DEFINITIONS AND EPIDEMIOLOGY
Each year, more than 5 million central venous catheters (CVCs) are inserted in patients in the United States. Types of catheters are listed in Table 75-1, and five different CVC configurations are shown in Figure 75-1. Many of these are used in children for delivery of intravenous fluids, total parenteral nutrition, antibiotics, and chemotherapy and for the performance of hemodialysis. Bloodstream infections (BSIs) in patients with CVCs or central lines are among the most common healthcare-associated infections, causing substantial morbidity and mortality in pediatric patients and increasing healthcare costs.
TABLE 75-1Types of Central Catheters ||Download (.pdf) TABLE 75-1Types of Central Catheters
|Catheter Type ||Typical Insertion Site ||Comments |
|Nontunneled CVC ||Subclavian, jugular, femoral veins ||For short-term intravenous therapy, typically less than 21 days |
|Tunneled CVC ||Subclavian, jugular, femoral veins ||Broviac, Hickman, Groshong; can remain in place for months to years |
|Totally implantable CVC ||Subclavian or internal jugular ||“Infusaport” or “port”; can remain in place for months to years |
|Percutaneously inserted central catheter (PICC) ||Peripheral vein in the arm, leg, or scalp; terminates in central vein ||Commonly used for outpatient therapy; can remain in place for weeks to months |
|Umbilical ||Umbilical artery or vein || |
Used in neonates
Umbilical artery catheters generally not used > 5 days
Umbilical venous catheters generally used up to 14 days
Types of central venous catheters. (A) Nontunneled central venous catheter; (B) tunneled central venous cathether; (C) totally implantable central venous cathether; (D) percutaneously inserted central catheter; (E) umbilical venous cathether. [Figure 75-1E: Reproduced with permission from Reichman EF. Emergency Medicine Procedures. 2nd ed. New York, NY: McGraw-Hill; 2013.]
Various definitions have been used to characterize infections in patients with central lines (Table 75-2). CRBSI—a BSI attributable to the catheter—is often difficult to diagnose in children because obtaining a peripheral culture is not always feasible and catheters are often not removed for diagnostic purposes because of the difficulty of inserting another catheter. The most commonly used definition in pediatrics is central line–associated bloodstream infection (CLABSI), as defined by Centers for Disease Control and Prevention (CDC) and National Healthcare Safety Network (NHSN). Broadly speaking, a CLABSI is a bloodstream infection in a patient with central line that is not attributable to infection at another site (e.g., a urinary tract infection or pneumonia). Because the CDC revises the criteria for healthcare-associated infection periodically, the CLABSI definition by multicenter quality improvement collaboratives and research groups may differ slightly from current NHSN definitions.