颈内、颈外静脉置管皮下埋入化疗泵在肿瘤患儿中的临床应用

化疗是恶性肿瘤主要的治疗方法之一 ,但是长期静脉穿刺输药给患儿带来了不便和痛苦。长期中心静脉置管在国外已经普遍运用于肿瘤患儿的化疗[1] ,但在国内肿瘤患儿中未见报道。我院近1年来为 16例肿瘤患儿采用经颈内、颈外静脉置管 ,皮下埋入化疗泵 ,术后进行灌注化疗药物 ,取得了较满意的效果。材料与方法1.临床资料　 1999年 6月～ 2 0 0 0年 6月共为 16例恶性肿瘤患儿安置化疗泵。其中女 12例 ,男 4例。年龄 1～12岁。病种 :神经母细胞瘤 6例 ,卵黄囊瘤 4例 ,白血病 3例 ,肾母细胞瘤 2例 ,淋巴瘤 1例。经颈内或颈外静脉置管于上腔静脉 ,皮…     

植入式中心静脉给药装置在儿童肿瘤应用中常见并发症的预防和处理

目的讨论植入式中心静脉给药装置（化疗泵）在恶性肿瘤患儿治疗中常见并发症的预防和处理。方法1999年6月～2004年6月，共计79例肿瘤患儿安装化疗泵并经泵化疗。60例经颈外静脉切开插管．导管头端置于上腔静脉；10例经颈内静脉插管；9例锁骨下静脉穿刺插管，泵体置于侧胸壁皮下。结果79例患儿平均带泵天数721d。其间10例发生导管阻塞，1例置泵1年后泵体处皮肤磨损。79例经泵抽血培养98次，其中有菌生长17次。结论全麻下经颈外静脉切开插管为安装化疗泵的首选方法。化疗泵安装和应用的规范化是减少和预防并发症发生的主要措施，并发症的预防和及时有效的处理是化疗泵安装得以全面推广的可靠保证。     

植入性中心静脉通道装置(Port)在肿瘤患儿中的应用

目的 探讨植入性中心静脉通道装置(Port)在肿瘤患儿中应用的疗效.方法 通过对176例安装化疗泵的恶性肿瘤患儿的观察,分析其置管的途径、导管放置的长度、并发症发生的原因及处理.结果本组176例患儿经颈外静脉切开123例,锁骨下静脉穿刺插管38例,经颈内静脉穿刺插管15例.导管应用期间共有46例出现相应的并发症,占26.1%.其中导管相关性感染占15.3%,导管的阻塞占16.8%.结论 化疗泵在肿瘤患儿中有良好的应用价值.导管相关性感染是化疗泵使用过程中最常见的并发症,导管的阻塞多因放置的位置或者长度不当而引起.操作医师的专业化对减少并发症的发生具有相当重要的作用.     

399例儿童畸胎瘤的单中心临床诊疗分析

目的回顾性分析小儿畸胎瘤的治疗及预后特点。方法收集重庆医科大学附属儿童医院1994年10月至2015年6月收治的畸胎瘤患儿,共399例,按照性别、年龄、部位、病理类型、血清AFP水平、治疗及预后等因素进行回顾性分析。结果①成熟型畸胎瘤301例;未成熟畸胎瘤17例,其中组织学Ⅰ级9例,Ⅱ级5例,Ⅲ级3例;恶性畸胎瘤81例,按COG/CCG肿瘤分期标准,Ⅰ期5例,Ⅱ期14例,Ⅲ期44例,Ⅳ期18例。②成熟型畸胎瘤及未成熟型畸胎瘤共318例一期接受手术治疗,其中未成熟畸胎瘤Ⅲ级及部分Ⅱ级病例术后辅以化疗;81例恶性肿瘤患儿中,Ⅰ、Ⅱ期均手术完全或完整切除肿瘤,部分Ⅱ期病例术后辅以化疗;40例接受术前新辅助化疗、手术治疗、术后化疗的个体化综合治疗;另外22例中断治疗并放弃;③术后随访1~10年,3例成熟型畸胎瘤患儿术后良性复发,再次予以完整切除后,截止随访时间,301例均无瘤存活;1例未成熟畸胎瘤Ⅲ级术后恶性复发,放弃治疗后死亡;恶性畸胎瘤完成治疗的患儿仅1例恶性复发后死亡,未完成治疗患儿中10例死亡,其余患儿各有不同程度的病情进展。结论在儿童畸胎瘤治疗中,一期完整切除肿瘤,避免肿瘤破溃是预防复发及恶变的关键,未成熟畸胎瘤依据AFP、影像学、肿瘤组织分级、病理免疫组化、术中情况等选择是否化疗;对于恶性畸胎瘤,彻底手术切除的同时结合化疗,术后密切随访,可获得较高的生存率。     

完全植入式静脉输液港在儿童血液肿瘤中的临床应用和护理

目的探讨完全植入式静脉输液港（TIVAP）在肿瘤患儿化疗过程中的应用方法和护理效果。方法分析八一儿童医院血液肿瘤科护理的10例肿瘤患儿应用TIVAP的使用情况及护理效果。结果本研究中,10例患儿在化疗过程中应用TIVAP无外渗、外漏现象,无导管相关性血行感染等并发症。结论在肿瘤患儿化疗过程中应用TIVAP解决了反复静脉穿刺的困难,减轻了化疗对肿瘤患儿外周血管的损害,同时导管相关感染机率降低,减轻了患儿的痛苦,提高了肿瘤患儿的生存质量。     

贝伐珠单抗治疗儿童视路胶质瘤的疗效分析

目的 分析贝伐珠单抗治疗儿童视路胶质瘤（OPG）的效果,为儿童OPG的治疗探索新方向。方法 回顾性分析术后化疗的OPG患儿30例,根据是否加用贝伐珠单抗分为传统化疗组（卡铂、长春新碱、依托泊苷,n=12）和联合化疗组（贝伐珠单抗、卡铂、长春新碱、依托泊苷,n=18）。随访至化疗后6个月,比较两组患儿化疗前后的视力、肿瘤大小及化疗期间出现的不良反应。结果 联合化疗组肿瘤缩小患儿比例高于传统化疗组（P < 0.05）。两组视力好转率、不良反应发生率差异无统计学意义（P > 0.05）。两组均无化疗相关的死亡病例。结论 贝伐珠单抗联合传统化疗可有效使肿瘤体积缩小,且与传统化疗相比,化疗的不良反应并不增加,可作为儿童OPG新的治疗方向。     

儿童骨肉瘤单中心诊治分析:附25例报告

目的制定本中心儿童骨肉瘤治疗方案,对该方案进行疗效分析。方法前瞻性制定包括病理分型、临床分期、分组、化疗、手术的整体性诊断治疗方案,方案适用对象为1998年10月-2009年12月期间经病理检查确诊为骨肉瘤的连续初治病例,共25例,按方案根据不同个体对治疗反应的差异在不同治疗阶段手术,按影像学和病理学对治疗反应的评估,给予不同强度的化疗。分析本组患儿的治疗依从性和远期预后。结果全组25例,放弃治疗1例,接受手术10例,完成术前化疗2～4个疗程后拒绝手术14例。完成手术及化疗计划8例,其中4例无事件生存>32个月;2例手术者在术后化疗中复发。未手术者14例中3例在2～36个月内重新进展,12例失访。结论儿童骨肉瘤治疗依从性差,局部病灶根治性手术率低是影响预后的最重要因素。     

小儿纵隔气肿合并皮下气肿的紧急处理

目的 总结纵隔气肿合并皮下气肿的临床特点和紧急处理方式.方法 回顾性分析10例小儿纵隔气肿合并皮下气肿的病例资料.结果 采用局麻下行颈胸腹部皮下气肿小口减张切开的方法治疗纵隔气肿合并皮下气肿.除1例死亡外,其余病例气肿均逐渐自行吸收和消退,经保守治疗2～3周后痊愈.结论 准确及时的皮下气肿小口减张切开,可有效地缓解纵隔气肿对纵隔内器官的压迫,有利于缓解病情,避免手术创伤,提高治愈率.     

14例儿童肝母细胞瘤综合治疗的疗效观察

目的：肝母细胞瘤是儿童时期最为常见的原发性肝脏恶性肿瘤。新辅助化疗﹢手术﹢术后化疗已成为肝母细胞瘤治疗的基本原则。该文旨在总结肝母细胞瘤综合治疗的疗效,进而探讨合理治疗的策略。方法：回顾性分析14例儿童肝母细胞瘤患者的临床资料,并追踪随访其治疗后的生存状况。结果：12例肝母细胞瘤患儿接受全程治疗,中位随访时间为18个月（1.5~74月）。9例无瘤存活,1例死亡,1例肿瘤转移,1例未发现肿瘤残留但术后甲胎蛋白持续不降。结论：手术及规范化疗能有效提高儿童肝母细胞瘤患者的生存率。［中国当代儿科杂志,2009,11（6）：456-459］     

心电监护仪在新生儿PICC置管中的定位效果

目的 探讨心电监护仪辅助定位法在新生儿经外周静脉置入中心静脉导管（PICC）置管中的应用效果。方法 选取2015年1月至2017年12月入住新生儿重症监护室（NICU）的经上肢静脉PICC置管患儿160例,按随机数字表法分为观察组和对照组,每组80例。对照组患儿行体表测量+术后X线胸片定位;观察组患儿行体表测量+心电定位+术后X线胸片定位。比较两组患儿一般资料、置管一次性到位率及操作耗时。结果 两组患儿性别构成、胎龄、置管日龄、疾病类型及穿刺部位的比较差异无统计学意义（P > 0.05）。观察组置管一次性到位率高于对照组（95% vs 79%; P < 0.05）;观察组PICC置管耗时短于对照组（P < 0.05）。心电监护仪定位技术具有较高的敏感性（97%）和特异性（100%）。结论 在新生儿PICC置管过程中,利用心电监护仪辅助判断导管尖端位置,能提高置管一次性到位率,并可节省置管耗时。     

Comparison of implantable central venous ports with catheter insertion via external jugular cut down and subclavian puncture in children: single center experience

Purpose  The purpose of this study is to demonstrate the efficacy, safety and long-term advantages of catheter insertion via external jugular vein (EJV) cut down for implantable central venous port in children. Materials and methods  Thirty-nine central venous ports were implanted with catheter insertion via subclavian puncture in the children (group 1) with average age of 4.2 years. Forty-three were done by inserting the catheter via EJV cut down in the children (group 2) with average age of 4.8 years. Ports remained functional for a total of 11,890 patient days in group 1 and 15,743 patient days in group 2. Results  The ports were unplanned removed in 28.2% of patients (11/39) in group 1 with comparison of 7.0% of patients (3/43; p < 0.01) in group 2. Five patients (12.8% of ports implanted) suffered an infectious complication in group 1 and just one patient (2.3% of ports implanted; p < 0.01) occurred in group 2. Permanent aspiration occlusion occurred in every two patients for each group with incidence of 5.1% in group 1 and 4.7% in group 2. Catheter fracture occurred in three patients in group 1 (7.7%). One case with catheter disconnected to the port was found in group 1 (2.6%). The disconnected catheter was removed from right ventricle by interventional therapy. Conclusion  Insertion of the catheter via the EJV cut down for implantable central venous port is significant better than insertion of the catheter via subclavian puncture in children.     

Complications of central venous catheterization in critically ill children

BACKGROUND: Placement of central venous catheter is essential in the management of critically ill children. The purpose of the present paper was to evaluate the success rate, mechanical and thrombotic complications and risk factors associated with these complications from different central venous access sites in critically ill children. METHODS: A prospective study was undertaken from February 2000 to March 2005 of 369 central venous catheterizations in children in a pediatric intensive care unit. RESULTS: The veins most frequently used were femoral vein (45%), subclavian vein (32.2%), and internal jugular vein (22.8%). Mean +/- SD duration of catheterization was 9.5 +/- 6.5 days. The procedure was performed under emergency conditions in 18% of patients with an overall success rate of 92.4%. The success rate was significantly lower in younger patients with subclavian catheterization. Insertion-related complications were noted, including 33 arterial punctures (8.9%), 27 cases of malposition (7.3%), 19 hematomas (5.2%), 12 cases of minor bleeding (3.3%), and three cases of pneumothorax (0.8%), and they were more common in the subclavian vein than in the internal jugular and femoral vein. Multiple attempts and failed attempts significantly correlated with higher incidence of complications. Maintenance-related complications included obstruction (n = 26; 7%), accidental removal (n = 14; 3.8%), central venous thrombosis (n = 8; 2.2%), subcutaneous extravasation (n = 14; 3.8%), dislodgment (n = 1; 0.25%), and extravascular infusion (n = 1; 0.25%). The frequency of catheter maintenance-related complications was significantly higher in femoral catheterizations and increased significantly with an increase in the duration of catheterization. A total of five serious complications were seen (pneumothorax in three, dislodgment in one and extravascular infusion in one) in the present series. CONCLUSIONS: Central venous catheterization in critically ill children is a relatively safe procedure, with a 1.3% rate of serious complications and no mortality. It seems safer to choose initially the femoral or internal jugular vein instead of the subclavian vein because of high success rate without serious insertion-related complications.     

Morbidity using subcutaneous ports and efficacy of vancomycin flushing in cancer.

An evaluation of totally implanted venous access systems inserted in 163 consecutive children with cancer is reported. From 1988 to 1994, 180 subcutaneous ports were inserted in children more than 1 year old. Initial diagnosis was acute leukaemia (n = 79), non-Hodgkin''s lymphoma (n = 33), and solid tumour (n = 51). Median age was 85 months. All venous procedures were performed through the device. Chemotherapy was either moderate (n = 13) or intensive (n = 119) or very intensive (n = 48), including 16 patients undergoing marrow transplantation. Cumulative venous access totalled 55,770 patient days with a mean of 305 days/subcutaneous port. The cause of device removal was, end of treatment (n = 111), death due to malignancy (n = 20), catheter related infection (n = 7), and occlusion of the system (n = 4). Mechanical complications occurred in 19 ports; 16 were due to clots, of which 14 were cleared with instillation of urokinase. Documented infectious episodes occurred in 47 ports, recurred once in 14, and twice in five cases. Among these infections, 47 were septicaemic; 31 due to Staphylococcus epidermidis. Twenty seven of initial septic episodes were considered to be catheter related; the rate was 15%/subcutaneous port or 0.05/100 catheter days. Risk factors for the development of a first infection were age below 4 years and the time of use. Since February 1993, vancomycin (50 micrograms/ml) has been given and this has reduced the rate of S epidermidis infection from 26/83 subcutaneous port to 4/97. Life table analysis showed that the infection free interval for staphylococcus was significantly better after this technique ws initiated (log rank rest=0.02). Time saved was approximately 30minutes/patient/week compared with external catheters, or 45 hours/month for the cohort of children treated. Subcutaneous ports in paediatric cancer patients are reliable, safe, and durable and may offer an attractive alternative to external catheters for prolonged venous access and intensive treatment.     

Cathlink 20: a subcutaneous implanted central venous access device used in children with sickle cell disease on long-term erythrocytapheresis--a report of low complication rates

BACKGROUND: Experience with the use of central venous access device (CVAD) in children with sickle cell disease (SCD) on hypertransfusion is limited and published studies report wide variability in the rates of CVAD-associated complications. PROCEDURE: In this study, a total of 18 Cathlink 20 ports (Bard Access systems, Salt Lake City, UT) were implanted in 15 patients aged 7-20 years with SCD for 19, 230 catheter patient days. RESULTS: No peri-operative complications were observed. Three episodes of catheter occlusion requiring replacement occurred in two patients for an observed rate of 0.16 per 1,000 catheter patient days for thrombotic occlusion. One patient required port replacement and another patient required replacement twice. In 13 out of 15 patients, the median duration of port use was 45 months. No episode of catheter-associated bacteremia or catheter tunnel infections was observed. CONCLUSIONS: Comparing our results with other reported studies of CVAD-associated complications in patients with SCD, we observed a lower rate of complications with the use of Cathlink 20 ports. These findings may be partly related to the design of the port and partly to a dedicated group of nurses accessing the ports in a controlled environment in an apheresis unit.     

Central venous catheter with subcutaneous injection port (Port-A-Cath): clinical experience with children

Long-term intermittent venous access was established in 26 children by means of a central venous catheter (CVC) with a subcutaneous injection port (Port-A-Cath) (PAC). As of December, 1985, PACs had been in place for 20-750 days (cumulative 10,890 days) with 647 entries into the system. The PACs were used for blood sampling and administration of chemotherapy, antibiotics, fluids, total parenteral nutrition (TPN), and blood products. One patient with sever neutropenia (absolute neutrophil granulocyte count [ANC] less than 0.1 x 10(9)/L) at the time of the PAC implant developed an infection around the port after 2 days, with subsequent septicemia (Bacillus cereus) necessitating removal of the PAC. Otherwise, no definite PAC-related infections occurred, including 258 days of neutropenia (ANC less than 0.5 x 10(9)/L). Two PACs were found occluded with greyish deposits of fat and organic material after long-term (45 and 61 days) continuous TPN and were removed. Malposition of catheter, extravasation, thrombosis, and other potential technical or psychological complications were not observed. The children continued normal activities, and the easy venous access decreased emotional stress during treatment. Local doctors were trained to use the PACs, with which they administered maintenance chemotherapy. We conclude that the use of PACs in children is safe, even in the first year of life, and has many advantages when compared with other CVCs currently in use. Strict indications, meticulous implantation technique, and adequate handling are, however, mandatory.     

The external left jugular vein as an access for placement of long-term permanent central venous catheters in children

We consider the approach through the left external jugular vein v/s right external jugular vein (Heinbach-Ivey technique) for the placement of central venous catheters (Broviac Hickman type and others) in pediatric patients. Between January '84 and February '87, 65 central venous catheters were inserted using the Heinbach Ivey technique. In 24.6% of the cases we failed and had to place the catheter through the right internal jugular vein. Between March '87 and November '88, 72 catheters were inserted through the left external jugular vein, only 5 through the left internal jugular vein, with a failure rate of 6%. Our data show that a more favourable anatomy makes easier and quicker the correct placement of a central venous catheter through a left external jugular vein approach.     

Critical appraisal of surgical venous access in children

Central venous catheters (CVC) have become an important adjunct to the overall management of paediatric patients, but their use is associated with frequent complications resulting in premature removal. This report evaluates the insertion techniques and complications of 295 consecutive surgically inserted CVC from 1987 to 1991 in a paediatric hospital. Fully implanted catheters had significantly less incidence of catheter-related problems necessitating removal (infection, dislodgment, leaking, blockage, or migration — 31%) compared to exteriorised catheters (58%). One-third of catheters were removed because of infection, one-third as they were no longer needed, and the remaining for multiple reasons. Infected (110±18 days), dislodged (18 ± 4 days), or migrated (44 ± 6 days) catheters were removed significantly earlier than those removed because they were no longer needed (195 ± 24 days). Catheters became dislodged more frequently in the younger patients. Catheters with the tip in the subclavian vein (29%) migrated more frequently than those in the right atrium. There was a significantly increased incidence of infection in catheters inserted into the saphenous vein (43%) compared to those in the internal jugular vein (11%). Some episodes of catheter infection were managed with antibiotics, with short-term resolution of symptoms and signs. However, all 71 infected catheters ultimately required removal for further sepsis. Fully implanted catheters had 1.1 episodes of catheter-related sepsis per 1,000 catheter days compared to 3.7 for exteriorised catheters. The position of the catheter tip, vein used for insertion, training of young surgeons, and location of the subcutaneous tunnel need particular attention in order to reduce catheter complications.     

Totally implantable venous access ports via the external jugular vein: safety and effectiveness for young pediatric patients

BACKGROUND AND AIMS: Various venous approaches are possible during implanting a totally venous access port. The veins, which are commonly used in pediatric patients are internal and external jugular veins. Comparison of different venous approaches has been discussed in a few reports only. The present study reviews the complication rate, operation time of implanting the port via different veins in children. PATIENTS AND METHODS: From January 2003 to December 2005, 94 venous access ports were implanted in 88 consecutive patients in the Pediatric Surgical section of the Taipei Veterans General Hospital. The patients were classified according to the vein used. Group A (n=45), the external jugular vein access group; and group B (n=43), the internal jugular vein access group. RESULTS: The operation time in group A and B were 38.4+/-11.1 and 57.6+/-20.3 min, respectively. The mean operation time of group A was significantly shorter than that of group B (P<0.001). The overall complication rates in group A and B were 8.5%, and 19.1%, respectively. These differences, however, were not significant (P>0.05). CONCLUSIONS: The external jugular vein approach has a shorter operation time and a lower complication rate than the internal jugular vein approach. This approach may be a method of choice in selected pediatric patients.