Use Caution When Placing Catheters in Children with Cancer

San Diego, CA—Prospective, observational, and multicenter trials have documented a dramatic increase in venous thromboembolism (VTE) in children with cancer over the past decade. VTE is associated with increased mortality and longer hospital stays and is to be avoided whenever possible. A new study has found that the type of catheter used to administer medications and to draw blood makes a difference in terms of causing blood clots.

Peripherally inserted central catheters (PICCs) had a much higher incidence of blood clots than tunnel lines (TLs), suggesting that caution be used when choosing a central line during the treatment of children with cancer. In the study, 85% of the blood clots that occurred were found in children who had a PICC placed.

PICCs are being increasingly used at pediatric centers, and senior study author Julie Jaffray, MD, Children’s Hospital Los Angeles, CA, believes that this is related to the increasing numbers of VTEs seen in children of all ages—a 70% increase over the past 15 years regardless of the age-group being studied.

“An overwhelming number of blood clots happen in patients with PICCs when compared to tunneled lines,” Dr Jaffray said. “We know children with cancer or who are in the pediatric intensive unit will need a central line placed. But these lines aren’t perfect. The important question is: are we choosing the right line for them or are we just putting in the line that is easier to place?”

PICCs are easier to place, and placement can be done at the bedside with minimal sedation, if necessary, whereas TLs require anesthesia and placement by a surgeon or interventional radiologist. TLs are placed centrally versus PICCs, which can go up the arm.

At the 2016 Annual Meeting of the American Society of Hematology, Dr Jaffray presented an interim analysis of the CIRCLE study, which is the first prospective, multicenter pediatric study to compare the occurrence of blood clots in children receiving PICCs or centrally inserted TLs.

The analysis was based on 1096 children aged 6 months to <18 years with a total of 1233 newly placed central venous catheters be­tween September 2013 and October 2016 at 4 different children’s hospitals in the United States; 67% were PICCs and 33% were TLs. The study is ongoing with a planned accrual of 2000 children.

Preliminary results showed a cumulative incidence of 5.7% for central venous line–associated VTE. When broken down by type of catheter placed, the cumulative incidence was 7.5% for PICCs versus 2% for TLs.

The researchers also found that the incidence of central line–associated bloodstream infection was 12% in the entire cohort, 16% in children with TLs, and 9% in those with PICCs. “Bloodstream infection was more likely in TLs over PICCs,” Dr Jaffray stated.

Other notable findings included an increased risk for VTE in children with cancer (especially leukemia), children with congenital heart disease, and children with multiple lumen central venous catheters placed.

“We would like to create guidelines for central venous catheter insertion with regards to catheter type, insertion technique, and need for prophylaxis with anticoagulation and/or antiseptic,” Dr Jaffray said. “For now, although these are preliminary findings, I would say think twice before placing a PICC in children and see if you can get by with an IV line. More information will be forthcoming with our final analysis,” she stated.