PED1 Complications of central venous access devices in pediatric hemophilia patients. (Pediatrics & Adolescent Medicine).

PED1 COMPLICATIONS OF CENTRAL VENOUS ACCESS DEVICES IN PEDIATRIC HEMOPHILIA PATIENTS. Jennifer Ann Domm, MD, and Robert L. Janco, MD. Vanderbilt University Medical Center, Nashville, Tenn.

We conducted a retrospective survey of our experience with central venous access devices (CVADs) implanted in children with hemophilia seen at the Vanderbilt Hemostasis-Thrombosis Clinic from 1986 to 2000. Following discussion with parents on the merits and risks associated with the use of CVADs for immune tolerance induction or factor prophylaxis, catheters were inserted under sterile technique in the operating room. One nurse provided demonstration and teaching about catheter care and access. During the study period, 30 CVADs were inserted in 22 children. The catheters remained in place for a total of 30,117 days yielding an average duration of catheter life 1,004 days (range 34 to 2,460 days with a median of 1,099 days). The two most common complications associated with CVADs seen at our institution were bacteremia and thrombosis. We found a sepsis rate of 0.30/1,000 catheter-days or one episode of bacteremia for every 3,346 days of catheter use. Two-thirds of bacteremia were the result of gram-positive co cci, specifically coagulase-negative Staphylococci (n = 5) and MRSA (n = 1). One-third of bacteremic episodes were caused by gramnegative bacilli, specifically Acinetobacter. The thrombosis rate in our cohort was 0.13/1,000 catheter-days or one episode of thrombosis for every 7,529 days of catheter use. Uncomplicated venous access is essential in children with severe hemophilia who require prophylaxis or immune tolerance induction. While infection was the most common complication observed in our series, we experienced a lower overall infection rate than several reported series. The common organisms documented in bacteremia represent superficial skin flora possibly related to poor access technique or contamination from the gastrointestinal tract. As previously proposed in the literature, catheter thrombosis and subsequent obstruction may occur as a result of intraluminal fibrin deposits. The use of implantable CVADs is an effective method for accessing children with hemophilia. We accept that the benefits of C VADs in the treatment of pediatric hemophilia patients outweigh the previously documented risks. Future prospective studies should be accomplished to more precisely define all risks and to determine effective strategies to reduce them.