| BackgroundCentral venous catheters (CVC) refer to any catheters which tips are located at large central veins, are suitable for a large number of rapid infusion, blood purification treatment, central venous pressure monitoring, and parenteral nutrition therapy etc. Femoral vein, internal jugular vein, and subclavian vein are the common locations of the central venous catheter insertion. Central venous catheters are widely used in the pediatric intensive care unit (PICU), provide fast and effective infusion channels for rescuing and treating critically ill children in the pediatric intensive care unit, which protect the peripheral vascular and reduce patients’pain of the repeated vein puncture. But the complications during the catheter indwelling affected the use of central venous catheter and the rescue and treatment of patients. As literature pointing, Complications appeared 6h after placement were defined as the catheter indwelling complications or maintenance-related complications.Complications of central venous catheters in pediatric patients, were differences in various researches. Foreign scholars Karapinar et al, through surveying, found that the total incidence of maintenance-related complications was 17.3%. The complications included occlusion, accidental removal, central venous thrombosis, subcutaneous extravasation, dislodgment, and extravascular in pediactric intensive care unit. The incidence of obstruction was the highest, was 7%. There were also foreign scholars thought catheter-related deep vein thrombosis and catheter-related infections be the most common complications in children. Domestic Zhang Xiu-fen and Chang Yan-qin respectively observed 48 and 31 children with indwelling central venous catheter, the results of complications were occlusion, pipeline slip, infection and the occurrence of complications are less. Lou Xiao fang observed 479 children with central venous catheters in femoral veins in PICU, there were 33 patients with limb swelling in puncture side. Thus, as domestic and international studies, the common maintenance-related complications of CVC were catheter-related infections, occlusion, accidental extubation, deep vein thrombosis, fluid extravasation, catheter displacement, puncture side limb swelling, effusion of puncture site and so on. The categories and incidence of complications are different in different areas and in different periods.Central venous catheter related infections include systemic infection and local infection and catheter colonization. Local infection occurrs around the catheter or local skin tissue; Systemic catheter-related infection also called the catheter-related bloodstream infection(CR-BSI) is the most common nosocomial infection in PICU, Patients with systemic infectional symptom, in addition to central venous catheter bloodstream infections, have no other obvious source of infections, the same pathogenic microorganisms were isolated from the patient’s peripheral blood culture and part of catheter semi-quantitative and quantitative. Systemic catheter-related infections accounted for 28%-52% of all infections. Foreign literature reported that the incidence of CR-BSI in pediatric studies were ranging from 1.55/1,000 catheter-days to 20.6/1,000 catheter-days. The most common pathogens of bloodstream infections were coagulase negative staphylococcus aureus, enterococcus, staphylococcus aureus, intestinal bacteria (genus), candida albicans, pneumonia klebsiella, etc. In the domestic, The incidence and etiology of children catheter-related bloodstream infection reported few. Foreign literature reported incidence of central venous catheter related deep vein thrombosis (DVT) in infants were ranging from 5% to 50%. The rate of asymptomatic thrombosis of critically ill children in PICU was 15.8%. Chen Shuo-Hui retrospectively analyzed 21 children of central venous catheter-related thrombosis, He analyzed reasons of its occurrence and suggusted what kind of care measures should be taken, And did’nt reported it’s incidence. Occlusion was one of the most common non-infectious complications in the process of long-term indwelling catheters. The incidence was different. The incidence of central venous catheter occlusion was 7% in PICU, Karapinar reported. Zhang Xiu-fen observed 48 children with indwelling central venous catheters, found 2 catheters were to be occluded, the rate of occlusion was 4.2%. Chang Yan-qin retrospectively studyed 31 patients with liver tumor surgery indwelling central venous catheters, found 2 patients’catheters to be occluded, the rate of occlusion was 6.5%. Catheter displacement refers to the position of catheter moving 0.5cm or more, but catheter still can be used; Prolapse is the catheter accidentally to come out and the catheter can not continue to be used. Pelosin pointed the main reason of unplanned extubation was catheter displacement. Few researches reported specifically central venous catheter puncture site exudate. Yu Rui-xiang et al, through observing 216 patients with indwelling central venous catheters found that there were 14 patients with cahteter puncture site exudate. Lin Yue-shuang et al, reported that 12 patients were puncture site exudate occured within 24 hours after inserting intravenous catheter in femoral vein. However, studies did not do specifically for children with central venous catheters.Some abroad scholars had studied part of complications of central venous catheters in PICU, Especially catheter-related infections and catheter-related deep vein thrombosis. However, studies on the analysis of the incidence and risk factors of complications during central venous catheter indwelling were relatively few. Most studies did not distinguish between long-term indwelling percutaneous peripherally inserted central venous catheters and short-term central venous catheters, And researches were more focused on insertion-related complications.In Domestic, researches on children’s maintenance-related complications of central venous catheters most were for small sample and retrospective summary, Or only analysed and researched a single complications, In their process of researches seldom did statistical analysis the in risk factors of complications. No study of CVC maintenance-related complications in PICU has been reported.Objective1. To understand maintenance-related complications and the main causes of unplanned extubation of center venous catheters in PICU, provide the foundation the epidemiological data for the prevention and management of complications.2. To investigate the common maintenance-related complications and risk factors of maintenance-related complications of central venous catheters in PICU, And provide theoretical support for making the preventive measures.Object and methods1. Research objectPatients with indwelling central venous catheter at a level of first-class hospital PICU in guangzhou from October 30,2012 to November 31,2013. Inclusion criteria: The central venous catheter was inserted during hospitalization, and the indwelling time of was more than 6 hours. Exclusion criteria:(1) Patients’central venous catheters were inserted in other hospitals; (3) Indwelling time of patients’central venous catheter was less than 6 hours.2. Research methodsAccording to the central venous catheter maintenance record list, Nurses observed and recorded the condition of insertion site every shift. The central venous catheter maintenance record list was repeatedly modified 4 times to be determined through reviewing literature and consulting clinicians, nurse specialists and intravenous infusion nurse specialists and 2 weeks of clinical trial in PICU, It’s content included patient’s general situation, puncture process, CVC general condition, the situation of puncture site, the maintenance of cathater, the cause and time of removel and so.3. Statistical methodsData collection and statistical analysis were all using SPSS 19.0 statistical software. The incidence of various complications was descriptive statistics analysis. Statistically significant risk factors was determined by single factor analysis. If the measurement data was normal distribution, the statistical method was used t test, Otherwise, nonparametric statistical method. Count data was used x 2 test or the Fisher exact test. Clinically significant risk factors of the total complications, catheter-related infections, catheter displacement were selected. Respectively with total complications, catheter-related infections, catheter displacement were as the dependent variable, Risk factors wtith statistically significant in univariate analysis (P<0.05) were as independent variables, done the anylisis of multivariate stepwise logistic regression to get independent risk factorsResults1. Results of the basic data1.1 A total of 422 central venous catheters were placed in 371 patients.2 central venous catheters were placed in other hospitals.2 central venous catheters were extubated because of signing discharge.5 central venous catheters were extubated due to death. At last, a total of 413 CVCs, corresponding to 364 patiens in the PICU, were analyzed. The total indwelling time of CVC was 3035 days.46 (11.1%) CVCs were double cavities,367(88.9%) CVCs were three cavities. Categories of patients’ diseases:234 patients were congenital heart disease,136 patients were simple congenital heart diseases,98 patients were Complex congenital heart diseases; 130 patients were other diseases. There were 243 (66.8%) female and 121 (33.2%) male patients, with age range 1-166 (46.2±28.7) months, and their Weight 2-50 (15.22±6.84) kg.1.2 The duration of CVC was 1-28 (7.32±4.1) days. The duration of catheterization was<7days in 267 patients (64.6%), and≥7 days in 146 patients (35.4%).1.3 Location of catheter Catheters were placed in the femoral vein in 82 cases (19.9%), in the subclavian vein in 24 cases (5.8%), and in the jugular vein in 307 cases (74.3%).2. The rate of complications during the catheter indwellingThe rate of complications during the catheter indwelling was 30.7%. The incidence of catheter-related infections was 13.3%, the incidence of catheter displacement was 8.2%, the incidence of puncture site exudate was 4.6%, the incidence of occlusion was 3.1%, the incidence of accidental extubation was 1.0%, the deep vein thrombosis 0.5%. In catheter-related infections cases,36 (8.7%)cases were infections of the puncture site.16(3.9%) cases were catheter-related bloodstream infections, the infection rate was 5.3/1000 catheter days.3(0.7%)cases were catheter colonization.101(24.5%) CVCs had been removed due to CVC-related complications.3. Results of catheter-related infection pathogen18 pathogens were monitored out in 16 cases of catheter-related bloodstream infections. There are two cases to be found two kinds of microorganisms (Staphylococcus epidermidis and Candida albicans). Results:7 cases were Staphylococcus epidermidis,3 cases were Acinetobacter baumannii,3 cases were Klebsiella pneumoniae,1 case was Klebsiella pneumoniae,1 case was Staphylococcus aureus,3 cases were Candida albicans.4. Indwelling catheter location and time on the complicationsThe incidence of total complications and complications except for deep vein thrombosis in the femoral vein, internal jugular vein, subclavian vein was not statistically significant difference. The longer indwelling catheter, the incidence of total complications, catheter-related infections, puncture site exudate, occlusion were higher, there were statistically significant difference in different catheter indwelling time(P<0.05).5. Results of the risk factors analysis of complications during the catheter indwellingUnivariate analysis showed suture-off, bleeding of insertion site, catheter type, indwelling time of catheter, the patients’maximum channels of intravenous infusion were statistically significant (P<0.05). Multivariate Logistic regression analysis showed suture-off, bleeding of insertion site, the patients’maximum channels of intravenous infusion were significant risk factors of central venous catheter complications.6. Results of the risk factors analysis of catheter displacementUnivariate analysis showed that central venous pressure monitoring, suture-off, catheter type, bleeding of insertion site, the patients’maximum channels of intravenous infusion were statistically significant (P<0.05). Multivariate Logistic regression analysis showed suture-off, bleeding of insertion site were two significant risk factors for central venous catheter displacement.7. Results of the risk factors analysis Catheter-related infectionsUnivariate analysis showed that central venous pressure monitoring, suture-off, bleeding of insertion site, indwelling time of catheter, the patients’ maximum channels of intravenous infusion were statistically significant (P<0.05). Multivariate Logistic regression analysis showed bleeding of insertion site, the patients’ maximum channels of intravenous infusion were two significant risk factors for catheter-related infections.Conclusions1. Complications during the catheter indwelling of CVC include catheter-related infections, catheter displacement, puncture site exudate, occlusion, accidental extubation, catheter-related deep vein thrombosis. The incidence of catheter-related infections was highest. Catheter-related infections, catheter displacement and puncture exudate were the main reasons for catheter unplanned removel.2. The insertion location of CVC is not the risk factor of complications during the catheter indwelling in the PICU. Puncture location of CVC can be selected according to the actual situation of patients and the least puncture complications in PICU.3. Suture-off, bleeding of insertion site, the patients’ maximum channels of intravenous infusion were significant risk factors of complications during the central venous catheter indwelling. Suture-off, bleeding of insertion site were two significant risk factors for central venous catheter displacement. Bleeding of insertion site, the patients’ maximum channels of intravenous infusion were two significant risk factors for central venous catheter displacement. Bleeding of insertion site, the patients’ maximum channels of intravenous infusion were two significant risk factors for central venous catheter-related infections. It is important to reduce the bleeding of insertion site and fix ing catheter properly for reducing the complications of CVC. |
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