Avoiding placement of implanted central venous catheters in neutropenic patients decreases complication rates

The authors of this study evaluated the outcome of the implementation of a protocol that restricts the placement of implanted central venous catheters to patients with an ANC greater or equal to 500. This was based on previous findings that suggested that placement of implantable central venous devices in neutropenic patients is associated with higher rate of complications.

The authors found a higher rate of complications (infectious and technical) in neutropenic patients. Additionally, the rate of these complications was substantially decreased after implementation of a protocol that excludes neutropenic from device placement.

Gollin G, Gutierrez I. Exclusion of neutropenic children form implanted central venous catheter placement: impact on early catheter removal. J Pediatr Surg 2010;45:1115-1119

Mediports and neutropenia

As pediatric surgeons, we are frequently faced with the the request for an "urgent" line to be placed in children with a newly diagnosed ALL. Having been involved in several situations where I am asked to place a mediport in a neutropenic child in order to start induction therapy, I decided to look at the available literature addressing the risk of line placement this patient population.

Understandably, the presence of a central line in any child increases the risk of infection. Rackoff et al (J Ped Heme Onc (1999) 21(4):260) in a study looking at the risk of infection in patients with ALL, showed that the presence of a line increases the risk of infection 4 fold.
Another study by Saul et al. (J Am Col Surg (1998) 186(6):654-8) looking at the risk of infection of line placement in children in general (most of whom had ALL), showed that the two main risk factors for line infection are neutropenia (ANC<1,000/mm) and failure to administer perioperative antibiotics.
Finally, as a direct answer my main question regarding whether we should place lines in neutropenic ALL patients or not, McLean et al (J Clin Onc (2005) 23(13):3024) looked at the risk of complications in lines placed early (<15 days) vs late (>15days) after initiation of induction therapy and noted that early placement was associated with a higher risk of positive blood cultures (OR 2.2) ,with the mean ANC being significantly lower in patients whose lines had to be removed (601/mm vs. 1,390/mm).

The way I see it, the best way to manage patients with newly diagnosed ALL (particularly if they are neutropenic), is to place a PICC line to start induction therapy then schedule an elective mediport placement at day 28 when these patients routinely get a repeat BM biopsy under general anesthesia as part of the protocol.