Pediatr Blood Cancer 2006;47:886–888

The Safety of Central Line Placement Prior to Treatment ofPediatric Acute Lymphoblastic Leukemia

Emily Carr, BA,1 Somasundaram Jayabose, MD,1 Gustavo Stringel, MD,2 Michel Slim, MD,2

M. Fevzi Ozkaynak, MD,1 Oya Tugal, MD,1 and Claudio Sandoval, MD1*

INTRODUCTION

Pediatric acute lymphoblastic leukemia (ALL) manifests

as bone marrow failure, and pancytopenia may persist for 2–

3 weeks during the induction phase of chemotherapy. Central

venous lines facilitate the management of ALL by providing

constant availability of venous access for inpatient and

outpatient therapy and reducing the need for peripheral

venipuncture. Central venous lines can result in significant

morbidity including infections, thrombosis, non-thrombotic

occlusion, and mechanical malfunction. Moreover, central

venous lines are placed during a phase of pancytopenia,

which may enhance the risk of hemorrhagic and infectious

complications.

As there is a dearth of information regarding the safety of

central venous line placement during the induction phase of

chemotherapy for pediatric ALL, this communication reports

on our experience with placement of central lines prior to

induction chemotherapy.

PATIENTS AND METHODS

We reviewed the records of 115 consecutive pediatric

ALL patients. These patients were diagnosed with ALL and

treated at New York Medical College/Westchester Medical

Center during a 10-year period (7/01/93–6/30/03). The data

abstracted comprised gender, age, presenting and preopera-

tive blood counts, duration of neutropenia, type of central line

(subcutaneously implanted port or external), type of induc-

tion chemotherapy, ALL subtype, blood products transfused

preoperatively, and central line-associated morbidity during

induction chemotherapy. Types of morbidity included

infections, line thrombosis, and wound dehiscence. The

two pediatric surgeons (GS, MS) used one dose of

Cefotaxime (50 mg/kg) after the induction of anesthesia

and 6–8 hr after central line placement. Seventy-one patients

were treated as standard-risk (age, >1 year and <10 years;

white cell count, <50,000; favorable cytogenetics) with

30 receiving BFM induction [1], 26 CCG 1991 induction,

and 15 CCG 1952 induction [2], and 44 were treated as high-

risk (age, <1 year or >10 years; white cell count, >50,000;

unfavorable cytogenetics) with 28 receiving New York

Protocol induction [3], 15 receiving CCG 1961 induction

[4], and 1 receiving POG 9407 (Table I). Statistical analysis

of complication rates was performed using Fisher exact

test.

RESULTS

There were 66 male and 49 female patients with a median

age of 4 years (range, 3.5 months–16 years). The respective

blood counts at diagnosis and prior to surgery were as

follows: white cell count (ml), 4.2 (0.5–554,000) and 5.55

(0.6–271,000); hemoglobin (g/dl), 7.7 (2.5–16.2) and

Background. Central venous lines are placed in children withacute lymphoblastic leukemia at diagnosis, despite significantcytopenias, to facilitate the administration of chemotherapy andblood sampling. The present study aimed to determine the safety ofcentral line placement in these patients. Methods. We reviewed thecharts of 115 consecutive patients treated during a 10-year period.Data abstracted comprised age, gender, presenting and preoperativeblood counts, type of central line, blood products transfusedpreoperatively, duration of neutropenia (absolute neutrophil count[ANC], <500/ml), treatment, and central line-associated complica-tions. Results. There were 66 male and 49 female patients with amedian age of 4 years. Seventy-one patients were classified asstandard-risk and 44 as high-risk. Respective median blood counts atdiagnosis and prior to surgery were white cell count (ml), 4,200 and5,550; hemoglobin (g/dl), 7.7 and 9.4; platelet count (ml), 63,000 and

72,000; and ANC (ml), 3,950 and 4,900. The median duration ofneutropenia was 15 days in the standard-risk group and 18 days inthe high-risk group. Thirty-eight patients were not transfused pre-operatively. There were no episodes of bacteremia. Seven patients(7%) with life-ports experienced a complication: in four blood couldnot be aspirated, two ports needed realignment, and one a woundinfection developed without dehiscence. Four patients (27%) withexternal lines had a complication: one each with line occlusion,accidental removal by patient, line rupture, and line leakage atinsertion site. The complication rate between ports and external lineswas different (P¼0.045). Conclusions. Central line placement priorto anti-leukemia treatment is safe. Most complications are mechan-ical and not due to leukemia, chemotherapy, or cytopenias. PediatrBlood Cancer 2006;47:886–888. � 2005 Wiley-Liss, Inc.

Key words: acute lymphoblastic leukemia; central lines; safety

� 2005 Wiley-Liss, Inc.DOI 10.1002/pbc.20629

——————1Department of Pediatrics, New York Medical College, Valhalla,

New York; 2Department of Pediatric Surgery, New York Medical

College, Valhalla, New York

*Correspondence to: Claudio Sandoval, New York Medical College,

Munger Pavilion Room 110, Valhalla, NY 10595.

E-mail: claudio_sandoval@nymc.edu.

Received 21 June 2005; Accepted 15 August 2005

9.4 (4.5–14.5); platelet count (ml), 63 (4–665,000) and

72 (10–347,000); absolute neutrophil count (ml), 3.95 (0.11–

372.4) and 4.9 (0.37–253.3); and blast percentage, 32.5

(0–99) and 4.9 (0–93). Twelve patients had an absolute

neutrophil count of <500 and 9 had an absolute neutrophil

count of between 501 and 1,000. The median duration of

neutropenia was 15 days (range, 0–30) in the standard-risk

group and 18 days (range, 0–32) in the high-risk group.

Sixteen standard-risk and 4 high-risk patients did not develop

neutropenia during induction chemotherapy. Thirty-eight

patients were not transfused preoperatively. Thirty-eight

received blood and platelets; 30 received blood only;

8 received platelets only; and 1 received blood and fresh

frozen plasma.

One hundred single lumen life-ports and 15 external lines

were placed prior to or on the day treatment commenced. No

patient developed bacteremia. Seven patients (7%) with life-

ports experienced a complication during the induction phase

of chemotherapy. In four patients, blood could not be

aspirated, two life-ports needed realignment, and one a

wound infection developed without dehiscence. Four

patients (27%) with external lines experienced a complica-

tion. In one patient each, the line became occluded, was

removed by the patient, ruptured, and had leakage. The

occluded and self-removed lines were replaced with ports

without further complications. The remaining two lines were

repaired by the pediatric surgery staff and remained

functional throughout the induction phase of chemotherapy.

The complication rate between life-ports and external lines

was different (P¼ 0.045). The complication rate between

standard-risk (8 of 71) and high-risk patients (3 of 45) was

similar.

DISCUSSION

Previous investigations have reported major complica-

tions associated with central lines, including thrombotic

occlusion, infection, and mechanical malfunction [5–8]. It

has been suggested that the most common complication is

infection, with thrombosis being a major complication as

well [6,7]. One investigation found that catheter use was

associated with a significant increase in hospitalization

during the induction phase of chemotherapy [8]. Another

study concluded that mechanical episodes related to

catheters were more prevalent than infectious episodes [5].

Our retrospective chart review of 115 children with the

specific diagnosis of ALL over a 10-year period was intended

to evaluate the safety of central line insertion at the time of

diagnosis in order to examine the prevalence of complica-

tions during the first 30 days of treatment. Very few studies

have been done in which the relative safety of external and

port-type catheters was examined at this particular phase of

bone marrow failure. Some of the limited research on this

subject suggests that port-type catheters have a lower

incidence of mechanical malfunctioning than Broviac lines

[7]. The Pediatric Oncology Group recently preformed a

retrospective analysis on 362 patients treated for standard-

risk ALL [9]. Central lines placed within the first 15 days of

induction were associated with an increased risk (odds ratio,

2.2) of having a positive blood culture. External lines were at

increased risk for positive blood culture (odds ratio, 3.1),

thrombosis (odds ratio, 3.9), and removal (odds ratio, 5.6).

Abbas et al. found that delaying catheter placement for

more than 3 weeks did not influence the risk of infection [10].

Shaul et al. studied risk factors for early infection of central

TABLE I. Acute Lymphoblastic Leukemia Induction Regimens

Study (n) Induction medications Reference

BFM (30) Intrathecal methotrexate dose age adjusted day 1, 14, and 28; vincristine 1.5 mg/m2 day 1, 8, 15, and

22; daunomycin 25 mg/m2 day 1, 8, 15, and 22; L-asparaginase 6,000 IU/m2 for 9 doses;

and prednisone 60 mg/m2 for 28 days

[1]

CCG-1952 (15) Intrathecal cytarabine day 0 and intrathecal methotrexatea days 7 and 28 doses age adjusted;

vincristine 1.5 mg/m2 day 0, 7, 14, and 21; L-asparaginase 6,000 IU/m2 for 9 doses; and prednisone

60 mg/m2 for 28 days

[2]

CCG-1991 (26) Intrathecal cytarabine day 0 and intrathecal methotrexatea days 7 and 28 doses age adjusted; Vincristine

1.5 mg/m2 day 0, 7, 14, and 21; peg-asparaginase 2,500 IU/m2 day 3; and dexamethasone

6 mg/m2 for 28 days

NP

New York (28) Intrathecal cytarabine day 0 and intrathecal methotrexate days 15 and 29 doses age adjusted;

cyclophosphamide 1,200 mg/m2 day 0; vincristine 1.5 mg/m2 day 1, 8, 15, 22, and 29;

daunorubicin; 60 mg/m2 day 2 and 3; L-asparaginase 6,000 IU/m2 for 6 doses; and prednisone

60 mg/m2 for 28 days

[3]

CCG-1961 (15) Intrathecal cytarabine day 0 and intrathecal methotrexatea days 7 and 28 doses age adjusted;

vincristine 1.5 mg/m2 day 0, 7, 14, and 21; daunorubicin 25 mg/m2 day 0, 7, 14, and 21;

L-asparaginase; 6,000 IU/m2 for 9 doses; and prednisone 60 mg/m2 for 28 days

[4]

P9407 (1) Intrathecal cytarabine, hydrocortisone, and methotrexate day 1, 8, and 15 doses age adjusted;

vincristine 0.05 mg/kg day 1 and 15 and 0.03 mg/kg day 8; daunorubicin day 1 and 2 doses age

adjusted; cyclophosphamide 250 mg/m2 and mesna 125 mg/m2 day 3 and 4; L-asparaginase

6000 IU/m2 for 8 doses; and prednisone 40 mg/m2 for 21 days

NP

NP, not published. aExtra doses if central nervous system leukemia.

Pediatr Blood Cancer DOI 10.1002/pbc

Central Line Placement Prior to ALL Treatment 887

lines [11]. They found that neutropenia and failure to provide

perioperative prophylactic antibiotics were associated with a

high risk of central line infections in pediatric patients;

however, the diagnosis of malignancy was not (leukemia was

the most common of 26 diagnoses). In our series, no episode

of bacteremia was detected, and only one case of wound

infection without dehiscence occurred. This finding may be

attributed to the use of perioperative antibiotics.

In our series of patients with central lines placed at the

time of ALL diagnosis, mechanical complications were

observed. The specific mechanical complications included

rupture, leakage, malalignment, and removal by the patient.

These complications showed a slightly higher prevalence in

patients with external lines. Moreover, the complication rate

was similar between standard-risk and high-risk patients.

In conclusion, the placement of central lines at diagnosis

of pediatric ALL is safe. Mechanical problems related to

catheter placement account for most complications, particu-

larly when external lines are used.

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