ArticlePDF AvailableLiterature Review

Evidence‐Based Strategies and Recommendations for Preservation of Central Venous Access in Children

Authors:

Abstract and Figures

Children with chronic illness often require prolonged or repeated venous access. They remain at high risk for venous catheter–related complications (high‐risk patients), which largely derive from elective decisions during catheter insertion and continuing care. These complications result in progressive loss of the venous capital (patent and compliant venous pathways) necessary for delivery of life‐preserving therapies. A nonstandardized, episodic, isolated approach to venous care in these high‐need, high‐cost patients is too often the norm, imposing a disproportionate burden on affected persons and escalating costs. This state‐of‐the‐art review identifies known failure points in the current systems of venous care, details the elements of an individualized plan of care, and emphasizes a patient‐centered, multidisciplinary, collaborative, and evidence‐based approach to care in these vulnerable populations. These guidelines are intended to enable every practitioner in every practice to deliver better care and better outcomes to these patients through awareness of critical issues, anticipatory attention to meaningful components of care, and appropriate consultation or referral when necessary.* 1 These recommendations have been endorsed by the Board of Directors of the American Society for Parenteral and Enteral Nutrition.
Content may be subject to copyright.
Clinical Guidelines
Journal of Parenteral and Enteral
Nutrition
Volume 00 Number 0
xxx 2019 1–24
C2019 American Society for
Parenteral and Enteral Nutrition
DOI: 10.1002/jpen.1591
wileyonlinelibrary.com
Evidence-Based Strategies and Recommendations
for Preservation of Central Venous Access in Children
Kevin M. Baskin, MD1; Leonard A. Mermel, DO, ScM2;
Theodore F. Saad, MD3; Janna M. Journeycake, MD4; Carrie M. Schaefer, MD5;
Biren P. Modi, MD, MPH6; John I. Vrazas, MD7; Beth Gore, PhD8;
Barbie B. Drews, RN, CPNP9; Darcy Doellman, RN, BSN, CRNI10;
Samuel A. Kocoshis, MD11; Kareem M. Abu-Elmagd, MD, PhD12;
Richard B. Towbin, MD13; and Venous Access: National Guideline and Registry
Development (VANGUARD) Initiative Affected Persons Advisory Panel1
Abstract
Children with chronic illness often require prolonged or repeated venous access. They remain at high risk for venous catheter–
related complications (high-risk patients), which largely derive from elective decisions during catheter insertion and continuing
care. These complications result in progressive loss of the venous capital (patent and compliant venous pathways) necessary for
delivery of life-preserving therapies. A nonstandardized, episodic, isolated approach to venous care in these high-need, high-cost
patients is too often the norm, imposing a disproportionate burden on affected persons and escalating costs. This state-of-the-
art review identies known failure points in the current systems of venous care, details the elements of an individualized plan of
care, and emphasizes a patient-centered, multidisciplinary, collaborative, and evidence-based approach to care in these vulnerable
populations. These guidelines are intended to enable every practitioner in every practice to deliver better care and better outcomes
to these patients through awareness of critical issues, anticipatory attention to meaningful components of care, and appropriate
consultation or referral when necessary.*(JPEN J Parenter Enteral Nutr. 2019;00:1–24)
Keywords
central venous access complications; coordination of care; guidelines; pediatrics; shared decision-making; venous access
From the 1VANGUARD, Venous Access (VANGUARD) Task Force, Society of Interventional Radiology (SIR), Pittsburgh, Pennsylvania, USA;
2Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA; 3Nephrology Associates of Delaware, Newark, Delaware,
USA; 4Jimmy Everest Center for Cancer and Blood Disorders in Children, University of Oklahoma, Oklahoma City, Oklahoma, USA; 5Pediatric
Interventional Radiology, Phoenix Children’s Hospital, Phoenix, Arizona, USA; 6Center for Advanced Intestinal Rehabilitation, Children’s
Hospital of Boston, Harvard Medical School, Boston, Massachusetts, USA; 7Royal Children’s Hospital, Melbourne, Victoria, Australia;
8Association for Vascular Access, Herriman, Utah, USA; 9Children’s Medical Center of Dallas, Dallas, Texas, USA; 10Vascular Access Team,
Children’s Hospital of Cincinnati Medical Center, Cincinnati, Ohio, USA; 11Pediatric Nutrition and Intestinal Care Center, Children’s Hospital
of Cincinnati Medical Center, University of Cincinnati, Cincinnati, Ohio, USA; 12Cleveland Clinics Foundation Hospitals and Clinics, Case
Western Reserve University, Cleveland, Ohio, USA; and the 13Department of Radiology, Phoenix Children’s Hospital, Phoenix, Arizona, USA.
A complete list of nonauthor contributors appears in Appendix 1.
These recommendations have been endorsed by the Board of Directors of the American Society for Parenteral and Enteral Nutrition.
Financial disclosure: None declared. No funding was secured for this study.
Conict of interest: None declared.
Disclaimer: These standards do not constitute medical or other professional advice and should not be taken as such. To the extent that the
information published herein may be used to assist in the care of patients, this is the result of the sole professional judgment of the attending
healthcare professional whose judgment is the primary component of quality medical care. The information presented in these standards is not a
substitute for the exercise of such judgment by the healthcare professional. Circumstances in clinical settings and patient indications may require
actions different from those recommended in this document and in those cases, the judgment of the treating professional should prevail.
Received for publication January 25, 2019; accepted for publication March 19, 2019.
This article originally appeared online on xxxx 0, 2019.
Corresponding Author:
Kevin M. Baskin, MD, 138 Chapel Harbor Drive, Pittsburgh, PA 15238.
Email: kevinbaskin@comcast.net
2Journal of Parenteral and Enteral Nutrition 00(0)
Introduction
Children are particularly vulnerable to complications
of chronic disease, and symptoms of severe acute
complications can often be missed in these patients.1,2
Central venous catheter (CVC)-related complications can
be life-threatening, with an estimated 12.5%–25% mortality
associated with catheter-related bloodstream infections
(CRBSIs).3,4 Catheter-related complications also add tens
of billions of dollars to healthcare costs in the United States
annually,5chiey attributable to chronic (prolonged or
repeated) venous access. Additional systemic complications,
interruption of life-preserving therapies, and increased fre-
quency of thrombosis and endocarditis are associated with
bloodstream infections in certain high-risk populations.6,7
Because conventional venous access routes are frequently
impaired, establishing and maintaining high-quality venous
access in high-risk children can be very challenging.8
In 2016, the VANGUARD (Venous Access: National
Guideline and Registry Development) multistakeholder
symposium prioritized anticipatory planning for chronic
venous access, including individualized review of venous
access history, to preserve central venous pathways (venous
capital) and reduce complications in pediatric patients who
require chronic central venous access, and thereby save lives
and reduce the frequency and duration of hospitalization
and associated healthcare costs.5A multidisciplinary panel
of subject matter experts was invited to meet this charge
and, based on available evidence and expert consensus,
develop recommendations regarding common CVC failure
points and critical components of care that anticipate the
potential need for lifetime access (Table 1). The purpose of
these guidelines is to help the clinical community improve
the quality of CVC-related care and the quality of life for
patients who require chronic central venous access.
Methodology
An in-depth Medline (PubMed) search of the relevant
medical literature was performed. Peer-reviewed articles
were critically reviewed with regard to study methodol-
ogy, results, and conclusions. To fulll the Institute of
Medicine standards for guideline development, a subset of 5
panel members used a modied Grading of Recommenda-
tions Assessment, Development, and Evaluation (GRADE)
process to evaluate the quality of evidence for and the
strength of each recommendation, similar to the classica-
tion systems used by specialty practice societies such as the
American College of Cardiology and the American Heart
Association.9
The strength of each recommendation reects the au-
thors’ judgments about the relative strengths and weak-
nesses of study data, including the risks and benets iden-
tied by the evidence and a synthesis of conicting nd-
ings among multiple studies. The Good Practice Statement
(GPS) was used for recommendations without published
evidence or consensus.10 GPS recommendations were de-
veloped from indirect literature and the experience of the
expert panel and may address social, legal, and ethical
questions and implementation issues not appropriate to
more formal evidence grading. Details of the classication
hierarchy are included with the recommendations. Where
evidence was weak and expert opinions were conicting or
contradictory, a modied Delphi technique was utilized to
facilitate effective decision-making.11 Perspectives of an ad-
visory panel of affected persons (patients, parents, families,
caregivers, and support organizations) were incorporated
into the document (Appendix A1).
Failure Points and Essential Components
of Care
Widely advocated practices to reduce catheter-related com-
plications in the acute care environment include insertion
and maintenance bundles and removal of catheters that are
no longer required.12-16 For patients who require chronic
venous access for life-preserving therapy, the situation is
more complex, the opportunities for device failure and
adverse events more varied, the accumulation of venous
injuries more insidious, and the need for collaborative,
evidence-driven care more pivotal. Compartmentalized and
discontinuous clinical reasoning too often results in avoid-
able adverse outcomes with potentially devastating results.
The following sections encourage collaborative manage-
ment reasoning17 through critical practices and precautions
that facilitate optimal preservation of venous health and
patency in high-risk chronic venous access patients.
Diagnostic Venous Imaging and Evaluation
Venous compromise is prevalent in patients requiring
chronic access. At least 40%–50% of intestinal failure and
renal failure patients have obstruction of at least 1 major
venous pathway.18,19 Vascular imaging studies should an-
swer clinical questions and characterize the location, nature,
and extent of abnormalities, directed by experts in vascular
imaging and interventions. Imaging must be timely, problem
centered, and task oriented for identication of relevant
issues and therapeutic planning, to assess and document
venous patency and outcomes of device or pathway salvage
interventions.
Venous injury can be cumulative, progressing from dis-
organized thrombus and perivascular edema through suba-
cute thrombus or stenosis to mature clot or vein wall brosis.
However, even a single injury can lead to irreversible ob-
struction. Early recognition and aggressive intervention are
necessary to preserve venous capital at risk.20 Initial venous
injuries, often subtle and occult, inuence the success of
Baskin et al 3
Table 1. Recommendations for Preservation of Central Venous Access in High-Risk Patients.
Grade Class Strength Recommendations
Venous imaging and evaluation
1.1.1 C I Strong In high-risk patients, venous imaging and evaluation should include review of all available and
relevant prior vascular imaging studies.
Diagnostic contrast venography
1.2.1 B I Strong DIV should be used as the primary initial modality to survey the venous system for patency,
obstruction, or abnormalities of the major venous pathways.
1.2.2 GPS Strong Baseline DIV should ideally be performed before the patient’s rst venous access device is
removed regardless of the reason for removal and should include each pathway in which an
access device has been inserted.
1.2.3 GPS Strong If prior history cannot be conrmed, then an initial survey of all major venous pathways should
be performed.
Diagnostic venous ultrasound
1.3.1 C IIa Strong Venous ultrasound should be used as a secondary diagnostic modality to follow targeted lesions
and evaluate specic clinical questions as part of a comprehensive plan to routinely survey the
state of the patient’s venous capital.
1.3.2 B I Strong Venous ultrasound examination and its documentation should adhere to appropriate standards.
Venous access planning
2.1.1 C IIa Strong Prospective venous access planning should begin at the time the high-risk patient is rst diagnosed
with an indication for chronic access.
2.1.2 C IIa Strong The prospective venous access plan should govern every elective venous event; no elective
vein-related intervention should be undertaken outside the scope of this plan.
2.1.3 C IIb Strong If an experienced multidisciplinary venous access team (see 6.1.1) does not exist within the
treating institution, consultation with or referral to such a center should be considered.
2.1.4 C I Strong For high-risk patients with a history of difcult access or venous access–related complications,
liaison with or transfer to a pediatric tertiary care facility with expertise treating high-risk
patients should be obtained as early after diagnosis as practicable.
Elective access conditions
3.1.1 C IIa Strong Venous access should be performed under the supervision of an experienced practitioner,
preferably an expert in venous access and related salvage procedures in high-risk children.
3.1.2 A I Strong Only individuals appropriately educated to protect the integrity of the device and access site and
to prevent access-related complications should provide continuing care of venous access devices.
3.1.3 A I Strong Elective venous access in high-risk patients should always be performed in a sterile environment
with sterile technique, appropriate apparel, and other sterile barriers.
3.1.4 B I Strong If temporary venous access (ie, a nontunneled, noncuffed central catheter or a catheter, including
a midline catheter, that does not terminate near the cavoatrial junction) must be acquired for a
central venous indication due to exigent clinical circumstances, it should be accompanied by a
plan for removal or elective access in an appropriate theater as soon as possible thereafter.
3.1.5 A I Strong For venous access, real-time ultrasound guidance for percutaneous venipuncture is preferred to
the cut-down or landmark techniques.
3.1.6 A I Strong Guide wire positioning and catheter delivery and positioning during CVC insertion should be
performed with real-time uoroscopic control.
Access site
3.2.1 B I Strong Conventional access sites from most to least preferred include neck veins (eg, internal or external
jugular), arm veins (eg, brachial or basilic), femoral vein, and subclavian vein.
3.2.2 C IIa Strong Use of upper extremity veins for access should be avoided in patients with potential future need
for hemodialysis.
Catheter tip position
3.3.1 B I Strong A long-term catheter tip should be positioned in the proximal cava near the cavoatrial junction.
3.3.2 B I Strong The tip(s) of a long-term hemodialysis catheter should be positioned within the right atrium.
3.3.3 C IIa Strong A temporary catheter tip should be positioned in the lower SVC from above the diaphragm, or
above the iliac conuence from below.
3.3.4 C IIa Strong A CVC should not be used until the catheter tip position has been veried with medical imaging.
3.3.5 B IIa Strong If a catheter is malpositioned, it should be promptly repositioned or replaced.
3.3.6 GPS Strong In a growing child, catheter tip location should be veried at least every 12 months.
Device selection
3.4.1 C I Strong Peripherally inserted or tunneled, cuffed central catheters are preferred to temporary or uncuffed
catheters.
3.4.2 B I Strong Subcutaneous indwelling venous ports should be reserved for chronic intermittent therapy in
patients immunocompetent at the time of insertion.
3.4.3 C I Strong In all cases, the smallest catheter diameter and the fewest lumens required to deliver anticipated
therapy safely are recommended.
3.4.4 B I Strong Antimicrobial-impregnated catheters should be considered for CVC insertion in all high-risk
patients.
(continued)
4Journal of Parenteral and Enteral Nutrition 00(0)
Table 1. (continued)
Grade Class Strength Recommendations
3.4.5 B IIb Weak Antimicrobial lock therapy should be considered for CVC care in all high-risk patients.
Catheter-related infection
Documentation of suspected catheter-related infection
4.1.1 C I Strong For all high-risk patients with a venous catheter in place with signs and symptoms that suggest a
bloodstream infection, diagnosis of a catheter-related infection should follow a rigorous
cognitive pathway.
4.1.2 C I Strong The associated elements that lead to support for or rejection of a diagnosis of catheter-related
infection in each case should be clearly documented in the medical record.
4.1.3 A I Strong Diagnosis should ideally be supported by central and peripheral culture, or culture from the
dialysis bloodline, of an organism known to cause catheter infections with a differential latency
to positivity, or by purulent discharge related to the exit site, subcutaneous tract, or port pocket,
or by catheter tip culture, which grows the same microorganism as the peripheral or bloodline
blood culture.
4.1.4 B IIa Weak For suspected CRBSI, blood cultures should be obtained from each catheter lumen if possible.
4.1.5 A I Strong If the catheter is removed under suspicion of infection, a roll-plate culture of the catheter tip
should be obtained.
Catheter removal
4.2.1 C I Strong In a high-risk patient, a functioning noninfected and appropriately positioned chronic venous
access device should be removed only at the end of therapy.
4.2.2 B I Strong In the event of a CVC-related infection that cannot be successfully treated with the catheter in
situ, including Staphylococcus aureus, Gram-negative enterococcus, and catheter-associated
fungemia, the catheter should be removed.
4.2.3 A I Strong When the patient is symptomatic of sepsis, including cardiovascular instability or end organ
failure, particularly with positive blood cultures, and another focus cannot be identied, the
catheter should be removed.
Catheter-related thrombosis and venous obstruction
5.1.1 B I Strong If there are signs or symptoms of deep venous obstruction, or a known history of obstruction or
previous difcult access, proactive investigation should be instituted prior to attempting new
access placement.
5.1.2 C I Strong Diagnosis of venous obstruction or injury should be documented in the EHR, using standard
nomenclature, including the nature and extent of involvement and the outcome of any related
intervention.
5.1.3 GPS Weak If central venous obstruction is diagnosed, it should be preemptively treated.
5.1.4 C IIa Strong In the event of central venous obstruction, every reasonable attempt should be made to reestablish
patency for the purpose of venous access across an injured vein before accessing an uninjured
vein.
5.1.5 C IIa Strong Insertion of a venous stent should be avoided except as a last option to permit transplantation,
alleviate risk to a vital organ, relieve intractable pain, or reduce functional impairment from
venous hypertension and related inammation and secondary lymphedema.
5.1.6 C IIb Weak Consideration should be given to prophylactic anticoagulation in patients with chronic need for
central venous access.
5.1.7 B IIa Strong Alternate routes should be considered only if conventional venous pathways cannot be accessed
or recanalized for access.
Treatment
5.2.1 C IIb Weak Vascular specialists with training and experience in difcult access and vessel and catheter salvage
should perform treatment of venous obstruction, catheter salvage and venous recanalization
procedures, stent insertion, and access via unconventional pathways.
Collaborative care and information management
6.1.1 C IIa Strong Each institution routinely caring for high-risk patients who require chronic central venous access
should identify a CVAT.
6.1.2 C IIa Strong Ideally, the CVAT should supervise continuing venous access device care and maintenance,
guideline and policy development, and resolution of difcult or contentious issues regarding the
maintenance of venous health and successful venous access in children at high risk for
catheter-related complications.
6.1.3 C I Strong To preserve venous capital and minimize risks of catheter-related dysfunction, it is strongly
recommended that the CVAT develop and maintain a long-term plan for preservation of venous
access for each high-risk patient.
6.1.4 C IIa Strong The unied plan developed by the CVAT should be maintained as part of continuing care
documentation.
6.1.5 GPS Strong Patient and device selection, device insertion, continuing catheter care, device and venous pathway
salvage, treatment of related complications, and device removal should be considered in
accordance with the existing CVAT preservation plan or in consultation with the CVAT
responsible for maintaining and updating that plan.
(continued)
Baskin et al 5
Table 1. (continued)
Grade Class Strength Recommendations
6.1.6 GPS Strong The CVAT should work to achieve full engagement of affected persons (patients, parents, families,
caregivers, and support organizations) in the planning and process of care to ensure that
patient-important outcomes are prioritized.
6.1.7 C I Strong The patient-healthcare relationship should include bidirectional communication and shared
decision-making, support for patient self-management, and appropriate use of eHealth
technology as a complement to care.
Electronic medical record
6.2.1 GPS Strong Development of a unied set of interoperable CDE specic for the venous access domain is
essential.
6.2.2 GPS Strong A continuous electronic summary of all venous access events should be part of continuing care
documentation, easily accessible to and transferable by the patient.
6.2.3 GPS Strong The venous access event record should be reviewed prior to any new venous intervention.
6.2.4 C I Strong Active patient-reported outcomes and other patient-generated health data should be integrated
with clinical data to develop real-world evidence reective of data and issues important to the
patient.
CDE, common data elements; CRBSI, catheter-related bloodstream infection; CVAT, Collaborative Venous Access Team; CVC, central venous
catheter; DIV, diagnostic infusion venography; EHR, electronic health record; SVC, superior vena cava.
Grade criteria
A: Recommendation based on evidence from multiple randomized trials or meta-analyses.
B: Recommendation based on evidence from a single randomized trial or nonrandomized studies.
C: Recommendation based on expert opinion, case studies, or standards of care.
GPS: Good Practice Statement.
Class criteria
Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective.
Class II: Conditions for which there is conicting evidence and/or a divergence of opinion about the usefulness/efcacy of a procedure or
treatment.
Class IIa: Weight of evidence/opinion is in favor of usefulness/efcacy.
Class IIb: Usefulness/efcacy is less well established by evidence/opinion.
Class III: Conditions for which there is evidence or general agreement that the procedure/treatment is not useful/effective and in some cases may
be harmful.
Strength criteria
For each recommendation, an overall rating was provided:
S: Strongly recommended.
W: Weakly recommended.
subsequent efforts to maintain or restore venous patency.
A baseline study of the major central veins should ideally
be obtained at or before the time the high-risk patient’s rst
CVC is removed.
Although venous ultrasound (US) is strongly recom-
mended in some guidelines,21 it is neither a survey modal-
ity nor adequate for diagnosis, especially in a high-risk
population.22 However, it is very useful as a secondary
modality to follow targeted lesions and evaluate specic
clinical questions. The use of diagnostic venous US should
adhere to established guidelines.23-25
Conventional diagnostic infusion venography (DIV)
demonstrates ow dynamics and is highly sensitive and
specic with a high negative predictive value,22 but must
be directed to each vascular territory of interest. DIV is
considered the reference standard to evaluate the patency
of conventional central venous pathways and to document
the nature and extent of anatomic abnormality or central
venous obstruction.26-29
Computed tomography (CT) and magnetic resonance
(MR) venography have technical limitations but offer useful
information regarding venous obstruction.30 Superparam-
agnetic iron oxide–based contrast agents may help avoid
gadolinium-based MR contrast complications, such as in
patients with renal failure.31 The venous information con-
tained in CT and MR studies, especially in delayed-phase
imaging, should be reviewed and incorporated into the
documented venous history.32,33 Volumetric reconstruction
may help delineate location and extent of obstruction and
involvement of collateral pathways.34 Intravascular ultra-
sound can also provide high-quality cross-sectional imaging
of focal venous segments and may add critical information
regarding pathophysiology (eg, compression, wall thicken-
ing, or perivenous brosis) and the response to therapeutic
interventions (eg, recoil following venoplasty).35,36
Venous Access Planning
According to the VANGUARD Affected Persons Advisory
Panel, affected persons perceive that central venous access is
often treated as an incidental series of episodic events until
something catastrophic happens. Although extraordinary
measures can manage life-threatening complications and re-
canalize obstructed pathways, they are not always successful
6Journal of Parenteral and Enteral Nutrition 00(0)
and can incur disproportionate clinical and economic costs.8
The anticipatory planning and preventive measures repre-
sented within these recommendations should be initiated
at the time a patient is rst diagnosed with a condition
likely to require chronic venous access of an indeterminate
period (from months to a lifetime).37 Once initiated, such
individualized planning should govern every elective venous
access–related event, over time and across venues.
Elective Access Conditions
A multidisciplinary approach to venous access care in
patients with chronic venous access is advised. For patients
whose underlying diagnosis predicts long-term reliance on
central venous access or whose venous history is already
marked by difcult access or signicant central obstruc-
tion, elective venous access procedures should ideally be
performed at a center with advanced expertise.8,38
Imaging is critically important during the primary ve-
nous cannulation and catheter insertion procedure to reduce
injuries that threaten venous patency and to ensure suitable
location of the catheter tip. US with high-quality near-eld
imaging and penetration and the training and experience to
use it effectively reduces the number of punctures necessary
to gain access and helps to avoid injury to related vital
structures. Real-time cross-sectional imaging also facilitates
adaptation to local anatomic variations and identication
of undiagnosed irregularities such as thrombophlebitis or
venospasm.39,40 Real-time US is the modality of choice for
venous access guidance.41-43
Preferred sites of access include the deep veins of the
neck and chest (eg, internal jugular or brachiocephalic
veins) or the deep veins of the arm and shoulder (brachial,
proximal basilic, and axillary),44-46 although patient-specic
factors may affect selection. Other conventional routes,
including femoral,47 subclavian, and cephalic veins, are
associated with higher rates of mechanical and infectious
complications. The subclavian route in particular should
be avoided, especially for elective insertion of hemodiaysis
catheters.48
Alternative routes are available. Transmediastinal access
to the brachiocephalic veins or distal superior vena cava can
be achieved with coronal retroclavicular US with good long-
term stability.38,49 Translumbar and transhepatic inferior
vena cava access are more technically difcult. Transhep-
atic access is associated with greater mechanical instabil-
ity, higher short-term and long-term complication rates,
and risk of infection.50-53 Hemizygosorazygoscollaterals
are feasible54 albeit rarely used. Transthoracic transatrial
access51,55 is sometimes performed at the time of cardiac
surgery. More invasive alternatives such as creation of an
arteriovenous (AV) access56 and use of arterial access57 have
been described, but experience in children is too limited to
make a recommendation.
To date, no published studies evaluate the risk prole
of catheter tip position against an anatomically validated
reference standard. It is common empiric practice to intend
CVC tip position near the cavoatrial junction58 or in the case
of hemodialysis catheters, within the right atrium.59 Un-
ambiguous methods for accurately describing catheter tip
position relative to anatomic structures that are visible on
a plain radiograph have been published60,61 and integrated
into quality improvement guidelines.62
High-quality uoroscopy is essential for control of cen-
tral venous guide wire and catheter positioning.44 Alter-
native tracking technologies for tip positioning (eg, elec-
trocardiographic and electromagnetic) are promising but
have not yet been objectively validated.63 Transthoracic
echocardiography has been suggested to determine catheter
tip position, but randomized, controlled trials (RCT) have
not been published and expertise with the technique and
equipment is not widely available.64,65 The frequency of
unsuccessful and complicated insertions without imaging
(eg, at the bedside) remains unacceptably high and should
not be routinely attempted in high-risk patients.66,67 Collab-
oration between vascular access nurses and interventional
radiologists may offer improved outcomes compared with
bedside insertion.68
Emergent and urgent devices (ie, “temporary catheters”)
placed without maximum sterile barrier precautions, or
catheters with tips positioned at a distance from the cavoa-
trial junction, should be removed as soon as possible after
stabilization of the patient.69-75 A malpositioned catheter
(that was not too short initially) should be promptly eval-
uated with imaging and either repositioned or replaced to
avoid adverse outcomes.76,77
For elective central venous access, device selection should
be governed by specic indications documented prospec-
tively as part of the assessment/insertion process, including
the expected duration and endpoint of therapy and the
intended route and tip position (Appendix A2). Affected
persons should be considered shared decision makers in the
selection process, especially when issues such as preference,
comfort, and body image do not compromise safety and
preservation of venous pathways. The smallest lumen num-
ber and diameter should be used that accomplish the clinical
objectives safely and effectively.78-80 Vesicants, including
high osmolal, extreme pH, and many chemotherapeutic
agents, should be administered centrally.81,82 Chronic con-
tinuous or frequent infusions should employ a tunneled,
cuffed catheter through veins of the neck, chest, or groin.
There have been no RCTs evaluating midline catheters as
an alternative to CVCs or evaluating their use in high-risk
pediatric patients, and current evidence does not support
such use.83,84 Peripherally inserted central catheters are
an acceptable alternative. However, arm veins should be
avoided in patients with potential future need of hemodial-
ysis (chronic kidney disease higher than grade G2A2 or
Baskin et al 7
Table 2. Reported Central Venous Catheter Infection Rates in
Pediatric Patient Populations.
Pediatric Patient Population
Infections per 1000 Catheter
Days96-98,170-173
General population 0.2–0.9
Intensive care units 1–5
Hematology-oncology units 1–4
Hemodialysis patients 2
Intestinal failure patients 1–11
Neonatal intensive care units 11–29
Burn units 30
G3a85) because of the cumulative risk of thrombosis and
loss of potential AV stula sites.26,86 For chronic intermit-
tent access, an indwelling venous port may be placed in
the veins of the chest, extremity, or groin. Ports should be
used with caution in patients who are immunocompromised
at the time of insertion.87 For example, in patients with
intestinal failure, ports may be relatively contraindicated
prior to intestinal adaptation.88 The port septum should
be distant from contaminated sites. Chronic hemodialysis
catheters are ideally tunneled, cuffed devices that should
deliver adequate dialysis blood ow to achieve target dose
(Kt/V at least 1.2) while arterial and venous pressures
remain within acceptable parameters.89
Antibiotic-impregnated catheters have shown signi-
cant reduction in catheter-related infections in high-risk
children90 and have demonstrated superiority to con-
ventional and heparin-bonded catheters in a large pe-
diatric RCT91 without increasing resistance to bacterial
pathogens.92 They may be especially valuable for chil-
dren in the intensive care unit91 and those with intestinal
overgrowth,93 those with active infection at the time of
insertion,4,90 immunocompromised patients, those with a
history of multiple catheter-related infections, or those with
deep venous obstruction of VANGUARD Class II or higher
either above or below the diaphragm (Appendix 4).
Evidence for prophylactic use of antimicrobial lock
solutions has been encouraging in small samples.74,94-98
Meta-analysis suggests they reduce infection risk and can
be additive to other therapies,99,100 although support for
ethanol lock therapy was equivocal in a recent double-blind,
placebo-controlled RCT.101 Similarly, evidence regarding
heparin-bonded catheters in children remains too weak for
a recommendation at this time.102
Catheter-Related Infection
The reported frequency of venous catheter–related infec-
tions is unacceptably high and still may signicantly un-
derestimate the true rate. Infection rates seem signicantly
higher in populations that require chronic access (Table 2),
although the quality of most currently available data is
low, representing retrospective review of small numbers
of patients with great variability in methodology.103,104 To
know the actual rate of catheter-related infection in high-
risk populations, one must know how many catheters are
placed in high-risk patients; dwell time; number of culture-
positive bloodstream infections, exudates, or catheter tips
(if explanted); and whether there is an alternate source of
primary infection.
Reliable meta-analysis of catheter-related infections is
not currently available. The majority of published studies
report infection rates using the surveillance denition of
central line–associated bloodstream infections, which may
signicantly overestimate the true CRBSI rate.105 Con-
versely, the inuence of penalties for reporting healthcare-
associated infections and the associated reluctance to obtain
blood cultures (as well as the historic aversion to peripheral
venous sampling in children) may account for signicant
underreporting of catheter infections.5,106,107 Both strate-
gies increase uncertainty and may result in presumptive
treatment of catheter-related infection without adequate
conrmation, leading to unnecessary catheter removal and
other potentially harmful treatment. To better ensure ap-
propriate recognition of catheter-related infections and
to prevent inappropriate treatment and device removal,
all high-risk patients with a chronic venous catheter and
signs or symptoms that suggest sepsis should be rigorously
evaluated for a venous catheter–related infection,12 ideally
including differential time to positivity74,108,109 from each
catheter lumen if possible,110,111 and roll-plate culture of
the catheter tip if it is removed.4A consensus strategy for
such evaluation is provided in Infectious Disease Society
of America (IDSA) guidelines (in press). It is essential
that studies of catheter-related infection express results in
events per 1000 catheter days. Because CRBSI signicantly
increases risk of mortality, especially in transplant and
immunocompromised patients, it is also important that
sepsis and mortality be included as key outcome measures
whenever possible.112
Removing the source is fundamental in the treatment of
infection. This creates a difcult conict because of the need
for critical catheter-dependent therapies such as parenteral
nutrition and hemodialysis, the risk of loss of venous path-
ways, and the increased vulnerability of malnourished, im-
munocompromised patients to risks of catheter reinsertion
and delays in therapy. It is especially problematic because
proof of CRBSI has traditionally included catheter removal
and culture of the tip if another source cannot be identied
and because a large proportion of catheters removed for
suspicion of infection lack microbiologic conrmation.4,113
Ideally, a functioning CVC in a high-risk patient should
be removed at the end of therapy and not before. Quanti-
tative and semiquantitative analysis has allowed more ac-
curate in situ diagnosis of CRBSI.114 Nevertheless, when a
patient is in septic shock due to suspected or proven CRBSI
8Journal of Parenteral and Enteral Nutrition 00(0)
(fever with circulatory compromise or collapse), or remains
symptomatic of sepsis115-117 for >48 hours after initiation of
broad-spectrum therapy, or has a complicated infection (eg,
purulent discharge from the port pocket or subcutaneous
tract, septic thrombosis, endocarditis, osteomyelitis), it is
imperative to remove the catheter.4If the catheter is to
be removed in the setting of septic shock, other vascular
access should rst be established.118 If alternative access is
difcult, the catheter may be exchanged for an antibiotic-
impregnated catheter.4
Catheter-Related Thrombosis and Venous
Obstruction
Infectious and thrombotic complications of CVCs are
interrelated.119 Since thrombus serves as a nidus of infec-
tion, there is a higher catheter-related sepsis rate in the
presence of thrombosis.120 Thrombosis and stenosis occur
in children with a history of chronic central venous access
with an incidence of 26%–75% in prospective and cross-
sectional studies.22,37,121 Compromise of central veins leads
to increased hospital admissions for venous access–related
complications and contributes to high morbidity and cost
of care.26,122-124 Thrombosis risk is signicantly increased
in patients who have had multiple CVCs, in patients with
temporary and midline catheters, and in patients with
cardiovascular implanted electronic devices.125-127 Inherited
or acquired thrombophilia should be considered in any child
who develops deep vein thrombosis (DVT).128,129
The true incidence of DVT and stenosis in patients who
require chronic access is unknown because most studies
are limited to symptomatic patients130 and reporting has
been largely nonstandardized.131 However, asymptomatic
thrombosis has clearly been demonstrated in children with
CVCs37,132,133 with serious consequences including loss of
venous access, infection, pulmonary embolic disease, and
post-thrombotic syndrome.134 For these reasons, at the time
of CVC removal in a high-risk patient, especially with a
history of prior venous compromise, venography should be
performed to document patency and to treat compromising
lesions before access is lost. This opportunity for vessel and
catheter salvage may be invaluable to facilitate preservation
of venous capital.
A variety of methods to salvage CVC complications and
to recanalize obstructed pathways have been reported.135-138
For patients with obstructive thrombus in whom thrombec-
tomy or systemic thrombolysis fails or is unsuitable, balloon
or aspiration thrombectomy or catheter-directed pharma-
comechanical thrombolysis have demonstrated effectiveness
in children.139,140 For recanalization of mature thrombus
or nonthrombotic obstruction, less invasive methods (eg,
softer guide wires and dilators, noncompliant angioplasty
balloons) should be attempted before more aggressive tech-
niques and devices (eg, sharp recanalization, cutting bal-
loons, stent insertion) are employed, although risk-benet
analysis and the experience of the procedural team will ulti-
mately govern these decisions. Without long-term outcomes
data for venous stents in children, they should be used with
caution and restraint.141-143
Although evidence for high morbidity and mortality
in children with venous catheter–related DVT is
compelling,8,144,145 until recently, data favoring anticoagu-
lation for CVC-related thrombi and infection prophylaxis
have been relatively weak.146 Evidence regarding the
effectiveness of a shorter duration of therapy and selective
use is evolving.147-149
Standard nomenclature and relationships for veins
commonly involved in venous access are illustrated in Ap-
pendix A3, Figure A1.150 Following the lead of the Interna-
tional Small Bowel Transplant Symposium,18 a comprehen-
sive VANGUARD classication system for supradiaphrag-
matic (Appendix 4, Figures A2-A6) and infradiaphragmatic
(Appendix A4, Figures A7-A11) venous obstruction is illus-
trated. This system is equally useful for documenting the lo-
cation, extent, and nature of venous lesions, including fresh
thrombus, wall thickening/brosis, stenosis, perivascular
brosis, external compression, extravasation/perforation,
and persistent stenotic elastic recoil. A similar framework
can be used to document the location, extent, and nature
of venous salvage procedures and other interventions, such
as adherent catheter retrieval, catheter tip repositioning,
recanalization, venoplasty, and stent insertion. As data
accumulate on the relationship between patterns of venous
injury, obstruction, and other critical endpoints, disease-
specic analysis may prove increasingly useful.131,151
Collaborative Care and Information
Management
Healthcare institutions that routinely care for high-risk
CVC patients should have designated multidisciplinary
Collaborative Venous Access Teams (CVATs).152 Although
the components of care addressed by such a team should
be universal, personnel will vary from site to site but
should ideally consider patient and caregiver representa-
tives; vascular access, infusion, intestinal care, and apheresis
nurses; interventional radiologists; hepatologists; surgeons;
nephrologists; gastroenterologists; infectious disease physi-
cians; intensivists; hematologists; pharmacists; and home
health planning experts. Unfortunately, with the current
focus on indiscriminate reduction of cost, the tendency has
been to disband such teams rather than to form, strengthen,
and value them.153,154
The existence of a multidisciplinary team does not ensure
improved outcomes.155 To be effective, the CVAT should
supervise continuing CVC care and maintenance, guideline
and policy development, and resolution of difcult or con-
tentious access-related issues. CVAT leadership should have
Baskin et al 9
signicant experience with advanced access and salvage
techniques, understand the challenges inherent in treatment
of high-risk populations, and be current with the evidence
base that guides relevant best practices. To preserve venous
capital and minimize risks of catheter-related dysfunction,
the team should develop and maintain individualized long-
term plans for preservation of venous access.156,157 Con-
tinuing care of CVCs in high-risk populations should be
performed by healthcare providers with appropriate educa-
tion and experience, including currency with principles of
exit-site management including antimicrobial-impregnated
dressings and passive disinfection caps, catheter access
technique and protocols, and locking solutions or other cap-
devices to reduce infection risk.12,21,74,158-161
Persons affected by chronic diseases experience signi-
cant disruption in their lives due to morbidity and mortality
from CVC complications; frequent hospitalizations; loss
of time at work, home and school; and other related
costs of care. Healthcare providers often misunderstand
quality of life issues for these patients, especially emotional
disruption, perceptions of pain and discomfort, and impact
on family.162,163 The CVAT should pursue full engagement
of affected persons in the planning and process of care
to ensure that patient-important outcomes are prioritized
and that patient values guide all clinical decisions.164 The
patient-healthcare relationship should include bidirectional
communication and shared decision-making, support for
patient self-management, appropriate use of eHealth tech-
nology as a complement to care, education on safety and
access preservation, and respect for the experiences and
concerns of affected persons.165
Through the 21st Century Cures Act, the U.S. Congress
emphasized the need for interoperability, that is, the ability
for health information access, use, and exchange by au-
thorized persons “without special effort.”166 The concepts
embodied in this law are timely and germane to the complex
coordination-of-care needs of high-risk patients. Develop-
ment of unied and unambiguous electronic vocabulary
specications is essential.5It is imperative that such a unied
venous access vocabulary become the community standard,
including electronic health record, registry, and other health
information technology vendors; payers; publishers; and
government and private agencies. It should also be used
in structured reporting of catheter insertions and other
venous access–related events.167 Each documented event
should become part of a continuous summary of venous
events available to the patient and to health providers across
time and venue. The summary record and multidisciplinary
plan of care should be reviewed prior to any new venous
intervention.
Inputs from affected persons should be integrated with
clinical data to develop a body of real-world experience,
accessible to the patient, to improve communication and
shared decision-making. Data could also be linked through
the patient’s Unique Device Identier168 to permit coordi-
nation with national outcome tracking networks like the
National Health Safety Network and other big data sources
to inform guidelines, standards, reimbursement, and policy
development. The needs for a robust and interoperable
central venous access registry and for large-scale prospective
research have been identied as national multistakeholder
priorities.5
Conclusions
More than half of Americans have a chronic medical
condition, and more than three-quarters of each health-
care dollar is spent on their care.169 High-risk pediatric
patients are by denition disproportionately vulnerable.
Reliance on central venous access and the impact of re-
lated complications are particularly concentrated in this
population. This paper provides recommendations that can
help stakeholders improve care and quality of life for these
patients. The authors recognize that the quality of evidence
underlying these issues is generally weak, although the need
for consistent guidance and improved communication is
highly compelling. These recommendations should serve
as a foundation for the carefully constructed investigations
needed to provide high-quality evidence that can guide their
use and modication over time.
Acknowledgments
The authors would like to thank Ms. Stephanie Pitts for her
review of the manuscript.
Statement of Authorship
K. M. Baskin contributed to the conception and design of
the research and drafted the manuscript; K. M. Baskin, T.
F.Saad,B.P.Modi,J.I.Vrazas,andC.M.Schaefercon-
tributed to the acquisition and analysis of the data. All authors
contributed to the interpretation of the data, critically revised
the manuscript, agree to be fully accountable for ensuring the
integrity and accuracy of the work, and read and approved the
nal manuscript.
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Appendix
A1. Collaborators
The following members of the Venous Access: National
Guideline and Registry Development (VANGUARD) Ini-
tiative and the VANGUARD Affected Persons Advi-
sory Panel are nonauthor contributors: Swapna Kakani,
Emily Hoopes, Aly Becker, Kristin Huibregste, Ansley
McCormick, Alaina McCormick, and Sarah Palya.
A2. Essential Data Elements of a Venous
Access Record for Children at High Risk
of Venous Catheter Complication
1. Diagnostic category: underlying disease, patient
acuity, comorbid illness, American Society of
Anesthesiologists class
2. Any contraindicating or complicating factors
a. Coagulopathy
b. Thrombophilia
c. Fever, sepsis, known infection, immunode-
ciency, nutrition status
d. Venous stenosis
e. Acute thrombosis
f. Local skin infection
g. Evidence of intestinal overgrowth
3. Referring service and provider; inpatient or
outpatient status
4. Indication(s) for venous access placement
or replacement; intended function (eg,
parenteral nutrition, blood products, antibiotic
administration, uid and electrolyte therapy,
dialysis, plasmapheresis/apheresis, phlebotomy,
chelation, simultaneous delivery of incompatible
medications)
5. Anticipated duration of and endpoint for venous
access
6. Intended route and catheter tip position
Baskin et al 15
7. Provider responsible for access (interventionalist,
surgeon, nurse, etc)
8. Procedure location (interventional suite, operating
room, bedside, etc)
9. Preprocedural or periprocedural interventions (eg,
antibiotics; blood products; thrombolytic, antico-
agulant or antiplatelet agents; imaging)
10. Initial access
a. Entry side and site (eg, basilic vein, internal
jugular vein, femoral vein)
b. Method (eg, visual landmarks, uoroscopic
venography, ultrasound, cut-down)
c. Route (eg, percutaneous, transmediastinal,
paraspinal (eg, translumbar), transhepatic,
endoscopically assisted174)
d. Device (eg, angiocatheter, single wall needle,
venotomy)
e. Number and location of unsuccessful and suc-
cessful attempts
f. Complications (eg, arterial puncture, pneu-
mothorax)
g. Reason for deferral, discontinuation, or failure,
if insertion not completed
11. Access device and position
a. Catheter manufacturer, description, lumen
number and diameter, nal internal length,
composition, coating or impregnation, etc.
(documentation of unique device identier
preferred)
b. Implanted, tunneled, or direct?
c. Cuffed or uncuffed?
d. Tip position (for method, see Baskin et al60 )and
catheter functional status
e. Method of catheter xation, wound closure, and
dressing
f. Preventive therapy (eg, alcohol or antibiotic
lock, heparinization, vitamin K antagonists, tis-
sue plasminogen activator (tPA))
g. Procedure time, radiation exposure (eg,
uoroscopy time or estimated radiation
dose)
h. Procedural complications (eg, venospasm, ex-
travasation) and management
i. Adjunctive therapies required (eg, papaverine,
nitroglycerine, hot packs)
12. Complications, including
a. Catheter-related infection (include dates)
i Type (phlebitis; catheter-related sepsis; bac-
teremia; colonization; exit site, tunnel, or
pocket infection, etc)
ii Suspected (basis) or proven (method and
results175)
iii Management (eg, antibiotics, catheter re-
moval, repeat cultures)
iv Result of catheter tip and blood cultures
v Outcome
b. Catheter dysfunction (include dates)
i Type (eg, phlegmasia, extravasation or in-
ltration, fracture, fragment embolization,
brin sheath formation, tip thrombus, etc)
ii Management
iii Outcome
c. Vein injury or obstruction (eg, stenosis,
thrombosis, brosis, or occlusion) (include
dates)
i Method of diagnosis or documentation
ii Location and extent
iii Related complications (eg, superior vena
cava syndrome, post-thrombotic syndrome)
iv Management
v Outcome
d. Dislodgment, migration, or malposition (in-
clude dates)
i Method of diagnosis or documentation
ii Site of malposition
iii Management
iv Outcome
e. Other catheter-related complications
13. Catheter and venous pathway salvage procedures
(include dates)
a. In situ antibiotic therapy
b. In situ lock therapy (eg, ethanol, antibiotic,
amphotericin, echinocandins)
c. tPA catheter thrombolysis
d. Hydrochloric acid clearance
e. Over-the-wire exchange
f. Endovenous repositioning
g. Blunt recanalization
h. Sharp recanalization
i. Venoplasty
j. Stent or stent-graft insertion
14. Complications (include dates and additional de-
tails)
a. Major (early [within 30 days of insertion] or late)
i Admission to hospital for therapy
ii Unplanned increase in level of care
iii Prolonged hospitalization
iv Permanent adverse sequelae
vDeath
b. Minor
i No sequelae
ii Nominal therapy
iii Short hospital stay (for observation)
c. Procedurally related (within 24 hours of inser-
tion)
15. Removal or replacement (reason and date; end-
point achieved?)
16 Journal of Parenteral and Enteral Nutrition 00(0)
Figure A1. (a) Central venous anatomy. (b) Upper extremity venous anatomy. (c) Lower extremity venous anatomy.
Modied from Baskin, with permission. Baskin KM.
Venous Access and Related Procedures. Temple M, Marshal-
lack F, eds. Philadelphia, PA: Springer; 2014.
A3. Venous Anatomy
The central veins are illustrated in Figure A1A. Variant
anatomy, communicating, and collateral veins are not rep-
resented. The common supercial (blue) and deep (green)
veins of the extremities are illustrated in the right upper ex-
tremity in Figure A1B and the right lower extremity in Fig-
ure A1C. These are mirrored on the left. The numerous
short perforating branches that pierce the supercial muscle
fascia to join the supercial and deep systems are not shown.
The supercial veins of the extremities form extensive and
highly redundant networks, often duplicated or even trip-
licated, the visualizable components of which are variably
expressed. The great (GSV) and small (SSV) saphenous
venous trunks run within sheaths of dense perivascular
connective tissue. Common branches of the supercial veins
of the lower extremity may include anterior and posterior
accessory saphenous veins that parallel the GSV and SSV,
with their conuence near the saphenofemoral junction in
the thigh and near the saphenopopliteal junction in the
posterior calf. Other anterior and posterior tributary veins,
sometimes only visualized when pathologically dilated, may
join the saphenous veins at variable locations along their
length and take their name from their position and drainage
(eg, right posterior thigh tributary of the GSV, left anterior
distal leg tributary of the SSV). Communicating veins may
also join the GSV and SSV, the largest of which is the
postero-medial communicating vein of the thigh, known as
the vein of Giacomini.
Baskin et al 17
Figure A1. Continued.
Figure A2. (a and b) SDO Class I venous obstruction: hemodynamically signicant deep venous obstruction AND at least 1
preserved (uninvolved) conventional systemic venous pathway from each side.
18 Journal of Parenteral and Enteral Nutrition 00(0)
Figure A3. (a and b) SDO Class II venous obstruction: hemodynamically signicant deep venous obstruction involving both
pathways from 1 side, with preservation of contralateral thoracic pathways.
Figure A4. (a and b) SDO Class III venous obstruction: hemodynamically signicant deep venous obstruction involving both
pathways from 1 side, with preservation of at least 1 conventional thoracic pathway.
Baskin et al 19
Figure A5. (a and b) SDO Class IV venous obstruction: hemodynamically signicant deep venous obstruction with no patent
conventional thoracic pathways, with preservation of antegrade ow from the azygos to the right atrium.
Figure A6. (a and b) SDO Class V venous obstruction: hemodynamically signicant deep venous obstruction with no patent
conventional thoracic pathways AND retrograde or static ow through the azygos (all blood returns to the right atrium from
below the diaphragm).
20 Journal of Parenteral and Enteral Nutrition 00(0)
Figure A7. (a) IDO Class IA: Unilateral hemodynamically signicant venous obstruction below the femoral vein without
contralateral involvement. (b) IDO Class IB: Bilateral hemodynamically signicant venous obstruction below the femoral veins.
Baskin et al 21
Figure A8. (a) IDO Class IIA: Unilateral hemodynamically signicant obstruction between the popliteal vein and the inguinal
ligament with patent contralateral ow proximal to the popliteal vein. (b) IDO Class IIB: Bilateral hemodynamically signicant
obstruction between the popliteal veins and the inguinal ligaments.
22 Journal of Parenteral and Enteral Nutrition 00(0)
Figure A9. (a) IDO Class IIIA: Unilateral hemodynamically signicant iliofemoral obstruction with patent ow proximal to the
contralateral common femoral vein. (b) IDO Class IIIB: Bilateral hemodynamically signicant iliofemoral obstruction with
infrarenal inferior vena cava reconstitution.
Baskin et al 23
Figure A10. (a) IDO Class IVA: Hemodynamically signicant infrarenal obstruction with venous return via renal capsular,
portomesenteric, hepatic, and azygos/hemizygos collaterals. (b) IDO Class IVB: Hemodynamically signicant suprarenal inferior
vena cava obstruction with venous return via portomesenteric, hepatic, and azygos/hemizygos collaterals.
24 Journal of Parenteral and Enteral Nutrition 00(0)
A4. VANGUARD Classication of Venous
Obstruction
The obstruction of systemic central venous segments
can be classied by the extent of involvement. Supra-
diaphragmatic venous obstruction (SDO; Figures A2–A6)
is reported separately from infra-diaphragmatic venous
obstruction (IDO; Figures A7–A11).
Figure A11. IDO Class V: Hemodynamically signicant
suprahepatic inferior vena cava obstruction with all venous
return to the right atrium from above the diaphragm.
... Ellos han reportado que su uso prolongado no se asocia a déficit de ácidos grasos esenciales, crecimiento y neurodesarrollo. 67,68 Esto es discutido por los centros europeos, que utilizan las EL compuestas y solo proponen el uso de EL con 100 % de aceites de pescado cuando la EHFI progresa y por períodos limitados de 2 a 4 semanas 53,63 (Tabla 7). ...
... La presencia de un catéter venoso (CV) es el principal factor de riesgo para las complicaciones mayores potencialmente letales, como la infección asociada a catéter (IAC) y la trombosis venosa, 70 con una mortalidad estimada del 12,5 % al 25 % ocasionada solo por la primera. 68 U n a i m p o r t a n t e p r o p o r c i ó n d e l a s c o m p l i c a c i o n e s p u e d e n p r e v e n i r s e mediante la selección de un catéter apropiado con relación al sitio, método de inserción, tipo, calibre, cuidados de enfermería, manejo e higiene de este. 70 Las vías de acceso venoso para la NP pueden ser periféricas o centrales, según la ubicación de la punta en el árbol venoso vascular. ...
... La IAC es una causa importante de morbilidad y mortalidad en los pacientes pediátricos con FI que dependen de la NP. 68 Los reportes de series publicados muestran que la tasa de mortalidad por sepsis es mayor en los niños que en los adultos. 23 La sepsis recurrente lleva a la pérdida progresiva de accesos venosos y, por lo tanto, a la indicación de trasplante intestinal. ...
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Intestinal failure secondary to short bowel syndrome in pediatrics, is a rare condition with high morbimortality. A follow up multidisciplinary team is necessary to minimize complications and optimize the intestinal rehabilitation. There are no gold standard guidelines for the management of this group of complex patients. The development of clinical guidelines may contribute for an adequate management of patients with intestinal failure and short bowel syndrome. This Clinical Guideline for the Management was developed by 16 experts based on modified Delphi methodology. The meetings were held at the Argentinian Association of Enteral and Parenteral Nutrition (Asociación Argentina de Nutrición Enteral y Parenteral); the topics analyzed were definitions, epidemiology, enteral and parenteral nutrition, pharmacological and surgical treatments, and criteria for referring patients to intestinal rehabilitation centers. The document is aimed to provide basic scientific knowledge for medical institutions, health providers, healthcare providers, patients and families.
... 1,2 All reasons for CVAD insertion are life-changing for the child and their family or caregiver. 3 The selection, insertion, and management of CVADs span traditional health disciplines. 4 Children enter the health system via multiple departments (e.g., emergency, admissions), are managed by several sub-specialties (e.g., cancer care, cardiology, gastroenterology, trauma), and have CVAD insertion procedures carried out by further specialist groups (e.g., interventional radiologist, surgeons, anesthesiologists, intensivists). ...
... Children and their families are the primary manager of their devices in the home setting, especially for life-long vascular access dependent conditions, such as gut enteropathy requiring parenteral nutrition. 3 Even for acute illnesses, outpatient parenteral antimicrobial therapy is the new standard of care for the treatment of many infections. 5 However, having a complex and complication-prone device in the community setting may be challenging for many children and families. ...
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Background Our study aims to explore the experience of having a central venous access device (CVAD) from the perspective of the child and family and how movements within and outside of hospital environments influence this experience. Methods A mixed-methods study was conducted across Children’s Health Queensland (Australia), including inpatient and home-care settings. Children less than 18 years with CVADs were eligible and followed for 3 months or CVAD removal. A subgroup of primary caregivers participated in semi-structured interviews. Quantitative and qualitative measures of child and family CVAD experiences were explored. Results In total, 163 patients with 200 CVADs were recruited and followed for 6993 catheter days (3329 [48%] inpatients; 3147 [45%] outpatients; 517 [7%] home). Seventeen participants were interviewed. Experiences of having a CVAD were complex but predominantly positive primarily related to personalized CVAD care, healthcare quality, and general wellbeing. Their experience was shaped by their movements through hospital and home environments, including care variation and distress with procedures. Device selection and insertion location further influenced experience, including safety, impairments in activities of daily living, school, and recreation. Conclusions CVAD experiences were influenced by nonmodifiable (e.g., diagnosis) and modifiable factors (e.g., education; care variation). Clinical approaches and policies that account for family and child considerations should be explored. Impact Variation in decision making and management for pediatric CVADs is accepted by many clinicians, but the influence this variation has on the health experience of children and their families is less well explored. This is the first study to draw from a broad range of children requiring CVADs to determine their experience within and outside of healthcare facilities. Interdisciplinary clinicians and researchers need to work collaboratively with children and their families to provide resources and support services to ensure they have positive experiences with CVADs, no matter where they are managed, or who they are managed by.
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Transitions of care require coordination between inpatient healthcare providers, care managers, outpatient/ambulatory providers, and the patient/caregiver and family members. Poor communication during transitions of care can affect health outcomes and economic costs for patients/caregivers, healthcare providers, and healthcare systems. The goal of this paper is to identify risk‐prone processes in the transition of care for patients requiring parenteral nutrition (PN) between healthcare environments, including the hospital, home, skilled nursing facility, and long‐term acute care hospital settings. To facilitate the evaluation of the transition, a sequential series of steps in the transition process were identified: initial notification, assessment in preparation for transfer, identifying the receiving organization, identifying accountable providers at each sending/receiving organization, communicating the nutrition care plan, implementing the plan and additional considerations regarding PN preparation and readmissions. Safety concerns with risk‐prone processes are identified and recommended best practices are proposed for improving processes at each step of the transition. Pediatric considerations are included in the evaluation of the various steps in the transition of care. This paper was approved by the American Society for Parenteral and Enteral Nutrition (ASPEN) Board of Directors.
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This review discusses complications unique to pediatric surgical populations. Here the authors focus primarily on five of the most common procedures performed in children: appendectomy, central venous catheterization, pyloromyotomy, gastrostomy, and inguinal/umbilical hernia repair.
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Purpose of Review Pediatric intestinal failure is a complex condition requiring specialized care to prevent potential complications. In this article, we review the available evidence supporting recent advances in care for children with intestinal failure. Recent Findings Multidisciplinary intestinal rehabilitation teams utilize medical and surgical management techniques to help patients achieve enteral autonomy (EA) while preventing and treating the complications associated with intestinal failure. Recent advances in lipid management strategies, minimization of intestinal failure associated liver disease, prevention of central line-associated blood stream infections, and loss of access, as well as development of promising new hormone analogue therapy have allowed promotion of intestinal adaptation. These advances have decreased the need for intestinal transplant. Summary There have been recent advances in the care of children with intestinal failure decreasing morbidity, mortality, and need for intestinal transplantation. The most promising new therapies involve replacement of enteroendocrine hormones.
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Background Current evidence regarding the efficacy of ethanol locks in preventing catheter-related bloodstream infection (CRBI) is inconclusive. Methods Electronic databases, including PubMed, Web of Science, Embase, and the Cochrane Library (until April 2018),were systematically searched for relevant studies. Two reviewers independently screened the retrieved records and identified RCTs that met the inclusion criteria. Relevant data were extracted for pooled analyses using Review Manager 5.3 software. Subgroup analysis was performed according to the study quality, duration of the ethanol lock, disease type and CRBI definition. Eggs’ method was applied to detect publication bias. Sensitivity analysis was conducted to check the stability of the meta-analysis results. ResultsTen RCTs involving 2760 patients were included in the analysis. The overall pooled result indicated that ethanol locks significantly reduced the incidence of CRBI (RR 0.66, 95% CI 0.51–0.86). Subgroup analysis suggested that an ethanol lock significantly decreased the incidence of CRBI in patients with hematological diseases (RR 0.50, 95% CI 0.31–0.80). An ethanol lock significantly reduced the incidence of CRBI in a2-hour ethanol lock group (RR 0.49, 95% CI 0.33–0.73). The meta-analysis showed that an ethanol lock significantly reduced the incidence of CRBI according to analysis of high-(RR 0.66, 95% CI 0.47–0.94) or low-(RR 0.66, 95% CI 0.46–0.95) quality studies. Meta-analysis of studies with a strict CRBI definition showed that an ethanol lock can significantly prevent CRBI (RR 0.61, 95% CI 0.42–0.89). The results of sensitivity analysis suggested that the pooled result was stable. Meta-analysis of adverse events showed that an ethanol lock did not increase the incidence of thrombosis (RR 1.05, 95% CI 0.51–2.18) or mortality (RR 0.99, 95% CI 0.90–1.08) but did result in increased nausea (RR 1.54, 95% CI 1.01–2.35), dizziness (RR 4.21, 95% CI 2.40–7.39),elevated blushing rates (RR 3.27, 95% CI 2.05–5.22) and altered taste rates (RR 2.61, 95% CI 1.93–3.54). Conclusions An ethanol lock may play a role in the prevention of CRBI, especially in immunocompromised patients with hematological diseases.
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Background: Central line-associated bloodstream infections (CLABSIs) affect about 25% of children with cancer, and treatment failure is common. Adjunctive ethanol lock therapy might prevent treatment failure but high-quality evidence is scarce. We evaluated ethanol lock therapy as treatment and secondary prophylaxis for CLABSI in children with cancer or haematological disorders. Methods: This randomised, double-blind, placebo-controlled superiority trial, with two interim futility and efficacy analyses (done when the first 46 and 92 evaluable participants completed study requirements), was done at two paediatric hospitals in the USA and Australia. Patients aged 6 months to 24 years, inclusive, with cancer or a haematological disorder and new CLABSI were eligible. Participants were randomly assigned (1:1) to receive either ethanol lock therapy (70% ethanol) or placebo (heparinised saline) for 2-4 h per lumen daily for 5 days (treatment phase), then for up to 3 non-consecutive days per week for 24 weeks (prophylaxis phase). The primary composite outcome was treatment failure, consisting of attributable catheter removal or death, new or persistent (>72 h) infection, or additional lock therapy during the treatment phase, and recurrent CLABSI during the prophylaxis phase. This trial is registered with ClinicalTrials.gov, number NCT01472965. Findings: 94 evaluable participants were enrolled between Dec 14, 2011, and Sept 12, 2016, of whom 48 received ethanol lock therapy and 46 received placebo. The study met futility criteria at the second interim analysis. Treatment failure was similar with ethanol lock therapy (21 [44%] of 48) and placebo (20 [43%] of 46; relative risk [RR] 1·0, 95% CI 0·6-1·6; p=0·98). Some adverse events, including infusion reactions and catheter occlusion, were more frequent in the ethanol lock therapy group than in the placebo group. Catheter occlusion requiring thrombolytic therapy was more common with ethanol lock therapy (28 [58%] of 48) than with placebo (15 [33%] of 46; RR 1·8, 95% CI 1·1-2·9; p=0·012). Discontinuation of lock therapy because of adverse effects or patient request occurred in a similar proportion of participants in the ethanol lock therapy (nine [19%] of 48) and placebo groups (ten [22%] of 46; p=0·72). Interpretation: Ethanol lock therapy did not prevent CLABSI treatment failure and it increased catheter occlusion. Routine ethanol lock therapy for treatment or secondary prophylaxis is not recommended in this population. Funding: American Lebanese Syrian Associated Charities to St Jude Children's Research Hospital and an Australian Government Research Training Scholarship.
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Central venous thromboses are common and pose challenges in the care of chronically ill pediatric patients. Among patients with intestinal failure (most commonly because of short bowel syndrome) who depend on parenteral nutrition, progressive loss of central venous access sites is a potentially fatal complication. We present the case of a 5-year-old girl with parenteral nutrition-dependent short bowel syndrome and no remaining standard central venous access sites despite medical anticoagulation, in whom angioplasty and stent implantations were used to reconstruct chronically occluded central veins. The patient presented with a bloodstream infection necessitating tunneled central venous line removal from the left internal jugular vein. All other standard access sites had known occlusions. The right iliofemoral vein (RIFV) and infrarenal inferior vena cava were recanalized and dilated with high-pressure balloons. The left internal jugular line was removed and a line was placed in the now-patent RIFV for antimicrobial therapy. After treatment, the RIFV line was removed and the vessels were stented open for future access. The occluded left innominate vein was recanalized and dilated to allow a new tunneled line to be placed. At 10 months, the line was functional and uninfected and the RIFV and inferior vena cava stents were patent without in-stent restenosis. We propose a new paradigm that uses these techniques to prevent access site exhaustion in patients who do not respond to anticoagulation therapy. This approach may reduce morbidity and mortality in patients with chronic access needs and the need for intestinal transplantation in patients with intestinal failure.
Article
Objectives: To determine which factors confer the greatest risk of central line-associated bloodstream infection (CLABSI) in children with intestinal failure and fever presenting to an emergency department (ED), and to assess whether a low-risk group exists that may not require the standard treatment of admission for 48 hours on intravenous antibiotics pending culture results. Study design: This retrospective cohort study included children with intestinal failure and fever presenting to an ED over a 6-year period. Multivariable models were created using risk factors selected a priori to be associated with CLABSI as well as univariate predictors with P < .2. Results: Among 81 patients with 278 ED encounters, 132 (47.5%) CLABSI episodes were identified. Multivariable models showed higher initial temperature in the ED (aOR, 1.99; 95% CI, 1.25-3.17) and low white blood cell count (aOR, 2.65; 95% CI, 1.03-6.79) and platelet count (aOR, 2.65; 95% CI, 1.20-5.87) relative to age-specific reference ranges were strongly associated with CLABSI. Among the 63 encounters in which the patient had none of these risk factors, the rate of CLABSI was 25.4%. Conclusions: Children with intestinal failure who present to the ED with fever have high rates of CLABSI. Although higher temperature in the ED, lower white blood cell count, and lower platelet count are strongly associated with CLABSI, patients without these risk factors frequently have positive blood cultures as well. Antibiotics should, therefore, be given to all children with intestinal failure and fever until CLABSI is ruled out.