Technical requirements and devices available for long-term hemodialysis in children-mind the gap!

Children requiring long-term kidney replacement therapy are a "rare disease" cohort. While the basic technical requirements for hemodialysis (HD) are similar in children and adults, key aspects of the child's cardiovascular anatomy and hemodynamic specifications must be considered. In this article, we describe the technical requirements for long-term HD therapy for children and the devices that are currently available around the world. We highlight the characteristics and major technical shortcomings of permanent central venous catheters, dialyzers, dialysis machines, and software available to clinicians who care for children. We show that currently available HD machines are not equipped with appropriately small circuits and sensitive control mechanisms to perform safe and effective HD in the youngest patients. Manufacturers limit their liability, and health regulatory agencies permit the use of devices, only in children according to the manufacturers' pre-specified weight limitations. Although registries show that 6-23% of children starting long-term HD weigh less than 15 kg, currently, there is only one long-term HD device that is cleared for use in children weighing 10 to 15 kg and none is available and labelled for use in children weighing less than 10 kg anywhere in the world. Thus, many children are being treated "off-label" and are subject to interventions delivered by medical devices that lack pediatric safety and efficacy data. Moreover, recent improvements in dialysis technology offered to adult patients are denied to most children. We, in turn, advocate for concerted action by pediatric nephrologists, industry, and health regulatory agencies to increase the development of dedicated HD machines and equipment for children.

Post-operative Chylothorax in Patients with Repaired Transposition of the Great Arteries.

Patients with dextro-transposition of the great arteries (d-TGA) require surgical repair as neonates. These patients are at risk for post-operative chylothorax. We sought to describe the presentation, imaging, and outcomes after intervention for patients with d-TGA with post-operative chylothorax. A retrospective chart review was performed in patients with repaired d-TGA who were referred from 1/1/2013 to 4/1/2020 for evaluation of chylothorax. Patient history, lymphatic imaging, and interventional data were collected. Impact of intervention on lymphatic drainage was evaluated with a student's t-test. Eight patients met inclusion criteria for this study. Five patients had a history of central venous thrombus leading to thoracic duct outlet occlusion. Five patients underwent intervention, two were managed conservatively, and one was not a candidate for intervention. Chylothorax resolved in six patients. There was a significant difference in output from 7 days prior to first intervention (114 mL/kg/day) compared to 28 days following final intervention (27 mL/kg/day, p = 0.034). There were no procedural complications. Chylothorax in patients with repaired transposition of the great arteries is often amenable to intervention. Early surveillance and management of central venous thrombosis may reduce the burden of lymphatic disease in these patients.

Vasopressor Administration via Peripheral Intravenous Access for Emergency Department Stabilization in Septic Shock Patients.

Background: Septic shock is commonly treated in the emergency department (ED) with vasopressors. Prior data have shown that vasopressor administration through a peripheral intravenous line (PIV) is feasible. Objectives: To characterize vasopressor administration for patients presenting to an academic ED in septic shock. Materials and methods: Retrospective observational cohort study evaluating initial vasopressor administration for septic shock. ED patients from June 2018 to May 2019 were screened. Exclusion criteria included other shock states, hospital transfers, or heart failure history. Patient demographics, vasopressor data, and length of stay (LOS) were collected. Cases were grouped by initiation site: PIV, ED placed central line (ED-CVL), or tunneled port/indwelling central line (Prior-CVL). Results: Of the 136 patients identified, 69 were included. Vasopressors were initiated via PIV in 49%, ED-CVL in 25%, and prior-CVL in 26%. The time to initiation was 214.8 minutes in PIV and 294.7 minutes in ED-CVL (p = 0.240). Norepinephrine predominated all groups. No extravasation or ischemic complications were identified with PIV vasopressor administration. Twenty-eight-day mortality was 20.6% for PIV, 17.6% for ED-CVL, and 61.1% for prior-CVL. Of 28-day survivors, ICU LOS was 4.44 for PIV and 4.86 for ED-CVL (p = 0.687), while vasopressor days were 2.26 for PIV and 3.14 for ED-CVL (p = 0.050). Conclusion: Vasopressors are being administered via PIVs for ED septic shock patients. Norepinephrine comprised the majority of initial PIV vasopressor administration. There were no documented episodes of extravasation or ischemia. Further studies should look at the duration of PIV administration with potential avoidance of central venous cannulation altogether in appropriate patients. How to cite this article: Kilian S, Surrey A, McCarron W, Mueller K, Wessman BT. Vasopressor Administration via Peripheral Intravenous Access for Emergency Department Stabilization in Septic Shock Patients. Indian J Crit Care Med 2022;26(7):811-815.

Optimizing Duration of Empiric Management of Suspected Central Line-Associated Bloodstream Infections in Pediatric Patients with Intestinal Failure.

OBJECTIVES: To assess whether a 24-hour length of hospitalization and empiric antibiotic therapy to exclude central line-associated bloodstream infection (CLABSI) in children with intestinal failure is potentially as safe as 48 hours, which is the duration most commonly used but not evidence based. STUDY DESIGN: A prospective single-institution observational cohort study was conducted among pediatric patients with intestinal failure from July 1, 2015, through June 30, 2018, to identify episodes of suspected CLABSI. The primary end point was time from blood sampling to positive blood culture. Secondary end points included presenting symptoms, laboratory test results, responses to a parent/legal guardian-completed symptom survey, length of inpatient stay, costs, and charges. RESULTS: Seventy-three patients with intestinal failure receiving nutritional support via central venous catheters enrolled; 35 were hospitalized with suspected CLABSI at least once during the study. There were 49 positive blood cultures confirming CLABSI in 128 episodes (38%). The median time from blood sampling to positive culture was 11.1 hours. The probability of a blood culture becoming positive after 24 hours was 2.3%. Elevated C-reactive protein and neutrophil predominance in white blood cell count were associated with positive blood cultures. Estimated cost savings by transitioning from a 48-hour to a 24-hour admission to rule-out CLABSI was $4639 per admission. CONCLUSIONS: A 24-hour duration of empiric management to exclude CLABSI may be appropriate for patients with negative blood cultures and no clinically concerning signs. A multi-institutional study would more robustly differentiate patients safe for discharge after 24 hours from those who warrant longer empiric treatment.

Routine Chest Radiographs in Children After Image-Guided Central Lines Offer Little Diagnostic Value.

BACKGROUND: The aim of this study was to investigate the utility of postoperative chest radiograph (CXR) after image-guided central venous line (CVL) placement in children. METHODS: A retrospective review was conducted of all tunneled CVLs placed at two pediatric institutions from 2010 to 2017. A subgroup analysis comparing a clinically driven approach to postoperative imaging against routine imaging was performed. RESULTS: During the study period, 1080 lines were placed in 915 patients. There were 892 postoperative CXRs (82.6%). An abnormality was seen on 40 radiographs (4.5%, n = 891), with 16 false-positive (1.3%) and 5 false-negative (0.6%) CXRs. The sensitivity and specificity of CXR to identify complications requiring intervention were 50.0% (95% confidence interval [95% CI], 10.0-90.0) and 95.8% (95% CI, 94.5-97.1), respectively. Positive predictive value of CXR was 7.5% (95% CI, 0-15.7) with a negative predictive value of 99.6% (95% CI, 99.2-100). A clinically driven approach to postoperative imaging was associated with 41% decrease in CXR (P < 0.001) without increased incidence of missed complications. Only three complications requiring intervention (0.3%) were suspected on postoperative CXR alone, and all of those were symptomatic before intervention. CONCLUSIONS: Routine postoperative CXR offers minimal value in identifying technical complications requiring intervention after image-guided CVL placement in asymptomatic children. We recommend abandoning this practice in favor of a clinical symptom-driven approach to postoperative imaging.

Stent-retriever thrombectomy in the treatment of infants with acute thrombosis of the superior vena cava and innominate vein.

OBJECTIVES: To describe the efficacy and safety of stent-retriever thrombectomy in infants with thrombosis of the superior vena cava (SVC) and innominate vein. BACKGROUND: Thrombosis of the SVC and of the innominate vein is a potentially life threatening complication in infants during intensive care treatment following major surgical procedures. To avoid reoperations, we evaluated interventional revascularization by stent-retriever thrombectomy. METHODS: From 2015 to 2017, five infants were diagnosed with acute thrombosis of the SVC and innominate vein following major cardiac or pediatric surgery. Using a femoral venous access and 4 or 5 French guiding catheters stent-retriever systems (4/20 mm or 6/30 mm) were placed into the thrombus and retrieved under suction. We aimed to revascularize not only the SVC but also the innominate, jugular, and subclavian veins. RESULTS: Following repeated stent retrieving manoeuvers, we were able to reestablish flow in the major veins of all patients. Due to significant residual thrombotic material, we decided to perform additional balloon dilatation of the SVC and innominate vein in 3/5 patients. There were no complications related to the procedure and none of our patients required blood transfusion. Following the intervention, the patients received treatment with low-molecular-weight heparin. Interventional treatment achieved persistent patency of the SVC and innominate vein in all patients. CONCLUSION: Stent-retriever thrombectomy is a safe and effective method for interventional treatment of acute thrombosis of the central veins in infants. Due to the large amount of thrombotic material, it is frequently required to combine this method with balloon compression of residual thrombotic material.

Vascular access in children requiring maintenance haemodialysis: a consensus document by the European Society for Paediatric Nephrology Dialysis Working Group.

BACKGROUND: There are three principle forms of vascular access available for the treatment of children with end stage kidney disease (ESKD) by haemodialysis: tunnelled catheters placed in a central vein (central venous lines, CVLs), arteriovenous fistulas (AVF), and arteriovenous grafts (AVG) using prosthetic or biological material. Compared with the adult literature, there are few studies in children to provide evidence based guidelines for optimal vascular access type or its management and outcomes in children with ESKD. METHODS: The European Society for Paediatric Nephrology Dialysis Working Group (ESPN Dialysis WG) have developed recommendations for the choice of access type, pre-operative evaluation, monitoring, and prevention and management of complications of different access types in children with ESKD. RESULTS: For adults with ESKD on haemodialysis, the principle of "Fistula First" has been key to changing the attitude to vascular access for haemodialysis. However, data from multiple observational studies and the International Paediatric Haemodialysis Network registry suggest that CVLs are associated with a significantly higher rate of infections and access dysfunction, and need for access replacement. Despite this, AVFs are used in only ∼25% of children on haemodialysis. It is important to provide the right access for the right patient at the right time in their life-course of renal replacement therapy, with an emphasis on venous preservation at all times. While AVFs may not be suitable in the very young or those with an anticipated short dialysis course before transplantation, many paediatric studies have shown that AVFs are superior to CVLs. CONCLUSIONS: Here we present clinical practice recommendations for AVFs and CVLs in children with ESKD. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system has been used to develop and GRADE the recommendations. In the absence of high quality evidence, the opinion of experts from the ESPN Dialysis WG is provided, but is clearly GRADE-ed as such and must be carefully considered by the treating physician, and adapted to local expertise and individual patient needs as appropriate.

The superiority of point of care ultrasound in localizing central venous line tip position over time.

The primary objective was to study agreement between X-rays and point of care ultrasound (POC-US) in determining central venous line (CVL) tip position. The secondary objective was to examine malposition rates over time using POC-US. Fifty-six neonates were enrolled who had a CVL placed. Initial X-rays and POC-US were obtained. POC-US was performed daily thereafter for the total of 6 days. US video clips were acquired in four standard echocardiographic views: subcostal, four-chamber, and short- and long-axis parasternal views. Gwet's agreement coefficient (AC1) for agreement measured inter-rater reliability of X-rays and POC-US (correct position/malposition). A generalized linear mixed model for binary clustered data estimated malposition rate over time. All analyses were conducted using SAS version 9.4 and Agree Stat. The study included 108 "pairs" of X-rays and POC-US images. Agreement coefficient (AC1), with respect to correct position/malposition of CVL tip, was high AC1 = 0.872 (UVC-AC1 = 0.814, PICC-AC1 = 0.94). Among birth weight (BW) < 1000 g, 1000-1499 g, and BW > 1500 g, AC1 values were 0.922, 0.774, and 0.873, respectively. CVL tip malposition rate decreased over time.Conclusions: Agreement between POC-US and X-rays for CVL tip position was high, with the highest in BW < 1000 g. The data suggest that POC-US can be used for initial confirmation and follow up of CVL tip position. What is Known • X-ray is currently the gold standard for localizing central venous line (CVL) tip position. • Malposition of CVL tip can lead to life-threatening complications. What is New • POC-US is superior to X-ray as it can follow CVL tip position over time, detecting malpositioned lines, adjusting them in a timely manner thus preventing complications. • Standardizing CVL placement, X-ray acquisition, POC-US acquisition with four views with video clips and ultrasound operator training increases accuracy and thus agreement between X-ray and POC-US. • UVC tip is more likely to be malpositoned than PICC tip. Malposition of UVC tip using POC-US decreased over time due to shrinking of the umbilical cord in the first 48 of life.

Immediate Removal of an Entrapped Central Venous Catheter Guide Wire.

Extravasal guide wire entrapment due to fraying during central venous catheter placement using the Seldinger technique is a rare complication, which should be resolved as soon as possible. A 68-year-old male was scheduled for open right-side decortication. After the induction of general anesthesia, an attempt was made to place a central venous line in the right subclavian vein. However, the guide wire was entrapped extravasally between the right clavicle and the first rib. The exact site was located by palpating the bend of the guide wire in the subclavian triangle and the thoracic surgeon was available. Therefore, it was decided not to try to visualize the guide wire any further and to immediately proceed with surgical removal of the guide wire. The platysma muscle was dissected allowing access to the subclavian triangle. Venotomy of the external jugular vein was performed and the entrapped guide wire was removed via the venotomy. The whole complication was resolved within 30 minutes and the primary procedure was then performed. Managing rare complications of central venous line placement requires skill, ingenuity and, sometimes, interdisciplinary cooperation, either with a radiologist or a surgeon. The decision to proceed with immediate surgical removal of the guide wire proved a right one, and, to the best of our knowledge, such a strategy has not been described in the relevant literature to date.

Increased Risk of Thrombosis Associated with Peripherally Inserted Central Catheters Compared with Conventional Central Venous Catheters in Children with Leukemia.

OBJECTIVE: To study the risk of catheter-associated thrombosis (CAT) between peripherally inserted central catheters (PICCs) and tunneled central venous catheters in children with leukemia. STUDY DESIGN: We analyzed all PICCs and conventional tunneled catheters placed in patients aged <18 years and admitted to our institute for leukemia treatment between February 2008 and April 2014. Cases of symptomatic CAT were confirmed by ultrasound and treated with low-molecular-weight heparin. RESULTS: During the study period, 157 PICCs and 138 conventional tunneled catheters were placed in 192 patients with leukemia. CAT incidence was 1.5% (n = 2) in the conventional tunneled catheter group and 10.2% (n = 16) in the PICC group. The OR for CAT occurrence after PICC vs conventional tunneled catheter placement was 5.6 (95% CI, 1.2-26.5). CONCLUSION: Our results suggest that the use of PICCs in children with leukemia increases the risk of CAT in comparison with the use of conventional tunneled catheters. Further randomized controlled studies are needed to characterize this risk and to better define indications.

Impact of a training program on adherence to recommendations for care of venous lines in internal medicine departments in Spain.

A high percentage of venous lines (VLs) are placed in non-ICU patients, particularly those treated in the internal medicine department (IMD). We assessed adherence to VL care after a training program aimed at nurses and clinicians attending patients admitted to Spanish IMDs. We performed a multicenter prospective observational point prevalence study in 14 Spanish IMDs in 2013 and 2016. We included all adult patients (> 18 years) admitted to IMDs on the study day and reviewed nursing records for patients with VL in place before and after a 1-year training program during 2015. Answers from an interview with head nurses of the IMDs regarding commonly used practices in the daily management of VLs were also compared. A total of 638 and 693 patients were seen during each period, respectively, and 530 and 598 patients had ≥ 1 VL implanted (83.1 vs. 86.3%). Catheters were considered unnecessary in 12.8 and 15.0% of cases (p = 0.28). Daily recording of the need for catheter use increased from 43.8 to 71.8% (p < 0.001). Furthermore, daily monitoring of the insertion site remained very frequent (94.4 vs. 92.2%; p = 0.16). The date of insertion was recorded in 86.3 and 85.5% of cases (p = 0.73), and no combination of closed connectors with open caps increased from 74.8 to 90.3% (p < 0.001). Overall, head nurses' knowledge improved in 4 out of 14 recommendations assessed (28.6%). A simple and easy program for training on management of VLs in Spanish IMDs was associated with improved quality of care.

Evaluation of the need for chest X-rays in the management of asymptomatic, intraluminal vascular access device occlusion in childhood cancer.

BACKGROUND: Venous access device (VAD) occlusion from intraluminal thrombus is a common complication during childhood cancer treatment. Current practice at many institutions is to assess VAD position with a chest X-ray (CXR) prior to intraluminal administration of tissue plasminogen activator (tPA). We aimed to determine the utility of this practice. PROCEDURE: A retrospective chart review of children with newly diagnosed cancer with a VAD, treated at The Hospital for Sick Children between 2010 and 2011, was performed. Episodes of line occlusion were identified both by reviewing patient CXRs for indication and identifying tPA doses dispensed. These episodes were reviewed to determine whether CXR findings resulted in management other than tPA. Cases in which the X-ray resulted in a change in management were further reviewed to determine whether administration of tPA could have resulted in potential patient harm. RESULTS: A total of 330 patients with newly diagnosed cancer with VADs were identified. Eighty-five (25.8%) patients experienced 123 episodes of VAD occlusion. VAD occlusions occurred more frequently in patients with tunneled external central venous lines (16/39, 41.5%) and peripherally inserted central catheters (PICC) (27/73, 37.0%) versus PORT (42/216, 19.4%; P = 0.001). There were nine (8.1%) episodes of VAD occlusion evaluated with a CXR in which the findings led to a change in management other than administering tPA. In each case, multiple specialists independently concluded that administration of tPA would have been unlikely to cause patient harm. CONCLUSION: Routine CXRs prior to the administration of tPA for asymptomatic VAD occlusion can safely be omitted.

Health care institutional charges associated with ambulatory bloodstream infections in pediatric oncology and stem cell transplant patients.

BACKGROUND: The impact of ambulatory bloodstream infections (Amb-BSIs) in pediatric oncology and stem cell transplant (PO/SCT) patients is poorly understood, although a large portion of their treatment increasingly occurs in this setting. This study aimed to understand the economic impact and length of stay (LOS) associated with these infections. PROCEDURE: Charges and LOS were retrospectively collected and analyzed for Amb-BSI events leading to a hospital admission between 2012 and 2013 in a tertiary, university-affiliated hospital. Events were grouped as BSI-MIXED when hospitalizations with care unrelated to the infection-extended LOS by more than 24 hr or as BSI-PURE for all others. Billing codes were used to group charges and main drivers were analyzed. RESULTS: Seventy-four BSI events were identified in 61 patients. Sixty-nine percent met definition for central line-associated BSI (CLABSI). Median total charge and LOS for an Amb-BSI were $40,852 (interquartile range [IQR] $44,091) and 7 days (IQR 6), respectively. Median charges for BSI-PURE group (N = 62) were $36,611 (IQR $34,785) and $89,935 (IQR $153,263) in the BSI-MIXED (N = 12) group. Median LOS was 6 (IQR 5) days in the BSI-PURE group and 15 (IQR 24) in the BSI-MIXED. Room, pharmacy, and procedure charges accounted for more than 70% of total charges in all groups. CONCLUSIONS: Amb-BSIs in PO/SCT patients result in significant healthcare charges and unplanned extended hospital admissions. This analysis suggests that efforts aiming at reducing rates of infections could result in substantial system savings, validating the need for increased efforts to prevent Amb-BSIs.

The influence of parents' voice on the consumption of propofol for pediatric procedural sedation-a randomized controlled trial.

BACKGROUND: In pediatric patients, invasive procedures such as the insertion of a central venous catheter or gastroscopy require deep sedation. It is unknown whether listening to parental voice during deep sedation in children can reduce sedative doses. AIM: The aim of this prospective study was to determine the effect of listening to a parent's voice during deep sedation on consumption of sedatives in children. METHODS: Fifty children aged 2-14 years undergoing central line placement or gastroscopy under deep sedation with propofol were randomly assigned to two groups: (A) listening or (B) not listening their parents' recorded voice reading a standardized text by the use of earphones. Depth of sedation was monitored by Comfort Score and by Bispectral Index. RESULTS: Mean sedative dose of propofol in both groups was equal (A 0.25 mg·kg-1 ·min-1 ; B 0.28 mg·kg-1 ·min-1 ; Δ -0.03 mg·kg-1 ·min-1 (CI 95% -0.08 to 0.01); P = 0.089). Furthermore, complication rate (P = 1.0) and recovery time (A 14.5 min; B 16.1 min; Δ = -1.6 min (CI 95% -6.98 to 3.81); P = 0.60) did not differ between the intervention and the control group. CONCLUSION: Listening to parental voice during deep sedation does not result in a reduction of sedative dose in children undergoing short medical procedures.

Indications and outcomes for tunneled central venous line placement via the axillary vein in children.

PURPOSE: To assess the indications, safety and outcomes of tunneled central venous catheters (CVCs) placed via a cutdown approach into the axillary vein in children, an approach not well described in this population. METHODS: A retrospective cohort study was performed on pediatric patients who received CVCs via open cannulation of the axillary vein or one of its tributaries between January 2006 and October 2016 at two hospitals. RESULTS: A total of 24 axillary CVCs were placed in 20 patients [10 male (42%); mean weight 7.0 kg (SD 2.9); mean age 10 months (SD 6)]. The most common indications for axillary vein access included neck or chest wall challenges (tracheostomies or chest wall wounds) (n = 18). The median duration of line placement was 140 days (IQR 146). The most common indications for removal were completion of therapy (n = 7, 39%) and infection (n = 5, 28%). There were no early complications. Long-term complications included infection (n = 5) or catheter malfunction (n = 3). CONCLUSIONS: Tunneled CVC placement via a cutdown approach into the axillary vein or its tributary can be an effective alternative approach to obtain long-term vascular access in children. Outcomes may be comparable to lines placed in traditional internal jugular and subclavian vein locations.

Hemodynamic changes in patients with extracorporeal membrane oxygenation (ECMO) demonstrated by contrast-enhanced CT examinations - implications for image acquisition technique.

Extracorporeal membrane oxygenation (ECMO) is an established tool for respiratory and circulatory support. In computed tomography, altered hemodynamics in ECMO patients requires special considerations and handling in contrast injection and its timing. In this article, we demonstrate changes in hemodynamics in ECMO patients captured on contrast-enhanced CT examinations and pitfalls in strategies for contrast injection in relation to the ECMO flow, cardiac function and the placement of ECMO cannulas. Contrast-enhanced CT of patients with ECMO requires prior knowledge of the ECMO cannulas, central venous lines, changes of hemodynamics induced by low cardiac output and the influence of adjustment of ECMO on blood flow in order to optimize injection of the contrast material and timing of the scan. Special considerations include temporary reduction of the ECMO flow, selection of the injection site and increasing volume or flow rate of the contrast material.

Hemodialysis in children with ventriculoperitoneal shunts: prevalence, management and outcomes.

BACKGROUND: Hemodialysis (HD) in children with a concomitant ventriculoperitoneal shunt (VPS) is rare. Registry data suggest that peritoneal dialysis with a VPS is safe, but little is known about HD in the presence of a VPS. METHODS: We performed a 10-year survey to determine the prevalence of a VPS, complications and outcome in children with a VPS on HD in 15 dialysis units from the 13 countries participating in the European Pediatric Dialysis Working Group. RESULTS: Eleven cases of HD with a VPS were reported (prevalence 1.33 %; 328 patient-months) and compared with prospective Registry data. The median age at start of dialysis was 9.6 [inter-quartile range (IQR) 1.0-15.0] years and median HD vintage was 2.4 (IQR 1.7-3.0) years. Dialysis was performed through a central venous line (CVL) and through an arteriovenous fistula in six and five children, respectively. Three CVL infections occurred in two children, but these children did not develop VPS infections or meningitis. Symptoms of hemodynamic instability were reported in six (55 %) children at least once per week, with hypotension or hypertension occurring in four of these children and nausea, vomiting and headaches occurring in two; four other children reported less frequent symptoms. Seizures on dialysis occurred in two children, at a frequency of less than once per month, with one child also experiencing visual disturbances. During follow-up (median 4.0; IQR 0.38-7.63 years), three children remained on HD and eight had a functioning transplant. No patients were switched to PD. CONCLUSIONS: Hemodialysis in children with a VPS is safe, but associated with frequent symptoms of hemodynamic instability. No episodes of VPS infection or meningitis were seen among the children in the survey, not even in those with CVL sepsis.

Arrhythmias in the paediatric intensive care unit: a prospective study of the rates and predictors of arrhythmias in children without underlying cardiac disease.

OBJECTIVE: Arrhythmias are common in patients admitted to the paediatric intensive care unit. We sought to identify the rates of occurrence and types of arrhythmias, and determine whether an arrhythmia was associated with illness severity and paediatric intensive care unit length of stay. DESIGN: This is a prospective, observational study of all patients admitted to the paediatric intensive care unit at the Children's Hospital at Montefiore from March to June 2012. Patients with cardiac disease or admitted for the treatment of primary arrhythmias were excluded. Clinical and laboratory data were collected and telemetry was reviewed daily. Tachyarrhythmias were identified as supraventricular tachycardia, ventricular tachycardia, and arrhythmias causing haemodynamic compromise or for which an intervention was performed. RESULTS: A total of 278 patients met the inclusion criteria and were analysed. There were 97 incidences of arrhythmia in 53 patients (19%) and six tachyarrhythmias (2%). The most common types of arrhythmias were junctional rhythm (38%), premature atrial contractions (24%), and premature ventricular contractions (22%). Tachyarrhythmias included three supraventricular tachycardia (50%) and three ventricular tachycardia (50%). Of the six tachyarrhythmias, four were related to placement or migration of central venous lines and two occurred during aminophylline infusion. Patients with an arrhythmia had longer duration of mechanical ventilation and paediatric intensive care unit stay (p<0.001). In multivariate analysis, central venous lines (odds ratio 3.1; 95% confidence interval 1.3-7.2, p=0.009) and aminophylline use (odds ratio 5.1; 95% confidence interval 1.7-14.9, p=0.003) were independent predictors for arrhythmias. CONCLUSIONS: Arrhythmias were common in paediatric intensive care unit patients (19%), although tachyarrhythmias occurred rarely (2%). Central venous lines and use of aminophylline were identified as two clinical factors that may be associated with development of an arrhythmia.

[Doctor-nurse delegation of the insertion of central venous lines]. / Délégation médico-infirmière dans la pose des voies veineuses centrales.

The Léon Bérard Cancer Centre treats the disease in all its complexity with numerous disciplines such as surgery, medicine, radiotherapy, palliative care, home care, etc. The insertion of a central venous line is an essential part of cancer care and the nursing profession. It enables patients to have their treatment administered in the best possible conditions and without risk.

Angiographic evidence of an inadvertent cannulation of the marginal sinus following central line migration: illustrative case.

BACKGROUND: Central venous catheters (CVCs) play an indispensable role in clinical practice. Catheter malposition and tip migration can lead to severe complications. The authors present a case illustrating the endovascular management of inadvertent marginal sinus cannulation after an internal jugular vein (IJV) catheter tip migration. OBSERVATIONS: A triple-lumen CVC was inserted without complications into the right IJV of a patient undergoing a repeat sternotomy for aortic valve replacement. Two weeks postinsertion, it was discovered that the tip had migrated superiorly, terminating below the torcula in the posterior fossa. In the interventional suite, a three-dimensional venogram confirmed the inadvertent marginal sinus cannulation. The catheter was carefully retracted to the sigmoid sinus to preserve the option of catheter exchange if embolization became necessary. After a subsequent venogram, which displayed an absence of contrast extravasation, the entire catheter was safely removed. The patient tolerated the procedure well. LESSONS: Clinicians must be vigilant of catheter tip migration and malposition risks. Relying solely on postinsertion radiographs is insufficient. Once identified, prompt management of the malpositioned catheter is paramount in reducing morbidity and mortality and improving patient outcomes. Removing a malpositioned catheter constitutes a critical step, best performed by a specialized team under angiographic visualization.