A systematic review for effective management of central venous catheters and catheter sites in acute care paediatric patients.

BACKGROUND

Central venous catheters (CVCs) have provided many benefits in modern-day medical practice; however, they also put patients at risk of catheter-related complications. Numerous studies have been carried out in relation to the management of central venous catheters with conflicting results. While there were several systematic reviews of central venous catheter-related issues, it is clear that there was no systematic review of CVC-related studies specific to the paediatric population in the acute care setting.

OBJECTIVE

To present the best available evidence for effective management of central venous catheters and catheter sites in the prevention and/or reduction of catheter-related complications in hospitalised paediatric patients.

METHODS

A systematic review was undertaken according to the approach of the Centre for Reviews and Dissemination (CRD; http://www.york.ac.uk/inst/crd).

DATA SOURCE

Literature was identified by electronic searching of Cochrane Library, MEDLINE, CINAHL, HealthSTAR, and CancerLit; checking references of all review articles; hand searching of key relevant journals and conference proceedings; and contact with expert informants, medical suppliers, and pharmaceutical companies.

INCLUSION/EXCLUSION CRITERIA: The review included randomised and non-randomised controlled trials conducted with hospitalised paediatric patients. Studies that included mixed adult and paediatric populations and mixed hospitalised and home care settings were excluded.

DATA EXTRACTION

Two independent reviewers extracted data onto a standard data extraction form, with differences resolved by discussion.

QUALITY ASSESSMENT

The quality assessment of retrieved studies included: study design, the degree to which systematic bias was avoided or minimised, the degree to which the assessment was "blind," the degree to which follow up was completed.

DATA SYNTHESIS

Quantitative pooling of studies was not feasible due to the diversity of interventions and outcome measures between similar studies. A narrative account of the study characteristics and results was therefore undertaken.

RESULTS

Thirty-eight randomised and quasi-randomised controlled trials were retrieved for critical appraisal. Of these, 32 were excluded from the review because the studies did not meet the inclusion criteria and some lacked reporting of appropriate data. Six studies met the criteria with interventions such as antibiotic flushes, antiseptic skin preparations, and dressing materials.

CONCLUSION

Quality of reporting was generally lacking. Statistical pooling of results was not possible due to diversity in the reporting of outcomes. There was no evidence to make recommendations on the degree of barrier precautions and the type of aseptic technique to be used at the time of catheter insertion in the paediatric population to prevent catheter-related infection. There was insufficient evidence to support the routine use of an antibiotic flushing solution. There was a lack of randomised controlled trial (RCT) evidence on the benefit of heparin flushes, the use of in-line filters, the frequency of fluid administration set changes, or the type of dressing to use and the frequency of dressing changes. There was some evidence to suggest that chlorhexidine lotion is superior to povidone iodine as a cutaneous antiseptic at the catheter insertion site. However, no recommendation can be made for the use of chlorhexidine in neonates less than 2 weeks old or in premature infants. This systematic review concluded that there is an urgent need for well-designed randomised controlled trials with sufficient power to determine the effectiveness of various interventions in relation to management of CVCs.