Spotlight Case May 2003

Central Line Complications in an Infant

webmm.ahrq.gov

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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.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

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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

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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.

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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.

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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.

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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.

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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

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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.

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Pulmonary Angiogram

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High Probability VQ Scan

Ventilation Perfusion

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Spiral CT

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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.

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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.

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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.

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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.

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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

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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.

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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.

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• 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

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• 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

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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

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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