Long-term IV access in paediatrics - why, what, where, who and how.

Establishment of long-term central venous access imposes the risk of procedural adverse events (air embolism, pneumothorax, accidental arterial cannulation of the great vessels, tricuspid valve damage and cardiac tamponade) as well as the risk of increased morbidity and mortality due to catheter related blood stream infections, vessel stenosis, deep vein thrombosis and the often high risk anaesthetic management of syndromic children. This narrative review aims to provide a historical and clinical background for the development and use of CVADs (central venous access devices), origin and management of the most common complications (catheter related thrombosis, infections and persistent withdrawal occlusion) and present the reader with an update on the "why, what, where, who and how" in paediatric long-term central venous access. Finally, we will present the reader with a clinical method for applying a retrograde inserted tunnelled and cuffed catheter using the left brachiocephalic vein access.

Hydrochloric acid prolongs the lifetime of central venous catheters in haematologic patients with bacteraemia.

INTRODUCTION: Bacteraemia in adult patients undergoing treatment for leukaemia is common and associated with profound morbidity and mortality. Infections related to the use of a central venous catheter (CVC) are difficult to eliminate with systemic antibiotics. Premature catheter removal is often due to retained biofilm infection. This study investigated if the additional use of hydrochloric acid (HCl) as an intraluminal lock solution may prolong the lifetime of the CVC. METHODS: The study was performed retrospectively based on a database including patients with a tunnelled Leonard 10 F dual or triple lumen CVC implanted who received HCl instillation due to bacteraemia during a five-year period. RESULTS: In a total of 71 cases of bacteraemia, HCl instil-lation was performed. Following HCI instillation, the CVC was not removed due to infection in 49 out of 71 patients (69%). Furthermore, 22 patients (31%) retained their CVC until the end of treatment. Non-infectious mortality (19/71), accidental pull (2/71) or mechanical CVC dysfunction (6/71) were other reasons for premature removal. Twenty-two catheters (31%) had to be removed due to ongoing infection. The median time from CVC placement until HCl instillation was 39 days. The median time from HCl instillation until removal of CVC was 58 days. The most common bacteriological findings were coagulase-negative staphylococci 34%, Enterococcus spp 14% and Escherichia coli 14%. CONCLUSIONS: The study's findings indicate that a prolonged use of CVC is possible following HCl instillation in adult haematologic patients with bacteraemia. FUNDING: none. TRIAL REGISTRATION: not relevant.

Bench-to-bedside review: Challenges of diagnosis, care and prevention of central catheter-related bloodstream infections in children.

Central venous catheters (CVCs) are indispensable in modern pediatric medicine. CVCs provide secure vascular access, but are associated with a risk of severe complications, in particular bloodstream infection. We provide a review of the recent literature about the diagnostic and therapeutic challenges of catheter-related bloodstream infection (CRBSI) in children and its prevention. Variations in blood sampling and limitations in blood culturing interfere with accurate and timely diagnosis of CRBSI. Although novel molecular testing methods appear promising in overcoming some of the present diagnostic limitations of conventional blood sampling in children, they still need to solidly prove their accuracy and reliability in clinical practice. Standardized practices of catheter insertion and care remain the cornerstone of CRBSI prevention although their implementation in daily practice may be difficult. Technology such as CVC impregnation or catheter locking with antimicrobial substances has been shown less effective than anticipated. Despite encouraging results in CRBSI prevention among adults, the goal of zero infection in children is still not in range. More high-quality research is needed in the field of prevention, accurate and reliable diagnostic measures and effective treatment of CRBSI in children.

[The use of ultrasound for nerve block in children seems beneficial]. / Lovende resultater ved ultralydvejledt anlæggelse af nerveblokade hos børn.

Nerve blocks play an increasingly important role in pediatric regional anaesthesia. The benefits are numerous compared to standard pain regimens. The use of ultrasound (US) for nerve blocks lowers the volume of local anaesthetics applied, shortens the on-set time and results in higher success rates. Furthermore, US has the potential to reduce the rate of complications. This review describes both classic and US guided techniques for the peripheral nerve blocks used for pediatric abdominal and thoracic surgery and briefly discusses the advantages and disadvantages of applying US.

[Partial occlusion of the Bain circuit causes respiratory acidosis under general anesthesia]. / Partiel okkluderet Bain-system medfører respiratorisk acidose under generel anaestesi.

The Bain circuit is a modification of the Mapleson D ventilation system used in general anaesthesia in children and adults. It has several advantages over other systems as it is light in weight, convenient, and has no valves. But it contains the risk of undetected leak or occlusion, because of its construction with a small inner tube, which provides the patient with fresh gas, inside a larger corrugated tube. We report a partial occlusion in the T-piece of the Bain circuit, leading to high peak pressure and respiratory acidosis under controlled ventilation in a 15-year-old boy.