151 Central venous catheter associated bloodstream infections and thrombosis in patients treated for gastroschisis and intestinal atresia Chapter 6 Introduction Total parenteral nutrition (TPN) via a central venous catheter is essential in the treatment of children with an intestinal atresia or gastroschisis. Without TPN, patients would experience severe malnutrition because of impaired intestinal function. The duration of TPN feeding is a median of 26 days in gastroschisis patients and 20 days in intestinal atresia patients [1, 2]. The central venous catheters used to administer parenteral nutrition differ in the mode of insertion, either tunnelled subcutaneously before entering a vein or non-tunnelled, and the anatomical location of the vein used for insertion, either a large central vein or a smaller peripheral vein. The choice between these types of central venous catheters is a trade-off between the advantages and disadvantages. For instance, tunnelling the catheter subcutaneously before entering the vein supposedly results in less central venous catheter associated bloodstream infections (CLABSIs) [3]. Moreover, a cuffed segment of a tunnelled catheter adheres to the body, limiting the risk of dislocation which can be a problem when using non-tunnelled catheters [3]. However, tunnelled central venous catheters have to be placed surgically, necessitating operation room capacity and general anaesthesia. A non-tunnelled central venous catheter can often be placed in the ward under local anaesthesia. Inserting a central venous catheter in a peripheral vein can also be done in the ward and is supposed to have less risks of iatrogenic damage, such as pneumothorax, which can occur during direct insertion into a central vein. Furthermore, peripherally inserted central venous catheters seem to have a slightly lower risk of CLABSI compared to centrally inserted catheters in pediatric intensive care patients in general [4]. However, it is assumed that catheters inserted in a peripheral vein have an increased risk of thrombosis, through a number of mechanisms, including injury of the vessel wall by both parenteral nutrition and the catheter, chronic inflammation and disruption of blood flow, compared to catheters which are directly inserted into a central vein [3]. Although it must be noted that this increased risk is most profound in patients treated for cancer or patients with chronic intestinal failure treated with TPN at home[5]. American national database studies, which included over 2000 pediatric patients, showed that patients treated for gastroschisis or intestinal atresia who received a central line are seemingly more at risk of CLABSI compared to pediatric patients in general, but they were limited in the amount of risk factors they could analyse [6, 7]. Moreover, they did not look into the risk of catheter related thrombosis which is why the incidence of this complication is still unknown.
RkJQdWJsaXNoZXIy MTk4NDMw