Immediate complications of percutaneous central venous cannulation in children.

OBJECTIVE: To study the incidence of immediate complications associated with percutaneous central venous catheterization.
MATERIALS AND METHODS: A total of 103 central venous catheters were inserted in 70 children over a period of 18 months, governed by a uniform protocol. Sixty-three percent of the catheters were inserted in neonates, 23.3% in infants and 13.6% in children between 1 and 12 years of age. STATISTICAL ANALYSIS USED: Software SPSS version 15.
RESULTS: There were a total of 41 insertion-related immediate complications, of which 75.6% were in neonates. Neonatal age, hemodynamic instability and more number of attempts to catheterize the vein had a higher risk of insertion-related problems. There was no mortality directly as a result of the procedure.
CONCLUSION: In our practice, it was observed that complications were fewer with increasing familiarity with the procedure. Hence, percutaneous central venous catheterization is a safe procedure when performed in experienced hands.

INTRODUCTION

Invasive central venous catheterization is often necessary in critically ill patients for hemodynamic monitoring and for the administration of hypertonic fluids, drugs and parenteral nutrition. Percutaneous central venous catheterization reduces the need for the stress of repeated venepuncture and also saves the vein for future use, which is not the case if venous access is achieved using the cut-down technique. The widespread use of central venous catheters during the last few years has been reported to be associated with many complications, some of them lethal. This paper audits our immediate complications noted during the procedure of percutaneous central venous catheterization at a tertiary referral center.

MATERIALS AND METHODS

One hundred and three consecutive percutaneous central venous catheters inserted in 70 children within the age group of 0–12 years over a period of 18 months were studied. Routes of insertion were internal jugular, femoral and basilic veins. The common types of catheters used included Leaderflex 22G (Vygon, Gurgaon, India), Leadercath 20G (Vygon) and Primicath (Vygon). The type of catheter inserted depended on the age of the patient and the indication of insertion.

All lines were inserted by a single person (resident in the Department of Paediatric Medicine) using the Seldinger technique by a uniform protocol initially under supervision and later independently by the bedside. Each catheterization was followed by an X-ray to confirm the position of the tip of the catheter. Each skin puncture was defined as an attempt. Success was defined as the ability to cannulate the vein.[1] Data collected included age, weight, sex, hemodynamic status, indication for placement, site of catheterization, number of attempts and immediate complications. Analysis of the data was performed using SPSS version 15. Percentages, test of proportion and odds ratio were applied to compare the two groups.

RESULTS

Of the 103 catheters, 65 (63.1%) were inserted in neonates, 24 (23.3%) in infants and 14 (13.6%) in children between 1 and 12 years of age. There were 86 (83.5%) males and 17 (16.5%) females. Among the neonates, 53.8% were term and 46.2% were preterm. Catheterization was performed in neonates with a mean weight of 2.276 ± 0.847 kg, the smallest being 0.5 kg, and the range of weight of the non-neonates was 3.060–21.0 kg, with a mean weight of 7.315 ± 4.144 kg. Of the neonatal catheterizations, 53.8% were in hemodynamically unstable patients and 47.4% among the non-neonatal catheterizations were in unstable patients. Also, 64.6% of the catheterizations were on neonates with ventilatory support while 42.1% of the non-neonates were on ventilator during catheterization.

The indications for catheterization are summarized in Table 1. The most common indication was failure of peripheral venous access in both neonates and non-neonates (63.1% and 76.3%, respectively). Routes of insertion included internal jugular (89.2% in neonates and 81.6% in non-neonates), femoral vein (4.6% in neonates and 18.4% in non-neonates) and basilic vein (6.2% in neonates and none in non-neonates).

Table 1

Indication for insertion of central venous access devices

The complications related to the procedure of insertion and various factors influencing them are summarized in Tables 2 and 3. A single attempt at catheterization was successful in 70.7% of the neonates and in 79.3% of the non-neonates. The overall success rate of the procedure was 92.9% and on only five occasions (four neonates and one non-neonate), percutaneous insertion failed and a venesection was required. Success rate (after one or multiple attempts) was seen to be increasing with increasing age, with a 90.2% success rate in neonates and 100% in children in the age group of 5–12 years. The immediate complications, namely pneumothorax, hydrothorax and subcutaneous extravasation, were noticed only in neonates at a rate of 1.5% each. Both pneumothorax and extravasation developed in the hemodynamically unstable patients (complication rate of 2.9%) while hydrothorax developed in the hemodynamically stable neonate (complication rate of 3.3%). Similarly, pneumothorax developed in a patient with ventilatory support (complication rate of 2.4%) while hydrothorax and extravasation developed in patients with spontaneous breathing (complication rate of 4.3%). Also, none of the cases of pneumothorax, hydrothorax and extravasation developed in neonates in whom catheterization was achieved in single attempt. In case of hydrothorax and extravasation (complication rates of 8.3%), catheterization was achieved in two attempts while multiple attempts at catheterization were made in case of pneumothorax (complication rate of 4.2%). No mortality was directly attributed to the percutaneous central venous catheter.

Table 2

Line-related complications and influencing factors in total catheterizations

Table 3

Distribution of immediate complications of PCVCs in neonates according to the influencing factors

DISCUSSION

Central venous catheterization is an important procedure in the pediatric intensive care unit. Hemodynamic monitoring, fluid infusion, administering hypertonic solutions and also complex procedures like hemodialysis are the benefits of a central venous catheterization. Cannulation can be carried out in major central veins like the internal jugular, external jugular, subclavian, basilic or femoral veins.

Of the 103 catheterizations in our study, 63.1% were carried out in neonates and 36.9% in non-neonates, majority in critically unstable patients and the most common indication being non-availability of suitable peripheral venous access followed by need for prolonged venous access. Rao et al. also reported the same indications for catheterizations in their study.[2] There were a total of 41 complications with a rate of 39.8% at the time of insertion. Of the 41 complications, 38 were failed attempts at cannulation. Of all complications, the majority (75.6%) were seen in neonates. Thus, neonates had a greater risk of problems at insertion. This was due to their smaller veins, resulting in an increase in the number of attempts taken to catheterize the vein.[2] The success rate of percutaneous central venous catheterization was seen to be increasing with increasing age, which is similar to that seen by Venkataraman et al.[3] The overall success rate of our series was comparable with the published literature.[34]

The rate of immediate complications in this group is comparable to other reported series.[35-7] Eichelberger et al. and Filston and Grant have reported lower rates of pneumothorax in infants, but their studies did not include hemodynamically unstable patients.[89] Hemodynamically unstable patients had a slightly higher rate of immediate complications than those with normal blood pressure, mainly because of the greater number of attempts made to catheterize the vessel in these patients. The low incidence and absence of statistical significance may be attributed to the small sample size. We recommend a larger sample size to further validate these findings. Venkataraman et al. in a metaanalysis found similar results.[3] Respiratory status did not seem to affect the incidence of immediate complications. None of the patients (neonates/non-neonates) in the present study developed hemothorax, air embolism, subclavian artery puncture, cardiac arrhythmias or cardiac perforation, which were seen in a few of the studies.[3610] No statistically significant conclusion could be drawn regarding the bearing of insertion site and type of catheter used on the occurrence of complications at catheter insertion as the numbers of catheters inserted by routes other than the internal jugular vein were few and so were the catheters other than polyurethane catheters.

No mortality was associated directly with the procedure. It was observed that complications were fewer with increasing familiarity with the procedure with two-third of the complications being seen in the first half of the cannulations and one-third in the later half. Hence, it is a safe procedure when performed in experienced hands.