to the break, cleaned with alcohol and covered with sterile dressing until repaired Optimally, a person familiar with the procedure will be available within a short time of clamping the catheter or folding the catheter on itself, or, if feasible, tying the broken end into a knot If the externalized portion is too small to clamp, hemostasis may be achieved by putting pressure on the site of venous entry A scar is usually apparent at this site However, if the scar is not apparent, the catheter should be palpated from the exit site on the skin to the location at which it can no longer be palpated and pressure should be applied at that site Repair kits are available for each catheter size ( Fig 135.9 ) These kits contain a new external catheter segment with a hollow male connector that fits into a cleanly sliced proximal end The kits also contain a syringe and needle to apply the glue to the male connector If an implantable catheter leaks, fluid or blood that collects subcutaneously may cause a bulge or painful swelling at the site A broken implanted catheter must undergo prompt surgical management The broken segment can often be easily visualized by chest radiography Catheter Displacement Occasionally, the patient or caregiver inadvertently pulls on the externalized portion of a tunneled catheter, and can be noted by visualization of the cuff at or outside of the exit site The venous portion of the catheter may eventually be displaced from the venous system Externalized catheters are at higher risk for dislodgment within a few weeks of insertion, because the cuff is not fully anchored by fibrosis Exsanguination after catheter dislodgment is a rare event because of the advancement of the tip inside the vein and the natural tendency toward venous hemostasis However, children with clotting disorders are at increased risk of life-threatening blood loss after catheter displacement Totally implanted devices are at risk of dislodgment at both ends; however, few events apart from major thoracic trauma place enough tension on the catheter to dislodge it from the vein Migration of the venous catheter tip is rare but can lead to cardiac arrhythmias, pneumothorax, cardiac tamponade, and superior vena cava syndrome FIGURE 135.9 Repair kit for tunneled catheters Detecting catheter dislodgment is easier in patients with externalized catheters If the Dacron cuff is noted outside the skin surface, the catheter must be considered dislodged and should not be used until the tip’s location can be confirmed by chest radiography Failure to draw back free-flowing blood from the device increases the suspicion that the catheter is no longer in the central vein In this situation, the catheter should be clamped and secured close to the skin and immediate surgical or interventional radiology consultation should be obtained A dye study may be necessary to locate the catheter tip For totally implanted devices, dislodgment of the catheter from the vein should be suspected if the device no longer functions after thoracic trauma If the catheter is disconnected from the reservoir, fluid or blood may collect subcutaneously and cause a bulge or painful swelling at the site Prompt surgical management is required Catheter migration should be considered in patients with totally implanted venous catheters who experience respiratory distress or palpitations Radiologic evaluation of catheter location should rapidly ensue, with subsequent surgical consultation if the catheter tip has migrated Infection The presence of an indwelling venous catheter places a patient at higher risk for infection, which can occur at the catheter exit site, the tunnel through which the line is placed, the catheter itself, or in the patient’s bloodstream Tunneled catheters carry a higher overall risk of infection than fully implanted devices The presence of erythema, tenderness, or purulent drainage at any skin site related to an indwelling catheter suggests a catheter infection Less commonly, infection can also occur at the subcutaneous pocket of a patient’s fully implantable catheter The entire dressing must be removed for to inspect the site Fever is common in patients with catheter-related bacteremia or sepsis but may be absent in early, localized infection Immunocompromised patients can exhibit rapid deterioration, and more commonly acquire fungal, gram-negative, and polymicrobial infections Patients receiving parenteral alimentation are also at higher risk for gramnegative infections Still, the most common pathogens in patients with indwelling catheters are gram-positive organisms such as S epidermidis, S aureus , and Streptococcus viridans The signs of infection may be more subtle or absent in neutropenic patients Catheter-related bacteremia can also occur without apparent skin manifestations It is sometimes difficult to tell if the catheter itself is infected or simply seeded the bloodstream, and many consider both to have occurred in the presence of a positive culture result Blood cultures should be obtained from the catheter and, in most cases, from a peripheral vein as well At least to mL of blood should be used for this purpose More than 90% of positive blood cultures will yield results within 36 hours Fungal cultures are appropriate in immunocompromised patients or those who have had prior invasive fungal infections Cultures of any purulent fluid are helpful A complete blood cell count with differential count is warranted, although a normal result should not dissuade the clinician from suspecting an invasive bacterial infection Other blood tests, such as lactate and coagulation studies, should be considered if the patient is ill appearing Initial treatment consists of IV antibiotic therapy and supportive measures Bacterial catheter infections can be eradicated without catheter removal, although infections with S aureus and fungi usually necessitate catheter removal Persistent infection, infection of the subcutaneous tunnel, critical illness, endocarditis, and thrombophlebitis are also indications for removal Initial antibiotic therapy should include agents active against both gram-positive and gram-negative infections Time to antibiotic administration, in particular for febrile, neutropenic patients, can be demonstrably reduced when quality improvement initiatives provide ongoing feedback and education to hospital staff Clinical pathways, such as those publically available through Children’s Hospital of Philadelphia (https://www.chop.edu/pathways-library ), can also guide therapy In patients without oncologic disease, many centers use cefepime as empiric coverage; the disease process and overall appearance of the child can often dictate the addition of expanded coverage such as vancomycin If there is a suspected intra-abdominal source, piperacillin/tazobactam can be substituted for cefepime to treat for enteric organisms Local antibiotic resistance patterns should determine the antibiotic choice Persistent colonization of CVCs may respond to installation of antibiotic or ethanol into the lumen for 12 to 24 hours (antibiotic lock or ethanol lock) Other Complications Other complications related to indwelling catheters can occur, albeit rarely Direct injury to the exit site can be a result of either erosion of tissue by the Dacron cuff of an externalized catheter or breakdown of the skin site from vigorous cleansing This condition can lead to a localized infection On physical examination, excoriation, erythema, tenderness, or purulent drainage is present at the exit site of the catheter Select patients with a localized site infection who are afebrile and well appearing, have a normal leukocyte count, and have close follow-up may be managed as outpatients with oral antibiotic therapy As previously mentioned, phenytoin and diazepam can interact with the silicone lining of the catheters and the administration of these medications through Silastic catheters should be avoided if possible In addition, a large volume of saline flush should be administered between medications that are incompatible with each other, such as calcium and bicarbonate ENTERAL FEEDING TUBES Background A stoma, derived from the Latin word for “mouth,” is an opening from the GI or urinary tract to the outside of the body A gastrostomy is a surgically, endoscopically, or radiologically created stoma that provides access to the stomach from the level of the skin A jejunostomy is a surgically created stoma that brings the jejunum to the skin surface Gastrostomy is performed most typically in children who are unable to take adequate oral nourishment for a prolonged period The inability to tolerate sufficient oral feedings can be related to numerous conditions, including esophageal atresia, chronic malabsorptive syndromes, significant craniofacial abnormalities, tracheostomy, neurologic impairment, severe gastroesophageal reflux, esophageal burns, chronic systemic diseases, and, rarely, anorexia nervosa Jejunostomy feedings are used when postpyloric feeding is required and carried out in such patients as those with delayed gastric emptying, recurrent aspiration pneumonia, or severe