Robert O. Hickman

Hickman catheter infections in patients with malignancies.

The infectious complications associated with implantation of 1,088 Hickman catheters (HCs) in 992 patients reported in 18 published series are presented (including data on 129 previously unreported HCs from our own institution). HCs allow reliable long-term venous access (mean, 92.4 days) with low complication and infection rates (0.30 and 0.14 cases per 100 catheter days, respectively). Exit site infections were the most common form of infection encountered (45.5%), followed by septicemia alone (30.8%), tunnel infections (20.3%), and septic thrombophlebitis (3.5%). Staphylococcus epidermidis (54.1%) and S. aureus (20.0%) were the most common pathogens responsible for catheter infections. HC infections were associated with a low mortality rate (maximum rate of 0.5%). Risk factor analysis of 129 HCs demonstrated that catheter thrombosis was the major risk factor associated with development of catheter infection. Presence of fever, distant infection, neutropenia or antibiotic administration on the day of catheter insertion was not significantly associated with HC infection in this series (although there was a trend suggesting an increased risk of infection of HCs inserted during febrile episodes). Based on observations at our institution and from a review of the literature, tentative recommendations for management of the various types of HC infections are outlined.

Hickman catheter complications in marrow transplant recipients.

The complications associated with the insertion and use of 95 single lumen and 312 double lumen Hickman right atrial catheters in 357 marrow transplant recipients were retrospectively analyzed. Three-hundred (84%) first inserted catheters were in place for a median of 93 days (range, 16-209) without complications and were removed electively. Thirty-nine (9.6%) of all catheters were removed for infections and 24 (5.9%) for mechanical complications. Ninety-five patients (26.6%) had 111 episodes of septicemia involving 128 separate organisms and 25 patients had 25 episodes of localized catheter infection with 26 separate organisms. The most frequently isolated organism was coagulase-negative staphylococcus. Twelve of 24 removals due to mechanical complications were caused by accidental pulling of the catheter by the patient.

Renal Transplantation for Childhood Cystinosis

Abstract Four cystinotic children with renal failure received a renal allograft from a parent. The follow-up durations for the four patients were eight, 14, 16 and 32 months; final creatinine clear...

Experience with Double Lumen Right Atrial Catheters

A double lumen right atrial catheter was placed in 57 allogeneic marrow transplant recipients, and its use was compared to a concurrent series of 63 patients receiving the large-bore single lumen catheter. Ten double lumen catheter recipients developed septicemia, while neutropenic with granulocyte counts less than 100 per cubic centimeter, and three had their catheters removed for persistent septicemia. Seventeen single lumen catheter recipients developed septicemia while granulocytopenic, and one had the catheter removed for persistent septicemia. Hyperalimentation was more effectively delivered with the double lumen catheter which provides a route for infusion of hyperalimentation solutions at a constant rate during infusions of blood products, antibiotics, and other fluids.

Chromosome 7 short arm deletion and craniosynostosis. A 7p-syndrome.

SummaryA patient with craniosynostosis and a small deletion of part of the short arm of chromosome 7 is described. A review of the literature indicates that craniosynostosis has occurred in at least four of the five infants (the fifth having microcephaly) affected by structural changes (resulting in deletion) within the terminal region of the short arm of chromosome 7.

Asymptomatic inferior vena cava abnormalities in three children withend-stage renal disease: Risk factors and screening guidelines for pretransplant diagnosis

We report two children with end‐stage renal disease (ESRD) found to have inferior vena cava (IVC) thrombosis at the time of renal transplantation. The children suffered from renal diseases that included congenital hepatic fibrosis and portal hypertension as part of their pathophysiology. Neither child had evidence of hypercoaguability or clinical symptoms of IVC thrombosis. Prior to transplantation, the renal replacement therapy consisted primarily of peritoneal dialysis. During their hospital courses, these children had central venous catheters placed for temporary hemodialysis, episodes of peritonitis and numerous abdominal surgeries. The medical literature to date has not identified a link between IVC thrombosis and portal hypertension, nor has an association between the patients’ primary renal disease and IVC thrombosis been found. We also report the finding of asymptomatic IVC narrowing in a third patient with obstructive uropathy, colonic dysmotility and numerous abdominal surgeries. IVC narrowing was diagnosed by CT scan during his pretransplant evaluation. In this paper, we consider similarities between these three patients that may have predisposed each of them to asymptomatic IVC pathology, including large‐bore central venous access as young children and/or recurrent scarring abdominal processes. A discussion regarding appropriate screening of the ‘high‐risk patient’ for IVC pathology prior to kidney transplantation and surgical options for children with this rare complication are presented.

The central venous catheter as a source of medical chaos in Munchausen syndrome by proxy

PURPOSE The aim of this study was to determine what percentage of childhood central venous catheters (CVC) are placed in victims of Munchausen syndrome by proxy (MSBP) and to evaluate the clinical indications and complications of CVCs in MSBP. METHODS Study design was by retrospective chart review. Data were obtained from the regional childrens hospital and regional child abuse consultation network. Patients in the MSBP series were all children who on consultation were determined to be victims of MSBP, from 1974 through 1996. Patients in the central catheter series were all children who had central venous catheters placed 1991 through 1995, excluding children whose catheters were placed for cancer chemotherapy or for chronic renal failure. Consultation records of MSBP cases were abstracted noting the clinical characteristics of victims and perpetrators. Hospital procedure codes were reviewed for children who had CVCs placed. Those who had discharge diagnostic codes that commonly require CVC placement were not reviewed, but charts of children with diagnoses not usually requiring CVCs were evaluated. Descriptive statistics and chi2 and Fishers Exact test were used for comparisons. RESULTS Sixteen of ninety-three (17%) of MSBP victims had central lines, including two deaths caused by assault through the lines. Line sepsis occurred in 9 of 16 (56%) patients. Primary reasons for CVC were for administration of medicines that can normally be administered orally or subcutaneously (7) or for severe nutritional depletion (8). All but one of the children had symptoms of multiple organ system involvement. Siblings had frequently been victimized. The mean age of symptom onset was 19 months, yet the mean age at diagnosis was delayed until 82 months. All perpetrators were the mother. Fathers were usually physically or emotionally unavailable. Nearly one third of mothers had prior medical training and one third had themselves been victims of prior physical or sexual abuse. Ten of fifteen mothers previously exhibited Munchausen behavior themselves. Of children at our institution who had central venous catheter placement, 8 of 709 (1.1%) were MSBP victims. CONCLUSIONS CVCs are frequently placed in MSBP victims for physiological problems, malnutrition, or failure to respond to normal treatments. Surgeons should consider requesting systematic evaluation for MSBP in patients seeking CVC placement for diagnoses not usually requiring CVCs lest they become unintentional collaborators in abuse of these children.

New ultrasound approaches to dialysis access monitoring.

The failure of dialysis access is a frequent source of morbidity and hospitalization. Traditional methods of graft surveillance include: (1) clinical examination, (2) venous line pressure measurements during dialysis, (3) urea or tracer recirculation measurement, (4) continuous wave (CW) Doppler methods, (5) duplex ultrasonography, and (6) radiograph angiography. All these methods require special training and/or laboratory tests. The purpose of this study was to test a simple continuous-wave Doppler method that could be applied to measure the flow rate in dialysis access every time the patient undergoes dialysis. Twenty dialysis patients, 15 with polytetrafluoroethylene grafts and 5 with arteriovenous fistulae, were studied. Two hundred fifty-three examinations were performed over an 8-month period. Doppler waveforms of the access flow were obtained with the pump on, with the pump off, and with the pump on again. Systolic and diastolic Doppler frequency measurements were made, and the pump-on and pump-off measurements were compared. In an access functioning normally, the Doppler frequencies are higher with the pump off than with the pump on. In 22% of the cases, there were abnormal findings in which the Doppler frequencies were lower with the pump off than with the pump on. This occurs if the needles are incorrectly placed, suggesting that recirculation is occurring. Recirculation also occurs if there is stenosis of the access. Examining the hemodialysis access during each dialysis session with an inexpensive directional Doppler may identify a significant stenosis and improve the efficiency of dialysis by detecting those patients in whom the arterial and venous needles are reversed.

Renal microangiopathy of the hemolytic-uremic syndrome in childhood.

18 children with clinical and laboratory findings characteristic of the hemolytic-uremic syndrome were retrospectively studied. Thrombocytopenia due to platelet destruction was accompanied by only min

Early diagnosis and management of renovascular hypertension

Renovascular hypertension is more common in hypertensive children than in hypertensive adults, and renal artery stenosis is second only to coarctation of the thoracic aorta as a cause of surgically correctable hypertension. Three infants presented with uncontrollable hypertension secondary to renal artery thrombosis due to umbilical artery catheterization for respiratory distress in the neonatal period. They all responded to nephrectomy. A fourth infant had stenosis of a polar vessel secondary to umbilical artery catheterization and was cured by partial nephrectomy. Two infants with renal artery stenosis secondary to fibromuscular dysplasia benefited from revascularization and, at last follow-up, were normotensive and off all blood pressure medication. Ultrasonography, isotope scanning, angiography and selective renal vein renin assays should be used to identify patients with surgically correctable lesions. The use of fine suture material and microvascular surgical techniques, including ex vivo revascularization and autotransplantation, can salvage renal parenchyma and relieve hypertension. Infants with less than 10 percent renal function on the involved side should have a nephrectomy. The infant with an umbilical arterial catheterization line needs blood pressure monitoring and aggressive evaluation and treatment of persistent hypertension.