Pediatric Central Venous Catheters In Patients Less Than Two Years Of Age: Do Complication Rates Differ Between Tunneled IJ, Tunneled Femoral, and PICCs? Jessica Brown, MPAS, MHA, PA-C Shireen Hayatghaibi, MPH Daniel Ashton, MD 4:3 Header and affiliation is locked and may not be altered

Conflicts of interest None

Objectives Differentiate CVC vs PICC based on catheter insertion site List potential complications of CVCs and PICCs Recall the complication rates comparing IJ CVCs, Fem CVCs, and upper extremity PICCs, and determine optimal and sub-optimal insertion site(s) for catheter placement

background Central venous access is essential to treatment at TCH Central venous catheters (CVC) and peripherally inserted central catheters (PICC) CVC: Femoral (Fem), Internal Jugular (IJ), Subclavian PICC: Basilic, Brachial, Cephalic, Saphenous Multiple techniques and insertion sites for placement Goal: Catheter tip terminates in the central venous circulation Central venous access is vital to the treatment and long term therapy of many pediatric patients at Texas Children’s Hospital. As an increasing number of peripherally inserted central catheters (PICCs) and central venous catheters (CVCs) are being placed using various techniques and venous access locations. CVCs include femoral vein (FEM) or the internal jugular vein (IJ) as insertion sites, and can include tunneled or non-tunneled catheters, cuffed catheters, and PACs. PICCs are inserted into a peripheral vein (hence the name), such as into the basilic or brachial veins, or less commonly in IR the cephalic or saphenous vein. Regardless of the insertion site, the catheter should terminate in the central venous circulation, SVC/RA junction for “upper” or *** for “lower”. It is important to understand potential complications for the different access sites when determining a plan for placing a catheter into the central venous system. IJ is considered for CVC access site when the patient is small and there is increased catheter-to-vessel size ratio. FEM is also considered in small patients, especially if sedation is contraindicated or the line must be placed at bedside.

purpose Evaluate CVCs and PICCs in children less than two years of age and determine if vascular access location affects complication rates The study was initially designed to evaluate CVCs, particularly Femoral and IJ insertion sites, and PICCs in a population less than two years of age to determine if the vascular access location affected complication rates, and if so, the types of complications. The vascular access sites compared were tunneled IJ, tunneled femoral, and PICCs.

Materials and methods Retrospective cohort study CVC placement by Interventional Radiology (IR) in patients < 2 y.o. January 1, 2014 through December 31, 2015 Electronic medical record and PACS imaging system REDCap database Fisher’s exact test After receiving IRB approval, a retrospective study was completed using the EMR and PACS system at a large pediatric hospital to query all central venous catheters placed from January 2014 through December 2015. A team compiled data into REDCap on each CVC that was queried, and the data was then analyzed using Fisher’s exact test

Materials and methods Patient demographics and indication for CVC or PICC Technical details of the procedure Complications IR response to complication Data points collected included patient demographics and the indication for central line placement, procedural details regarding CVC location, complications such as infection, line malfunction, malposition, thrombus, and follow-up including line removal date and reason (if any complication) for line removal???

Demographics: top patient populations FEM Cardiology (54%) Neonates (21%) IJ TPN (36%) Oncology (26%) PICC Antibiotics (24%) Cardiology (19%) Antibiotics group included osteomyelitis, meningitis, etc., most intended for only 10-14 days of therapy FEM: 75 IJ: 62 PICC: 43

results Overall Complications (CHART) Overall complications in <2 y.o. patients from 1/1/14-12/31/15 and the p-values when comparing between FEM vs IJ, IJ vs PICC, and PICC vs FEM Fem 37/278; IJ 56/198; PICC 59/322

results Overall Complications and Comparison Between CVC Sites IJ 28% PICC 18% FEM 13% P<0.001 P=0.009 (CHART) Overall complications in <2 y.o. patients from 1/1/14-12/31/15 and the p-values when comparing between FEM vs IJ, IJ vs PICC, and PICC vs FEM P=0.118

complications: Detailed Results Percentages are #/total

complications: Detailed Results 4.9k fem line days 8.9k IJ line days 12.5K PICC Per 1,000 Line Days Femoral 7.3 overall complications per 1,000 line days PICC 4.6 IJ 6.2 IJ infection 0.8/1,000 line days PICC infection 1.3/1,000 line days Femoral infection 4.6/1,000 line days (context, these are all inpatient lines)

results Comparison of Infection rates P=0.43 P=0.266 Digging deeper still into the comparison of complication types between CVC locations, we specifically assessed infection rates. As you can see from the p-values, there was no statistically significant difference in infection rates between CVC sites.

results Comparison of Complications: Single vs. Double Lumen (CHART) Comparison of complications (overall, infection, line malfunction, and malposition) for Single vs. Double lumen *one FEM with 3 lumens, not included in the data

results Comparison of Complications: ≤3 French vs. ≥4 French (CHART) Comparison of the overall complications between “3Fr or smaller” vs. “4Fr or larger” within each individual CVC type As seen in the p-values, when comparing complications within the CVC groups, there was no difference in complications between the smaller size and large size catheter groups.

conclusions CVC access site affects overall complication rates IJs had a higher overall complication rate No statistically significant difference comparing infection rates between access sites Per 1,000 line days, FEM showed higher overall complications and infections In a cohort of pediatric patients less than two years of age, the CVC access site does affect complication rates. IJ CVCs had a greater overall complication rate when compared to PICCs. Though there was an increased rate of complications in IJs, there were a greater proportion of larger sized catheters and oncology patients But without a significant difference in infections as a complication It is noteworthy that the FEMs include only inpatient lines, with cardiology and neonates accounting for the largest proportion of the patient population As a greater number of IJ CVCs are being placed by IR, it is important to consider multiple variables and weigh the increased risk of complications against the potential benefits to IJ placement.

conclusions Double lumen catheters had a higher overall complication rate compared to single lumen No statistically significant difference in overall complication rates comparing larger (>3Fr) catheters to smaller catheters Further inquiry into the data is necessary to investigate the many variables that affect complication rates and better understand factors that contribute to complications.

limitations Retrospective study Predominant patient populations varied between groups Included lines that were rewired