E. H. Steen1, J. J. Lasa3, T. C. Nguyen3, S. G. Keswani2, P. A. Checchia3, M. M. Anders3 1Baylor College Of Medicine,Department Of Surgery,Houston, TX, USA 2Texas Children’s Hospital,Division Of Pediatric Surgery, Department Of Surgery,Houston, TX, USA 3Texas Children’s Hospital,Section Of Critical Care Medicine, Department Of Pediatrics,Houston, TX, USA
Introduction: Central venous catheter (CVC) use is common in the management of critically ill children, especially those with congenital or acquired heart disease (CHD). Prior reports suggest that the presence of a CVC augments the risk of deep vein thrombosis (DVT). How CVC-associated DVTs contribute to morbidity and mortality in this high risk patient population is unknown. Taken together, the aim of this study is to identify the factors associated with DVT and thrombus propagation in the pediatric cardiovascular intensive care unit (CVICU) population.
Methods: The PC4 database and a radiologic imaging database for patients admitted to Texas Children’s Hospital were retrospectively reviewed. During the one year study period (January – December 2017), there were 1215 unique central lines placed in 851 admissions. Information gathered included demographics and outcomes of patients requiring central line placement in the TCH CVICU, as well as the incidence of DVT and complications. Data shown as OR [95% CI] by univariate linear regression; p value < 0.05 considered significant.
Results: DVT was diagnosed in 8% of admissions with a CVC. Almost 30% of these patients demonstrated thrombus extension into the inferior vena cava (IVC). The diagnosis of DVT is a highly significant risk factor for mortality in these patients (p=.0001, OR 6.1 [2.8, 13.1]). In a univariate regression model, the risk factors most significantly associated with DVT include the presence of more than one line and higher total line hours (defined as the sum of all lines multiplied by the number of hours each line was in place), as well as longer duration of intubation and extended CVICU admission times. A diagnosis of low cardiac output syndrome (LCOS), sepsis, UTI, CLABSI, and cardiac catheterization during admission are also significant risk factors. Of these, only longer catheter dwell times (p=.0001) and cardiac catheterization (p=.002) are significantly associated with the diagnosis of DVT on multivariate analysis. Interestingly, both LCOS and CLABSI (p<0.0001 in each) are significantly associated with propagation of the thrombus into the IVC. Of note, cardiac surgery with cardiopulmonary bypass appears to be protective of clot development (p=0.001, OR 0.38 [0.22, 0.67]).
Conclusion: We have defined risk factors for CVC-associated DVT in the pediatric CVICU population, as well as specific factors associated with clot propagation into the IVC. CVC-associated DVTs impart a significant risk of morbidity and mortality in critically ill children, highlighting the need for well-designed studies to determine the best preventive and therapeutic strategies and to establish guidelines for appropriate monitoring and follow up of these patients.