Continuous heparin infusion to prevent thrombosis and catheter occlusion in neonates with peripherally placed percutaneous central venous catheters.
BACKGROUND
Peripherally placed percutaneous central venous catheters (PCVC) are used in neonates to provide long-term vascular access. Major complications associated with these catheters include mechanical complications (catheter thrombosis, occlusion or dislodgement) and infection. Strategies to prevent catheter thrombosis and occlusion include the use of heparin. Systematic review has revealed that heparin is effective in prolonging the umbilical arterial catheter stay in neonates. However, heparin is known to be associated with complications such as bleeding and thrombocytopenia which may result in serious long-term sequelae.


OBJECTIVE
The primary objective is to assess the effectiveness of heparin for prevention of catheter related thrombosis. The secondary objectives are to assess the effectiveness of heparin on catheter occlusion, duration of catheter patency, catheter related sepsis and complications associated with the use of heparin.


METHODS
A literature search was performed using the following databases: MEDLINE (1966- February 2001), EMBASE (1980-February 2001), CINAHL (1982-February 2001) and the Cochrane Controlled Trials Register ((Issue 1, 2001 of Cochrane Library) and abstracts from the annual meetings of the Society for Pediatric Research/American Pediatric Society and Pediatric Academic Societies published in Pediatric Research (1991-2000). No language restrictions were applied.


METHODS
Selection criteria applied to the clinical trials were: the population had to be neonates, intervention had to be heparin infusion compared to placebo or no treatment for prevention of any of the complications related to peripherally placed PCVC, the trial had to be randomized or quasi-randomized and at least one of the primary or secondary outcomes reported.


METHODS
The methodological quality of included trials was assessed using criteria for masking of randomization, masking of intervention, completeness of follow-up and masking of outcome measurement. Data on relevant outcomes were extracted and the effect size was estimated by calculating relative risk (95% CI) and risk difference (95% CI).


RESULTS
One randomized trial on the use of heparin for peripherally placed PCVC was identified. The trial was excluded due to several methodological issues: 1. randomization was at the time of umbilical catheter placement rather than later PCVC placement 2. multiple PCVC were used in some infants, with reported results based on number of catheters rather than infants. Thus, the trial was not included in the review.


CONCLUSIONS



CONCLUSIONS
Prophylactic use of heparin for prevention of complications related to peripherally placed PCVC has not been studied in well designed randomized controlled clinical trials. With the current state of knowledge routine use of heparin for this purpose cannot be recommended. Implication for research: Increasing survival of extremely low birth weight infants may be accompanied by prolonged intravenous access for nutrition. Well designed randomized controlled trials of sufficient power to determine the benefits and risks of continuous infusion of heparin in neonates with peripherally inserted PCVC are warranted.
Shah
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Division of Neonatology, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, Canada, M5G 1X8. sparsh1@hotmail.com
Shah
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V
D000925:Anticoagulants / Q000008:administration & dosage*; D002405:Catheterization, Central Venous / Q000009:adverse effects* / Q000295:instrumentation; D004868:Equipment Failure; D006493:Heparin / Q000008:administration & dosage*; D006801:Humans; D007231:Infant, Newborn; D007261:Infusions, Intra-Arterial; D013927:Thrombosis / Q000517:prevention & control*
D000925:Anticoagulants; D006493:Heparin