CRITICAL-APPRAISAL OF SURGICAL VENOUS ACCESS IN CHILDREN

Central venous catheters (CVC) have become an important adjunct to the overall management of paediatric patients, but their use is associate d with frequent complications resulting in premature removal. This rep ort evaluates the insertion techniques and complications of 295 consec utive surgically inserted CVC from 1987 to 1991 in a paediatric hospit al. Fully implanted catheters had significantly less incidence of cath eter-related problems necessitating removal (infection, dislodgment, l eaking, blockage, or migration - 31%) compared to exteriorised cathete rs (58%). One-third of catheters were removed because of infection, on e-third as they were no longer needed, and the remaining for multiple reasons. Infected (110 +/- 18 days), dislodged (18 +/- 4 days), or mig rated (44 +/- 6 days) catheters were removed significantly earlier tha n those removed because they were no longer needed (195 +/- 24 days). Catheters became dislodged more frequently in the younger patients. Ca theters with the tip in the subclavian vein (29%) migrated more freque ntly than those in the right atrium. There was a significantly increas ed incidence of infection in catheters inserted into the saphenous vei n (43%) compared to those in the internal jugular vein (11%). Some epi sodes of catheter infection were managed with antibiotics, with short- term resolution of symptoms and signs. However, all 71 infected cathet ers ultimately required removal for further sepsis. Fully implanted ca theters had 1.1 episodes of catheter-related sepsis per 1,000 catheter days compared to 3.7 for exteriorised catheters. The position of the catheter tip, vein used for insertion, training of young surgeons, and location of the subcutaneous tunnel need particular attention in orde r to reduce catheter complications.