Central Venous Catheter Utilization and Complications in the Pediatric Cardiac ICU: A Report From the Pediatric Cardiac Critical Care Consortium (PC4)*

Abstract

Objectives: Current central venous catheter utilization in patients within pediatric cardiac ICUs is not well elucidated. We aim to describe current use of central venous catheters in a multi-institutional cohort and to explore the prevalence and risk factors for central line–associated thrombosis and central line–associated bloodstream infections. Design: Observational analysis. Setting: Pediatric Cardiac Critical Care Consortium hospitals. Patients: Hospitalizations with at least one cardiac ICU admission from October 2013 to July 2016. Interventions: None. Measurements and Main Results: There were 17,846 hospitalizations and 69% included greater than or equal to one central venous catheter. Central venous catheter use was higher in younger patients (86% neonates). Surgical hospitalizations included at least one central venous catheter 88% of the time compared with 35% of medical hospitalizations. The most common location for central venous catheters was internal jugular (46%). Central venous catheters were in situ a median of 4 days (interquartile range, 2–10). There were 248 hospitalizations (2% overall, 1.8% medical, and 2.1% surgical) with at least one central line–associated thrombosis (271 total thromboses). Thrombosis was diagnosed at a median of 7 days (interquartile range, 4–14) after catheter insertion. There were 127 hospitalizations (1% overall, 1.4% medical, and 1% surgical) with at least one central line–associated bloodstream infection (136 total infections) with no association with catheter type or location. Central line–associated bloodstream infection was diagnosed at a median of 19 days (interquartile range, 8–36) after catheter insertion. Significant risk factors for central line–associated thrombosis and central line–associated bloodstream infection were younger age, greater surgical complexity, and total catheter days. Conclusions: Utilization of central venous catheters in pediatric cardiac ICUs differs according to indication for hospitalization. Although thrombosis and central line–associated bloodstream infection are infrequent complications of central venous catheter use in cardiac ICU patients, these events can have important short- and long-term consequences for patients. Total central venous catheter line days were the only modifiable risk factor identified. Future study must focus on understanding central venous catheter practices in high-risk patient subgroups that reduce the prevalence of thrombosis and central line–associated bloodstream infection.

Reply

“…While in one study 7% of adolescents with MIS‐C were reported to have developed deep venous thrombosis or pulmonary embolism, other large cohorts have demonstrated rates closer to 0–2% (5–7). This rate of thrombotic events is similar to that observed in children without MIS‐C who have central venous lines, and many children with MIS‐C require intensive care measures and central venous access (8). d ‐dimer levels are frequently elevated in MIS‐C patients, but it is unclear if this laboratory parameter is directly reflective of hypercoagulability risk.…”

“…We read with great interest the article by Dong et al on the role of STAT4 activation in Tfh cell production of IL-21 and IFNγ in lupus (8). The authors present exhaustive data demonstrating that type I IFN can maintain STAT4 activation in Tfh cells and Tfh cell production of IL-21 and IFNγ as the disease in lupus-prone mice progresses.…”

“…Second, Dong and colleagues found that IFNβ can promote more significant phosphorylation of STAT4 in splenic Tfh cells and Th1 cells at a later stage of disease compared to the predisease stage (8). However, we wonder why the authors did not further investigate the role of IFNβ in regulating IL-21 and IFNγ production by splenic Tfh cells and Th1 cells by direct stimulation with IFNβ.…”

The Michigan Appropriateness Guide for Intravenous Catheters in children with congenital heart disease: miniMAGIC-CHD

“…Central access via upper-extremity peripherally inserted central catheter or internal jugular vein was preferred based on consensus in order to preserve femoral vein access. This preference was secondary to concern for thrombosis inherent to femoral vascular access devices and the potential need for future femoral venous access for cardiac catheterization procedures [1,3,4]. Subclavian venous access was rated uncertain by the panel, due to the limitations of ultrasound use with this placement technique and the variable experience of operators.…”

“…DiPietro and colleagues previously evaluated multi-institutional central venous access device use in patients in North American paediatric cardiac intensive care units [4]. Within the cohort, central venous access device location varied extensively based on physiology and need for cardiac procedure.…”