1. Spotlight Case May 2003 Central Line Complications in an Infant webmm.ahrq.gov

2. 2 Source and Credits This presentation is based on the May 2003 AHRQ WebM&M Spotlight Case in Pediatrics See the full article at http://webmm.ahrq.govhttp://webmm.ahrq.gov CME credit is available through the Web site –Commentary by: Adrienne Randolph, MD, Harvard Medical School –Editor, AHRQ WebM&M: Robert Wachter, MD –Spotlight Case Editor: Tracy Minichiello, MD –Managing Editor: Erin Hartman, MS

3. 3 Objectives At the conclusion of this educational activity, participants should be able to: –List the complications of central line manipulation –Appreciate the limitations of diagnostic studies for PE in children –Describe modalities for prevention of catheter-related venous thrombosis

4. 4 Case: Central Line Complications An 8-month-old girl was in the ICU for 6 days for treatment of septic shock secondary to meningococcemia, and was to be transferred to a general pediatrics ward. In preparation, the nurse flushed the patient’s central venous catheter with heparin and locked the line. Within minutes, the infant became cyanotic and apneic. A full code ensued and the patient was stabilized with a blood pressure 95/55, heart rate 120, RR 35, and O2 sat 90% on 100% non-rebreather.

5. 5 Complications of Central Line Manipulation Arrhythmias Irritation of conduction system by catheter tip Venous air embolism Venous thromboembolism Polderman KH, et al. Intensive Care Med. 2002;28:1-17.

6. 6 Pulmonary Thromboembolism in Pediatrics Thromboembolism less common in infants and children than adults – Lower incidence vs. underdiagnosis Index of suspicion must be high to start anticoagulation Grandas OH, et al. Am Surg. 2000:66:273-276.

7. 7 Data Supporting PE in this Infant Sudden high O2 requirement Marked hemodynamic instability Proximity to manipulation of catheter Potential hypercoagulable state – Sepsis – Meningococcemia associated with acquired protein C deficiency Faust SN, et al. NEJM. 2001;345:408-16.

8. 8 Clinical Management of Suspected Catheter-Related PE Immediate aspiration of central line – Patient in right-side-up position Consider empiric anticoagulation If hemodynamically unstable, consider stat portable echocardiogram to assess RV function – Septal deviation, pulmonary hypertension

9. 9 Diagnosis of PE in Children Gold standard: pulmonary angiogram –Rarely performed, not readily available V/Q scan –Limited diagnostic value if atelectasis or effusions Spiral CT –Pediatric radiologists experience limited –No studies evaluating diagnostic characteristics in children Velmahos GC, et al. Arch Surg. 2001;136:505-11. Baile EM, et al. Am J Respir Crit Care Med. 2000;161:1010-5.

10. 10 Pulmonary Angiogram

11. 11 High Probability VQ Scan Ventilation Perfusion

12. 12 Spiral CT

13. 13 Diagnosis of PE in Children D-dimer –Good negative predictive value in adults with low probability of PE –Poor specificity –No studies in children Kelly J, et al. Arch Intern Med. 2002;162:747-756.

14. 14 Case (cont.): Central Line Complications A spiral CT revealed a large central pulmonary emboli. Anticoagulation therapy was started. The patient improved and was discharged to home several days later without sequelae from this event.

15. 15 Incidence of DVT in Children Incidence of DVT/PE not well studied in children – Prospective study of 59 children with more than 2 risk factors found only 1 DVT – Retrospective study evaluated 2746 trauma patients, 3 DVTs identified Rohrer MJ, et al. J Vasc Surg.1996;24:46-9. Grandas OH, et al. Am Surg. 2000:66:273-276.

16. 16 Incidence of DVT in Children Clots often related to central venous catheters – Catheter-related DVTs detected in 8%- 25% of infants and children in the ICU by ultrasound – 1/3 of clots in infants and young children associated with central lines Pierce CM, et al. Intensive Care Med. 2000;26:967-72; Krafte-Jacobs B, et al. J Pediatr. 1995;126:50-4; van Ommen CH, et al. J Pediatr 2001:139:676-81.

17. 17 Risk Factors for DVT in Children Central venous catheters Sepsis DIC Immobility Cancer Nephrotic syndrome Dehydration >150% ideal body weight Oral contraceptives History DVT/PE Acquired/hereditary deficiencies of anticoagulation

18. 18 Consequences of Central Line Thrombosis Pulmonary Embolism –Incidence unknown, registry data now available but flawed Thrombus propagation –IVC, ileofemoral, subclavian occlusion –Typically recanalize, but may cause SVC or postphlebitic syndromes van Ommen CH, et al. J Pediatr 2001:139:676-81; Monagle P, et al. Pediatr Res 2000;47:763-6; Andrew M, et al. Blood 1994;83:1251-7.

19. 19 Preventing Catheter-Related Thrombosis Heparin-bonded catheters –Best data available for prevention –Marked decrease in thrombus formation –Decrease incidence of catheter-related infections Pierce CM, et al. Intensive Care Med. 2000;26:967-72. Krafte-Jacobs B, et al. J Pediatr. 1995;126:50-4.

20. 20 Low dose heparin flushes not beneficial in adult literature –No studies in children –Higher dose may be effective but risk systemic anticoagulation Randolph AG, et al. Chest. 1998;113:165-71. Smith S, et al. Am J Pediatr Hematol Oncol. 1991;13:141-3. Preventing Catheter-Related Thrombosis

21. 21 Low molecular weight heparin –No clinical trials for prophylaxis in pediatric population Compression stockings and pneumatic compression devices –Not available in pediatric sizes Preventing Catheter-Related Thrombosis

22. 22 Take-Home Points Complications of central line manipulation include arrhythmias, thrombosis, and embolism The low reported incidence of DVT/PE in infants and children may be due to underdiagnosis Majority of thrombotic episodes in pediatrics related to central lines

23. 23 Take-Home Points (cont.) Central line thrombosis can result in serious morbidity – PE, SVC syndrome, iliofemoral and IVC clots Heparin-bonded catheters may prevent central line-related thrombosis – RCT needed to determine if this should be standard of care