There is now evidence to show beneficial effect of heparin for preventing complications when used with central catheters to give access to the tiny veins of premature and critically ill babies
Critically ill or premature babies (born before 37 weeks of pregnancy) often need medication and feeding through their veins. These veins are small and fragile so repeated injections can be hard and painful for the baby. A central catheter is a small tube that can be inserted into the vein, allowing medications and other liquids to be given to the baby for a prolonged period. It can get dislodged, blocked or infected. The drug heparin allows to complete intended therapy in more patients without increasing complications of bleeding or allergic reactions. The review found that there was now evidence to show benefit of heparin. If it is used routinely, careful monitoring of side effects is warranted.
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Complications associated with peripherally placed percutaneous central venous catheters (PCVC) in neonates include catheter thrombosis, occlusion or dislodgement and infection. Strategies to prevent catheter thrombosis and occlusion include the use of heparin. However, heparin is known to be associated with complications such as bleeding and thrombocytopenia.
Objectifs
To assess the effectiveness of heparin for prevention of catheter related thrombosis.
Secondary objectives included assessment of the effectiveness of heparin on catheter occlusion, duration of catheter patency, catheter related sepsis and complications associated with the use of heparin.
Stratégie de recherche documentaire
A literature search of MEDLINE, EMBASE, CINAHL from their inception to September 13, 2010, The Cochrane Library (Issue 2, 2010) and abstracts from the annual meetings of the Pediatric Academic Societies was performed.
Critères de sélection
Randomized or quasi-randomised clinical trials of neonates where heparin infusion was compared to placebo or no treatment for prevention of any of the complications related to peripherally placed PCVC were included.
Recueil et analyse des données
We collected and analysed the data in accordance with the recommendations of the Cochrane Neonatal Review Group.
Résultats principaux
Four randomised trials were identified. Three trials (including 477 infants) of adequate methodology met the eligibility criteria. There was reduced risk of catheter occlusion (typical RR 0.39, 95% CI 0.22 to 0.67; and NNT 9, 95% CI 6 to 20). There was no statistically significant difference in the duration of catheter patency; however, in one study survival analyses identified benefit with heparin (adjusted hazard ratio 0.55, 95% CI 0.36, 0.83). This could be due to higher incidence of elective removal of catheters in neonates at the completion of therapy in the heparin group in that study (63% vs. 42%; p = 0.002). There was no statistically significant differences in the risk of thrombosis (typical RR 0.93, 95% CI 0.58 to 1.51), catheter related sepsis (typical RR 0.82, 95% CI 0.43 to 1.57), or extension of intraventricular haemorrhage (typical RR 0.50, 95% CI 0.19 to 1.28) between the two groups.
Conclusions des auteurs
Prophylactic use of heparin for peripherally placed PCVC allows a greater number of infants to complete their intended use (complete therapy) by reducing occlusion. Evidence from this systematic review support the prophylactic use of heparin for PCVC in neonates. None of these studies was powered to evaluate a lower incidence rate of adverse events. If this therapy is adopted in routine practice, monitoring of side effects is indicated.
