Substantial harm associated with failure of chronic paediatric central venous access devices

Abstract

Central venous access devices (CVADs) form an important component of modern paediatric healthcare, especially for children with chronic health conditions such as cancer or gastrointestinal disorders. However device failure and complications rates are high.

Over 2½ years, a child requiring parenteral nutrition and associated vascular access dependency due to ‘short gut syndrome’ (intestinal failure secondary to gastroschisis and resultant significant bowel resection) had ten CVADs inserted, with ninesubsequently failing. This resulted in multiple anaesthetics, invasive procedures, injuries, vascular depletion, interrupted nutrition, delayed treatment and substantial healthcare costs. A conservative estimate of the institutional costs for each insertion, or rewiring, of her tunnelled CVAD was $A10 253 (2016 Australian dollars).

These complications and device failures had significant negative impact on the child and her family. Considering the commonality of conditions requiring prolonged vascular access, these failures also have a significant impact on international health service costs.

Background

Central venous access devices (CVADs) are an essential component of short-term and long-term care provision for ~50 000 children in Australia and millions of children internationally.^{1 2} Despite their necessity, one in four of these devices is associated with a severe complication and fails prior to completion of treatment.³ These rates of CVAD failure, in addition to higher rates of complications that resolve after interventions, are unacceptable and place an enormous burden on the healthcare system, children and families.

For children with chronic health conditions, and dependence on vascular access for nutrition and treatment, device failures substantially reduce morbidity, quality of life and longevity.⁴ However seminal literature and international guidelines^5–7 are principally focused on the prevention of only infectious complications, despite the higher prevalence of other types of CVAD dysfunction.³ Mechanical and vascular injuries associated with CVADs, such as venous thrombosis, are critical. Each result in treatment disruption, additional resources and difficulty associated with replacement CVAD insertion, morbidity and long-term vessel depletion.^{3 8} Vessel depletion further seriously impacts on the health and well-being of children who have a lifelong dependency on vascular access and existing chronic conditions such as immunocompromised or malabsorption nutritional disorders.⁴

A demonstration of the burden and harm associated with CVADs for children with chronic, vascular access dependent conditions is not evident in the literature. With consent from the legal guardian, a case study has been used to illustrate the current complex and harmful experience of paediatric CVAD dependency and failure. The case study also explains the local resources wasted due to potentially preventable adverse events associated with ineffective paediatric CVAD practices.

Case presentation

The child was born in an Australian tertiary referral hospital in June 2014 with gastroschisis. After early surgical repair, she required significant bowel resection (15 cm, including the ileocecal valve), resulting in short bowel syndrome (or intestinal failure) and a long-term dependency on parenteral nutrition (PN). While the child’s treatment nutritional goal is enteral autonomy, she is currently heavily dependent on vascular access for the safe administration of PN and is likely to remain so for the foreseeable future.

Outcome and follow-up

By 2½ years of age, she has had ten CVADs inserted, with ninesubsequently failing: five tunnelled CVADs; three peripherally inserted central catheters (PICCs) and one non-tunnelled CVAD, with one tunnelled CVAD still in situ. The timeline and sequelae of each CVAD is described in table 1. This equates to the child having a CVAD inserted every 100 days, each requiring a general anaesthetic and surgical procedure. Most complications resulting in CVAD failure were related to mechanical causes, most frequently dislodgement and fracture. In addition, over the last 2 years, the child’s central vasculature has developed significant thrombotic occlusion, limiting future CVAD placements. Each failed CVAD restricted her PN, required the insertion of temporary peripheral intravenous devices and/or necessitated antimicrobial therapy.

Table 1.

Central vascular access device timeline

Date inserted	CVAD type inserted and site	Complications (not resulting in CVAD removal) during CVAD dwell	Date CVAD removed	Complication and reason for CVAD removal	Time period CVAD successful
18 June 2014	PICC; left brachial	–	6 August 2014	Complete occlusion	49 days
7 August 2014	PICC; right brachial	–	18 November 2014	Dislodged; tip no longer in central position	103 days
18 November 2014	Tunnelled, cuffed CVAD; left internal jugular	6 March 2015: occluded right subclavian vein 7 March 2015: tip position in right atrium, traversing tricuspid valve. Reposition required	2 June 2015	CVAD blocked, right chest swelling. Internal catheter fracture, confirmed by contrast study	196 days
7 June 2015	Tunnelled, cuffed CVAD; right internal jugular	5 June 2015: occluded true right subclavian vein; multiple collaterals formed 9 June 2015: partial CVAD dislodgement (from SVC/RA junction to proximal SVC)	29 August 2015	Dislodged; tip no longer in central position	83 days
29 August 2015	Tunnelled, cuffed CVAD; right internal jugular (rewire)	–	14 October 2015	CVAD-associated bloodstream infection (Klebsiella pneumoniae) and catheter fracture	46 days
25 October 2015	PICC; right brachial	–	26 March 2016	Dislodged; tip no longer in central position Unsuccessful PICC replacement	153 days
28 March 2016	Non-tunnelled CVAD; right internal jugular	–	30 March 2016	Elective replacement of an inappropriate device	2 days
30 March 2016	Tunnelled, cuffed CVAD; right internal jugular	–	3 April 2016	Catheter fracture; repair unsuccessful Required prophylactic intravenous antibiotics, PIVC insertion, partial PN only	4 days
4 April 2016	Tunnelled, cuffed CVAD; right internal jugular (rewire)	6 June 2016: Catheter fracture; repaired successfully Required prophylactic intravenous antibiotics, PIVC insertion, partial PN only	6 October 2016	Catheter fracture; repair unsuccessful Required prophylactic intravenous antibiotics, PIVC insertion, partial PN only	185 days
7 October 2016	Tunnelled, cuffed CVAD; right internal jugular (rewire)			Currently in situ

CVAD, central venous access device; PICC, peripherally inserted central catheter; PIVC, peripheral intravenous catheter; PN, parenteral nutrition; RA, right atrium; SVC, superior vena cava.

In 2015, the child developed a CVAD-associated bloodstream infection caused by Klebsiella pneumoniae. This infection resulted in a 22-day admission to a tertiary paediatric hospital; 14 days of intravenous antibiotics (ceftriaxone) and 3 days of gentamicin locks; hypokalaemia (K⁺ 2.7 mmol/L) requiring overnight potassium chloride infusion; CVAD fracture during hospital stay that was unable to be repaired resulting in CVAD removal; insertion of three peripheral intravenous catheters (one necessitating ultrasound guidance) until PICC insertion and 7 days of missed PN.

The local, institutional resources used when inserting each of these CVADs is substantial. An example of the immediate financial costs associated with inserting, or rewiring, a tunnelled CVAD at the case study facility is described in table 2. This does not include additional costs associated with treating, or attempting to treat, the underlying complication. A cost of $A10 253 (2016 dollars) per device is a major cost to paediatric hospitals, and the child has undergone six tunnelled CVAD insertion, or rewiring, in her short life time.

Table 2.

Local resources used to insert, or rewire, a tunnelled CVAD in 2016 Australian dollars

Resources	Cost ($A)
Staff24 25
Consultant paediatric surgeon ($A199.16/hour): 2 hours	398.32
Training (registrar, resident medical officer) paediatric surgeon ($A128.98/hour): 2 hours	257.55
Registered nurses or equivalent (operating specialty)($A42.4711/hour): two nurses, 2½ hours per nurse	212.36
Consultant anaesthetist ($A199.16/hour): 2½ hours	497.90
Training (registrar, resident medical officer) paediatric anaesthetist ($A128.98/hour): 2½ hours	322.45
Registered nurse or equivalent (anaesthetics and recovery specialty) ($A42.4711/hour): 3 hours	127.42
Location26
Dedicated theatre suite (including equipment such as ultrasonography, imaging) ($A80/minute): 1 ½ hours	7200.00
Anaesthetic recovery: at least 30 min	89.98
Hospital bed: at least 8 hours	803.95
Consumables26 27
Central venous access device and insertion equipment: frequently >1 required	275.00
Sterile personal protective equipment ($A5.00 each): four at least	20.00
Anaesthetic medications (including inhaled, intravenous): multiple	34.38
Device dressing and security	14.00
Total	10 253.31

CVAD, central venous access device.

Discussion

The child’s vascular access progression may seem unremarkable to paediatric clinicians, because such complications are common and in-depth data on repercussions are lacking. Yet these experiences were extraordinarily negative for the child, her family and the healthcare system. Children with chronic health conditions requiring prolonged vascular access are common place.⁹ The potentially preventable harm associated with their CVADs places a large burden on the healthcare system.

The costs and events described by the case study are in accordance with recent case-control studies demonstrating that paediatric CVAD-associated bloodstream infections cost healthcare systems around US$55 646 (2011 US dollars) and 19 additional days in hospital,¹⁰ with even higher costs (U$69 332; 2011 US dollars; 21.2 additional days in hospital) for the haematology and oncology paediatric population.¹¹ Delays to treatment and the insertion of replacement CVADs due to other (non-infectious) types of CVAD failure and complication are also expensive for healthcare systems, and significantly reduce the quality of life, morbidity and mortality of paediatric patients.¹²

As demonstrated in the case study, the immediate interruption to necessary treatment results in an inability to receive prescribed fluids, nutrition, antibiotics and other necessary medicines. In addition to the immediate costs associated with the insertion of a replacement device, the insertion of new CVADs can result in serious complications such as pneumothorax and arterial puncture.^{3 13} Overall, the treatment of the complication, the interruption to necessary treatment and complications associated with the new CVAD insertion are associated with an increased length of hospital stay, ICU stay and mortality.^{14 15} This case study has not explored the further financial and other costs borne by the patient and family such as lost time in paid employment and opportunity costs in attendance at playgroup or family occasions.

It is timely for a new focus on long-term vessel health and preservation in paediatrics. Children with CVADs are frequently managed by multiple medical and health professionals. ‘Siloed’ healthcare commonly sees decisions regarding device selection, placement and management made in isolation by individual clinicians from varying backgrounds (eg, oncologist, surgeons, anaesthetists, nurse consultants). A paediatric vascular access continuity of care model, which has been advocated across many other areas of healthcare,^{16 17} has not been applied, and this is resulting in harm to the patients, their families and the healthcare institutions.

It is also time for high-quality evidence to be generated to improve vascular access outcomes for paediatric patients. A recent focus on preventing harm associated with CVAD insertion and immediate infection has been highly successful in intensive care units;^{7 18 19} however, evidence is weaker on how to maintain CVAD performance during device dwell and in chronic use settings. The child’s case study, in agreement with previous literature,^{2 3} has demonstrated that the harm associated with CVADs frequently occurs during the later stages of CVAD dwell, not on the early days after insertion. Paediatric CVAD maintenance procedures such as flushing,²⁰ dressing,²¹ administration set changes,²² and hub decontamination²³ are not well supported by evidence, likely perpetuating these preventable complications for patients.

Learning points.

• Children with vascular access dependent chronic health conditions are at great risk for harm associated with vascular access complications.

• Paediatric central venous access device failure and complication rates are high and have a substantial impact on the healthcare system, patient and family.

• High-quality evidence to improve vascular access outcomes for paediatric patients is urgently needed.