8th World Congress on Vascular Access 2024

Risk Factors and Biomarker Profiles Associated with Pediatric Arterial Catheter- Associated Proximal Ischemic Injuries

Background

•Critically ill patients frequently require arterial access for hemodynamic management and blood sampling

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•Some patients who require arterial access may exhibit dysregulation of their microvascular circulation

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•Dysregulation combined with the presence of an arterial catheter can put the surrounding tissues at risk for injury

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•Arterial Catheter Associated Proximal Ischemic Injury (ACAPII) can present with various degrees of injury

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•Previous institutional work has defined mild ACAPII as exhibiting blanching, erythema and ecchymosis

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•Severe ACAPII includes the progression to an open wound or severe diminished distal pulses

Objective

•Identify risk factors, including biomarker profiles, associated with AC-associated ischemic injuries in critically children

Methods

•Retrospective analysis of arterial catheters placed in children > 1 month and < 18 years from January 2020 to December 2022 in a single center pediatric intensive care unit

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•Assessment of patient, provider and device related factors

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•Additional assessment using a biomarker repository data comparing a subset of patients with ACAPII with control patients

Results

2111 index arterial catheters were evaluated (45% female)

Incidence of ACAPII

72 patients had an episode of ACAPII, 12 of which has severe ACAPII

Patient Related Factors Seen in ACAPII ------------> sicker and smaller patients

Younger age (5.2 (0.9, 12.2) vs 8.5 (2.8, 14.6)

Higher vasopressor usage (62% vs. 40%; p<0.01)

Higher PIM3 ROM (3 [1,5] vs. 1 [0,3]; p<0.01).

Provider Related Factors

No significance related to vessel accessed or insertion attempts

Device Related Factors Seen in ACAPII -------------> more frequent in smaller patient

Smaller catheters 24g (39% vs. 11%; p<0.01)

Shorter Catheters < 2.5 cm (31% vs. 12%)

Biomarker Data Seen in ACAPII ------------> mimics thrombotic microangiopathies

Lower platelets (168 [57,230] vs. 199 [133,267]; p=0.01),

Elevated D- Dimer dimer (20 [6,31] vs. 4 [1,12]; p=0.03),

Decreased Albumin (2.5 [2.3,3.18] vs. 2.8 [2.3,3.5] p=0.04)

Lower pH (pH 7.23 (7.15,7.33) vs. 7.31 (7.24,7.38); p<0.01)

Plasma Protein Expression Seen in ACAPII ---------> genetic predilection to microthrombi during illness

(biobank data of 5 patients with ACAPII compared to 66 without)

Increased expression of TSLP, LIF, and IL24, proinflammatory factors related to endothelial dysfunction

These three factors lead to signaling of the Stat3 pathway

Stat3 signaling leads to a protein scaffold encouraging platelet activation

The platelet activation can lead to increased microthrombi in certain critically ill children

Conclusions

•We identified candidate pathways of immune dysregulation and endothelial dysfunction at MODS onset which are associated with the development of arterial catheter associated proximal ischemic injury.

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•These injuries likely develop in the setting of hyperinflammation, endothelial dysfunction, and platelet aggregation.

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•Further studies linking these dysregulated pathways to platelet aggregation and thrombosis could suggest new therapeutic targets for pediatric patients at risk for ACAPII

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•Increased use of Papaverine may limit occurrence of severe ACAPII

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•Further validation of the grading scales with inter-rater reliability would improve diagnostic accuracy

8th World Congress on Vascular Access 2024

Risk factors and biomarker profiles associated with pediatric arterial catheter- associated proximal ischemic injuries.

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