# Presentation: 237392

## Spotlight Case May 2003

**Central Line Complications in an Infant**

**webmm.ahrq.gov**

## Source and Credits

- This presentation is based on the May 2003 AHRQ WebM&M Spotlight Case in Pediatrics
- See the full article at _[http://webmm.ahrq.gov](http://webmm.ahrq.gov/)_
- CME credit is available through the Web site
- Commentary by: **Adrienne** **Randolph**, **MD**, Harvard Medical School
- Editor, AHRQ WebM&M: Robert Wachter, MD
- Spotlight Case Editor: Tracy Minichiello, MD
- Managing Editor: Erin Hartman, MS

## Objectives

*At the conclusion of this educational activity, participants should be able to:*
- List the complications of central line manipulation
- Appreciate the limitations of diagnostic studies for PE in children
- Describe modalities for prevention of catheter-related venous thrombosis

## Case: Central Line Complications

*An 8-month-old girl was in the ICU for 6 days for treatment of septic shock secondary to meningococcemia, and was to be transferred to a general pediatrics ward. In preparation, the nurse flushed the patient’s central venous catheter with heparin and locked the line.** **Within minutes, the infant became cyanotic and apneic. A full code ensued and the patient was stabilized with a blood pressure 95/55, heart rate 120, RR 35, and O2 sat 90% on 100% non-rebreather.*

## Complications of Central Line Manipulation

- Arrhythmias
- Irritation of conduction system by catheter tip
- Venous air embolism
- Venous thromboembolism

*Polderman KH, et al. Intensive Care Med. 2002;28:1-17. *

**Notes:**
Polderman KH, Girbes AJ. Central venous catheter use. Part 1: mechanical complications. Intensive Care Med. 2002;28:1-17. 

## Pulmonary Thromboembolism in Pediatrics

- Thromboembolism less common in infants and children than adults
- Lower incidence vs. underdiagnosis
- Index of suspicion must be high to start anticoagulation

*Grandas OH, et al.  Am Surg. 2000:66:273-276. *

**Notes:**
Grandas OH, Klar M, Goldman MH, Filston HC. Deep venous thrombosis in the pediatric trauma population: an unusual event: report of three cases. Am Surg. 2000:66:273-276. 

## Data Supporting PE in this Infant

- Sudden high O2 requirement
- Marked hemodynamic instability
- Proximity to manipulation of catheter
- Potential hypercoagulable state
- Sepsis
- Meningococcemia associated with acquired protein C deficiency

*Faust SN, et al. NEJM.  2001;345:408-16. *

**Notes:**
1.       Faust SN, Levin M, Harrison OB, Goldin RD, Lockhart MS, Kondaveeti S, Laszik Z, Esmon CT, Heyderman RS. Dysfunction of endothelial protein C activation in severe meningococcal sepsis. N Engl J Med. 2001;345:408-16.

## Clinical Management of Suspected Catheter-Related PE

- Immediate aspiration of central line
- Patient in right-side-up position
- Consider empiric anticoagulation
- If hemodynamically unstable, consider stat portable echocardiogram to assess RV function
- Septal deviation, pulmonary hypertension

## Diagnosis of PE in Children

- Gold standard: pulmonary angiogram
- Rarely performed, not readily available
- V/Q scan
- Limited diagnostic value if atelectasis or effusions
- Spiral CT
- Pediatric radiologists experience limited
- No studies evaluating diagnostic characteristics in children

*Velmahos GC, et al. Arch Surg. 2001;136:505-11. **Baile EM, et al. Am J Respir Crit Care Med. 2000;161:1010-5.*

**Notes:**
Point 3#
1.       Velmahos GC, Vassiliu P, Wilcox A, Hanks SE, Salim A, Harrel D, Palmer S, Demetriades D. Spiral computed tomography for the diagnosis of pulmonary embolism in critically ill surgical patients: a comparison with pulmonary angiography. Arch Surg. 2001;136:505-11.
2.       Baile EM, King GG, Muller NL, D'Yachkova Y, Coche EE, Pare PD, Mayo JR. Spiral computed tomography is comparable to angiography for the diagnosis of pulmonary embolism. Am J Respir Crit Care Med. 2000;161:1010-5

## Pulmonary Angiogram

**Notes:**
This angiogram demonstrates filling defects in the right lower lobe and shows no perfusion to the right middle lobe. 

## High Probability VQ Scan

** ****Ventilation ****	****	****	****Perfusion  **

**Notes:**
Ventilation is homogenous. However, perfusion scan shows multiple miss matched defects, at least 8.

## Spiral CT

**Notes:**
Large centrally located pulmonary embolism

## Diagnosis of PE in Children

- D-dimer
- Good negative predictive value in adults with low probability of PE
- Poor specificity
- No studies in children

*Kelly J, et al. Arch Intern Med. 2002;162:747-756.*

**Notes:**
Kelly J, Rudd A, Lewis RR, Hunt BJ. Plasma D-dimers in the diagnosis of venous thromboembolism. Arch Intern Med. 2002;162:747-756. 

## Case (cont.): Central Line Complications

*	**A spiral CT revealed a large central pulmonary emboli. Anticoagulation therapy was started. The patient improved and was discharged to home several days later without sequelae from this event.** *

## Incidence of DVT in Children

- Incidence of DVT/PE not well studied in children
- Prospective study of 59 children with more than 2 risk factors found only 1 DVT
- Retrospective study evaluated 2746 trauma patients, 3 DVTs identified

*Rohrer MJ, et al.  J Vasc Surg.1996;24:46-9. **Grandas OH, et al. Am Surg. 2000:66:273-276.*

**Notes:**
Point#1
Rohrer MJ, Cutler BS, MacDougall E, Herrmann JB, Anderson FA Jr, Wheeler HB. A prospective study of the incidence of deep venous thrombosis in hospitalized children. J Vasc Surg. 1996;24:46-9. 
Point #2
Grandas OH, Klar M, Goldman MH, Filston HC. Deep venous thrombosis in the pediatric trauma population: an unusual event: report of three cases. Am Surg. 2000:66:273-276. 

## Incidence of DVT in Children

- Clots often related to central venous catheters
- Catheter-related DVTs detected in 8%-25% of infants and children in the ICU by ultrasound
- 1/3 of clots in infants and young children associated with central lines

*Pierce CM, et al. Intensive Care Med. 2000;26:967-72; Krafte-Jacobs B, et al. **J Pediatr. 1995;126:50-4; van Ommen CH, et al. J Pediatr 2001:139:676-81.*

**Notes:**
 point #1
 Pierce CM, Wade A, Mok Q. Heparin-bonded central venous lines reduce thrombotic and infective complications in critically ill children. Intensive Care Med. 2000;26:967-72.
 Krafte-Jacobs B, Sivit CJ, Mejia R, Pollack MM. Catheter-related thrombosis in critically ill children: comparison of catheters with and without heparin bonding. J Pediatr. 1995;126:50-4. 

point#2
van Ommen CH, Heijboer H, Buller HR, et al. Venous thromboembolism in childhood: a prospective two-year registry in the Netherlands. J Pediatr 2001:139:676-81. 

## Risk Factors for DVT in Children

- Central venous catheters
- Sepsis
- DIC
- Immobility
- Cancer
- Nephrotic syndrome

- Dehydration
- >150% ideal body weight
- Oral contraceptives
- History DVT/PE
- Acquired/hereditary deficiencies of anticoagulation

## Consequences of Central Line Thrombosis

- Pulmonary Embolism
- Incidence unknown, registry data now available but flawed
- Thrombus propagation
- IVC, ileofemoral, subclavian occlusion
- Typically recanalize, but may cause SVC or postphlebitic syndromes

*van Ommen CH, et al. J Pediatr 2001:139:676-81; Monagle P, et al. Pediatr Res 2000;47:763-6; Andrew M, et al. Blood 1994;83:1251-7.*

**Notes:**
van Ommen CH, Heijboer H, Buller HR, et al. Venous thromboembolism in childhood: a prospective two-year registry in the Netherlands. J Pediatr 2001:139:676-81.    

Monagle P, Adams M, Mahoney M, et al. Outcome of pediatric thromboembolic disease: a report from the Canadian Childhood Thrombophilia Registry. Pediatr Res 2000;47:763-6.

Andrew M, David M, Adams M, et al. Venous thromboembolic complications (VTE) in children: first analyses of the Canadian Registry of VTE. Blood 1994;83:1251-7.

## Preventing Catheter-Related Thrombosis

- Heparin-bonded catheters
- Best data available for prevention
- Marked decrease in thrombus formation
- Decrease incidence of catheter-related infections

*Pierce CM, et al. Intensive Care Med. 2000;26:967-72.**Krafte-Jacobs B, et al. J Pediatr. 1995;126:50-4.*

**Notes:**
Pierce CM, Wade A, Mok Q. Heparin-bonded central venous lines reduce thrombotic and infective complications in critically ill children. Intensive Care Med. 2000;26:967-72. 

Krafte-Jacobs B, Sivit CJ, Mejia R, Pollack MM. Catheter-related thrombosis in critically ill children: comparison of catheters with and without heparin bonding. J Pediatr. 1995;126:50-4. 

## Low dose heparin flushes not beneficial in adult literature
No studies in children
Higher dose may be effective but risk systemic anticoagulation

- No studies in children
- Higher dose may be effective but risk systemic anticoagulation

*Randolph AG, et al. Chest. 1998;113:165-71.**Smith S, et al. Am J Pediatr Hematol Oncol. 1991;13:141-3. *

**Preventing Catheter-Related Thrombosis**

**Notes:**
Randolph AG, Cook DJ, Gonzales CA, Andrew M. Benefit of heparin use in central venous and pulmonary artery catheters: a meta-analysis of randomized controlled trials. Chest. 1998;113:165-71. 

Smith S, Dawson S, Hennessey R, Andrew M. Maintenance of the patency of indwelling central venous catheters: is heparin necessary? Am J Pediatr Hematol Oncol. 1991;13:141-3. 

## Low molecular weight heparin
No clinical trials for prophylaxis in pediatric population
Compression stockings and pneumatic compression devices
Not available in pediatric sizes

- No clinical trials for prophylaxis in pediatric population
- Compression stockings and pneumatic compression devices
- Not available in pediatric sizes

**Preventing Catheter-Related Thrombosis**

## Take-Home Points

- Complications of central line manipulation include arrhythmias, thrombosis, and embolism
- The low reported incidence of DVT/PE in infants and children may be due to underdiagnosis
- Majority of thrombotic episodes in pediatrics related to central lines

## Take-Home Points (cont.)

- Central line thrombosis can result in serious morbidity
- PE, SVC syndrome, iliofemoral and IVC clots
- Heparin-bonded catheters may prevent central line-related thrombosis
- RCT needed to determine if this should be standard of care