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Early removal of a permanent catheter during the acute management of the unstable pediatric hemato-oncology patient with suspected catheter-related bloodstream infection: a multi-disciplinary survey and review of the literature

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Abstract

There are no guidelines for the optimal manner and timing of permanent central catheter removal in the hemodynamically unstable pediatric hemato-oncology patient with suspected catheter-related bloodstream infections (CRBSI). Our goals were to examine current practices of permanent central catheter management and choice of removal in the hemodynamically unstable pediatric patient with suspected CRBSI among practitioners in diverse subspecialties. We performed a literature review on the subject, and conducted a multi-disciplinary survey included pediatric oncologists, pediatric emergency medicine physicians, and pediatric intensive care physicians whom we queried about their choice of permanent central catheter management and removal while treating the hemodynamically unstable pediatric patient with suspected CRBSI. Most of the 78 responders (n = 47, 59%) preferred to utilize the existing permanent central catheter for initial intravenous access rather than an alternative access. There were no significant differences between physician subspecialties (p = 0.29) or training levels (p = 0.14). Significantly more pediatric emergency medicine physicians preferred not to remove the permanent central catheter at any time point compared to the pediatric hemato-oncologists, who preferred to remove it at some point during the acute presentation (44.4% vs. 9.4%, respectively, p = 0.02).

Conclusion: Our study findings reflect the need for uniform guidelines on permanent central catheter use and indications for its removal in the hemodynamically unstable pediatric patient. We suggest that permanent central catheter removal should be urgently considered in a deteriorating patient who failed to be stabilized with medical treatment.

What is Known:

• There are no guidelines for the optimal choice and timing of permanent central catheter removal in the hemodynamically unstable pediatric hemato-oncology patient with suspected catheter-related bloodstream infection (CRBSI).

What is New:

• We found variations in practices among pediatricians from diverse subspecialties and conflicting data in the literature.

• There is a need for prospective studies to provide uniform guidelines for optimal management of suspected CRBSI in the hemodynamically unstable pediatric patient.

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Data Availability

All data and original material are available for transparency.

Abbreviations

CRBSI:

Catheter-related bloodstream infections

IDSA:

Infectious Disease Society of America

IO:

Intraosseous

IQR:

Interquartile range

IV:

Intravenous

PEM:

Pediatric emergency medicine

PICU:

Pediatric intensive care unit

SD:

Standard deviation

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Author information

Author notes

  1. Neta Cohen and Tom Rosenberg contributed equally.

Authors and Affiliations

  1. Department of Pediatric Emergency Medicine, Tel Aviv Sourasky Medical Center, 6 Weizman Street, 6423906, Tel Aviv, Israel

    Neta Cohen & Ayelet Rimon

  2. Department of Pediatric Hematology-Oncology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel

    Tom Rosenberg

  3. Pediatric Intensive Care Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel

    Shirley Friedman

  4. Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

    Neta Cohen, Ayelet Rimon & Shirley Friedman

Authors
  1. Neta Cohen
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  2. Tom Rosenberg
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  3. Ayelet Rimon
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  4. Shirley Friedman
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Contributions

All authors contributed to the study conception and design. Material preparation and data collection were performed by Tom Rosenberg, Neta Cohen, Ayelet Rimon, and Shirley Friedman. Data analysis was performed by Neta Cohen and Tom Rosenberg. The first draft of the manuscript was written by Neta Cohen and Tom Rosenberg and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Neta Cohen.

Ethics declarations

Ethics approval

The study and the online survey were approved by the local institutional review board (0753–19-TLV). This article does not contain any studies with human participants or animals performed by any of the authors.

Consent to participate

Informed consent was obtained from all individuals participants who accepted the invitation to be included in the study.

Conflict of interest

The authors declare no competing interests.

Additional information

Communicated by Tobias Tenenbaum

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Appendix

Appendix

Case description:

A 6-year-old boy newly diagnosed with pre-B ALL is undergoing the first month of induction, with weekly chemotherapy in addition to systemic steroids (IV prednisolone 60 mg/m2) and omeprazole. Chemotherapy is given via a Port-A-Cath. He had been in good general condition when seen at the clinic during the preceding week. The CBC shows him to be neutropenic (WBC = 1000 cells/µL, absolute neutrophil count = 0 cells/µL). He is brought to the emergency department by his parents who report that he appeared to be weaker and more tired than usual over the past few hours. Inspection reveals a pale, weak-appearing child, who was only partially responsive to verbal stimulation.

Vital signs: temperature 39 °C (102.2 °F), heart rate 170 beats/min, blood pressure 65/40 mmHg, respiratory rate 40 breaths/min, and O2 saturation 93% in room air. Physical examination: extremities cool to touch, peripheral pulses weak, and capillary refill time significantly prolonged. Port site appearance is good, and there are no other abnormal findings.

Question #1:

Which venous access will you use for the initial management of this patient?

  • Insert a peripheral venous catheter

  • Use the existing central line (Port-A-Cath)

  • Insert an intraosseous catheter

  • Insert a temporary central line

  • No preference/no institutional guideline

Question #2:

Assuming an alternative venous access was established (peripheral or intraosseous) in addition to the pre-existing central line, which would you prefer to use for fluid resuscitation?

  • The alternative catheter—peripheral or intraosseous

  • The central line (Port-A-Cath)

  • No preference/no institutional guideline

Question #3:

Assuming an alternative venous access was established (peripheral or intraosseous) in addition to the pre-existing central line, which would you prefer to use for administering empiric antibiotics?

  • The alternative catheter—peripheral or intraosseous

  • The central line (Port-A-Cath)

  • No preference/no institutional guideline

Question #4:

Assuming an alternative venous access was established (peripheral or intraosseous) in addition to the pre-existing central line, which would you prefer to use for administering vasopressors/inotropes?

  • The alternative catheter—peripheral or intraosseous

  • The central line (Port-A-Cath)

  • No preference/no institutional guideline

Question #5:

In the patient who is hemodynamically unstable, at what point in this clinical scenario should an emergent removal of the pre-existing central line be considered?

  • Immediately at presentation of a hemodynamically unstable neutropenic patient, regardless of alternative vascular access

  • At the time of presentation of a hemodynamically unstable neutropenic patient, immediately after obtaining an alternative vascular access

  • After fluid resuscitation and empiric antibiotic treatment if they fail to stabilize the patient

  • After fluid resuscitation, empiric antibiotic treatment, and initiation of inotropes if they fail to stabilize the patient

  • There is no indication for emergent central line removal during this scenario

Demographics:

What is your subspecialty?

  • Pediatric Emergency Medicine

  • Pediatric Intensive Care

  • Pediatric Hematology-Oncology

What is your gender identification?

  • Male

  • Female

  • Prefer not to answer

Are you an attending or a fellow?

  • Attending

  • Fellow

Attending physician—how many years of experience do you have in your field?

Please add any additional comments or questions.

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Cohen, N., Rosenberg, T., Rimon, A. et al. Early removal of a permanent catheter during the acute management of the unstable pediatric hemato-oncology patient with suspected catheter-related bloodstream infection: a multi-disciplinary survey and review of the literature. Eur J Pediatr 182, 795–802 (2023). https://doi.org/10.1007/s00431-022-04747-7

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