IPSO Practice Guidelines on Venous Access for the Pediatric Cancer Patient

IPSO Practice Guidelines on Venous Access
for the Pediatric Cancer Patient

Authors:
Israel Fernandez-Pineda, Sharon Cox, Chan Hon Chui, Jörg Fuchs and Simone Abib

Disclaimer: The document, IPSO Practice Guidelines, and the information it contains are for authorized use by surgeons. IPSO cannot accept any liability and responsibility for any claims, loss or damage arising from the use of this document and its contents.
Version dated on 3 August 2020

Devices available:

There are three categories of central venous access devices (CVAD)1

  • non-tunneled lines like peripherally inserted central catheters (PICCs) and ‘push-in’ central venous catheters (CVCs)
  • tunneled CVCs such as Hickman® or Broviac® lines with single or multiple lumens
  • totally implantable venous access devices (TIVADs) or ports

Devices should be selected according to the indication and required duration. Simple CVC or PICC lines are suitable for days to weeks. Medium term access for weeks to months may require PICCs or tunneled catheters. If access is required for longer than 3 months CVADs or TIVADs are indicated, the choice being determined by factors including patient comfort and activity, nursing experience frequency of use and cost.

Low resource settings may have challenges with stocking multiple catheter types, lengths, and sizes and should determine which device sizes are most frequently used in their unit.1

Surgical goals

Central venous catheters (CVC) are extremely important in the management of children with malignancies.2 The surgical goals of CVC placement in the pediatric cancer patient include providing durable access for the administration of chemotherapy, antibiotics, blood products, support of patients undergoing hematopoietic stem cell transplantation or those receiving parenteral nutrition and dialysis, while minimizing the intraoperative and postoperative complications.3 These goals may be achieved by a peripherally inserted central catheter (PICC) or more commonly, by accessing a central vein with the placement of an external device (Hickman®, Broviac®) or a subcutaneous infusion port. The choice of the CVC device is dependent on institutional protocols. External devices are visible, easy to access with choice of single or multiple lumens, no needle stick be required but they are associated with a higher incidence of infection, although device removal without general anesthesia in an outpatient clinic is an advantage. Subcutaneous infusion ports are not visible, require needle stick to access and they are associated with a lower incidence of infection, although general anesthesia is usually needed at port removal.4

Preoperative evaluation, images and special needs

Pediatric patients, in particular, are less likely to tolerate an awake procedure with local anesthesia only. They are frequently taken to the operating room or a fluoroscopy suite for CVC placement under sedation or general anesthesia by either a pediatric surgeon or an interventional radiologist. Preoperative evaluation requires physical examination of the possible surgical sites to rule out local skin conditions. If previous multiple CVCs have been inserted, or the child has history of catheter infections or thrombosis, a preoperative ultrasonography with doppler and/or a preoperative contrast CT scan may be able to check the patency of the veins for procedure planning.

A chest-x ray is useful to reveal potential mediastinal mass, especially in leukemia/lymphoma patients, that may complicate the procedure under general anesthesia. The presence of mediastinal enlargement or elbow/thoracic wall tumors may lead to difficulty in achieving the optimum position of the catheter. Therefore, it is advisable to initiate chemotherapy via a peripheral vein to shrink the mediastinal tumor so as to facilitate the CVC placement later. Normal serum hemoglobin, leucocyte/platelet count and coagulation parameters are required to avoid perioperative complications. Low absolute neutrophil count (ANC) is not a contraindication for CVC placement. A study from St. Jude Children´s Research Hospital reviewed the safety of CVC placement at diagnosis of acute lymphoblastic leukemia (ALL). This study revealed that placement of a CVC is safe in children with ALL even when their ANC is <500/mm3.3,5,6 Absence of infection or antibiotic use should be checked before the procedure, in order to avoid catheter colonization and loss.

Surgery

subclavian vein punctureFigure 1A. Right subclavian vein puncture using the landmark technique. Note the angle of the needle toward the sternal notch, and traversing between the clavicle and first rib. Right internal jugular vein punctureFigure 1B. Right internal jugular vein puncture

PICC insertion:

PICC lines are threaded into central veins from peripheral veins in the upper (cephalic, basilic, and median cubital veins) or lower (saphenous vein) limbs. It is possible to insert PICC lines under local anaesthesia in an older cooperative child or under sedation, without a general anaesthesia in younger children. Generally, PICC packs include a venous access canula, guidewire, peel-away catheter and the line itself, and include a tape measure and instructions on insertion.

Tunneled line or port insertion

CVC placement procedures may be performed using the percutaneous or the cutdown techniques. The choice of the surgical technique is dependent on the surgeon’s experience and preference. For the purpose of this guideline, the percutaneous technique is preferred, for the vein can be used more times and long-term venous access is more easily achieved.

Percutaneous techniques

Percutaneous CVC placement procedures are performed in a standardized manner under general anesthesia. The use of prophylactic preoperative antibiotics (cephalosporin or clindamycin, if cephalosporin allergy) is dependent on institutional protocol. The most frequently accessed sites are the internal jugular vein, subclavian vein and femoral vein. Venous anatomy is more favorable on the right side of the neck for catheter-positioning and avoids thoracic duct injury that may occur on the left side. The left side may be used when there has been venous thrombosis or a previous procedure on the right internal jugular vein, or when the venous anatomy has been distorted by the tumor.

The IJV and SCV are accessed with the supine patient positioned with a roll beneath the shoulders and the head turned slightly to the contralateral side. A roll beneath the buttocks and frog leg position is advisable when accessing the femoral vein.

In the operating theatre, ultrasound machines are highly advisable and a sterile probe or probe with a sterile plastic sheath is used to locate the vein and observe the needle, subsequently, the guidewire entering the vessel.

The vein is accessed by anatomical landmarks or ultrasound guidance (Figs 1A and 1B). A guidewire is placed into the superior vena cava and its position is confirmed with fluoroscopy or conventional chest X-ray intraoperatively. The port or tunnelled line is inserted via an incision either on the anterior chest, avoiding the breast bud and tunnelled toward the guidewire access area using the instrument provided in the pack. The guidewire puncture wound needs a small extension to allow the tunnelled line to exit the skin. Seldinger technique and split-sheath are used for catheter placement, as illustrated as follows.

The measurement of the desired length of catheter may be done using fluoroscopy or anatomic landmarks.

Placement of introduce set over the guidewire.Figure 2. Placement of introduce set over the guidewire. Peeling split-sheath while inserting catheterFigure 3. Peeling split-sheath while inserting catheter Anchoring the port on the chestFigure 4. Anchoring the port on the chest

The final position of the CVC is confirmed with fluoroscopy or conventional chest X-ray intraoperatively.
Guidelines state that the ideal level of lines inserted via the neck is near the junction of the SVC and the right atrium. Those inserted via the femoral vein should rest above the renal vein at the level of the first lumbar vertebra1. Once the tip position is confirmed, the port can be secured in an appropriate manner. In order to avoid the use of contrast, the use of radio-opaque catheters is advised. In addition, intraoperative fluoroscopy or conventional chest X-ray is useful in the detection of any possible immediate complications such as pneumothorax, hemothorax and catheter malposition.

Blood return through the catheter should be obtained at the end of the procedure and the CVC should be flushed with heparinized saline solution to avoid immediate postoperative catheter thrombosis.

Open or Cutdown technique

Open techniques are used if percutaneous methods have failed, or in centers lacking experience or equipment in the form of ultrasound machines. Possible veins for cutdown technique are the external jugular vein, facial vein or the internal jugular (IJ) vein. Some centers use the cephalic vein at the deltopectoral groove. The vein is controlled with proximal and distal vessel loops. The catheter is tunnelled from the chest wall into the operative site. The catheter is measured and cut at an appropriate length and passed through a small venotomy between the vessel loops. The venotomy may require upper ligation or may be closed around the catheter with interrupted sutures to create a seal.

Postoperative period

The immediate postoperative period is usually uneventful and pain is easily controlled in the first post-operative days. Meticulous postoperative management of the CVC device by a trained team is critical to avoid complications such as catheter dysfunction, infection and thrombosis.

Complications

In order to avoid accidental removal, extra care should be taken while securing the line. Correct training of caregivers is imperative to prevent catheter dysfunction and infection.
Intraoperative and early complications include arterial puncture, hemothorax, pneumothorax, catheter malposition, cardiac arrhythmia, and thoracic duct injury. Catastrophic life-threatening events have been described in the literature7, such as massive hemothorax and hemopericardium due to atrial perforation by the dilatator or split-sheath during catheter placement or later due to the presence of the catheter, especially in small children. Such situations require damage-control expertise performing prompt and precise invasive procedures, such as thoracotomy, sternotomy and/or pericardium fenestration.
Late complications include infection, device extrusion, catheter fracture/embolism8, and catheter malfunction.

The use of CVC is associated with complications, including infection, catheter malfunction and thrombosis.8,9 The incidence of complications during de novo insertion of CVCs in pediatric cancer patients has been described as high as 20%.10 Pediatric cancer patients are at high risk for potential complications, given their compromised immune status.11 They have central line-associated bloodstream infection (CLABSI) rates as high as 18%. Other catheter-related complications, such as malfunction and dislodgement, are described in the literature at a range from 4% to 20% during de novo insertion of CVCs.12

Regarding the choice of vein used, there have been several studies examining the relative merits and common complications of CVC placement in the various venous locations, particularly comparing the subclavian vein versus the internal jugular vein. Most of these studies have been performed in adult oncology and critical care patients and generally support a higher infection rate in internal jugular lines and a higher thrombosis rate in subclavian lines. This is less consistent in pediatric studies, and there is a high variability of factors assessed when determining overall safety and complication rates between sites of access. In considering the relative incidence of CLABSI by site placement, femoral catheters have been associated with increased CLABSI rates.
Catheter extravasation needs surgical review and catheter replacement. Catheter fracture/embolism can occur during treatment or at catheter withdrawal, which may need radio-intervention procedures in order to remove the residual catheter from the patient.13,14

Tips and pitfalls

  • Guidewire-catheter exchange in pediatric cancer patients does not appear to increase CLABSI rate and may maintain a low risk of CLABSI while decreasing potential complications associated with de novo insertion. This is particularly important in pediatric patients with difficult venous access.11
  • Ultrasound guidance for CVC placement represents a helpful tool to avoid arterial puncture, pneumothorax, and hemothorax.
  • Use of fluoroscopy or conventional chest X-ray during the CVC placement represents a helpful tool to avoid line-malposition.
  • Expertise in damage control maneuvers to deal with eventual catastrophic complications
  • Experienced nursing team care is of essence to prevent catheter dysfunction and infection.

References

  1. Milford K, von Delft D, Majola N, Cox S. Long-term vascular access in differently resourced settings: a review of indications, devices, techniques and complications. Pediatr Surg Int (2020) 36:551-562.
  2. Kim HJ, Un J, Kim KH et al. Safety and effectiveness of central venous catheterization in patients with cancer: prospective observational study. J Korean Med Sci. 2010;25:1748–1753.
  3. Samaras P, Dold S, Braun J, Kestenholz P, Breitenstein S, Imhof A, Renner C, Stenner-Liewen F, Pestalozzi BC. Infectious port complications are more frequent in younger patients with hematologic malignancies than in solid tumor patients. Oncology 2008;74:237–244.
  4. Cesaro S, Corro R, Pelosin A, Gamba P, Zadra N, Fusaro F, Pillon M, Cusinato R, Zampieri C, Magagna L, Cavaliere M, Tridello G, Zanon G, Zanesco L. A prospective survey on incidence and outcome of Broviac/Hickman catheter-related complications in pediatric patients affected by hematological and oncological diseases. Ann Hematol 2004;83:183–188.
  5. VanHouwelingen LT, Veras LV, Lu M, Wynn L, Wu J, Prajapati HJ, Gold RE, Murphy AJ, Fernandez-Pineda I, Gosain A, Pui CH, Davidoff AM. Neutropenia at the Time of Subcutaneous Port Insertion May Not Be a Risk Factor for Early Infectious Complications in Pediatric Oncology Patients. J Pediatr Surg. 2019 Jan;54(1):145-149.
  6. Gonzalez G, Davidoff AM, Howard SC, Pui et al. Safety of Central Venous Catheter Placement at Diagnosis of Acute Lymphoblastic Leukemia in Children. Pediatr Blood Cancer. 2012;58:498–502.
  7. Goutail-Flaud MF, Sfez M, Berg A, Lauguenie G, Couturier C, Barbotin-Larrieu F, Saint-Maurice C. Central venous catheter-related complications in new borns and infants: a 587 case survey. J Pediatr Surg 1991; 26(6):645.
  8. Ribeiro RC, Abib SCV, Aguar AS, Schettini ST. Long-term complications in totally implantable venous Access devices: randomized study comparing subclavian and internal jugular vein puncture. Pediatr Blood Cancer 2012, 58:274-277.
  9. Kelly MS, Conway M, Wirth KE et al. Microbiology and risk factors for central line-associated bloodstream infections among pediatric oncology outpatients-a single institution experience of 41 cases. Am J Pediatr Hematol Oncol. 2013;35:e71–e76.
  10. Allen CR, Holdsworth MT, Johnson CA, et al. Risk determinants for catheter-associated blood stream infections in children and young adults with cancer. Pediatr Blood Cancer. 2008;51:53–58.
  11. Bamba R, Lorenz JM, Lale AJ et al. Clinical predictors of port infections within the first 30 days of placement. J Vasc Interv Radiol. 2014; 25:419–423.
  12. Fernandez-Pineda I, Ortega-Laureano L, Wu H, Wu J, Sandoval JA, Rao BN, Shochat SJ, Davidoff AM. Guidewire Catheter Exchange in Pediatric Oncology: Indications, Postoperative Complications, and Outcomes. Pediatr Blood Cancer. 2016 Jun;63(6):1081-5.
  13. Patel PA, Parra DA, Bath R, Amaral JG, Temple MJ, John PR, Connolly BL. IR Approaches to difficult removals of totally implanted venous access port catheters in children: a single-center experience. J Vasc Interv Radiol 2016, 27(6):876.
  14. Wilson GJP, van Noesel MM, Hop WCJ, van de Ven C. The catheter is stuck: complications experienced during removal of a totally implantable venous access device. A single center study in 200 children. J Pediatr Surg. 2006; 41:1694-98.