Bone Marrow Transplantation, (1997) 20, 53–56  1997 Stockton Press All rights reserved 0268–3369/97 $12.00

Non-tunneled catheters for the collection and transplantation of peripheral stem cells in children

L Madero, MA Dı´az, A Benito, M Villa and A Valdivielso

Department of Pediatric and Oncology, Hospital Infantil Nin˜o Jesu´s, Autonomous University of Madrid, Madrid, Spain

Summary: patients, vascular access problems and low volume of blood are important factors.7 We analyzed the use of non-tunneled (polyurethane, The collection of PBSC requires venous access which double lumen) central venous catheters (CVCs) for the ensures withdrawal and reinfusion of blood at high flow collection, conditioning, transplantation and immediate rates and allows repeated leukapheresis. The majority of post-transplantation periods in 56 children with various child candidates for PBSCT do not have adequate periph- malignant diseases. A total of 71 leukaphereses were eral veins for collection. A central venous catheter is there- performed, with a mean of 1.2 per patient, fore required at least for withdrawal of blood.8 following administration of colony- Here, we analyze our experience of collection procedures stimulating factor (G-CSF) using a continuous flow performed with non-tunneled catheters in pediatric patients. blood cell separator (Cobe Spectra). The mean TBV These catheters were used for collection, during condition- -total blood volume) processed was 4.5 ؎ 1.2 s.d. (range ing, transplantation and in the immediate post-transplan) 2.4–7). The mean flow rate was 30.6 ml/min and the tation period. duration of a single apheresis was 327 ؎ 84 s.d. (range 175–511 min). The mean purities and efficacies of collec- tions were 77.38 ؎ s.d. (range 42–100) and 42.78 ؎ s.d. Patients and methods (range 24–80), respectively. The mean numbers of mononuclear cells (MNC) and CD34+ cells collected Patients were 9.3 ؎ 6.9 s.d. × 108/kg (range 2–49) and 6.2 ؎ 7.2 We reviewed 56 pediatric patients (36 males and 20 s.d. × 106/kg (range 1–42), respectively. We observed the females) with various malignancies undergoing 71 leuka- following complications during catheter insertion for pheresis sessions, from November 1993 until May 1996. collection: pneumothorax (1.7%), mechanical dysfunc- The mean age was 7.8 Ϯ 4.4 s.d. years (range 1–16) and tion (3.5%) that resolved with thrombolytic therapy. the mean body weight 30.7 Ϯ 15.7 s.d. kg (range 9–62). Complications during conditioning, transplantation and Patients had the following diagnoses: nine acute lymphobl- immediate post-transplantation periods were entry site astic (ALL), five acute non-lymphoblastic leuke- infection in five patients (8.92%), catheter-related infec- mia (ANLL), six non-Hodgkin’s lymphoma (NHL), three tion in two (3.57%) and catheter-related sepsis in three Hodgkin’s disease (HD), 10 rhabdomyosarcoma, seven (5.35%). Our results indicate that the collection of neuroblastoma, five Ewing’s sarcoma, one Wilm’s tumor PBSC with non-tunneled catheters is safe, effective and and 10 central nervous system tumors. Parents and patients is associated with a low incidence of complications. Keywords: non-tunneled catheter; PBSC transplantation; were provided with information concerning the procedure. Patient characteristics are summarized in Table 1. PBSC collection; children

Table 1 Patients characteristics

The use of blood stem cells (PBSC) for rescue after high- Sex M/F 36/20 dose myeloablative therapy in children with malignant dis- Age mean, years (range) 7.8 ± 4.4 s.d. (1–16) ease has been shown to be effective and safe in childen.1,2 Diagnosis (%) Today the indications are largely clear, but there are contro- ALL 9 (16.07) versies about collection and mobilization in children.3,4 ANLL 5 (8.92) non-Hodgkin’s lymphoma 6 (10.71) Moreover, although the PBSCT procedure is now routinely Hodgkin’s disease 3 (5.35) used in adults, PBSC collection in children is limited Ewing’s sarcoma 5 (8.92) because of technical problems.5,6 The low weight of the Neuroblastoma 7 (12.5) Rhabdomyosarcoma 10 (17.85) CNS tumor 10 (17.85) Wilm’s tumor 1 (1.78) Correspondence: Dr L Madero, Department of Pediatrics, Bone Marrow Status at transplantation (%) Transplantation Unit, Hospital Infantil Nin˜o Jesu´s, Avda Mene´ndez Remission 46 (82.14) Pelayo, 65, 28009, Madrid, Spain Relapse 10 (17.86) Received 11 November 1996; accepted 6 March 1997 Non-tunneled catheters in PBSC collection L Madero et al 54 Catheters Cryopreservation According to the technique described by Seldinger,9 a cen- The cells were volume-adjusted to a final concentration of tral venous access was canalized; this was the subclavian Ͻ1 × 108 WBC/␮l, frozen following standard methods in a vein in 43 patients (61.4% right, 14% left) and the femoral controlled rate freezer (Cryoson MYC 15, Cryoson, vein in l4 (22.8% right, 1.75% left), 1 to 4 days before Scho¨llkrippen, Germany or Congelador 25 L, Carburos apheresis. A total of 57 CVCs were inserted. Meta´licos, Madrid, Spain) and stored in liquid nitrogen at Patients were sedated with propofol (priming dose of 2 −196°C. mg/kg and then continued perfusion of 1–5 mg/kg/h) and fentanest (doses of 1–2 ␮g/kg) and the procedure was per- formed in the intensive care unit with monitoring. Infection All patients had Ͼ50 × l09/l at the time of cath- When patients developed fever, two urine cultures, one eter insertion and none had abnormal coagulation. The stool culture, one nasopharyngeal smear, two cultures from CVCs used were standard double-lumen, Arrow-Howes central blood (one from each lumen), one peripheral blood (Reading, PA, USA) polyurethane catheters in 41 patients culture, and a chest radiograph (PA and lateral projections) and Cook (Cook, Bjaeverskov, Denmark) polyurethane were taken. catheters in 16. Entry site infection was defined as pain, induration and The catheter was removed immediately after apheresis erythema. Catheter-related infection was defined as the in those patients in whom transplantation could not be car- presence of fever and shivering after an infusion through ried out immediately. Catheter size was 5 FR for patients the CVC without other apparent causes of infection, and a Ͻ5 years, 7 FR for those aged 5–12 years and 9.5 FR for positive central but not peripheral blood culture. Catheter- those Ͼ12 years, and 15, 20 and 25 cm in length, respect- related sepsis was defined as the isolation of the same ively. Correct positioning of the catheter was confirmed by pathogen from the CVC and blood culture taken from a a PA chest film before attaching it to the skin with a 3– peripheral vein. The criteria for catheter removal were: (1) 0 nylon suture. No antibiotic prophylaxis was used after local infection in the form of abscess and/or entry site infec- the procedure. tion; and (2) catheter-related sepsis or infection that did not respond to antibiotic treatment. PBSC mobilization All the patients received subcutaneous granulocyte colony- Mechanical dysfunction stimulating factor (G-CSF), dose 12 ␮g/kg/day for 4–5 days Mechanical dysfunction was defined as inadequate flow (Neupogen; Amgen, Thousand Oaks, CA, USA). rates or failure to withdraw blood. When the foregoing was Leukapheresis was performed on the fifth day. suspected, the following procedure was adopted: lavage with saline solution +1% heparin (300 IU) and if catheter PBSC collection dysfunction persisted after 15 min, infusion of urokinase PBSC collections were performed using a Cobe Spectra (10–15 000 IU). blood cell separator (Cobe Spectra, Denver, CO, USA) as previously reported.10 Statistical analysis

+ A software program (Statview 4.0; Abacus Concept Inc, Efficacy calculation, mononuclear cell CD34 Berkeley, CA, USA) was used for statistical analysis. determinations and in vitro stem cell assay Efficacy of each procedure, expressed as a percentage, was calculated by dividing the number of MNCs collected in Results the final product by the total number of mononuclear cells that were processed. The total cell count was determined Catheters using an automated cell counter, and the differential cell count was performed manually. Mononuclear cells included All patients except one used one catheter for the apheresis. only and . Purity of the final pro- One required immediate replacement after insertion duct refers to the percentage of mononuclear cells accord- because of lumen obstruction. In 17 patients (30.3%) the ing to the differential cell count. catheter was used only for apheresis, and the mean duration Cells were labeled with fluorescence conjugated anti- of insertion was 2 days (range 1–4). In the remaining cases, CD34 (8GI2 CD; Becton Dickinson, Mountain View, CA, the catheter was also used for conditioning, transplantation USA) and analyzed using a FACScan flow cytometer and in the immediate post-transplantation period (39 (Becton Dickinson) to yield an absolute CD34+ result. patients (70.63%)) and the mean duration of insertion was Granulocyte– progenitor cells (colony- 47.9 days (range 5–200). forming unit granulocyte–macrophage, CFU-GM) were analyzed in each apheresis product. Fresh viable peripheral Progenitor cells collection results blood cells (2 × 105) were plated in triplicate using semi- solid medium. Cultures were incubated and colonies were Seventy-one aphereses were perfomed with a mean of 1.2 scored following standard methods. aphereses per patient (range 1–3). One patient received Non-tunneled catheters in PBSC collection L Madero et al 55 three aphereses, and 13 patients received two. In all other Discussion patients one collection was performed. The volume of blood processed in each apheresis ranged The aim of PBSC collection is to obtain an MNC product from 2209 to 19 370 ml (mean 9746 ml Ϯ 4179.5 s.d.). The of high purity. This can be achieved by leukapheresis with mean TBV processed was 4.5 Ϯ 1.2 s.d. (range 2.4–7). The a continuous flow blood cell separator which ensures the mean flow rate was 30.6 ml/min (range 6–61) and the dur- formation of a MNC layer with minimal contamination ation of a single apheresis was 327 Ϯ 84 s.d. (range 175– from other cell lines. Leukapheresis requires adequate 51 l). venous access. The ideal venous access is one which Mean purities and efficacies of collections were 77.38 Ϯ ensures adequate flow, permits performing various apher- s.d. (range 42–100) and 42.78 Ϯ s.d. (range 24–80). The eses and simple and safe insertion with minimal and easily total number of cells collected from each patient was as controlled complications. follows: mean 9.3 Ϯ 6.9 s.d. × 108/kg (range 2–49) for Experience in children using venous access for PBSC MNC cells and 6.2 Ϯ 7.2 s.d. × 106/kg (range 1–42) for collection is limited.11 In our experience, non-tunneled CD34+ cells. catheters inserted percutaneously, utilized during the con- ditioning, transplantation and immediate post-transplan- tation periods,12 can achieve the above-mentioned objec- tives. The most frequently canalized veins have been the Insertion complications subclavian, femoral inferior vena cava and internal jugular 13–15 One patient developed a pneumothorax (1.7%) during in adults. There is little experience in children. 16 insertion but this did not require drainage and resolved Although different access sites such as the radial artery spontaneously within 2 days. There were two other cases have been utilized, like other authors, we believe that the with technique-related complications including ectopic subclavian and femoral veins provide the most simple and 4,6,17 puncture or canalization of contralateral vessels. No safe access. We have chiefly utilized the subclavian hemorrhagic complications were observed. vein in patients in whom the catheter was also used for conditioning, transplantation and the immediate post- transplantation periods since this access allows the catheter to be left in situ for a longer period, with less risk of infec- Complications related to apheresis tion. Femoral vein access was used for leukapheresis exclusively in children who were not undergoing immediate Morbidity related to PBSC harvest was minor. Transient transplantation, since this site carries a higher risk of hypotensive episodes were observed at the beginning of infection. apheresis in two children (3.5%) who did not require treat- The most common complications of non-tunneled inser- ment. Hypocalcemia attributed to citrate occurred in 10 tion are infection, mechanical dysfunction and mechanical patients (17.5%); of these, eight were asymptomatic. There complications. Pneumothorax and hemopneumothorax are were two cases (3.5%) of mechanical dysfunction that complications specific to this technique. The incidence of resolved with thrombolytic therapy and seven cases (12%) these complications in our series was low (1.7%) and lower required extreme positional maneuvers due to low flow than the complication rate reported by other authors.18 rates; none required discontinuation of the apheresis pro- Mechanical dysfunction (which resolved in all cases) inci- cedure. Other minor complications included headache (one dence was 3.5%, which is lower than has been reported patient, 1.7%), low fever (one patient, 1.7%), and nausea elsewhere (10–20%).19 This may be due to the use of poly- and vomiting (three patients, 5.2%). No profound cytopenia urethane catheters, which are more rigid and have a lower post-apheresis was observed and no child required red cell mechanical dysfunction rate than silicone catheters.20 or transfusion. Some authors have used the Quinton–Mahurkar large- bore hemodialysis catheters,13 but experience in children is very limited. The catheter utilized in our series achieved a Complications during transplantation median inlet blood flow of 30.6 ml/min, maintained without variation throughout apheresis, and a high purity (77.3%). We observed a total of 10 infectious complications: entry This is similar to the rate achieved in adults using other site infection (five patients, 8.92%), catheter-related infec- catheters.15 Furthermore, these catheters were utilized for tion (two patients, 3.57%) and catheter-related sepsis (three large volume leukapheresis.7 patients, 5.35%). Four patients required catheter removal The numbers of CD34+ cells and MNC obtained with despite antibiotic therapy. mobilization with G-CSF alone was 6.2 × 106 (range 1–42) Pathogens isolated were Staphylococcus epidermidis and 9.8 × 108 (range 2–24), respectively, similar to those (five patients), Staphylococcus aureus (one patient), achieved by other authors using this mobilization tech- Staphylococcus hominis (one patient) and Staphylococcus nique.3,6,21 haemolyticum (one patient). The advantage of using these catheters is that in 39 Six patients had clinical events suggestive of CVC dys- patients the same catheter was used during conditioning, function (10.5%) which resolved with lavage with saline transplantation and the immediate post-transplantation per- solution plus heparin in three cases, and with urokinase iods, and the discomfort caused by insertion of another infusion in one case. The remaining two cases required catheter avoided. With the single non-tunneled catheter, we catheter removal. had an entry site infection rate of 8.9%, catheter-related Non-tunneled catheters in PBSC collection L Madero et al 56 infection rate of 3.57% and catheter-related sepsis rate of autologous peripheral blood progenitor cell transplantation: + 5.35%, which are similar to those reported by other authors influence of CD34 cell dose in engraftment kinetics. Bone for non-tunneled catheters18 and lower than those seen with Marrow Transplant 1996; 18: 699–703. subcutaneously tunneled catheters.22 11 Landolfo A, Angioni A, Deb G. Harvesting of peripheral stem Our results indicate that percutaneously inserted standard cells by hemapheresis in children with solid tumors. Med Ped Oncol 1990; 18: 392 (Abstr.). catheters are useful and safe for PBSC harvesting in chil- 12 Madero L, Ruano D, Villa M et al. Non-tunneled catheter in dren and that they can be utilized during conditioning, children undergoing bone marrow transplantation. Bone Mar- transplantation and immediate post-transplantation periods row Transplant 1996; 17: 82–89. as previously reported.12 13 Hahn U, Goldschmidt H, Salwender H et al. Large-bore cen- tral venous catheters for the collection of peripheral blood stem cells. J Clin Apheresis 1995; 10: 12–16. References 14 Haire WD, Lieberman RP, Lund GB et al. Translumbar inferior vena cava catheters. 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