title: Avoiding postoperative malposition of upper body tunneled central venous catheters in children: Evaluating technique and depth of placement.
abstract: BACKGROUND
  Suboptimal position of tunneled central venous catheters (Broviacs) decreases long-term catheter longevity, incurring morbidity and cost. We postulated that catheter malposition is related to patient's age, technique used, and initial catheter tip location (CTL).
  
  
  METHODS
  We performed a retrospective review with 1-year follow-up of Broviacs placed in patients at our children's hospital from 3/2010 to 10/2013. We defined malposition as a noncentral CTL that required replacement, excluding catheters physically dislodged. We used logistic regression to determine whether age, technique and CTL predicted malposition with p-value<0.05 deemed significant. We analyzed line longevity for different insertion techniques by survival analysis.
  
  
  RESULTS
  Overall, 404 upper body Broviacs were placed in 282 children (median age=1.4years [IQR:0.45-5.35]). Thirty-six (8.9%) were replaced for malposition, at median of 84.5days [IQR:36-159]. We found that older children were less likely to develop malposition (OR=0.91,p=0.002). Adjusting for patient age and placement technique, catheters placed ≥1.5 vertebral bodies below the carina were less likely to be malpositioned (OR=0.37,p=0.015). Cox-regression shows the lateral technique to have the lowest rate of malposition within 90days (HR=0.30,p=0.03).
  
  
  CONCLUSIONS
  Older patients and lines placed 1.5 vertebral bodies below the carina are less likely to become malpositioned. Using the lateral approach for insertion improves catheter longevity.
authors.affiliation: Section of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI. Electronic address: gishj@med.umich.edu.
authors.forename: Joshua
authors.initials: J
authors.lastname: Gish
authors.affiliation: Section of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI.
authors.forename: Tiffany
authors.initials: T
authors.lastname: Wright
authors.affiliation: Section of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI.
authors.forename: Samir
authors.initials: S
authors.lastname: Gadepalli
authors.affiliation: Section of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI.
authors.forename: Marcus
authors.initials: M
authors.lastname: Jarboe
mesh_terms: D000293:Adolescent; D002405:Catheterization, Central Venous / Q000379:methods*; D002408:Catheters, Indwelling; D062905:Central Venous Catheters / Q000592:standards*; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D007601:Jugular Veins / Q000033:anatomy & histology / Q000000981:diagnostic imaging*; D016015:Logistic Models; D008297:Male; D011184:Postoperative Period; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D014132:Trachea / Q000033:anatomy & histology; D018084:Ultrasonography, Interventional / Q000379:methods*; D055815:Young Adult
keywords: Central venous line; Malposition; Pediatric; Reoperation; Reposition