Closed-Hub Systems with Protected Connections and the Reduction of Risk of Catheter-Related Bloodstream Infection in Pediatric Patients Receiving Intravenous Prostanoid Therapy for Pulmonary Hypertension

Ivy, D. Dunbar; Calderbank, Michelle; Wagner, Brandie D.; Dolan, Susan A.; Nyquist, Ann‐Christine; Wade, Michael S.; Nickels, William M.; Doran, Aimee

doi:10.1086/605320

Cited by 66 publications

(57 citation statements)

References 18 publications

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“…We aimed to better understand these CVL complications by reviewing our experience with this therapy. Our overall rate of CVL-BSI (0.25 cases per 1,000 catheter-days) is remarkably similar to that reported by Ivy et al 6 among pediatric patients after instituting enhanced preventative measures (0.24 cases per 1,000 catheter-days), although we report a greater number of CVL-days (43,855 vs. 8,308). The REVEAL registry reported that the rate of CVL-BSI for patients ≤18 years old (n ¼ 83 patients; the number of patient-days was not given) was no different than the rate for adults (0.20 cases per 1,000 CVL-days), but the exact number was not given.…”

Section: Discussionsupporting

confidence: 90%

“…There are multiple reports focused on CVL-related bloodstream infections (BSIs) in adults [2][3][4][5] but only a single report regarding CVL-BSI with PGI 2 infusion in mostly pediatric patients (although the age of the patients is not given), 6 and we know of no information regarding the incidence of other complications (e.g., CVL superficial infection, fracture, displacement, and occlusion) in this setting. Children may be at different risk than adults for CVL complications owing to high activity levels, being less mindful of the need for CVL protection, and possibly other factors.…”

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confidence: 99%

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Central Venous Line Complications with Chronic Ambulatory Infusion of Prostacyclin Analogues in Pediatric Patients with Pulmonary Arterial Hypertension

et al. 2015

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Chronic infusion of prostacyclin (PGI 2 ) via a Broviac central venous line (CVL) is attended by risk of CVL-related complications, but we know of only one report regarding CVL-associated bloodstream infection (BSI) with PGI 2 in children and none regarding other complications. We conducted a retrospective cohort study involving pediatric patients with pulmonary hypertension treated with chronic intravenous infusion of PGI 2 at Boston Children's Hospital and determined the rate (per 1,000 line-days) of various CVL-related complications. We also determined how often complications necessitated line replacement and hospitalization, time to replacement of CVLs, and interpatient variability in the incidence of complications. From 1999 until 2014, 26 patients meeting follow-up criteria had PGI 2 infusion, representing 43,855 line-days; mean follow-up was 56 months (range, 1.4-161 months). The CVL complication rates (per 1,000 linedays) were as follows: CVL-BSI, 0.25; superficial line infection, 0.48; impaired integrity, 0.59; occlusion, 0.09; and malposition, 0.32. The total complication rate was 1.73 cases per 1,000 line-days. All CVL-BSI and malposition cases were treated with CVL removal and replacement. Of CVLs with impaired integrity, 23 could be repaired and 3 required replacement. Six of 21 superficial CVL infections required replacement of the CVL. Three of 4 occluded CVLs were replaced. CVL complications occasioned 65 hospitalizations. There was marked interpatient variability in the rate of complications, much but not all of which appeared to be related to duration of CVL placement. We conclude that non-BSI complications are very significant and that efforts to teach and emphasize other aspects of line care are therefore very important. Chronic intravenous infusion of the prostacyclin (PGI 2 ) analogues epoprostanol and treprostinil, usually through a Broviac central venous line (CVL), has been the most effective therapy for severe pulmonary arterial hypertension (PAH) since 1996, 1 but it is attended with the risk of CVL-related complications. There are multiple reports focused on CVL-related bloodstream infections (BSIs) in adults 2-5 but only a single report regarding CVL-BSI with PGI 2 infusion in mostly pediatric patients (although the age of the patients is not given), 6 and we know of no information regarding the incidence of other complications (e.g., CVL superficial infection, fracture, displacement, and occlusion) in this setting. Children may be at different risk than adults for CVL complications owing to high activity levels, being less mindful of the need for CVL protection, and possibly other factors. Noninfectious complications are also important, as they frequently require hospital visit, admission, or CVL replacement, and their rate of occurrence may substantially exceed that of CVL-BSI. 7,8 A better understanding of non-BSI complications associated with CVLs in pediatric patients receiving PGI 2 analogues could lead to strategies to reduce such events. Also, an alternative means o...

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Section: Discussionsupporting

confidence: 90%

mentioning

confidence: 99%

Central Venous Line Complications with Chronic Ambulatory Infusion of Prostacyclin Analogues in Pediatric Patients with Pulmonary Arterial Hypertension

et al. 2015

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“…312,313 Recently, the use of specific closed-hub systems has been described in children to decrease the risk of catheter-related infection. 314 Some children have an exceptional clinical response to intravenous epoprostenol, which includes near normalization of PAP. This subset of children may eventually be transitioned from intravenous to oral therapy with close monitoring.…”

Section: Pgi 2 Analogsmentioning

confidence: 99%

“…An increase in catheter-related and Gram-negative bloodstream infections among patients with PAH treated with intravenous treprostinil has been noted, but this risk may be mitigated by using watertight seals throughout the delivery system, using closed-hub systems, and changing the diluent of treprostinil to epoprostenol diluent. 313,314,321,322 Intravenous treprostinil may have fewer side effects than intravenous epoprostenol, but no studies have directly compared both agents. 323 Treprostinil has also been given in an inhaled form, 324 and studies have recently been published in children.…”

Section: Pgi 2 Analogsmentioning

confidence: 99%

Pediatric Pulmonary Hypertension

Abman¹,

Hansmann²,

Archer³

et al. 2015

Circulation

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948

405

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Abstract-Pulmonary hypertension is associated with diverse cardiac, pulmonary, and systemic diseases in neonates, infants, and older children and contributes to significant morbidity and mortality. However, current approaches to caring for pediatric patients with pulmonary hypertension have been limited by the lack of consensus guidelines from experts in the field. In a joint effort from the American Heart Association and American Thoracic Society, a panel of experienced clinicians and clinician-scientists was assembled to review the current literature and to make recommendations on the diagnosis, evaluation, and treatment of pediatric pulmonary hypertension. This publication presents the results of extensive literature reviews, discussions, and formal scoring of recommendations for the care of children with pulmonary hypertension. Key Words: AHA Scientific Statements ◼ bronchopulmonary dysplasia ◼ congenital diaphragmatic hernia ◼ congenital heart disease ◼ genetics ◼ persistent pulmonary hypertension of the newborn ◼ sickle cell disease © 2015 by the American Heart Association, Inc., and the American Thoracic Society.Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIR.0000000000000329 †Deceased. The American Heart Association and the American Thoracic Society make every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.This document was approved by the American Heart Association Science Advisory and Coordinating Committee on May 12, 2015, the American Heart Association Executive Committee on July 22, 2015, and the American Thoracic Society on July 24, 2015.The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIR.0000000000000329/-/DC1. The American Heart Association requests that this document be cited as follows: Abman SH, Hansmann G, Archer SL, Ivy DD, Adatia I, Chung WK, Hanna BD, Rosenzweig EB, Raj JU, Cornfield D, Stenmark KR, Steinhorn R, Thébaud B, Fineman JR, Kuehne T, Feinstein JA, Friedberg MK, Earing M, Barst RJ, Keller RL, Kinsella JP, Mullen M, Deterding R, Kulik T, Mallory G, Humpl T, Wessel DL; on behalf of the American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, Council on Clinical Cardiology, Council on Cardiovascular Disease in the Young, Council on Cardiovascular Radiology and Intervention, Council on Cardiovascular Surgery and Anesthesia, and the American Thoracic Society. Pediatric pulmonary hypertension: guidelines from the American Heart Association and American Thoracic Society. Circulation. 2015;132:2037-2099 Copies: This document is available on the World Wide Web site of the American Heart Associat...

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“…However, similarities between adult and pediatric PAH and compelling observational data (Yung et al, 2004;Lammers et al, 2007) have led to a consensus that epoprostenol provides significant benefit in children with idiopathic PAH, heritable PAH, and PAH associated with congenital heart disease (Barst et al, 2011a). As with adults, line dislodgement, local infection, and sepsis remain significant concerns (Doran et al, 2008;Ivy et al, 2009).…”

Section: Approved Drugsmentioning

confidence: 99%