In this study, the incidence of complications related to the use of TIVAP in children's chemotherapy was 39%, which is higher than the 14.7–33% reported in foreign children's studies[6, 7], which may be related to the short duration of TIVAP use in our hospital. Infectious complications were the most common. TIVAP-related infection generally results from skin infection at the puncture point, microorganisms migrating into the catheter along the port, or blood flow infection from other distant parts of the body, and there are also very few possible sources of pollution caused by infusion liquid. The results of a meta-analysis showed that infection prevention strategies and the education and training of professional nursing staff are the most effective means of preventing infection. The incidence of TIVAP-related infection complications in this group was 27.4%, which is higher than the 6.5% − 17.9% reported in the literature[7, 10], which may be related to the short operation time and insufficient experience in preventive nursing education in our hospital. A more recent study in the literature[7, 10] reported a lower incidence rate of infectious complications, suggesting that a large number of cases, surgical and maintenance procedures, and standardized care reduced the incidence of infection. In previous studies, coagulase-negative Staphylococcus (Staphylococcus epidermidis, human staphylococcus, and Staphylococcus saprophytes) were the most common infectious microorganisms, among which Staphylococcus epidermidis is the most common[8, 11]. Similar results were observed in this study. Coagulase-negative Staphylococcus is a common skin microorganism, suggesting that the infection may originate from the puncture site, which is consistent with the pathogenesis of infection complications. In this study, intravenous anti-infection therapy was administered after catheter infection with an effective rate of 75%.
There are many reasons for TIVAP catheter blockage, which can be divided into catheter factors such as catheter discount, compression or improper end position, catheter tip sticking to the vessel wall or catheter displacement, and non-catheter factors such as precipitation caused by parenteral nutrition infusion, blood products, and drug interactions during use. Mechanical blockage is often caused by catheter discount or compression. Pinch off syndrome is the most serious mechanical blockage and is common in subclavian vein catheterization. The catheter is compressed between the clavicle and the first rib for a long time, resulting in fragmentation of the catheter wall and debris falling off and moving to the central vein, right atrium, right ventricle, and pulmonary artery. It is a rare, but serious complication. In this study, internal jugular vein puncture was performed, and no such complications were found. Endothelial injury, the hypercoagulable state of malignant tumors, and chemotherapy itself are all factors that lead to thrombosis in cancer patients. Thrombosis can occur around or in veins at the top of the catheter. The manifestations of catheter-related thrombosis may be asymptomatic, with or without pain or swelling of the ipsilateral limb. Therefore, the evidence of thrombosis may not be clinically clear, but it is usually the most common cause of catheter blockage. In some studies, heparin treatment was compared with urokinase treatment, and urokinase treatment was found to be significantly associated with a lower thrombosis rate. In this study, 91.3% of the children with catheter obstruction improved after thrombolytic therapy with heparin or urokinase, suggesting that thrombolytic therapy with heparin and urokinase may reduce the risk of thrombosis. In the past, the incidence of thrombosis was reported to be 1.6-7%. No thrombosis cases were found in this study, which may be related to the small sample size of this study and the lack of routine regular vascular ultrasound follow-up of patients.
The literature reports that the incidence of drug extravasation is 0.26-6% The severity of lesions caused by extravasation depends on the nature, volume, concentration, and location of extravasation drugs and the contact time required for extravasation drugs to damage surrounding tissues. Prevention of drug extravasation complications should be emphasized. Training of the nursing team should be strengthened to prevent serious skin damage caused by chemotherapy drug extravasation and delay tumor treatment. In this study, there were 2 cases of drug extravasation. No serious consequences were observed after local symptomatic treatment or nursing. The literature reported that the incidence of catheter fracture ranged from 0.4–1.8% , which was not found in this study.
In a retrospective analysis of pediatric patients, Hung et al. found that younger patients had a higher risk of infection after TIVAP implantation. The results of the logistic regression analysis in this study suggest that the lower the age, the higher the risk of complications, which is consistent with the reported results and may be related to the nursing difficulties of low-age patients. Delaying catheter use has been reported that delaying the use of catheter can reduce the risk of infection. It is suggested that one week between the placement of TIVAP and the start of use can reduce the incidence of complications and the risk of unplanned port removal, which may be related to the healing time of incision after implantation. This study did not find an impact of the start time of TIVAP on the incidence of complications, and prospective studies with larger sample sizes are needed. Some studies have pointed out that the occurrence of complications is unrelated to the timing of TIVAP surgery, and others have pointed out that the risk of infection in children undergoing TIVAP surgery in the early stage of induction remission treatment of acute lymphoblastic leukemia will increase. It has been reported that neutropenia is a risk factor for catheter-related infection. In this study, it was found that neutrophils in the infection group were higher than those in the control group, and the difference was statistically significant, which is inconsistent with previous reports because the chemotherapy time and intensity of leukemia patients were higher than those of solid tumor patients; therefore, the degree and duration of potential neutropenia were also higher than those of solid tumors. We found that the incidence of clinical sepsis in the leukemia group was very high. However, because Hong Kong blood was not collected from all patients with sepsis for culture, the infection rate of catheter-related blood influenza in the leukemia group may be underestimated.
TIVAP, a device that can easily provide long-term venous access, is safe for pediatric malignant tumors. Special attention is required in the process of surgical placement and operation. Therefore, surgeons and nursing teams require professional training. The incidence of complications in this study was 39%, and there were no deaths due to complications at the infusion port. Infection is the most common complication, and CRBSI is the most common cause of unplanned pullout. Younger age may be a risk factor for CRBSI and complications.