Pediatric emergency medicine trisk 1168

to the break, cleaned with alcohol and covered with sterile dressing until repaired.
Optimally, a person familiar with the procedure will be available within a short
time of clamping the catheter or folding the catheter on itself, or, if feasible, tying
the broken end into a knot. If the externalized portion is too small to clamp,
hemostasis may be achieved by putting pressure on the site of venous entry. A
scar is usually apparent at this site. However, if the scar is not apparent, the
catheter should be palpated from the exit site on the skin to the location at which
it can no longer be palpated and pressure should be applied at that site. Repair kits
are available for each catheter size ( Fig. 135.9 ). These kits contain a new
external catheter segment with a hollow male connector that fits into a cleanly
sliced proximal end. The kits also contain a syringe and needle to apply the glue
to the male connector.
If an implantable catheter leaks, fluid or blood that collects subcutaneously
may cause a bulge or painful swelling at the site. A broken implanted catheter
must undergo prompt surgical management. The broken segment can often be
easily visualized by chest radiography.
Catheter Displacement
Occasionally, the patient or caregiver inadvertently pulls on the externalized
portion of a tunneled catheter, and can be noted by visualization of the cuff at or
outside of the exit site. The venous portion of the catheter may eventually be
displaced from the venous system. Externalized catheters are at higher risk for
dislodgment within a few weeks of insertion, because the cuff is not fully
anchored by fibrosis. Exsanguination after catheter dislodgment is a rare event
because of the advancement of the tip inside the vein and the natural tendency
toward venous hemostasis. However, children with clotting disorders are at
increased risk of life-threatening blood loss after catheter displacement. Totally
implanted devices are at risk of dislodgment at both ends; however, few events
apart from major thoracic trauma place enough tension on the catheter to dislodge
it from the vein. Migration of the venous catheter tip is rare but can lead to
cardiac arrhythmias, pneumothorax, cardiac tamponade, and superior vena cava
syndrome.

FIGURE 135.9 Repair kit for tunneled catheters.

Detecting catheter dislodgment is easier in patients with externalized catheters.
If the Dacron cuff is noted outside the skin surface, the catheter must be
considered dislodged and should not be used until the tip’s location can be
confirmed by chest radiography. Failure to draw back free-flowing blood from the
device increases the suspicion that the catheter is no longer in the central vein. In
this situation, the catheter should be clamped and secured close to the skin and
immediate surgical or interventional radiology consultation should be obtained. A
dye study may be necessary to locate the catheter tip. For totally implanted
devices, dislodgment of the catheter from the vein should be suspected if the
device no longer functions after thoracic trauma. If the catheter is disconnected
from the reservoir, fluid or blood may collect subcutaneously and cause a bulge
or painful swelling at the site. Prompt surgical management is required.
Catheter migration should be considered in patients with totally implanted
venous catheters who experience respiratory distress or palpitations. Radiologic
evaluation of catheter location should rapidly ensue, with subsequent surgical
consultation if the catheter tip has migrated.
Infection
The presence of an indwelling venous catheter places a patient at higher risk for
infection, which can occur at the catheter exit site, the tunnel through which the
line is placed, the catheter itself, or in the patient’s bloodstream. Tunneled


catheters carry a higher overall risk of infection than do fully implanted devices.
The presence of erythema, tenderness, or purulent drainage at any skin site related
to an indwelling catheter suggests a catheter infection. Less commonly, infection
can also occur at the subcutaneous pocket of a patient’s fully implantable catheter.

The entire dressing must be removed for to inspect the site. Fever is common in
patients with catheter-related bacteremia or sepsis but may be absent in early,
localized infection. Immunocompromised patients can exhibit rapid deterioration,
and more commonly acquire fungal, gram-negative, and polymicrobial infections.
Patients receiving parenteral alimentation are also at higher risk for gramnegative infections. Still, the most common pathogens in patients with indwelling
catheters are gram-positive organisms such as S. epidermidis, S. aureus , and
Streptococcus viridans. The signs of infection may be more subtle or absent in
neutropenic patients. Catheter-related bacteremia can also occur without apparent
skin manifestations. It is sometimes difficult to tell if the catheter itself is infected
or simply seeded the bloodstream, and many consider both to have occurred in
the presence of a positive culture result.
Blood cultures should be obtained from the catheter and, in most cases, from a
peripheral vein as well. At least 1 to 2 mL of blood should be used for this
purpose. More than 90% of positive blood cultures will yield results within 36
hours. Fungal cultures are appropriate in immunocompromised patients or those
who have had prior invasive fungal infections. Cultures of any purulent fluid are
helpful. A complete blood cell count with differential count is warranted,
although a normal result should not dissuade the clinician from suspecting an
invasive bacterial infection. Other blood tests, such as lactate and coagulation
studies, should be considered if the patient is ill appearing.
Initial treatment consists of IV antibiotic therapy and supportive measures.
Bacterial catheter infections can be eradicated without catheter removal, although
infections with S. aureus and fungi usually necessitate catheter removal.
Persistent infection, infection of the subcutaneous tunnel, critical illness,
endocarditis, and thrombophlebitis are also indications for removal. Initial
antibiotic therapy should include agents active against both gram-positive and
gram-negative infections. Time to antibiotic administration, in particular for
febrile, neutropenic patients, can be demonstrably reduced when quality
improvement initiatives provide ongoing feedback and education to hospital staff.
Clinical pathways, such as those publically available through Children’s Hospital

of Philadelphia ( ), can also guide therapy.
In patients without oncologic disease, many centers use cefepime as empiric
coverage; the disease process and overall appearance of the child can often dictate


the addition of expanded coverage such as vancomycin. If there is a suspected
intra-abdominal source, piperacillin/tazobactam can be substituted for cefepime
to treat for enteric organisms. Local antibiotic resistance patterns should
determine the antibiotic choice. Persistent colonization of CVCs may respond to
installation of antibiotic or ethanol into the lumen for 12 to 24 hours (antibiotic
lock or ethanol lock).
Other Complications
Other complications related to indwelling catheters can occur, albeit rarely. Direct
injury to the exit site can be a result of either erosion of tissue by the Dacron cuff
of an externalized catheter or breakdown of the skin site from vigorous cleansing.
This condition can lead to a localized infection. On physical examination,
excoriation, erythema, tenderness, or purulent drainage is present at the exit site
of the catheter. Select patients with a localized site infection who are afebrile and
well appearing, have a normal leukocyte count, and have close follow-up may be
managed as outpatients with oral antibiotic therapy.
As previously mentioned, phenytoin and diazepam can interact with the
silicone lining of the catheters and the administration of these medications
through Silastic catheters should be avoided if possible. In addition, a large
volume of saline flush should be administered between medications that are
incompatible with each other, such as calcium and bicarbonate.

ENTERAL FEEDING TUBES
Background
A stoma, derived from the Latin word for “mouth,” is an opening from the GI or
urinary tract to the outside of the body. A gastrostomy is a surgically,

endoscopically, or radiologically created stoma that provides access to the
stomach from the level of the skin. A jejunostomy is a surgically created stoma
that brings the jejunum to the skin surface. Gastrostomy is performed most
typically in children who are unable to take adequate oral nourishment for a
prolonged period. The inability to tolerate sufficient oral feedings can be related
to numerous conditions, including esophageal atresia, chronic malabsorptive
syndromes, significant craniofacial abnormalities, tracheostomy, neurologic
impairment, severe gastroesophageal reflux, esophageal burns, chronic systemic
diseases, and, rarely, anorexia nervosa. Jejunostomy feedings are used when
postpyloric feeding is required and carried out in such patients as those with
delayed gastric emptying, recurrent aspiration pneumonia, or severe