Peripherally inserted central catheters increase VTE risk among children

Issue: January 25, 2017

SAN DIEGO — Children with peripherally inserted central catheters demonstrated a significantly greater risk for venous thromboembolism than children who had centrally inserted tunneled lines, according to results of the prospective, observational CIRCLE study presented at the ASH Annual Meeting and Exposition.

Increased use of peripherally inserted central catheters (PICCs) due to their ease of insertion could be the primary contributor to greater pediatric VTE incidence, researchers wrote.

“I am hoping people start taking pause before putting in these central lines,” researcher Julie Jaffray, MD, attending physician in the Children’s Center for Cancer and Blood Diseases at Children’s Hospital Los Angeles, told HemOnc Today.

“We have come to a time in medicine when we are doing things that are easier and may not be completely beneficial for patients,” she added. “There has not been enough education that these little things might be riskier than we think. Maybe we should just take a step back before we place those simpler PICC lines.”

Venous thromboembolism incidence among children is increasing, primarily because of the improved care of critically ill children and the use of central venous catheters.

However, evidence about risk factors for central venous catheter–associated thrombosis is limited. Also, no guidelines exist to help clinicians determine which catheter type or insertion technique to use, or to help them determine which patients would derive the greatest benefit from prophylaxis.

Jaffray and colleagues conducted a multicenter study designed to compare VTE incidence among children with PICCs or centrally inserted tunneled lines (TL). They also sought to identify other risk factors for central venous catheter–associated thrombosis.

Researchers enrolled patients aged 6 months to 18 years treated at three large pediatric hospitals — Children’s Hospital Los Angeles, Children’s Hospital of Philadelphia and Texas Children’s Hospital — between September 2013 and April 2016. All patients had either a PICC or TL placed.

Investigators used electronic medical records to collect data on patient demographics and medical history, including presence of cancer or congenital heart disease, VTE history and infection status.

They also obtained details relevant to the use of central venous catheters — including the size, number of lumens, brand, material and reason for insertion — as well as the insertion technique, including catheter length, the number of insertion attempts and the vein accessed.

Jaffray and colleagues performed electronic medical record reviews to prospectively monitor all patients for VTE occurrence and other catheter-related complications — such as malfunction, infection or use of tissue plasminogen activator — for up to 6 months after their catheter was placed or after VTE diagnosis. VTE screening was not performed.

Researchers used univariable and multivariable logistic regression to evaluate associations between VTE incidence and either patient or catheter characteristics.

Jaffray presented results of an interim analysis that included 1,096 patients (median age, 6 years; range, 0.5-18; 53% male) who had 1,233 central venous catheters placed. Two-thirds (67%) catheters were PICCs and one-third (33%) were TLs.

Researchers reported 65 blood clots during follow-up, 55 (84.6%) of which occurred in children with PICCs. Median time to blood clot was 15 days among those with PICCs and 40 days among those with TILs.

Univariable analysis identified several factors associated with statistically significant increases in risk for VTE. They included history of VTE, history of congenital heart disease, use of PICCs rather than TLs, multiple lumen catheters of either type or catheter malfunction. Males demonstrated a reduced risk for VTE compared with females.

On multivariable analysis, three factors — type of catheter, number of lumens and VTE history — remained significant predictors of VTE incidence. Male sex remained inversely associated with VTE incidence (OR = 0.48; 95% CI, 0.3-0.9).

Infection incidence was 12% in the entire cohort, 16% among children with TLs and 9% among children with PICCs.

If children require a new central venous catheter, practitioners should consider avoiding PICCs and multiple lumen central venous catheters, Jaffray and colleagues wrote.

“If we do think they need the PICCs, we need to try to take them out every day,” Jaffray said. “The longer they stay in, the more risk ... for infection or VTE.”

Study enrollment continues, and researchers hope to create guidelines for central venous catheter insertion with regard to catheter type, insertion technique, and the need for anticoagulation or antiseptic prophylaxis.

“I’m hoping, when we finish the study, we can make more definitive recommendations,” Jaffray said. “At least right now, we need to take a step back and ask whether you really need to put the line in. If you do, every day you need to try to take it out.” – by Mark Leiser

Reference:

Jaffray J, et al. Abstract 331. Presented at: ASH Annual Meeting and Exposition; Dec. 3-6, 2016; San Diego.

Disclosure: The researchers report consultant and speakers bureau roles with Baxter, Biogen, Kedrion and Novo Nordisk.