Abstract
Background:
Once diagnosis of malignancy is made in pediatric patients, it can be important to initiate therapy to prevent delay in benefits derived from treatment. In certain diagnoses, prompt initiation of chemotherapy can help reduce complications such as hyperleukocytosis, mass effect from solid tumors, and spread of malignancy. These patients require provision of central vascular access in order to begin treatment. In children's hospitals patients often receive central venous catheters in the operating room under general anesthesia. However, this requires scheduling for the operating room, availability of pediatric surgeons, appropriate anesthesia consent and examination ahead of time for safety of proceeding. The benefit of having a pediatric vascular access team (PVAT) is that these providers are flexible with their availability, the time required to place the lines is often less and it eliminates the need for general anesthesia as well as the cost of the operating room. The aim of this study was to compare vascular access provision by a designated pediatric vascular access team with surgical placement of central venous access in pediatric oncology patients.
Methods:
This was an IRB-approved retrospective medical record review of subjects diagnosed with an oncologic malignancy with inclusion criteria: ages 0-21 years of age, treatment for pediatric malignancy at the University of Maryland Children's Hospital between 1/1/2017-12/31/2019. We performed bivariate analyses comparing variables between patients who had line placement by PVAT vs surgical placement. Analyses was performed using SAS 9.4.
Results:
We identified 69 patients who met inclusion criteria with 39% (n=27) having undergone line placement by PVAT. Surgical placement occurred for 55% (n=38), with interventional radiology (IR) or other placement making up the remainder 6% of patients (n=4). The mean age was noted to be younger in the surgical group (8.6 +/- 6 years) in comparison to the PVAT group (13+/-6.3 years), p=0.0061. The mean time from consult to line placement was 10 (+/-9) hours in the PVAT group vs 76 (+/-56) hours in the surgery group (p<0.0001). There was a statistically significant difference in procedure duration, with PVAT placement requiring less time (27+/-12 minutes) vs surgical placement (48+/-19 minutes), p=0.0005. There were no statistically significant differences among groups in race, sex, time-to-initiation of treatment after line placement, or complications. There was a small difference in mean number of attempts, with surgical requiring 1 (+/-0) vs. PVAT 1.2 (+/-0.4) attempts. Compared to complications of surgical line placement, the complications experienced by our PVAT team were largely related to need for revision of line placement, although not frequent enough to be statistically significant.
Conclusion:
Data show that having a PVAT for central line insertions demonstrates good safety profiles, successful insertion and low complication rates. PVAT has also increased the efficiency of vascular access at large academic institutions. The presence of vascular access teams allows for initiation of therapy in a timely fashion and allows central line placement under anesthesia to occur at a safer time. At our institution, having a PVAT in house has allowed for more efficient line placements, shorter time to provision of access and transition to placement of surgical lines when more stable. This allows for not only patients to receive care faster, but also to have lines placed in shorter times while optimizing patient safety.
Schultz TR, Durning S, Niewinski M, Frey AM. A multidisciplinary approach to vascular access in children. J Spec Pediatr Nurs. 2006;11(4):254-256. doi:10.1111/j.1744-6155.2006.00078.
Disclosures
No relevant conflicts of interest to declare.
Investigation of Time to Line Placement and Treatment Initiation in Pediatric Oncology Patients Utilizing a Pediatric Vascular Access Team