Permanent tunneled catheter applications in childhood oncological, hematological and chronic diseases and the effect of body mass index on complications

Indwelling catheter applications are now being used more frequently in children. The main reason for this increase is the difficulty of peripheral vascular access in pediatric patients, as well as the continuation of the treatment without interruption and the comfort of the patient during the treatment. Permanent tunneled catheter application techniques in childhood are the open method, the 'blind' Seldinger technique, or the ultrasonography (US)-guided Seldinger technique. The main types of catheters used are the port catheter, which is used with a reservoir placed under the skin, the Hickman catheter, which is used without a reservoir, and the hemodialysis catheters. The main diseases in which permanent tunneled catheter applications are preferred in children are oncological, hematological and chronic diseases. The main reasons for use are the use of chemotherapy agents (CT), the need for total parenteral nutrition (TPN), the use of antimicrobial agents, the provision of hydration, hemodialysis (HD), blood sampling, stem cell collection and plasmapheresis. In these diseases, various complications can be seen depending on the length of the treatment period, the type of treatment and the applications of permanent tunneled catheters. The most common complications are arterial puncture, subcutaneous hematoma, pneumothorax and hemothorax. Treatment-related complications are infections. In recent years, the widespread use of ultrasonography during catheterization has significantly reduced complications, especially in adult patients. In children, ultrasonography significantly reduces complication rates and, it is decisive on the choice of central vascular access and the duration of the procedure. The choice of catheters to be used is determined by the characteristics of the disease and the treatment to be applied. In our deparment, permanent tunneled catheter applications are performed under general anesthesia, in the operating room with appropriate asepsis and sterilization conditions. Although the Seldinger technique is used as the first choice, the open method is used in patients who are not suitable for the technique. The Seldinger technique is applied with the 'blind method' or US-guided. Preoperative patients are targeted to have platelets >50000/mm³ for permanent tunneled catheter, >70000/mm³ for subcutaneous port implantation and International Normalized Ratio (INR) <1.7. Our department has been using ultrasonography (USG) for shortening the operation time and reducing the number of punctures since January 2014. The effects of increased body mass index (BMI) on surgical complications in pediatric and adult patients have been evaluated in many studies. The negative effects of increased BMI and obesity on tissue healing mechanisms are known. Currently in literature there is no study on the effect of BMI on permanent tunneled catheter applications and complications. Therefore, in this study, our aim is to examine our results in patients who underwent permanent tunneled catheters procedure in our department, their pre-procedural Body Mass Index (BMI), age, primary diseases, the diameter and characteristics of the catheter used during the procedure, and the relationship between post-procedure complications and BMI. Material and Methods We included 400 patients who underwent permanent tunneled catheterization procedure between January 2006 and January 2022 by our department. The documents were scanned retrospectively and the patients' demographic characteristics and BMI values, surgery length, the usage of US, and complications were evaluated. Developing complications, BMI, duration of surgery, and assinting imaging modality were evaluated. IBM SPSS Statistics version 26 was used to evaluate the data. Descriptive statistics and numerical variables were given as mean ± standard deviation (SD). The chi-square test, parametric and nonparametric tests were used as statistical methods, and p<0.05 was accepted statistically significant. Results The mean age of 400 patients with indwelling tunneled catheters was 7.26 ± 5.27 (3 months-18 years). When all the patients were evaluated, 185 were oncology, 177 were hematology, 38 were patients who were treated for chronic diseases. Of the patients, 182 (45.50%) were girls and 218 (54.50%) were boys. The mean weight of the patients was 20.01 ± 20.07 kg, and their mean height was 118.00 ± 32.40 cm. Subcutaneous port was used in 325 (81.25%) patients, Hickman catheter in 46 (11.50%) patients, hemodialysis catheter in 6 (1.50%) patients, and port and Hickman catheter in 23 (5.75%) patients. The mean surgical time of the patients was 50.58 ± 17.19 minutes. The mean duration of catheter use of the patients was 14 ± 12.55 months. Among 140 (35.00%) patients with complications, 37 had early, 96 had late, and 7 had both early and late complications. Extrathoracic complications were observed most frequently in early complications with a rate of 5.75%, and intrathoracic complications were observed with a rate of 15.75% in late complications. Catheter-line associated bloodstream infection (CLABSI) is the most common late complication and among all general complications. According to BMI distribution, there were 26 patients with <3 percentile (p), 26 patients in the 3-15 p group, 259 patients in the 15-85 p group, 58 patients in the 85-97 p group, and 31 patients in the >97 p group. When the relationship between BMI and CLABSI was evaluated, it was seen that half of the <3 p group (n=13) and 34.62% (n=9) of the 3-15 p group were diagnosed with CLABSI. The 38 patients diagnosed with CLABSI were only 14.67% of the 259 patients in the 15-85 p group. It was observed that as BMI increased in patients, complications of CLABSI decreased. When the relationship between BMI and wound infection was evaluated, there were a total amount of 38 patients with wound infection. It was found that the highest rate was in the >97 p BMI group with 17 patients (44.7%). It was determined that CLABSI, an intrathoracic complication, is increased when BMI is decreased while, wound infection, an extrathoracic complication, is increased as BMI increased (p<0.05). When the relationship between surgery time and complications was evaluated, it was found that the surgery was significantly longer in patients with early complications (p<0.05). The relationship between the US usage and surgery time was compared. In the group with no US the time was 57.62 ± 18.21 while, the the group with US was found to be significantly shorter at 40.55 ± 8.59 minutes (p<0.05). In addition, the extended neck incision technique was used in 7 patients during revision because of the kink at the neck level of the permanent tunneled catheter which is the cause of early complications and is associated with the surgical technique. This technique was applied to a total of 117 patients and no kink was detected in any of them. Extended neck incision technique is routinely applied to all patients by our department. Conclusion In our department, permanent tunneled catheters are applied effectively and safely with the Seldinger method, accompanied by USG, in childhood oncological, hematological and chronic diseases. When the effects of patients BMI's on these complications were evaluated, it was determined that an increase in BMI increased wound infections and was protective against CLABSI. US-guided puncture, which is an assistive imaging technique, is thought to be effective in reducing complications by shortening the surgical time. This early complication could be completely avoided with the extended neck incision technique to prevent kinking in the neck of the surgical technique-related indwelling catheter.