CHALLENGES OFCENTRALVENOUS ACCESSSTART WITHSUCCESSFUL INSERTION 

K.POLÁŠKOVÁ, M.KÝR, T.MERTA, O.ROHLEDER

Department of Pediatric Oncology, University Hospital Brno

Introduction:

Pediatric oncological patients have to undergo many procedures as intravenous treatment, imaging with intravenous contrast media, parenteral nutrition or repeated blood tests. Long term central venous access is often key of successful oncological treatment. On the other hand wide range of complications from mechanical, through hematological to infectious can occur and some of these complications can be life threatening for the patients

Case report:

An 8-year-old boy was diagnosed with T-NHL lymphoblastic lymphoma. Initial tumor involvement was  supraclavicular, paratracheal, and mediastinal lymph nodes. Because of anticipated intensive oncological treatment, insertion of a centrally inserted central venous catheter was indicated. Based on the CT scan supraclavicular access for insertion was safe and the catheter was inserted from the right supraclavicular approach with tunneling to the pectoral area. 

In two months, the malfunction of the catheter with paravasation manifested. According to the X-ray with contrast, there was a leak in several sites and some depositions along the course of the catheter. 

We assumed the damage or more likely presence of the fibrin sheath. This was reason for removal of the catheter. The catheter was intact but the fibrin sheath remained in the vasculature. In a few days second catheter from left supraclavicular access was inserted. The insertion was uncomplicated under ultrasound guidance and X-ray control. In two weeks, the patient developed febrile, cough, pain, and attenuated breathing on the left side. According to the X-ray, there was pneumothorax on the left side and fluidothorax to 1/3 of the thorax. 

Based on MDCT there was extensive condensation of the lower lobe and marked volume reduction, probably because of extensive pneumonia with the presence of fluidothorax. The radiologist described discrete defects in the filling of segmental arteries, and it was not possible to exclude pulmonary embolism, but unfortunately CT angiography could not be done because of technical issues. The fluidothorax had to be solved surgically. Microbiological investigation did not prove any concrete infectious agent, but the patient was still febrile and therefore he was covered with wide spectrum antibiotics. 

Differential diagnosis in this patient: