Department of Pediatrics, Metropolitan Hospital, New York, NY, United States.
Department of Pediatrics, New York Medical College, Maria Fareri Children's Hospital, Valhalla, NY, United States.
Thromb Res. 2022 Oct;218:192-198. doi: 10.1016/j.thromres.2022.08.028. Epub 2022 Sep 3.
Lack of standardized definition impedes our ability to understand the clinical significance of asymptomatic central venous catheter (CVC) associated deep venous thrombosis (CADVT). Using standardized definitions, we aimed to determine the accuracy of physical examination in detecting CADVT in critically ill children and to identify characteristics associated with this accuracy.
In a post hoc study, we analyzed 236 children <18 years old admitted to the pediatric intensive care unit, had an untunneled CVC and surveilled for CADVT using ultrasound with paired physical examination.
Of 236 paired examinations, 79 (33.5 %) had CADVT on ultrasound, while 56 (23.7 %) had signs of inflammation or venous obstruction on physical examination or CVC dysfunction. Sensitivity was 29.2 % (95 % confidence interval, CI: 19.9 %, 38.5 %), specificity was 80.2 % (95 % CI: 73.9 %, 86.4 %) and area under the receiver operating characteristic curve (AUROC) was 0.55 (95 % CI: 0.49, 0.60). When CVC dysfunction was excluded, sensitivity was lower (11.1 %; 95 % CI: 4.6 %, 17.6 %; p = 0.002), but specificity was higher (88.7 %; 95 % CI: 83.6 %, 93.7 %, p = 0.04). AUROC was 0.50 (95 % CI: 0.46, 0.54; p = 0.17). Use of point-of-care ultrasound and CVC inserted in the internal jugular vein (vs femoral vein) had lower sensitivity. Sepsis or infection and vasoactive support had lower specificity. Center of enrollment was associated with variable sensitivity.
Physical examination has poor accuracy in detecting CADVT in critically ill children. Despite poor accuracy, physical examination that includes assessment of CVC dysfunction, in combination with imaging, is key to understanding the clinical significance of asymptomatic CADVT.
缺乏标准化的定义阻碍了我们理解无症状中心静脉导管（CVC）相关深静脉血栓形成（CADVT）的临床意义。使用标准化的定义，我们旨在确定体格检查在检测危重症儿童 CADVT 中的准确性，并确定与该准确性相关的特征。
在一项事后研究中，我们分析了 236 名 <18 岁的儿童，他们在内科重症监护病房住院，使用超声检查对未使用的 CVC 进行 CADVT 监测，并进行了体格检查。
在 236 对检查中，79 例（33.5%）超声检查有 CADVT，56 例（23.7%）体格检查或 CVC 功能障碍有炎症或静脉阻塞迹象。敏感度为 29.2%（95%可信区间：19.9%，38.5%），特异度为 80.2%（95%可信区间：73.9%，86.4%），受试者工作特征曲线下面积（AUROC）为 0.55（95%可信区间：0.49，0.60）。当排除 CVC 功能障碍时，敏感度较低（11.1%；95%可信区间：4.6%，17.6%；p=0.002），但特异性较高（88.7%；95%可信区间：83.6%，93.7%；p=0.04）。AUROC 为 0.50（95%可信区间：0.46，0.54；p=0.17）。使用即时超声和颈内静脉（而非股静脉）插入的 CVC 会降低敏感度。脓毒症或感染和血管活性支持会降低特异性。入组中心与可变的敏感度相关。
体格检查在检测危重症儿童 CADVT 方面准确性较差。尽管准确性较差，但包括评估 CVC 功能障碍在内的体格检查，结合影像学检查，是理解无症状 CADVT 临床意义的关键。
