organizations recommend placement with ultrasound guidance [6,17]. Similarly, ultrasound is user and experience dependent, limiting the generalizability of our results. Next, we excluded port placement and nontunneled lines and looked only at Broviac placement but we feel that similar results could be expected for other central venous access modalities. Finally, as mentioned above, our study was underpowered to discover any increased risk of rare but potentially serious complications such as great vessel injury or tamponade, which we did not see in this population. Despite these limitations, our study suggests that, when possible, central lines placed in the chest or neck should be placed with the tip located 1.5–2 vertebral body heights below the carina via a lateral approach to the internal jugular vein to limit the need for replacement owing to malposition.
References
Fig. 4. Cox proportional hazard for the superior versus the lateral approach.
[1] de Jonge RCJ, Polderman KH, Gemke RJBJ. Central venous catheter use in the pediatric patient: mechanical and infectious complications. Pediatr Crit Care Med 2005; 6(3):329–39. [2] Perin G, Scarpa MG. Defining central venous line position in children: tips for the tip. J Vasc Access 2015;16(2):77–86. [3] Vesely TM. Central venous catheter tip position: a continuing controversy. J Vasc Interv Radiol 2003;14(5):527–34. [4] Rupp SM, Apfelbaum JL, Blitt C, et al. American Society of Anesthesiologists. [Online] 2012 [cited 2015 October 17. Available from:] http://www.asahq.org/~/media/Sites/ ASAHQ/Files/Public/Resources/standards-guidelines/practice-guidelines-for-central-venous-access.pdf. [5] National Kidney Foundation. Clinical practice guidelines and clinical practice recommendations 2006 updates. [Online] 2006 [cited 2015 Oct 19. Available from:] http:// www2.kidney.org/professionals/KDOQI/guideline_upHD_PD_VA/va_guide2.htm. [6] Pittiruti M, Hamilton H, Biffi R, et al. ESPEN guidelines on parenteral nutrition: central venous catheters (access, care, diagnosis and therapy of complications). Clin Nutr 2009;28(4):365–77. [7] Hoffman MA, Langer JC, Pearl RH, et al. Central venous catheters—no X-rays needed: a prospective study in 50 consecutive infants and children. J Pediatr Surg 1988; 23(12):1201–3.
Please cite this article as: Gish J, et al, Avoiding postoperative malposition of upper body tunneled central venous catheters in children: Evaluating technique and depth of ..., J Pediatr Surg (2016), http://dx.doi.org/10.1016/j.jpedsurg.2016.01.010
J. Gish et al. / Journal of Pediatric Surgery xxx (2016) xxx–xxx [8] Chu KS, Hsu JH, Wang SS, et al. Accurate central venous port-a catheter placement: intravenous electrocardiography and surface landmark techniques compared by using transesophageal echocardiography. Anesth Analg 2004;98(4):910–4. [9] Andropoulos DB, Bent ST, Skjonsby B, et al. The optimal length of insertion of central venous catheters for pediatric patients. Anesth Analg 2001;93(4):883–6. [10] Jones BA, Hull MA, Richardson DS, et al. Efficacy of ethanol locks in reducing central venous catheter infections in pediatric patients with intestinal failure. J Pediatr Surg 2010;45(6):1287–93. [11] Song YG, Byun JH, Hwang SY, et al. Use of vertebral body units to locate the cavoatrial junction for optimum central venous catheter tip positioning. Br J Anaesth 2015;115(2):252–7. [12] Casado-Flores J, Barja J, Martino R, et al. Complications of central venous catheterization in critically ill children. Pediatr Crit Care Med 2001;2(1):57–62.
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[13] Weiner MM, Geldard P, Mittnacht AJC. Ultrasound-guided vascular access: a comprehensive review. J Cardiothorac Vasc Anesth 2013;27(2):345–60. [14] Baskin KM, Jimenez RM, Cahill AM, et al. Cavoatrial junction and central venous anatomy: implications for central venous access tip position. J Vasc Interv Radiol 2008;19:359–65. [15] Davis MBH. Pediatric central venous catheter management: a review of current practice. J Assoc Vasc Access 2013;18(2):93–8. [16] Askegard-Giesmann JR, Caniano DA, Kenney BD. Rare but serious complications of central line insertion. Semin Pediatr Surg 2009;18(2):73–83. [17] Troianos CA, Hartman GS, Glas KE, et al. Guidelines for performing ultrasound guided vascular cannulation: recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr 2011;24(12):1291–318.
Please cite this article as: Gish J, et al, Avoiding postoperative malposition of upper body tunneled central venous catheters in children: Evaluating technique and depth of ..., J Pediatr Surg (2016), http://dx.doi.org/10.1016/j.jpedsurg.2016.01.010