Peripherally inserted central catheters associated with a greater risk of thrombosis in children

In the first prospective, multicentre paediatric study to compare the occurrence of blood clots in children with a peripherally inserted central catheters (PICCs) or centrally inserted tunnelled lines (TLs), 85% of blood clots observed were in children who had a PICC placed. Due to their ease of insertion, PICCs are being placed at increasing rates in some paediatric centres, thus this finding may be the leading factor for the observed increasing paediatric venous thromboembolism (VTE) incidence. Other significant risk factors for VTE identified in this analysis were patients with multiple lumen central venous catheters (CVCs) and a history of VTE. Based on these findings, practitioners should try to consider avoiding PICCs and multiple lumen CVCs for children who require a new CVC.

The rates of VTE in children are increasing, largely due to the improved care of critically ill children and the placement of CVCs. There is limited evidence regarding risk factors for CVC-associated thrombosis, and there are no guidelines for paediatric patients on choosing catheter type, insertion technique or consideration for prophylaxis. Part of the draw to using PICC lines is that they are much easier to put in. In fact, they can be inserted at the bedside with a touch of sedation if needed. For tunnel lines, however, patients are booked for anaesthesia, and a surgeon or interventional radiologist is needed to place the tube. The presented study compared the VTE incidence between PICCs and centrally inserted TLs as well as identified additional risk factors for CVC-associated thrombosis.

The prospective, observational, multicentre CIRCLE study included 1,096 patients with 1,233 CVC inserted. In total, 406 (33%) patients had a TL and 827 had a PICC (67%). Patients in the study ranged in age from 6 months to just under 18 years old. A total of 65 blood clots were identified during follow up, 55 of which were found in children with PICCs. The cumulative incidence of VTE in patients with a PICC was 7.5%, while this was only 2% in patients with a TL. As such, 85% of the reported VTEs in this study were seen in patients with a PICC. The median time to developing a blood clot after a PICC was placed was 15 days; the median time to develop a blood clot after a TL was placed was 40 days. Overall, 49% of the CVCs were removed before six months. The average time a CVC was in place, which includes both PICCs and TLs, was 56 days. The data also show that children with congenital heart disease, who already have abnormal blood circulation, and those with cancer, especially with leukemia, have a greater risk for thrombosis. The use of multiple lumen venous lines was also associated with a higher risk of clots. Similarly, blood clots were four times more likely to occur if the patient was diagnosed with a central line infection. The incidence of infections was higher in the group of patients with a TL as compared to PICC (16% vs. 9%, respectively).

In summary, PICCs are increasingly being used in many paediatric centres, a trend that is paralleled by a noticeable rise in the number of blood clots seen in children. In this study, a significantly higher risk of VTE was seen in subjects with a PICC (as compared to TLs), cancer, congenital heart disease and multiple lumen CVCs. The study will continue to accrue patients and additional analyses will show whether the main reason for inserting the line (e.g., chemotherapy, prolonged courses of antibiotics, or feeding) plays a role.

Reference

Jaffray J, Witmer C, Vasquez B, et al. Determining the Incidence and Risk Factors for Central Venous Catheter Related Thrombosis in Children. Presented at ASH 2016; Abstract 419.