An 8-year-old boy with a history of standard-risk acute lymphoblastic leukemia presents to the ED with a fever. He has a port central line and is currently undergoing the delayed intensification phase of chemotherapy. He last received chemotherapy 1 day prior to presentation. He also reports a headache and a cough. Upon examination, he is febrile to 39.2ºC, with a heart rate of 120 beats/min and blood pressure of 108/60 mm Hg. He is breathing comfortably and has an oxygen saturation of 99% on room air. You consider what initial laboratory workup you might need…
A 4-year-old girl with a history of gastroschisis requiring intestinal resection that resulted in short gut syndrome presents with a history of fever, vomiting, and diarrhea. She is dependent upon total parenteral nutrition, which is delivered through a Broviac® catheter. She has a history of multiple previous line infections, including a recent MRSA line infection. On examination, her temperature is 38.2°C, and she has a heart rate of 105 beats/min and blood pressure of 100/55 mm Hg. You wonder what initial laboratory testing and imaging you should consider, and what the appropriate disposition for this patient should be…
Fever is a common chief complaint of pediatric patients presenting to the emergency department (ED), and patients with a central venous catheter (CVC) may also have common causes of fever similar to children without pre-existing medical conditions. While these common causes of fever may occur in patients with CVCs, it is imperative that emergency clinicians investigate all episodes of fever for catheter-associated bloodstream infections (CA-BSI), and initiate prompt and appropriate antibiotic therapy if catheter-associated infection is suspected.
The use of an indwelling CVC is essential in pediatric patients who require hemodialysis, parenteral nutrition, frequent blood draws, frequent blood product transfusions, or long-term intravenous medications (such as antibiotics or chemotherapeutics). Although essential to the treatment of these patients, there are several complications that may arise with the ongoing use of CVCs. In addition to catheter dysfunction, thrombosis, and embolization, patients with a CVC may also experience infection at the insertion site, the tunneled portion of the catheter, the subcutaneous pocket of a totally implanted intravascular device (a pocket infection), or within the catheter itself. The indwelling catheter provides a portal of entry for bacteria (and other organisms), and renders these patients susceptible to the development of a CA-BSI and the potential for progression to overwhelming infection and sepsis.
The rapid recognition and triage of these patients, with subsequent initiation of antibiotics and resuscitative measures, has been studied extensively and has been shown to improve outcomes in febrile neutropenic patients with indwelling central catheters.1 The time to antibiotic therapy has been consistently used as a quality-of-care measure in this patient population.1,2 Although less-studied in other pediatric populations relying on CVCs, a regular complication in these patients remains the occurrence of CA-BSI. Sepsis syndrome remains a leading cause of morbidity and mortality in pediatric patients, and the Surviving Sepsis Campaign (www.survivingsepsis.org) recommends initiation of empiric antibiotic therapy within 1 hour of the recognition of severe sepsis or septic shock in both adult and pediatric patients.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study will be included in bold type following the references, where available. The most informative references cited in this paper, as determined by the author, will be noted by an asterisk (*) next to the number of the reference.
Courtney Brennan, MD; Vincent J. Wang, MD, MHA
December 2, 2015
January 1, 2019
Upon completion of this article, you should be able to:
Physician CME Information
Date of Original Release: December 2, 2015. Date of most recent review: November 15, 2015. Termination date: December 2, 2018.
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