A. Fu1, E. Hodgman2, L. Burkhalter1, R. Renkes1, T. Slone3, A. C. Alder1,4 1Children’s Medical Center,Division Of Pediatric Surgery,Dallas, TX, USA 2University Of Texas Southwestern Medical Center,Department Of General Surgery,Dallas, TX, USA 3University Of Texas Southwestern Medical Center,Department Of Pediatrics,Dallas, TX, USA 4University Of Texas Southwestern Medical Center,Department Of Pediatric Surgery,Dallas, TX, USA
Introduction: Central venous access devices (CVADs) play an important role in the management of pediatric oncology patients; unfortunately, they are also associated with potentially serious peri-operative and long-term complication rates. Our aim was to evaluate the rates of peri-operative and long-term complications as well as risk factors for premature catheter removal among patients with acute leukemia at a single pediatric tertiary referral center.
Methods: We retrospectively studied clinical characteristics and procedure records for all patients admitted with a leukemia diagnosis at our institution from May 2009 – July 2014. Patient data, including demographics, CVAD type (subcutaneous port or tunneled catheter), complications, and patient outcomes were collected. Peri-operative complications (≤24 hours of surgery) include pneumothorax, hematoma, hemothorax, arterial puncture, and catheter malposition. Long-term complications (>24 hours after surgery) include deep venous thrombosis (DVT), line-associated infection (blood stream and/or port site infection), and line malfunction (kinks, leaks, breaks). Chi square, t-tests, and multivariable logistic regression were performed (significance p<0.05).
Results: A total of 292 CVADs were placed in 198 patients during the study period; these CVADs remained in place for an average of 488 ± 399.8 days and a total of 142,607 catheter-days are included in this study. Our observed peri-operative complication rate was 6%, including 3 hematomas, 1 hemothorax, and 10 catheter malpositions. Over 70% of lines had at least one long-term complication (thrombosis, catheter-related blood stream infection, or unexplained line malfunction). Seventy-five lines were removed prematurely: 31 due to infection, 36 due to malfunction, and 8 due to malposition. Obesity (OR 6.9, 95% CI 1.62-29.43), pre-operative dosage of packed red blood cells (OR 3.13 , 1.07-9.21), blood stream infection (OR 5.75, 1.69-19.56) were associated with increased risk of premature catheter removal; unexplained malfunction was associated with a lower risk (OR 0.28, 0.09-0.93).
Conclusion: While the rate of peri-operative complications is low, our observed long-term complication rate was higher than expected. Obesity, the preoperative dosage of packed red blood cells, presence of a blood stream infection, and unexplained line malfunction are significant predictors of premature CVAD removal in a pediatric leukemia population. Patients with these characteristics may represent a subset population that warrant closer CVAD surveillance and may benefit from additional prophylatic thrombolytic therapy. This study represents the largest recent evaluation on CVAD complications within a single institution and is also the largest report on a Hispanic pediatric leukemia population to date.