Contributors, complications, and causative factors for central venous catheter-related deep vein thrombosis in critically ill children with congenital heart disease - PCICS 2018
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This study investigates the incidence and complications of central venous catheter (CVC)-related deep vein thrombosis (DVT) in critically ill children with congenital heart disease (CHD) in a pediatric cardiovascular intensive care unit. Higher total line hours, multiple CVC lines, and prolonged intubation times were identified as significant risk factors for DVT, which is associated with increased morbidity and mortality. The findings aim to inform the development of risk models to improve screening and anticoagulation practices for this vulnerable population.
Contributors, complications, and causative factors for central venous catheter-related deep vein thrombosis in critically ill children with congenital heart disease - PCICS 2018
- 1. Emily H. Steen MD1, Javier J. Lasa MD2, Trung C. Nguyen MD2, Sundeep G. Keswani MD1,3, Paul A. Checchia MD2, Marc M. Anders MD2 1. Department of Surgery, Baylor College of Medicine, Houston, TX, USA 2. Section of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA 3. Division of Pediatric Surgery, Department of Surgery, Texas Children’s Hospital and Baylor College of Medicine, Houston, TX, USA . Contributors, complications, and causative factors for central venous catheter-related deep vein thrombosis in critically ill children with congenital heart disease RESULTS RESULTS REFERENCES METHODS QUESTIONS AND SUGGESTIONS Please contact Emily Steen at [email protected] OBJECTIVES • To report the outcomes after DVT in the pediatric cardiovascular intensive care unit (CICU) at a large, high-volume single center institution. • To identify the factors associated with DVT and DVT-related complications in the critically ill population with CHD, a group often excluded from study. • Pediatric Cardiac Critical Care Consortium (PC4) database and a radiologic database were retrospectively reviewed for CICU admissions involving CVC placement from Jan– Dec 2017. • Demographics, outcomes, DVT incidence, and DVT-related complications were gathered. • Central venous catheter (CVC) use is common in the management of critically ill children, especially those with congenital or acquired heart disease (CHD). • Prior studies suggest that the presence of a CVC augments the risk of deep vein thrombosis (DVT) in adults and children. • In recent years, the reported incidence of VTE in children has increased dramatically. • How CVC-associated DVTs contribute to morbidity and mortality in this high risk patient population is unknown. Demographics and Outcomes • Having more than one line (p < 0.0001), higher total line hours (p < 0.0001), longer intubation times (p < 0.0001), and longer CVICU admission duration (p < 0.0001) were associated with higher risk of DVT. • Of the above, only higher total line hours significantly increased the risk of DVT on multivariable analysis (p< 0.0001; ROC curve at right, AUC=0.89). CONCLUSIONS AND FUTURE GOALS • There is a strong correlation of CVC-associated DVT not only with morbidity, but also to mortality in the pediatric CICU population. • There are well-defined risk factors for CVC-associated DVT, as well as specific factors associated with clot propagation into the IVC. • Future goal: To provide data that will enable the development of specific risk models to guide screening and anticoagulation in critically ill children with CHD. 1. Raffini L, et al. Dramatic increase in venous thromboembolism in children's hospitals in the United States from 2001 to 2007. Pediatrics 2009. 2. Giglia TM et al. Prevention and treatment of thrombosis in pediatric and congenital heart disease: a scientific statement from the American Heart Association. Circulation 2013. 3. Monagle P et al. Antithrombotic therapy in neonates and children 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012. • LCOS (p < 0.0002), sepsis (p < 0.0025), CLABSI (p < 0.0174), and cardiac catheterization (p < 0.001) were significantly associated with DVT on both univariate and multivariable analysis. • LCOS (p = 0.0307) and CLABSI (p < 0.0001) were significantly associated with thrombus extension into the IVC. • Cardiac surgery with cardiopulmonary bypass was significantly associated with a decreased risk of DVT (p < 0.0011). BACKGROUND • The majority of patients were male and Caucasian, with a median age of 1.5 years. • 83% of admissions were post- cardiac surgery or other procedure, including cardiac catheterization. • 71% of patients only had one CVC placed. • The median total line hour duration (the sum of all central lines multiplied by the hours each central line was in place), was 70 hours and reflected the number of lines per patient. • The median CVICU admission duration was 92 hours. • 66% of patients required mechanical ventilation, with a median duration of ventilator support of 43 hours. • 12 admissions (1.4%) were complicated by CLABSI and 22 (2.6%) were complicated by sepsis. • 139 admissions (16.4%) had a reported episode of low cardiac output syndrome (LCOS). Outcomes and Risk of Mortality • 57 patients (7%) and 66 admissions (8%) had ultrasound-positive DVTs. • Almost 30% of those admissions noted DVTs that extended into the inferior vena cava (IVC). Outcomes and Risk of DVT LIMITATIONS AND STRENGTHS • Retrospective, single institution studies are subject to bias. • Large sample size and use of a comprehensive, validated database widens the generalizability of our findings and controls for possible confounders (e.g. consistent approach to surgical repairs). • Overall mortality was 4.95% (37 deaths), equivalent to the average CVICU mortality rate (4.82%). • A DVT diagnosis in this patient population was highly significant for mortality (p < 0.0001), as was LCOS, sepsis, CLABSI, cardiac catheterization, and clot in the IVC. • Cardiac surgery was associated with a decreased risk of death. • Univariate linear regression and multivariable regression analysis was performed; p < 0.05 considered significant.