Risk factors for unscheduled removal of vascular access while undergoing pediatric continuous blood purification: A retrospective single-center cohort study (2014-2023)

Risk factors for unscheduled removal of vascular access while undergoing pediatric continuous blood purification: A retrospective single-center cohort study (2014-2023) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Risk factors for unscheduled removal of vascular access while undergoing pediatric continuous blood purification: A retrospective single-center cohort study (2014-2023) Yozo Azuma, kentaro ide, Yusuke Tokuda, Junichiro Morota, Eisaku Nashiki, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7796715/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background During continuous blood purification (CBP), unscheduled vascular access (VA) removal occurs and interrupts treatment. This study aimed to characterize the incidence of unscheduled VA removal in pediatric CBP and identify associated risk factors. Methods We conducted a retrospective observational study of patients under 16 years of age who underwent CBP at a tertiary pediatric center between July 2014 and June 2023. Patients receiving extracorporeal membrane oxygenation or those with tunneled catheters were excluded. VAs were classified as either “planned removal” or “unscheduled removal”, with unscheduled removals further categorized by reason into “infection control”, “catheter dysfunction”, or “accidental dislodgement”. Factors associated with unscheduled removal were identified using logistic regression analysis. Results Among 222 eligible patients, 28 (13%) experienced unscheduled removal with a median catheter duration of 10 days (interquartile range, 5–14), corresponding to an incidence rate of 15.2 events per 1,000 catheter-days. Compared with those with planned removal, patients with unscheduled removal were significantly younger and were more likely to have femoral VA. In multivariable analysis, longer catheter duration (day) (OR 1.07, 95% CI 1.01–1.14) and femoral VA (OR 5.62, 95% CI 1.43–22.1) were independently associated with unscheduled removal. When stratified by reason for removal, unscheduled removals for infection control were associated with younger age and longer catheter duration, whereas those due to catheter dysfunction were associated with femoral VA. Conclusions Unscheduled removal occurred in 13% of pediatric CBP cases, with longer catheter duration and femoral VA identified as independent risk factors. Pediatric intensive care Continuous blood purification Continuous kidney replacement therapy Vascular access Dialysis catheter Unscheduled removal Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Continuous blood purification (CBP) is increasingly utilized for critically ill pediatric patients with acute kidney injury or multi-organ failure. The effectiveness of CBP depends largely on maintaining extracorporeal circuit patency for the prescribed duration [1]. Therefore, well-functioning vascular access (VA) is essential for the provision of adequate CBP [2]. However, VAs are associated with potential complications, such as catheter-related bloodstream infections (CRBSI), catheter dysfunction, and accidental dislodgement, all of which may necessitate unscheduled VA removal (hereafter referred to as unscheduled removal) [2–5]. Unscheduled removal can interrupt treatment, increase the risk of infection, and necessitate VA replacement or reinsertion, thereby posing additional risks to vulnerable pediatric populations. The incidence of unscheduled removal has not been well-characterized. Rus et al. [4] examined 28 pediatric patients requiring CBP and reported that 60% experienced unscheduled removal. In contrast, Ren et al. [6] examined 280 adult patients requiring CBP and reported that 11.4% underwent re-catheterization. Several studies have identified potential risk factors for unscheduled removal in both pediatric and adult populations, including femoral vein VA placement [2, 4, 7], smaller VA size [2, 3], left internal jugular vein placement [7], and prolonged catheter duration [6]. However, findings across studies have been inconsistent. Identifying modifiable factors associated with unscheduled removal is therefore essential to optimize VA longevity and the management of pediatric CBP. This study aimed to characterize unscheduled removal in pediatric CBP cases and to evaluate associated factors for unscheduled removal in a single-center cohort of pediatric patients undergoing CBP in Japan. Methods Study design and subjects This retrospective observational study was carried out at a single tertiary pediatric institution, the National Center for Child Health and Development (NCCHD) in Tokyo, Japan. We retrospectively analyzed medical records of patients under 16 years of age who received CBP therapies—including continuous hemodialysis, hemofiltration, or hemodiafiltration—between July 2014 and June 2023. Patients undergoing concurrent extracorporeal membrane oxygenation (ECMO) or those with tunneled dialysis catheters were excluded from the analysis. Only the first VA inserted for each patient was included in the analysis. The study adhered to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines for reporting observational cohort studies. Study settings The NCCHD is a tertiary pediatric center in Japan, with 20 PICU beds, and manages the highest number of pediatric CBP cases in the country, with an annual volume of approximately 40 to 50 cases [8]. In the PICU, CBP therapies are managed by pediatric intensivists in close collaboration with clinical engineers. The institutional CBP manual provides recommendations for dialysis catheter size based on patient body weight and designates the right internal jugular vein as the preferred insertion site. However, both the catheter size and insertion site were ultimately determined at the discretion of the pediatric intensivists. The diagnosis of CRBSI was conducted collaboratively by pediatric intensivists and pediatric infectious disease specialists. The necessity of VA removal was discussed within the care team, with the final decision made by the pediatric intensivists. Data collection and outcome Data collection and outcome Patient demographics and CBP-related variables were retrospectively extracted from medical records. Baseline information—including age, body weight, and the clinical indication for initiating CBP—was systematically recorded. Survey items referred to the prospective multicenter CBP registry of PICUs in Japan [9]. Procedural details, including VA site, VA size, catheter duration (days), and reason for VA removal, were also recorded. VAs were classified as either planned removal or unscheduled removal, with unscheduled removal defined as the primary outcome of the study. These unscheduled removals were further categorized by reason into infection control, catheter dysfunction, or accidental dislodgement. All data were collected by Yusuke Tokuda, Junichiro Morota, Eisaku Nashiki, Kentaro Nishi, and Mai Miyaji. Kentaro Ide reviewed the data for accuracy, and any discrepancies were discussed collaboratively with all data collectors and corrected accordingly. Statistical analysis Statistical analyses were carried out using R (version 4.5.0). Continuous variables were described using medians and interquartile ranges (IQRs), and group comparisons were performed with the Mann-Whitney U test. Categorical variables were summarized as frequencies and percentages, and differences between groups were assessed using Fisher’s exact test (two-tailed). To explore factors associated with unscheduled removal, both univariate and multivariable logistic regression analyses were conducted. Associations were reported as odds ratios (ORs) with corresponding 95% confidence intervals (CIs). In the multivariable logistic regression model, variables identified as potential risk factors based on clinical experience and prior literature, specifically longer catheter duration and femoral VA, were included, along with variables that had a P value < 0.1 in the univariate analysis, to identify independent predictors of unscheduled removal. To construct the final multivariable model, a backward stepwise selection procedure was employed, in which variables with P values ≥ 0.05 were progressively eliminated. The daily risk of unscheduled removal was calculated in 5-day intervals by dividing the number of unscheduled removals that occurred during each interval by the total number of VA during the same period. All statistical analyses were performed using two-tailed tests, with a significance threshold set at P < 0.05. Because of the study’s exploratory design, no formal calculation of sample size was carried out. The analysis was conducted on all patients who met the predefined eligibility criteria. Ethics The study protocol was reviewed and approved by the Ethics Committee of the NCCHD (approval number: 2023 − 103; date of approval: 19 September 2023; study title: Investigation of Continuous Renal Replacement Therapy in the Pediatric Intensive Care Setting), in accordance with the amended Declaration of Helsinki. Given that this was a retrospective study using pre-existing clinical data with minimal risk to participants, informed consent was obtained through an opt-out process in line with national ethical guidelines for medical research involving human subjects. Results A total of 222 patients were analyzed after excluding patients who received ECMO support and or those with tunneled catheters (Fig. 1 ). Among them, 28 patients (13%) experienced unscheduled removal with a median catheter duration of 10 days [interquartile range (IQR), 5–14], corresponding to an incidence rate of 15.2 events per 1,000 catheter-days (Fig. 2 ). Baseline patient demographics and VA characteristics were compared between the two groups (Table 1 ). Patients with unscheduled removal were significantly younger and had lower body weight compared to those with planned removal (median age in months: 3.5 [IQR 1.0-16.5] vs. 12.0 [IQR 3.0-61.8], P = 0.027; median body weight (kg): 4.5 [IQR 3.2–8.5] vs. 8.2 [IQR 5.3–15.6], P = 0.018). Moreover, they were more likely to have femoral VA (14% vs. 3%, P = 0.026). The catheter duration tended to be longer in those with unscheduled removal (median days: 10 [IQR 5–14] vs. 7 [IQR 6–9], P < 0.11). Regarding catheter size, there was a tendency toward the use of smaller VAs in those with unscheduled removal, with 6 Fr catheters used in 57% of cases compared to 28% in those with planned removal. Table 1 Patient characteristics and vascular access details Planned removal (N = 194) Unscheduled removal (N = 28) p -value Age in month 12.0 [3.0, 61.8] 3.5 [1.0, 16.5] 0.027 Weight (kg) 8.2 [5.3, 15.6] 4.5 [3.2, 8.5) 0.018 Indication Liver failure 85 (44%) 16 (57%) 0.56 Kidney failure 63 (33%) 9 (32%) Metabolic disorder 37 (19%) 3 (101%) Others 9 (5%) 0 VA site Right jugular 162 (84%) 21 (75%) 0.026 Left jugular 25 (13%) 2 ( 7%) Femoral 6 ( 3%) 4 (14%) Others 1 ( 1%) 1 ( 4%) VA size (Fr) 6 54 (28%) 16 (57%) 0.062 6.5-7 59 (30%) 5 (18%) 8 42 (22%) 4 (14%) 9.5–10 10 ( 5%) 0 ≥11 29 (15%) 3 (11%) VA days 7 (6, 9) 10 (5, 14) 0.11 Values are expressed as the number (%) or median [interquartile range]. VA, vascular access; Univariate and multivariable logistic regression analyses were conducted to investigate the associations between unscheduled removal and the following variables: catheter duration, age in months, femoral VA, and VA size (Fr) (Table 2 ). In the multivariable analysis, catheter duration (day) (OR 1.07, 95% CI 1.01–1.14) and femoral VA (OR 5.62, 95% CI 1.43–22.1) were independently associated with unscheduled removal. The temporal trend in the daily risk of unscheduled removal, calculated as the number of unscheduled removals divided by the number of VAs at risk, is shown in Fig. 3 . The daily risk remained low during the first 10 days (less than 1.5%), but gradually increased thereafter, peaking at 9.7% in the interval 21–25 days. Figure 4 compares the incidence rate of unscheduled removal by VA site. The rate was highest in femoral VAs (up to 42%), whereas it remained at approximately 10% in right and left internal jugular sites. Table 2 Factors associated with unscheduled vascular access removal Univariate analysis Multivariable analysis OR 95% CI P-value OR 95% CI p -value VA days 1.03 1.01–1.04 0.0019 1.07 1.01–1.14 0.030 Age (month) 0.99 0.98-1.00 0.013 VA at Femoral 5.22 1.37–19.8 0.015 5.62 1.43–22.1 0.014 VA size (Fr) 0.79 0.60–1.05 0.11 VA, vascular access; OR, odds ratio; CI, confidence interval We further examined the characteristics of unscheduled removals by reason. The reason for unscheduled removal included infection control (18 cases), catheter dysfunction (8 cases), and accidental dislodgement (2 cases). Patients who underwent unscheduled removal for infection control were significantly younger and had longer catheter duration compared to those with planned removal (Table 3 ). Of note, catheter-related bloodstream infection was diagnosed in 39% (7 out of 18) of the unscheduled removals for infection control. Among patients with unscheduled removals for catheter dysfunction, neither age nor catheter duration differed significantly compared to those with planned removal. However, the proportion of femoral VA was significantly higher in patients with unscheduled removals for catheter dysfunction (Table 4 ). Table 3 Comparison between planned removal and unscheduled removal for infection control Planned removal (N = 194) Unscheduled removal for infection control (N = 18) p -value Age in month 12.0 [3.0, 61.8] 1.5 [0.3, 15.5] 0.026 VA site Right jugular 162 (84%) 15 (83%) 0.65 Left jugular 25 (13%) 2 (11%) Femoral 6 (3%) 1 (6%) Others 1 (1%) 0 VA size (Fr) 6 54 (28%) 11 (61%) 0.062 6.5-7 59 (30%) 3 (17%) 8 42 (22%) 2 (11%) 9.5–10 10 ( 5%) 0 ≥11 29 (15%) 2 (11%) VA days 7 (6, 9) 11 (6, 14) 0.044 Values are expressed as the number (%) or median [interquartile range]. VA, vascular access Table 4 Comparison between planned removal and unscheduled removal due to catheter dysfunction Planned removal (N = 194) Unscheduled removal due to catheter dysfunction (N = 8) p -value Age in month 12.0 [3.0, 61.8] 11.5 [5.5, 16.5] 0.82 VA site Right jugular 162 (84%) 4 (50%) 0.001 Left jugular 25 (13%) 0 Femoral 6 (3%) 3 (38%) Others 1 (1%) 1 (12%) VA size (Fr) 6 54 (28%) 3 (38%) 0.97 6.5-7 59 (30%) 2 (25%) 8 42 (22%) 2 (25%) 9.5–10 10 (5%) 0 ≥11 29 (15%) 1 (12%) VA days 7 [6, 9] 6.5 [4.8, 10.5] 0.77 Values are expressed as the number (%) or median [interquartile range]. VA, vascular access Discussion This single-center cohort study revealed that unscheduled removal occurred in 13% (28/222) of children requiring CBP in the PICU, with an incidence rate of 15.2 events per 1,000 catheter-days. Multivariable analysis identified longer catheter duration and femoral vein insertion as independent risk factors for unscheduled removal in pediatric CBP. Prolonged catheter duration was identified as one of the risk factors for unscheduled removal in this study, consistent with the findings of the previous report [6]. Furthermore, in the subgroup analysis by reason for removal, catheter duration was significantly longer in removals for infection control compared to planned removals. This suggests that the incidence of infection may increase with prolonged catheter duration. Santiago et al. examined 55 children who underwent CBP and reported that infections occurred in 78% (43 out of 55) of the patients, with a median onset of 11 days after CBP initiation. Moreover, they identified a CBP duration longer than 4.5 days as the sole risk factor for infection. In this study, the incidence of unscheduled catheter removal remained low during the first 10 days (less than 1.5%), but gradually increased thereafter, peaking at 9.7% in the interval 21–25 days (Fig. 3 ). Therefore, in cases where prolonged CBP management is anticipated, it may be necessary to enhance monitoring for signs of infection after approximately two weeks of catheter placement and to consider switching to a tunneled catheter, which carries a lower risk of infection [10]. Another important finding was that only 39% (7/18) of the catheters removed for infection control were confirmed to be true CRBSI. Similarly, a study of adult VA reported that only 14% (4 out of 29) of catheters removed for infection control were CRBSI [11]. These findings highlight the need to improve diagnostic accuracy for VA-related CRBSI. Femoral vein VA placement was associated with unscheduled removal. This finding is consistent with previous reports in both pediatric [2, 4] and adult populations [7], which identified femoral vein placement as a risk factor for catheter dysfunction-related removal. However, Parienti et al. [12] conducted a randomized controlled trial involving 736 adult patients and reported no significant difference in catheter dysfunction between internal jugular and femoral vein placements, indicating that previous findings are not entirely consistent. Furthermore, as reported in an adult VA study showing no difference in infection rates between femoral and internal jugular vein placements [11], our study similarly found no increased proportion of femoral VA among unscheduled removals for infection control. Even though there may be no compelling reason to avoid femoral access from an infection control perspective, its association with catheter dysfunction cannot be ruled out. Although femoral VA is sometimes preferred due to its lower complication rates [4, 11], it has also been associated with a shorter circuit lifespan in pediatric CBP [2, 13]. Differences between adult and pediatric patients—such as the use of smaller VA sizes and limited ability to comply with movement restrictions—should also be taken into account. Larger-scale studies may be necessary to further investigate femoral VA and unscheduled removal in the pediatric population. This study has several limitations. First, this was a single-center, retrospective analysis conducted in a Japanese tertiary pediatric center, which may limit the generalizability of our findings. Second, the criteria for VA removal were not defined in a written protocol, and decisions were made through team discussions. However, the final decision rested with the pediatric intensivist, and variability in clinical judgment cannot be ruled out. Third, given the relatively small number of femoral vein VAs in this study, further validation is needed to assess the reproducibility of these findings. Conclusions In this single-center cohort of pediatric patients receiving CBP, unscheduled catheter removal occurred in 13% of cases, with prolonged catheter duration and femoral vein access identified as independent risk factors. These findings highlight the importance of timely risk assessment—particularly beyond two weeks of catheter use—and suggest the potential utility of alternative strategies, such as early conversion to tunneled catheters in selected patients. Further studies are warranted to investigate femoral VA and unscheduled removal in pediatric CBP. Declarations Acknowledgements: The authors thank Dr. Taiki Haga (Osaka City General Hospital) for his valuable contributions to this study’s conception, design, and data interpretation. Ethics approval and consent to participate This study was conducted in accordance with the amended Declaration of Helsinki and was approved by the Ethics Committee of the NCCHD (approval number 2023-103, date: 19 September 2023, title: Investigation of Continuous Renal Replacement Therapy in the Pediatric Intensive Care Setting). This study used existing data and posed minimal risk to patients; therefore, opt-out consent was obtained in accordance with national ethical guidelines for medical research involving human subjects and the principles of the Declaration of Helsinki. Competing interests The authors declare that they have no competing interests. Funding This work was supported by the National Center for Child Health and Development (grant number 2024B-4). Data availability The data used to support the findings of this study are available from the corresponding author, KI, upon reasonable request. Authors’ contributions KI, MT, MS, and SM conceived and designed the study. KI, YT, JM, EN, KN, and MM collected the data. YZ and KI performed the data analysis and interpretation. YZ and KI drafted the manuscript. All authors critically revised the manuscript and approved the final version. References Cortina G, McRae R, Chiletti R, Butt W (2020) The Effect of Patient- and Treatment-Related Factors on Circuit Lifespan During Continuous Renal Replacement Therapy in Critically Ill Children. Pediatr Crit Care Med 21:578-585. Hackbarth R, Bunchman TE, Chua AN, Somers MJ, Baum M, Symons JM, Brophy PD, Blowey D, Fortenberry JD, Chand D, Flores FX, Alexander SR, Mahan JD, McBryde KD, Benfield MR, Goldstein SL (2007) The effect of vascular access location and size on circuit survival in pediatric continuous renal replacement therapy: a report from the PPCRRT registry. Int J Artif Organs 30:1116-1121. Goldstein SL, Macierowski CT, Jabs K (1997) Hemodialysis catheter survival and complications in children and adolescents. Pediatr Nephrol 11:74-77. 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Westrope C, Morris KP, Kee CY, Farley M, Fleming S, Morrison G (2016) Experience of Circuit Survival in Extracorporeal Continuous Renal Replacement Therapy Using Small-Calibre Venous Cannulae. Pediatr Crit Care Med 17:e260-265. Supplementary Files GraphicalAbstract20251005.pptx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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14:33:10","extension":"png","order_by":18,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":55960,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure120250527.png","url":"https://assets-eu.researchsquare.com/files/rs-7796715/v1/48730ede83d4dbb67e62904c.png"},{"id":94204708,"identity":"1e7ee12f-de1c-4079-ad11-400a1b27c734","added_by":"auto","created_at":"2025-10-23 14:25:10","extension":"png","order_by":19,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":52172,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure220250530.png","url":"https://assets-eu.researchsquare.com/files/rs-7796715/v1/15d34d7da1de84b6bd78faf5.png"},{"id":94204711,"identity":"072c46bd-5c46-40fc-a2fe-bd4c17f1cece","added_by":"auto","created_at":"2025-10-23 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14:25:10","extension":"xml","order_by":22,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":57824,"visible":true,"origin":"","legend":"","description":"","filename":"PNEPD25009360structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7796715/v1/fc947f1725f79f0df5ae42fd.xml"},{"id":94205233,"identity":"b69a61ce-476d-4bfa-b2ca-683f7a4e1b07","added_by":"auto","created_at":"2025-10-23 14:33:11","extension":"html","order_by":23,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":63561,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7796715/v1/abdeea241ea359e5cd7ad549.html"},{"id":94204693,"identity":"c62a506b-2c32-4511-b7cf-548c6a461adb","added_by":"auto","created_at":"2025-10-23 14:25:10","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":123983,"visible":true,"origin":"","legend":"\u003cp\u003eTitle: Patient flow diagram\u003c/p\u003e\n\u003cp\u003eLegend: Patient flow diagram showing the selection of patients included in the study.\u003c/p\u003e","description":"","filename":"Figure120250527.png","url":"https://assets-eu.researchsquare.com/files/rs-7796715/v1/60613515af81341334881c67.png"},{"id":94204694,"identity":"0f5855a1-20a3-4d81-a197-97016e09c651","added_by":"auto","created_at":"2025-10-23 14:25:10","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":126597,"visible":true,"origin":"","legend":"\u003cp\u003eTitle: Kaplan-Meier curves of catheter survival\u003c/p\u003e\n\u003cp\u003eLegend: Kaplan-Meier curve showing the probability of catheter survival from the time of insertion among 222 pediatric patients receiving continuous blood purification. Censoring occurred at the time of planned catheter removal. The number at risk is indicated below the x-axis at selected time points (0, 10, 20, 30, 40, and 50 days after insertion).\u003c/p\u003e","description":"","filename":"Figure220250530.png","url":"https://assets-eu.researchsquare.com/files/rs-7796715/v1/8a086825aa08643718fdd88b.png"},{"id":94204695,"identity":"5e99512b-ab9d-453e-9127-6814a073172f","added_by":"auto","created_at":"2025-10-23 14:25:10","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":239347,"visible":true,"origin":"","legend":"\u003cp\u003eTitle: Temporal trend in daily risk of unscheduled catheter removal during CBP\u003c/p\u003e\n\u003cp\u003eLegend: Bar and line plot illustrating the average number of catheters at risk per day (gray bars, left y-axis) and the daily risk of unscheduled catheter removal (black line, right y-axis) across 5-day intervals following catheter insertion. The daily risk was calculated as the number of unscheduled removals divided by the total number of catheter-days within each interval.\u003c/p\u003e","description":"","filename":"Figure320250705.png","url":"https://assets-eu.researchsquare.com/files/rs-7796715/v1/d91ab876af0f88a5daad4c35.png"},{"id":94204696,"identity":"a0e97859-29c3-4493-8c72-cc4c545c4ba9","added_by":"auto","created_at":"2025-10-23 14:25:10","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":299641,"visible":true,"origin":"","legend":"\u003cp\u003eTitle: Incidence of unscheduled catheter removal by insertion site\u003c/p\u003e\n\u003cp\u003eLegend: Bar plot represents the total number of VAs inserted at each site, with the gray portion indicating the number of unscheduled removals (left y-axis). The access sites include right internal jugular (Right IJ), left internal jugular (Left IJ), and femoral vein.\u003c/p\u003e\n\u003cp\u003eThe black line represents the incidence of unscheduled removal for each site (right y-axis), calculated as the number of unscheduled removals divided by the total number of catheters inserted at that site.\u003c/p\u003e","description":"","filename":"Figure420250717.png","url":"https://assets-eu.researchsquare.com/files/rs-7796715/v1/c98299d351bb5f2fd5082524.png"},{"id":100547554,"identity":"efa74952-027c-4ac8-a5a5-823069743475","added_by":"auto","created_at":"2026-01-19 08:16:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1335989,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7796715/v1/2a141bad-2853-4fc4-9ec1-59ad2764bb30.pdf"},{"id":94204698,"identity":"083ccc8c-1b2c-4333-b0e3-df79284c43a8","added_by":"auto","created_at":"2025-10-23 14:25:10","extension":"pptx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":181540,"visible":true,"origin":"","legend":"","description":"","filename":"GraphicalAbstract20251005.pptx","url":"https://assets-eu.researchsquare.com/files/rs-7796715/v1/2eb439a8358ac8515b1b45a1.pptx"}],"financialInterests":"","formattedTitle":"Risk factors for unscheduled removal of vascular access while undergoing pediatric continuous blood purification: A retrospective single-center cohort study (2014-2023)","fulltext":[{"header":"Background","content":"\u003cp\u003eContinuous blood purification (CBP) is increasingly utilized for critically ill pediatric patients with acute kidney injury or multi-organ failure. The effectiveness of CBP depends largely on maintaining extracorporeal circuit patency for the prescribed duration [1]. Therefore, well-functioning vascular access (VA) is essential for the provision of adequate CBP [2]. However, VAs are associated with potential complications, such as catheter-related bloodstream infections (CRBSI), catheter dysfunction, and accidental dislodgement, all of which may necessitate unscheduled VA removal (hereafter referred to as unscheduled removal) [2\u0026ndash;5]. Unscheduled removal can interrupt treatment, increase the risk of infection, and necessitate VA replacement or reinsertion, thereby posing additional risks to vulnerable pediatric populations.\u003c/p\u003e\u003cp\u003eThe incidence of unscheduled removal has not been well-characterized. Rus et al. [4] examined 28 pediatric patients requiring CBP and reported that 60% experienced unscheduled removal. In contrast, Ren et al. [6] examined 280 adult patients requiring CBP and reported that 11.4% underwent re-catheterization. Several studies have identified potential risk factors for unscheduled removal in both pediatric and adult populations, including femoral vein VA placement [2, 4, 7], smaller VA size [2, 3], left internal jugular vein placement [7], and prolonged catheter duration [6]. However, findings across studies have been inconsistent. Identifying modifiable factors associated with unscheduled removal is therefore essential to optimize VA longevity and the management of pediatric CBP. This study aimed to characterize unscheduled removal in pediatric CBP cases and to evaluate associated factors for unscheduled removal in a single-center cohort of pediatric patients undergoing CBP in Japan.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design and subjects\u003c/h2\u003e\u003cp\u003eThis retrospective observational study was carried out at a single tertiary pediatric institution, the National Center for Child Health and Development (NCCHD) in Tokyo, Japan. We retrospectively analyzed medical records of patients under 16 years of age who received CBP therapies\u0026mdash;including continuous hemodialysis, hemofiltration, or hemodiafiltration\u0026mdash;between July 2014 and June 2023. Patients undergoing concurrent extracorporeal membrane oxygenation (ECMO) or those with tunneled dialysis catheters were excluded from the analysis. Only the first VA inserted for each patient was included in the analysis. The study adhered to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines for reporting observational cohort studies.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy settings\u003c/h3\u003e\n\u003cp\u003eThe NCCHD is a tertiary pediatric center in Japan, with 20 PICU beds, and manages the highest number of pediatric CBP cases in the country, with an annual volume of approximately 40 to 50 cases [8]. In the PICU, CBP therapies are managed by pediatric intensivists in close collaboration with clinical engineers. The institutional CBP manual provides recommendations for dialysis catheter size based on patient body weight and designates the right internal jugular vein as the preferred insertion site. However, both the catheter size and insertion site were ultimately determined at the discretion of the pediatric intensivists. The diagnosis of CRBSI was conducted collaboratively by pediatric intensivists and pediatric infectious disease specialists. The necessity of VA removal was discussed within the care team, with the final decision made by the pediatric intensivists.\u003c/p\u003e\n\u003ch3\u003eData collection and outcome\u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003eData collection and outcome\u003c/div\u003e\u003cp\u003ePatient demographics and CBP-related variables were retrospectively extracted from medical records. Baseline information\u0026mdash;including age, body weight, and the clinical indication for initiating CBP\u0026mdash;was systematically recorded. Survey items referred to the prospective multicenter CBP registry of PICUs in Japan [9]. Procedural details, including VA site, VA size, catheter duration (days), and reason for VA removal, were also recorded. VAs were classified as either planned removal or unscheduled removal, with unscheduled removal defined as the primary outcome of the study. These unscheduled removals were further categorized by reason into infection control, catheter dysfunction, or accidental dislodgement. All data were collected by Yusuke Tokuda, Junichiro Morota, Eisaku Nashiki, Kentaro Nishi, and Mai Miyaji. Kentaro Ide reviewed the data for accuracy, and any discrepancies were discussed collaboratively with all data collectors and corrected accordingly.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eStatistical analyses were carried out using R (version 4.5.0). Continuous variables were described using medians and interquartile ranges (IQRs), and group comparisons were performed with the Mann-Whitney \u003cem\u003eU\u003c/em\u003e test. Categorical variables were summarized as frequencies and percentages, and differences between groups were assessed using Fisher\u0026rsquo;s exact test (two-tailed). To explore factors associated with unscheduled removal, both univariate and multivariable logistic regression analyses were conducted. Associations were reported as odds ratios (ORs) with corresponding 95% confidence intervals (CIs). In the multivariable logistic regression model, variables identified as potential risk factors based on clinical experience and prior literature, specifically longer catheter duration and femoral VA, were included, along with variables that had a \u003cem\u003eP\u003c/em\u003e value\u0026thinsp;\u0026lt;\u0026thinsp;0.1 in the univariate analysis, to identify independent predictors of unscheduled removal. To construct the final multivariable model, a backward stepwise selection procedure was employed, in which variables with \u003cem\u003eP\u003c/em\u003e values\u0026thinsp;\u0026ge;\u0026thinsp;0.05 were progressively eliminated. The daily risk of unscheduled removal was calculated in 5-day intervals by dividing the number of unscheduled removals that occurred during each interval by the total number of VA during the same period. All statistical analyses were performed using two-tailed tests, with a significance threshold set at \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Because of the study\u0026rsquo;s exploratory design, no formal calculation of sample size was carried out. The analysis was conducted on all patients who met the predefined eligibility criteria.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEthics\u003c/h3\u003e\n\u003cp\u003e The study protocol was reviewed and approved by the Ethics Committee of the NCCHD (approval number: 2023\u0026thinsp;\u0026minus;\u0026thinsp;103; date of approval: 19 September 2023; study title: Investigation of Continuous Renal Replacement Therapy in the Pediatric Intensive Care Setting), in accordance with the amended Declaration of Helsinki. Given that this was a retrospective study using pre-existing clinical data with minimal risk to participants, informed consent was obtained through an opt-out process in line with national ethical guidelines for medical research involving human subjects.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 222 patients were analyzed after excluding patients who received ECMO support and or those with tunneled catheters (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Among them, 28 patients (13%) experienced unscheduled removal with a median catheter duration of 10 days [interquartile range (IQR), 5\u0026ndash;14], corresponding to an incidence rate of 15.2 events per 1,000 catheter-days (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Baseline patient demographics and VA characteristics were compared between the two groups (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Patients with unscheduled removal were significantly younger and had lower body weight compared to those with planned removal (median age in months: 3.5 [IQR 1.0-16.5] vs. 12.0 [IQR 3.0-61.8], \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.027; median body weight (kg): 4.5 [IQR 3.2\u0026ndash;8.5] vs. 8.2 [IQR 5.3\u0026ndash;15.6], \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.018). Moreover, they were more likely to have femoral VA (14% vs. 3%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.026). The catheter duration tended to be longer in those with unscheduled removal (median days: 10 [IQR 5\u0026ndash;14] vs. 7 [IQR 6\u0026ndash;9], \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.11). Regarding catheter size, there was a tendency toward the use of smaller VAs in those with unscheduled removal, with 6 Fr catheters used in 57% of cases compared to 28% in those with planned removal.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePatient characteristics and vascular access details\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePlanned removal\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;194)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUnscheduled removal\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;28)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge in month\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12.0 [3.0, 61.8]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.5 [1.0, 16.5]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.027\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWeight (kg)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8.2 [5.3, 15.6]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.5 [3.2, 8.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.018\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndication\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLiver failure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e85 (44%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16 (57%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.56\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKidney failure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e63 (33%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (32%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMetabolic disorder\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37 (19%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (101%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOthers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVA site\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRight jugular\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e162 (84%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21 (75%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.026\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft jugular\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25 (13%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 ( 7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemoral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 ( 3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (14%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOthers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 ( 1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 ( 4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVA size (Fr)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e54 (28%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16 (57%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.062\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6.5-7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e59 (30%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (18%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e42 (22%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (14%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9.5\u0026ndash;10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 ( 5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29 (15%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (11%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVA days\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (6, 9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (5, 14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eValues are expressed as the number (%) or median [interquartile range].\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eVA, vascular access;\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eUnivariate and multivariable logistic regression analyses were conducted to investigate the associations between unscheduled removal and the following variables: catheter duration, age in months, femoral VA, and VA size (Fr) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In the multivariable analysis, catheter duration (day) (OR 1.07, 95% CI 1.01\u0026ndash;1.14) and femoral VA (OR 5.62, 95% CI 1.43\u0026ndash;22.1) were independently associated with unscheduled removal. The temporal trend in the daily risk of unscheduled removal, calculated as the number of unscheduled removals divided by the number of VAs at risk, is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The daily risk remained low during the first 10 days (less than 1.5%), but gradually increased thereafter, peaking at 9.7% in the interval 21\u0026ndash;25 days. Figure\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e compares the incidence rate of unscheduled removal by VA site. The rate was highest in femoral VAs (up to 42%), whereas it remained at approximately 10% in right and left internal jugular sites.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFactors associated with unscheduled vascular access removal\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eUnivariate analysis\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003eMultivariable analysis\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eOR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVA days\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.01\u0026ndash;1.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0019\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.01\u0026ndash;1.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.030\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003cp\u003e(month)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.98-1.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.013\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVA at Femoral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.37\u0026ndash;19.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.43\u0026ndash;22.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.014\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVA size\u003c/p\u003e\u003cp\u003e(Fr)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.60\u0026ndash;1.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003eVA, vascular access; OR, odds ratio; CI, confidence interval\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eWe further examined the characteristics of unscheduled removals by reason. The reason for unscheduled removal included infection control (18 cases), catheter dysfunction (8 cases), and accidental dislodgement (2 cases). Patients who underwent unscheduled removal for infection control were significantly younger and had longer catheter duration compared to those with planned removal (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Of note, catheter-related bloodstream infection was diagnosed in 39% (7 out of 18) of the unscheduled removals for infection control. Among patients with unscheduled removals for catheter dysfunction, neither age nor catheter duration differed significantly compared to those with planned removal. However, the proportion of femoral VA was significantly higher in patients with unscheduled removals for catheter dysfunction (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison between planned removal and unscheduled removal for infection control\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePlanned removal\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;194)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUnscheduled removal for infection control\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;18)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge in month\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12.0 [3.0, 61.8]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.5 [0.3, 15.5]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.026\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVA site\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRight jugular\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e162 (84%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (83%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.65\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft jugular\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25 (13%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (11%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemoral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOthers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVA size (Fr)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e54 (28%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (61%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.062\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6.5-7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e59 (30%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (17%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e42 (22%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (11%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9.5\u0026ndash;10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 ( 5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29 (15%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (11%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVA days\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (6, 9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (6, 14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.044\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eValues are expressed as the number (%) or median [interquartile range].\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eVA, vascular access\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison between planned removal and unscheduled removal due to catheter dysfunction\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePlanned removal\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;194)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUnscheduled removal due to catheter dysfunction\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge in month\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12.0 [3.0, 61.8]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.5 [5.5, 16.5]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.82\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVA site\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRight jugular\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e162 (84%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (50%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft jugular\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25 (13%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemoral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (38%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOthers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (12%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVA size (Fr)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e54 (28%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (38%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.97\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6.5-7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e59 (30%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (25%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e42 (22%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (25%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9.5\u0026ndash;10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29 (15%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (12%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVA days\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 [6, 9]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.5 [4.8, 10.5]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.77\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eValues are expressed as the number (%) or median [interquartile range].\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eVA, vascular access\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis single-center cohort study revealed that unscheduled removal occurred in 13% (28/222) of children requiring CBP in the PICU, with an incidence rate of 15.2 events per 1,000 catheter-days. Multivariable analysis identified longer catheter duration and femoral vein insertion as independent risk factors for unscheduled removal in pediatric CBP.\u003c/p\u003e\u003cp\u003eProlonged catheter duration was identified as one of the risk factors for unscheduled removal in this study, consistent with the findings of the previous report [6]. Furthermore, in the subgroup analysis by reason for removal, catheter duration was significantly longer in removals for infection control compared to planned removals. This suggests that the incidence of infection may increase with prolonged catheter duration. Santiago et al. examined 55 children who underwent CBP and reported that infections occurred in 78% (43 out of 55) of the patients, with a median onset of 11 days after CBP initiation. Moreover, they identified a CBP duration longer than 4.5 days as the sole risk factor for infection. In this study, the incidence of unscheduled catheter removal remained low during the first 10 days (less than 1.5%), but gradually increased thereafter, peaking at 9.7% in the interval 21\u0026ndash;25 days (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Therefore, in cases where prolonged CBP management is anticipated, it may be necessary to enhance monitoring for signs of infection after approximately two weeks of catheter placement and to consider switching to a tunneled catheter, which carries a lower risk of infection [10]. Another important finding was that only 39% (7/18) of the catheters removed for infection control were confirmed to be true CRBSI. Similarly, a study of adult VA reported that only 14% (4 out of 29) of catheters removed for infection control were CRBSI [11]. These findings highlight the need to improve diagnostic accuracy for VA-related CRBSI.\u003c/p\u003e\u003cp\u003eFemoral vein VA placement was associated with unscheduled removal. This finding is consistent with previous reports in both pediatric [2, 4] and adult populations [7], which identified femoral vein placement as a risk factor for catheter dysfunction-related removal. However, Parienti et al. [12] conducted a randomized controlled trial involving 736 adult patients and reported no significant difference in catheter dysfunction between internal jugular and femoral vein placements, indicating that previous findings are not entirely consistent. Furthermore, as reported in an adult VA study showing no difference in infection rates between femoral and internal jugular vein placements [11], our study similarly found no increased proportion of femoral VA among unscheduled removals for infection control. Even though there may be no compelling reason to avoid femoral access from an infection control perspective, its association with catheter dysfunction cannot be ruled out. Although femoral VA is sometimes preferred due to its lower complication rates [4, 11], it has also been associated with a shorter circuit lifespan in pediatric CBP [2, 13]. Differences between adult and pediatric patients\u0026mdash;such as the use of smaller VA sizes and limited ability to comply with movement restrictions\u0026mdash;should also be taken into account. Larger-scale studies may be necessary to further investigate femoral VA and unscheduled removal in the pediatric population.\u003c/p\u003e\u003cp\u003eThis study has several limitations. First, this was a single-center, retrospective analysis conducted in a Japanese tertiary pediatric center, which may limit the generalizability of our findings. Second, the criteria for VA removal were not defined in a written protocol, and decisions were made through team discussions. However, the final decision rested with the pediatric intensivist, and variability in clinical judgment cannot be ruled out. Third, given the relatively small number of femoral vein VAs in this study, further validation is needed to assess the reproducibility of these findings.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn this single-center cohort of pediatric patients receiving CBP, unscheduled catheter removal occurred in 13% of cases, with prolonged catheter duration and femoral vein access identified as independent risk factors. These findings highlight the importance of timely risk assessment\u0026mdash;particularly beyond two weeks of catheter use\u0026mdash;and suggest the potential utility of alternative strategies, such as early conversion to tunneled catheters in selected patients. Further studies are warranted to investigate femoral VA and unscheduled removal in pediatric CBP.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank Dr. Taiki Haga (Osaka City General Hospital) for his valuable contributions to this study\u0026rsquo;s conception, design, and data interpretation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the amended Declaration of Helsinki and was approved by the Ethics Committee of the NCCHD (approval number 2023-103, date: 19 September 2023, title: Investigation of Continuous Renal Replacement Therapy in the Pediatric Intensive Care Setting). This study used existing data and posed minimal risk to patients; therefore, opt-out consent was obtained in accordance with national ethical guidelines for medical research involving human subjects and the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the National Center for Child Health and Development (grant number 2024B-4).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data used to support the findings of this study are available from the corresponding author, KI, upon reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKI, MT, MS, and SM conceived and designed the study. KI, YT, JM, EN, KN, and MM collected the data. YZ and KI performed the data analysis and interpretation. YZ and KI drafted the manuscript. All authors critically revised the manuscript and approved the final version.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCortina G, McRae R, Chiletti R, Butt W (2020) The Effect of Patient- and Treatment-Related Factors on Circuit Lifespan During Continuous Renal Replacement Therapy in Critically Ill Children. Pediatr Crit Care Med 21:578-585.\u003c/li\u003e\n\u003cli\u003eHackbarth R, Bunchman TE, Chua AN, Somers MJ, Baum M, Symons JM, Brophy PD, Blowey D, Fortenberry JD, Chand D, Flores FX, Alexander SR, Mahan JD, McBryde KD, Benfield MR, Goldstein SL (2007) The effect of vascular access location and size on circuit survival in pediatric continuous renal replacement therapy: a report from the PPCRRT registry. Int J Artif Organs 30:1116-1121.\u003c/li\u003e\n\u003cli\u003eGoldstein SL, Macierowski CT, Jabs K (1997) Hemodialysis catheter survival and complications in children and adolescents. Pediatr Nephrol 11:74-77.\u003c/li\u003e\n\u003cli\u003eRus RR, Premru V, Novljan G, Gro\u0026scaron;elj-Grenc M, Ponikvar R (2016) Fate of Central Venous Catheters Used for Acute Extracorporeal Treatment in Critically Ill Pediatric Patients: A Single Center Experience. Ther Apher Dial 20:308-311.\u003c/li\u003e\n\u003cli\u003eSantiago MJ, L\u0026oacute;pez-Herce J, Vierge E, Castillo A, Bustinza A, Bell\u0026oacute;n JM, S\u0026aacute;nchez A, Fern\u0026aacute;ndez S (2017) Infection in critically ill pediatric patients on continuous renal replacement therapy. Int J Artif Organs 40:224-229.\u003c/li\u003e\n\u003cli\u003eRen H, Ge Y, He X, Li C, Xu B, Gong D, Liu Z (2019) Vascular Access in Patients Treated with Continuous Renal Replacement Therapy: A Report from a Single Center in China. Ther Apher Dial 23:562-569.\u003c/li\u003e\n\u003cli\u003eLim L, Park JY, Lee H, Oh SY, Kang C, Ryu HG (2023) Risk factors of hemodialysis catheter dysfunction in patients undergoing continuous renal replacement therapy: a retrospective study. BMC Nephrol 24:334.\u003c/li\u003e\n\u003cli\u003eHaga T, Ide K, Tani M (2023) Characteristics of pediatric continuous renal replacement therapies in hospitals with pediatric intensive care units in Japan. Ther Apher Dial 27:562-570.\u003c/li\u003e\n\u003cli\u003eHaga T, Tani M, Oi T, Sakihama H, Sasaki K, Fujiwara N, Miyaji M, Okada H, Itakura R, Noda S, Wada S, Yamagami Y, Koizumi T, Horikawa A, Omori N, Sato M, Morota J, Ide K (2023) The Japanese Pediatric Continuous Renal Replacement Therapy (jpCRRT) Registry: Study Protocol. Ann Clin Epidemiol 5:121-126.\u003c/li\u003e\n\u003cli\u003eMa GMY, Ventura LM, Amiribadi A, Gnannt R, Nemec R, Noone D, Licht C, Amaral J, Temple M, Muthasami P, Parra D, Chamlati R, Connolly B (2020) Hemodialysis Catheters in Infants: A Retrospective Single-Center Cohort Study. J Vasc Interv Radiol 31:778-786.\u003c/li\u003e\n\u003cli\u003eBenichou N, Lebbah S, Hajage D, Martin-Lef\u0026egrave;vre L, Pons B, Boulet E, Boyer A, Chevrel G, Lerolle N, Carpentier D, de Prost N, Lautrette A, Bretagnol A, Mayaux J, Nseir S, Megarbane B, Thirion M, Forel JM, Maizel J, Yonis H, Markowicz P, Thiery G, Schortgen F, Tubach F, Ricard JD, Dreyfuss D, Gaudry S (2021) Vascular access for renal replacement therapy among 459 critically ill patients: a pragmatic analysis of the randomized AKIKI trial. Ann Intensive Care 11:56.\u003c/li\u003e\n\u003cli\u003eParienti JJ, M\u0026eacute;garbane B, Fischer MO, Lautrette A, Gazui N, Marin N, Hanouz JL, Ramakers M, Daubin C, Mira JP, Charbonneau P, du Cheyron D (2010) Catheter dysfunction and dialysis performance according to vascular access among 736 critically ill adults requiring renal replacement therapy: a randomized controlled study. Crit Care Med 38:1118-1125.\u003c/li\u003e\n\u003cli\u003eWestrope C, Morris KP, Kee CY, Farley M, Fleming S, Morrison G (2016) Experience of Circuit Survival in Extracorporeal Continuous Renal Replacement Therapy Using Small-Calibre Venous Cannulae. Pediatr Crit Care Med 17:e260-265.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Pediatric intensive care, Continuous blood purification, Continuous kidney replacement therapy, Vascular access, Dialysis catheter, Unscheduled removal","lastPublishedDoi":"10.21203/rs.3.rs-7796715/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7796715/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eDuring continuous blood purification (CBP), unscheduled vascular access (VA) removal occurs and interrupts treatment. This study aimed to characterize the incidence of unscheduled VA removal in pediatric CBP and identify associated risk factors.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe conducted a retrospective observational study of patients under 16 years of age who underwent CBP at a tertiary pediatric center between July 2014 and June 2023. Patients receiving extracorporeal membrane oxygenation or those with tunneled catheters were excluded. VAs were classified as either \u0026ldquo;planned removal\u0026rdquo; or \u0026ldquo;unscheduled removal\u0026rdquo;, with unscheduled removals further categorized by reason into \u0026ldquo;infection control\u0026rdquo;, \u0026ldquo;catheter dysfunction\u0026rdquo;, or \u0026ldquo;accidental dislodgement\u0026rdquo;. Factors associated with unscheduled removal were identified using logistic regression analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eAmong 222 eligible patients, 28 (13%) experienced unscheduled removal with a median catheter duration of 10 days (interquartile range, 5\u0026ndash;14), corresponding to an incidence rate of 15.2 events per 1,000 catheter-days. Compared with those with planned removal, patients with unscheduled removal were significantly younger and were more likely to have femoral VA. In multivariable analysis, longer catheter duration (day) (OR 1.07, 95% CI 1.01\u0026ndash;1.14) and femoral VA (OR 5.62, 95% CI 1.43\u0026ndash;22.1) were independently associated with unscheduled removal. When stratified by reason for removal, unscheduled removals for infection control were associated with younger age and longer catheter duration, whereas those due to catheter dysfunction were associated with femoral VA.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eUnscheduled removal occurred in 13% of pediatric CBP cases, with longer catheter duration and femoral VA identified as independent risk factors.\u003c/p\u003e","manuscriptTitle":"Risk factors for unscheduled removal of vascular access while undergoing pediatric continuous blood purification: A retrospective single-center cohort study (2014-2023)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-23 14:25:05","doi":"10.21203/rs.3.rs-7796715/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5018da61-89c4-4fa3-a5cd-bc42a2cbc9bb","owner":[],"postedDate":"October 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-16T16:49:35+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-23 14:25:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7796715","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7796715","identity":"rs-7796715","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}