2008 SOR guidelines for the prevention and treatment of thrombosis associated with central venous catheters in patients with cancer: report from the working group.

BACKGROUND: In view of the lack of recommendations on central venous catheter (CVC)-associated thrombosis in cancer patients, we established guidelines according to the well-standardized Standards, Options and Recommendations methodology. MATERIAL AND METHODS: A literature review (1990-2007) on CVC-associated thrombosis was carried out. The guidelines were developed on the basis of the corresponding levels of evidence derived from analysis of the 36 of 175 publications selected. They were then peer reviewed by 65 independent experts. RESULTS: For the prevention of CVC-associated thrombosis, the distal tip of the CVC should be placed at the junction between the superior cava vein and right atrium; anticoagulants are not recommended. Treatment of CVC-associated thrombosis should be based on the prolonged use of low-molecular weight heparins. Maintenance of the catheter is justified if it is mandatory, functional, in the right position, and not infected, with a favorable clinical evolution under close monitoring; anticoagulant treatment should then be continued as long as the catheter is present. CONCLUSIONS: Several rigorous studies do not support the use of anticoagulants for the prevention of CVC-associated thrombosis. Treatment of CVC-associated thrombosis relies on the same principles as those applied in the treatment of established thrombosis in cancer patients.

Long-term central venous catheter infection in HIV-infected and cancer patients: a multicenter cohort study.

OBJECTIVES: To evaluate and compare the risk of long-term central venous catheter (CVC) infection in human immunodeficiency virus (HIV)-infected and cancer patients. DESIGN: Prospective multicenter cohort study based on active surveillance of long-term CVC manipulations and patient outcome over a 6-month period. SETTING: Services of infectious diseases and oncology of 12 university hospitals in Paris, France. PARTICIPANTS: In 1995, all HIV and cancer patients with solid malignancy were included at the time of long-term CVC implantation. RESULTS: Overall, 31.6% of long-term CVC infections were identified in 32% of 201 HIV and 5% of 255 cancer patients. Most were associated with bacteremia, most commonly coagulase-negative staphylococci. The long-term CVC time-related infection risk was greater in HIV than in cancer patients (3.78 vs 0.39 infections per 1,000 long-term CVC days; P<.001). The independent risk factors of long-term CVC infection were as follows: in HIV patients, frequency of long-term CVC handling and neutropenia; in cancer patients, poor Karnofsky performance status; in both HIV and cancer patients, recent history of bacterial infection. The risk of long-term CVC infection was similar for tunneled catheters and venous access ports in each population. CONCLUSIONS: Prevention of long-term CVC infection should focus first on better sterile precautions while handling long-term CVC, especially in HIV patients who have frequent and daily use of the long-term CVC.

Quantitative blood cultures for diagnosis and management of catheter-related sepsis in pediatric hematology and oncology patients.

Paired quantitative blood cultures collected simultaneously via catheter and peripheral vein in Isolator 1.5 ml tubes, were performed in 50 febrile hematology children. Samples were taken to diagnose catheter-related sepsis (CRS) without catheter removal and to monitor the therapeutic efficiency of antimicrobials administered through the infected device by infusion and/or by the antibiotic lock technique (ALT). In 7 children (14%) the colony counts from catheter blood samples were 30-fold higher than the colony counts from peripheral samples, suggesting CRS; in 7 other patients (14%), identical colony counts in both samples suggested sepsis was not catheter-related. One patient (2%) had septicemia caused by E. coli found in the urinary tract; only the peripheral blood cultures were positive. In 6 patients (12%), the Isolator system was not effective for diagnosing bacteremia or CRS; in 29 patients (58%) the febrile episode was not microbiologically documented. All episodes of CRS were cured whatever the treatment was: infusion or ALT.

Negative catheter-tip culture and diagnosis of catheter-related bacteremia.

The accuracy of paired quantitative blood cultures (PQtBCs) collected in pediatric Isolator 1.5-ml tubes compared to central venous catheter (CVC) segment cultures (hub and tip) to diagnose catheter-related bacteremia (CRB) was evaluated in 58 bacteremic adult patients. The second aim of this study was to state precisely whether the tip or the hub (or both) of the infected device was the source of the bacteremia in case of significant results of PQtBC. Fifty-eight bacteremic patients with suspected CRB entered the study. In 52 patients, the diagnosis was obtained before CVC removal by PQtBC and was confirmed by CVC segment cultures: CRB in 30 patients, non-catheter-related bacteremia in 22 patients. Six patients had CRB not found by PQtBC. 1) PQtBC is 83% sensitive, 100% specific (negative predictive values 78%, positive predictive values 100%). 2) Sixteen bacteremic patients had authentic hub-related bacteremia (positive hub culture associated with negative tip cultures). When CRB is suspected in bacteremic patients, a negative tip culture cannot exclude the diagnosis of CRB. In all cases, CVC tip culture must be associated either with PQtBC or with hub cultures.

Catheter fragments embolization.

Although the use of central venous silicone catheters is widespread, little is known about the incidence of catheter rupture and embolization. Over a three-year period, 3916 silicone catheters were inserted in 3672 patients in the authors' hospital. Catheter or catheter fragments embolism occurred in 4 patients (1.2 embolizations per 1000 patients treated). Inappropriate mechanical deobstruction attempts resulted in 2 embolizations, and hence, these should be avoided. Chest roentgenography failed to detect the small fragments within the heart silhouette in 2 cases. Two-dimensional echocardiography showed the separated catheter fragment in all 4 cases. All four catheter fragments were subsequently removed from the right-heart chambers.

[Metabolic radiotherapy: what role will it have in 2001?]. / Radiothérapie métabolique: quel rôle en 2001?

Metabolic radiotherapy is a new therapy for management of bone pain in patients with bone metastatic prostate carcinoma. Strontium-89 and Samarium-153 concentrate in bone metastases and radiate them. A pain decrease is obtained in 60-70% of cases. Side effects are a significant hematological depression without great clinical consequences if good therapeutic indications are respected. Our multidisciplinary experience of these radionuclides in 54 performed treatments shows a rate of good responders of 66% with a rate of excellent results (total decrease of pain) in 47%. The therapeutic effectiveness is correlated with pain intensity measured by Visual Analogic Scale (VAS) and equivalent dose of morphine. Radionuclide therapy should be applied to patients as early as possible after establishment of bone metastases.

[Pain in lumbar puncture. Results of a 2-year discussion at the French Society of Pediatric Oncology]. / La douleur de la ponction lombaire. Résultats de 2 années de réflexion au sein de la Société Française d'Oncologie Pédiatrique.

BACKGROUND: Lumbar puncture is a common procedure in pediatric onco-hematology. Repeated invasive painful procedures may contribute to increase distress displayed during medical treatment, and cause regression, depression and other psychological disorders. MATERIAL AND METHODS: A two-year workshop of the Société française d'oncologie pédiatrique was reviewed through a questionnaire assessing changes in technical management of lumbar puncture, local anesthesia, sedation and cognitive-behavioral interventions. RESULTS: Significant changes were found for pain assessment, local anesthesia procedures, and nitrous oxide administration. The extensive use of the Emla cream largely contributed to reduce pain. Anxiety however remained an unsolved problem, particularly among young children. CONCLUSION: Pain in pediatrics remains a major challenge. This workshop is a model of reflexion to achieve a better management of pain during invasive medical procedures.

[Intravascular migration of fragments of central venous catheters. 3 cases]. / Migration intravasculaire de fragments de cathéters veineux centraux. Trois observations.

Intravascular embolization of catheter fragments is a severe and rare complication of indwelling intravenous catheters. The estimated rate of incidence is 0,1% of central venous catheter insertions. This report of three cases shows how this complication may occur and suggests preventive measures. Mortality from arrhythmia-related cardiac arrest, septic and thrombo-embolic complications, and the risk of perforation of the heart argue for an immediate extraction of the broken catheter. Surgical removal used to be the only method; a non-surgical technique is now available, in which the embolized fragment is removed by means of a loop snare. No death has been associated with this technique which seems to be safe and reliable.

[Central venous catheterization in pediatric hematology]. / Le cathétérisme veineux central en hématologie pédiatrique.

Central venous catheters (CVC) have proven to be a reliable route of the administration of chemotherapy, saline, blood cells and nutritional support in patients with malignant haematological disease. However, infection remained one of the most important causes of morbidity associated with this procedure. The aims of this study were a) to evaluate the efficacy of laminar air flow to prevent CVC infections, b) to study morbidity associated with polyethylene (PE) and silicone (S) catheters, and c) to evaluate the part played by increasing staff practice. 177 CVC were inserted in 170 children during a period of 20 months. Ages ranged from 5 months to 15 years (mean: 7 years). All the S CVC were tunnelled whereas, because of their rigidity, none of the PE CVC were. At the time of their removal, bacteriological samples from the CVC skin exit site, blood drawn through the catheter and the tips of these CVC were cultured. During the first period (one year), three groups of CVC were studied: in group 1, 37 S CVC in patients placed in a non-sterile ward; in group 2, 40 S CVC in children nursed under laminar air flow; in group 3, 60 PE CVC in patients of a non-sterile ward. During the second period (8 months), 40 new S CVC were inserted in children nursed in non-sterile wards, but after nursing staff training (group 4).(ABSTRACT TRUNCATED AT 250 WORDS)

[Schwannomas and schwannosarcomas of the duodenum and the duodenojejunal angle. Apropos of 3 cases]. / Schwannomes et schwannosarcomes duodénaux et de l'angle duodéno-jéjunal. A propos de trois cas.

The authors report on three cases of benign neurogenic tumors of the duodenum, two of which degenerated. They discuss the difficulties involved in diagnosis and treatment. In one case, the tumor was simply excised. In the two cases of malignant tumors, the excision was wider because of extensions to the liver or colon. Postoperative chemotherapy was applied in both cases, but to little effect as the two patients died within two years of the operation.

[Induction therapy of acute leukemia in children. Current results and problems related to therapeutic aplasia. Apropos of 146 cases]. / Traitement d'induction des leucémies aiguës de l'enfant. Résultats actuels et problèmes liés à l'aplasie thérapeutique. A propos de 146 observations.

Between 1983 and 1984, 146 children have been treated in the pediatric hematology department of Saint-Louis Hospital (Paris) for induction of acute leukemia (AL). 119 had an acute lymphocytic leukemia (ALL) and 27 an acute non lymphocytic leukemia (ANLL). The rate of complete remission was 94% for all patients (97% in ALL and 81.5% in ANLL). Fever occurred in 95% of children with positive blood cultures in one third on these. Four children died between the fifth and the twenty fifth days after onset of treatment from sepsis. One of these patients was a neonate with ANLL. 127 patients had a central venous line during induction used for blood sampling and treatment (chemotherapy, antibiotics, parenteral nutrition, platelets and red blood cells infusions). This supportive care is very important to improve prognosis of the AL particularly in very intensive chemotherapy.

[Elements for a cost/utility analysis of long term intravenous devices]. / Eléments pour une approche coût/utilité des dispositifs intraveineux de longue durée.

Three long-term intravenous infusion strategies were compared, namely an implantable port (IP), a tunneled central catheter (TCC), and repeated peripheral catheterization (RPC). A decision analysis model was used in which the sequence of decisions and their possible consequences was described as a decision tree for each of the three strategies. The likelihood of each event occurring was determined based on a literature review. Each event was assigned a cost and a utility. Direct medical costs for the society include the cost of the material, the cost of implantation and removal of the device in the operating room, and the cost of treating complications directly ascribable to the strategy used. Utility is a combination of efficacy (as evaluated based on the likelihood of use of the strategy for one year) and quality of life (as evaluated by experts). In the basic analysis, RPC was the most cost-saving method but had an adverse effect on quality of life (0.82). The cost of using IC or TCC for one year was higher, with the main contributors to the excess cost being the insertion procedure and the management of complications (primarily deep vein thrombosis and infection). Quality of life was better with IC (0.98) than with TCC (0.93). IC also had a higher cost-utility ratio (11,738 French francs [FF]) versus 17,393 FF). A one-way sensitivity comparison of IC and TCC showed that the only realistic change capable of reversing the order between these two methods was a decrease by one-third in the risk of infection with TCCs. This model, used here for the first time, establishes that IC is superior over TCC.

[Infectious complications of long term intravenous devices: incidence, risk factors, diagnostic tools]. / Complications infectieuses des dispositifs intraveineux de longue durée: incidence, facteurs de risque, moyens diagnostiques.

Implantable venous ports and Hickman central venous catheters are widely used in patients with cancer, blood disorders, or HIV infection, both for in-hospital care and at home. Infectious complications are among the common causes for readmission in these patients. The present review discusses the incidence, risk factors, and diagnostic tools for infectious complications associated with long-term venous access devices.

[Epidermoid cysts of the spleen. Apropos of 2 cases]. / Kystes épidermoïdes de la rate. A propos de deux cas.

The authors report two new cases of splenic epidermoid cyst. They stress the importance of sonography and the need for thorough examination of the surgical specimen for establishing the diagnosis. They also discuss several etiological hypotheses. Although uncommon, the possibility of an epidermoid cyst must always be considered once the echinococcal nature of the cyst has been ruled out, in all cases of splenic cysts in children or young adults.