Peripherally inserted central catheters significantly increase blood clot, infection risks among children
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Children with peripherally inserted central catheters demonstrated a significantly higher risk for venous thromboembolism, central line-associated bloodstream infections and catheter malfunctions than children with centrally inserted tunneled lines, according to a new analysis of data from the CIRCLE study published in Blood.
Factors associated with increased VTE risk included prior history of thrombosis, leukemia and use of multi-lumen central venous catheters.
“As health care providers, we need to take careful consideration before deciding to place any type of central venous catheters, for the risks involved may be higher than we originally thought,” Julie Jaffray, MD, director of the thrombosis program at the Cancer and Blood Disease Institute at Children’s Hospital Los Angeles and assistant professor of clinical pediatrics at Keck School of Medicine of University of Southern California, told Healio. “We should first determine if the patient can have their treatment with a peripheral IV only and avoid a central venous catheter altogether.”
Incidence of VTE among children has increased significantly during the past 2 decades. Approximately 80% of VTE cases in children are caused by central venous catheters, according to study background.
Jaffray and colleagues conducted a multi-institutional, prospective, observational study to examine incidence of catheter-related VTE among children aged 6 months to 18 years at four tertiary care centers — Children’s Hospital Los Angeles, Children’s Hospital of Philadelphia, Nationwide Children’s Hospital and Texas Children’s Hospital — between October 2013 and June 2018.
Results of an interim analysis, previously reported by Healio, showed a significantly increased risk for VTE with peripherally inserted central catheters (PICCs) compared with tunneled lines (TLs).
Use of PICCs has become more common because they can be inserted faster and easier than TLs, according to researchers.
For the current analysis, researchers evaluated incidence of VTE, central line-associated bloodstream infections and catheter malfunctions with PICCs compared with TLs. They also assessed risk factors for central venous catheter-associated VTE.
The analysis included 1,967 central venous catheters placed in 1,742 children (median age at insertion, 6.4 years; range, 0.6-17.9; 53% male). Sixty-four percent were PICCs and 36% were TLs. Most (62%) were single lumen.
Results showed overall incidence of central venous catheter-associated VTE of 5.9% ± 0.63%. Eighty percent of cases (n = 75 of 94) occurred among children with PICCs, for an incidence rate of 9% ± 1.4% compared with 2.9% ± 0.64 for TLs.
Median time from catheter insertion to VTE diagnosis was 14 days (range, 1-160) for PICCs and 42 days (range, 1-162) for TLs.
Multivariable analysis showed significantly higher risk for central venous catheter-associated VTE among those with PICCs vs. TLs (HR = 8.5; 95% CI, 3.1-23). Children with PICCs also appeared more likely to have central line-associated bloodstream infections (HR = 1.6; 95% CI, 1.2-2.2) and central venous catheter malfunctions (HR = 2; 95% CI, 1.6-2.4) than those with TLs.
Factors associated with increased risk for central venous catheter-associated VTE included prior history of VTE (HR = 23; 95% CI, 4-127), use of a multi-lumen central venous catheter (HR = 3.9; 95% CI, 1.8-8.9) and leukemia (HR = 3.5; 95% CI, 1.3-9).
“In the cases where a central venous catheter is necessary, clinicians should focus on modifiable risk factors, such as placing the smallest lumen central venous catheter possible and try to avoid a multi-lumen central venous catheter, if possible. In cases where patients initially have a PICC placed and later a TL, clinicians should consider placing a TL immediately and avoiding a PICC in the appropriate patient populations,” Jaffray told Healio.
The exclusion of temporary, nontunneled central venous catheters that are commonly used in critically ill children may be a study limitation, researchers acknowledged.
“Our immediate future plans are to perform a subanalysis of the data and focus on the high-risk populations, such as those with leukemia,” Jaffray told Healio. “We also hope to implement guidelines on central venous catheter insertion recommendations using data from this study. Another important group that this study did not focus on, and who are at significant risk for central venous catheter-associated VTE, are infants and neonates younger than 6 months of age, which we hope to focus on in the future.” – by Jennifer Southall
For more information:
Julie Jaffray, MD, can be reached at Children’s Hospital Los Angeles, 4650 W. Sunset Blvd., Mailstop #54, Los Angeles, CA 90027; email: jjaffray@chla.usc.edu.
Disclosures: The authors report no relevant financial disclosures.
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