The Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics: miniMAGIC

Neonates (Birth to 30 Days)

Within this population, the panel considered term neonates who, in the first 30 days of life, are admitted to a pediatric or mixed pediatric-adult facility. Infection and newly diagnosed congenital abnormalities, including cardiac conditions, are a common source of early hospital admission for this population. Reliable access to the vascular system is thus necessary for diagnosis and treatment.

For approximately the first week of life, the umbilical vein is a viable means of venous access. The panel determined that selection of an umbilical catheter should be influenced by the infusate characteristics, therapy duration, and the age of the neonate. The panel rated use of the umbilical catheter as appropriate up to 2 days after birth for peripherally compatible infusates for a therapy duration of ≤14 days. Inserting an umbilical catheter ≥5 days after birth (no matter the therapy duration) was rated as inappropriate. There was disagreement regarding the appropriateness of umbilical catheters for a longer therapy duration (≥15 days) because it was unclear whether the umbilical vascular system and catheter would remain patent for the predicted clinical need.^16,27

The panel rated umbilical catheters as appropriate for administering nonperipherally compatible infusates (with placement occurring up to 5 days after birth). Central tip positioning of umbilical catheters is frequently problematic, with the catheter tip often moving during treatment, which is related to a small target of safe positioning (due to patient size) and difficult securement.^4,27,28 The panel therefore endorsed frequent assessment of umbilical catheter tip positioning to safely administer nonperipherally compatible infusates. The panel rated it as appropriate to transition to alternative vascular access, from a functioning umbilical catheter, from 8 days after umbilical catheter placement but rated transition before 5 to 7 days after placement as uncertain rather than appropriate.

The miniMAGIC recommendations for appropriate device selection for hospitalized term neonates, across clinical indications and therapy durations, are summarized in Fig 1. PIVCs and midline catheters were rated appropriate for ≤7 days of peripherally compatible therapy; however, the panel rated them as uncertain or inappropriate for more prolonged therapies because of concerns regarding the device reliability. In agreement with the National Association for Neonatal Nurses, PICCs were rated as appropriate for nonperipherally compatible therapies and peripherally compatible therapies of ≥8 days of therapy.¹⁶ Tunneled, cuffed CVADs were rated as appropriate for administration of infusates when therapy was projected to last ≥31 days. The panel deliberated extensively on the selection of an appropriate device for frequent blood draws (more than once per day) because of the risk of catheter occlusion. Ultimately, midline catheters were rated as appropriate for short durations (≤7 days), and PICCs >3F catheter, or ≤20 gauge, were rated as appropriate for ≥8 days of therapy. Tunneled, cuffed CVADs were rated appropriate for all long-term therapies (≥31 days). Totally implanted venous devices were rated as inappropriate for all clinical scenarios for hospitalized neonates, regardless of therapy duration, reflecting difficulty in implanting these devices below the skin and rapid growth impacting tip position in neonates.

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FIGURE 1

miniMAGIC recommendations for appropriate device selection for hospitalized term neonates. ^a Less than or equal to 2 days after birth. ^b All neonatal ages. ^c Less than or equal to 5 days after birth. NTCVAD, nontunneled central venous access device; TcCVAD, tunneled, cuffed central venous access device; TIVD, totally implanted venous device.

Infants (31 Days to 1 year)

Infants require hospitalization for a range of conditions, with respiratory conditions, such as bronchiolitis, being highly prevalent. miniMAGIC recommendations for the selection of VAD for hospitalized infants are presented in Fig 2.

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FIGURE 2

miniMAGIC recommendations for appropriate device selection for hospitalized infants. ^a Disagreement. G, gauge; NTCVAD, nontunneled central venous access device; TcCVAD, tunneled, cuffed central venous access device; TIVD, totally implanted venous device.

For hospitalized infants, PIVCs were rated as appropriate for ≤14 days of therapy; however, robust evidence with which to rate the appropriate use of midline catheters in this population was lacking. Panelists reported successful use of these devices at some individual hospitals but stressed the necessity for high-quality insertion and maintenance practices to promote safety. Thus, ratings for midline catheters for peripherally compatible infusates lasting ≤7 days were uncertain.

As with hospitalized neonates, PICCs were rated as appropriate for administering nonperipherally compatible infusates, with nontunneled CVADs rated as appropriate for a therapy duration of ≤14 days. The panelists again deliberated extensively regarding the appropriateness of device selection for frequent blood draws (more than once per day). The panel rated the appropriateness of PIVCs and midline catheters for ≤7 days as uncertain and rated PICCs as appropriate for ≥8 days if >3F catheter, or ≤20 gauge. The panel discussed the risk/benefit ratio of VADs for this indication, including infection, thrombosis, and repeated procedures.⁴ Longer-term devices, including tunneled, cuffed CVADs and totally implanted venous devices, were rated as appropriate for ≥31 days of nonperipherally compatible therapy but as uncertain for other indications.

Children (>1–12 Years) and Adolescents (>12–<18 Years)

Although hospitalized children and adolescents represent a heterogeneous group, overall, the panelists determined that physiologic differences between children and adolescents do not make a clinically meaningful difference when it comes to VAD appropriateness. Thus, these sections were combined when ratings were performed. As displayed in Fig 3, consistent with the adult literature (including MAGIC), midline catheters and PIVCs were rated as appropriate for peripherally compatible infusates for ≤14 days.^8,11 Consequently, PICCs were rated as appropriate for use when ≥15 days of peripherally compatible therapy is planned. PICCs remained appropriate for all durations when nonperipherally compatible infusates are planned. Nontunneled CVADs were rated as appropriate by the panel for nonperipherally compatible therapies of up to 14 days’ duration and as uncertain in appropriateness for frequent blood draws of between 8 and 30 days’ duration. Tunneled, cuffed CVADs and totally implanted venous devices were rated as appropriate for most indications of ≥31 days.

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FIGURE 3

miniMAGIC recommendations for appropriate device selection for hospitalized children and adolescents. For boxes with 2 colors, the left is for children (>1–12 years), and the right is for adolescents (>12–<18 years). ^a Disagreement. NTCVAD, nontunneled central venous access device; TcCVAD, tunneled, cuffed central venous access device; TIVD, totally implanted venous device.

Malignant Hematologic and Oncological Conditions

Compared with general hospitalized pediatric patients, patients with malignant hematologic and oncological conditions are at increased risk of infection and thrombotic complications and adverse sequelae from treatment disruption.^4,5,29 In addition, treatments and supportive therapies are complex and diverse and often require cycles of peripherally and nonperipherally compatible infusates, frequent blood draws, and management across home and health care settings. In agreement with international guidelines,³⁰ the panel rated tunneled, cuffed CVADs as appropriate across this indication, with totally implanted venous devices also rated appropriate for patients ≥10 kg. The panel rated the appropriateness of PICCs (all ages and weights) and totally implanted venous devices (for patients <10 kg) as uncertain, citing concerns regarding procedural and postinsertion complications such as infection and thrombosis.³⁰

The panel rated it appropriate to place a PICC to commence urgent, nonperipherally compatible therapy for cancer and replace this with a definitive device. However, the appropriateness of routinely using this approach was rated as uncertain. When comparing the appropriateness of PICCs versus tunneled, cuffed CVADs, the panel rated it inappropriate to insert a PICC rather than a tunneled, cuffed CVAD for all aged populations undergoing bone marrow transplant or other treatment of cancer. Similarly, the panel rated insertion of a PICC, rather than a totally implanted venous device, for children and adolescents receiving treatment of active cancer as inappropriate. The panel rated the same comparison as appropriate for neonates and as uncertain for infants.

Patients With Critical Illness

For pediatric patients with critical illness, miniMAGIC panelists recommended VAD selection on the basis of illness severity (ie, physiologically unstable versus stable) rather than setting of care (ie, ICU versus emergency department) or other patient or clinical characteristics. Ratings for patients with critical illness were consistent with existing guidelines³¹ with respect to timeliness and importance of early venous access. Displayed in Fig 4, recommendations for a pediatric patient who is stable but critically ill varied on the basis of infusate characteristics and monitoring requirements. Nontunneled CVADs were rated as appropriate for up to 14 days of nonperipherally compatible therapy and for hemodynamic monitoring. Consistent with previous recommendations, PICCs were rated as appropriate for ≥8 days of peripherally compatible therapies and for all durations of nonperipherally compatible therapies. Despite minimal data, midline catheters were rated by the panel as appropriate for all durations of peripherally compatible therapies. For pediatric patients who are stable but critically ill requiring peripherally compatible therapy for ≤14 days, panelists preferred PIVCs over IO catheters. Panelists disagreed on the appropriateness of IO catheter use for managing pediatric patients without hemodynamic compromise without reliable vascular access for ≤7 days.

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FIGURE 4

miniMAGIC recommendations for pediatric patients who are critically ill. A, stable, critically ill patient. B, unstable, critically ill patient. ^a Disagreement. NTCVAD, nontunneled central venous access device; TcCVAD, tunneled, cuffed central venous access device; TIVD, totally implanted venous device.

Also displayed in Fig 4 (and in agreement with the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care),³¹ for an unstable pediatric patient, speed of access was first priority. For scenarios with hemodynamic compromise, panelists rated it inappropriate to attempt for PIVC access for ≥120 seconds or ≥2 attempts, instead recommending an IO device to gain intravenous (IV) access, citing how rapidly this can be inserted by clinicians with varying levels of training.³¹

Congenital Cardiac Conditions

For pediatric patients with congenital cardiac conditions, inappropriate VAD selection can directly impact both short- and long-term survival. Damage (thrombotic or stenotic) to key vessels can prevent or complicate future life-saving procedures, including catheterization interventions, palliation of patients with a functionally univentricular heart, and cardiac transplant.³² Because the implications of vascular access and route of access are highly relevant in decision-making, clinical scenarios for this population were divided into underlying cardiac physiology: univentricular versus biventricular circulation. Across all scenarios there were 2 common recommendations. First, the panel rated totally implanted venous devices as inappropriate regardless of indication because of concerns regarding irreparable vessel damage. Second, the panel rated umbilical catheters as an appropriate access option for neonates because these do not typically result in significant vessel compromise for future procedures.³²

Congenital cardiac procedures are primarily performed in highly specialized pediatric facilities. miniMAGIC does not include recommendations surrounding the selection of transthoracic intracardiac lines or other specialty cardiac devices (eg, extracorporeal membrane oxygenation catheters). However, the panel recognized that placement of transthoracic intracardiac lines can minimize the need for other types of VADs and thereby minimize the risks associated with percutaneous devices.³³

For patients with univentricular physiology, miniMAGIC recommendations were based on the patient’s stage of cardiac repair (stage 1, 2 or 3)¹⁷ and duration of therapy (Fig 5). Lower-extremity PICCs, umbilical catheters, and femoral CVADs (tunneled, uncuffed and nontunneled) were rated by the panel as appropriate for patients undergoing stage 1 and 2 repair to preserve upper-extremity vein patency for stage 2 and 3 palliation.³² To facilitate preservation of upper-extremity veins, a slightly varied CVAD insertion technique was included: the tunneled, noncuffed CVAD placed in the femoral vein.³⁴ After stage 3 repair, appropriateness was similar to recommendations for patients with critical illness. For patients with highly complex, functionally univentricular physiology at any stage of repair, the panel discussed the potential necessity to consider alternatives and recommended that such cases have coordinated, interdisciplinary device planning and consideration of specialist devices (eg, transhepatic CVAD).

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FIGURE 5

miniMAGIC recommendations for congenital cardiac conditions in pediatric patients. A, Functionally univentricular physiology. B, Biventricular circulation. ^a Disagreement. Fem, femoral; Jug, jugular; Low, lower body; NTCVAD, nontunneled central venous access device; Sub; subclavian; TcCVAD, tunneled, cuffed central venous access device; TIVD, totally implanted venous device; TncCVAD, tunneled, noncuffed central venous access device; Up, upper body.

For congenital cardiac conditions with biventricular circulation, miniMAGIC recommendations were based on patient age and duration of therapy. Appropriateness ratings were similar to those of pediatric patients who are stable but critically ill, owing to similar physiology and associated risk. The panel rated jugular-placed, nontunneled CVADs and upper extremity–placed PICCs as appropriate. Nontunneled CVADs placed in femoral and subclavian veins were rated as uncertain by the panel, reflecting the insertion-related complications associated with subclavian placement (which vary on the basis of operator experience and the use of ultrasound) and infection and thrombotic risk associated with femoral placement.³² Additionally, femoral vessel preservation was cited as being important for patients with conditions likely to require future transcatheter interventions (eg, patients with tetralogy of Fallot or pulmonary atresia and patients receiving a cardiac transplant who will need multiple myocardial biopsies).

Long-Term Vascular Access Dependent

With evolution in medical therapies, long-term (>2 months) and very long-term (>1 year) vascular access dependency in pediatrics is increasingly common.² This prolonged reliance on VADs includes pediatric patients receiving treatment of nonmalignant hematologic (eg, sickle cell), respiratory (eg, cystic fibrosis), gastrointestinal, metabolic, and immunologic conditions. Navigating VAD insertion decisions for children with chronic illness is vital but complex. To this end, our nonvoting patient representative was instrumental in providing context for these ratings. With her input and insight, the panel agreed that defining the appropriateness of basic principles to enable vessel preservation and complication prevention in chronic conditions was necessary. The panel strongly recommended that clinicians partner with the child and family or caregivers when selecting devices to ensure that their immediate and evolving clinical and lifestyle needs are met.

In contrast to MAGIC, the panel did not believe that frequency of hospitalization should be used as a proxy for illness severity or as a defining criterion in pediatric VAD selection. This distinction was made because acute hospitalization was considered an unreliable proxy of disease in pediatric populations with chronic conditions, in whom an emphasis is placed on avoiding hospitalization.⁸ Instead, in each of the clinical scenarios, it was recognized that children with long-term vascular access dependency spend time receiving treatment across home and health care facilities. In the scenarios, it was also considered that most children dependent on long-term vascular access are likely to have difficult vascular access, related to previous vessel damage and procedural fear.²

The criteria influencing the selection of VADs for this heterogenous population were focused on infusate characteristics (peripheral versus nonperipheral compatibility, including parenteral nutrition [PN]), continuous or intermittent therapies, and treatment duration. Specific recommendations are provided for children requiring long-term PN, and in accordance with the European Society for Parenteral and Enteral Nutrition, the panel rated use of tunneled, cuffed CVADs for all age groups as appropriate. However, the appropriateness of totally implanted venous devices for children and adolescents was rated as uncertain, and there was disagreement regarding the appropriateness of PICCs.³⁵

Recommendations for non-PN infusates are displayed in Fig 6. For continuous infusates, appropriateness mirrored PN recommendations, including tunneled, cuffed CVADs for all populations. The panel also rated use of PICCs in infants and children and use of totally implanted venous devices for children and adolescents as appropriate for this indication. For intermittent access, panelists rated PICCs and totally implanted venous devices in neonates and infants as uncertain, but they rated the use of tunneled, cuffed CVADs for all populations and the use of totally implanted venous devices in children and adolescents as appropriate. Peripheral devices, including PIVCs and midline catheters, were rated as being inappropriate across all long-term, complex therapies.

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FIGURE 6

miniMAGIC recommendations for pediatric patients with non–PN-related long-term VAD dependency. ^a Disagreement. NTCVAD, nontunneled central venous access device; TcCVAD, tunneled, cuffed central venous access device; TIVD, totally implanted venous device.

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FIGURE 7

Summary of miniMAGIC recommendations for the appropriate VAD insertion vessel and/or site in pediatric patients. ^aDisagreement.

For children and adolescents requiring regular, peripherally compatible intermittent treatments (eg, steroids and antibiotics) for short durations (<7 days), the panel rated PIVCs and totally implanted venous devices as appropriate. The panel rated the use of midline catheters and PICCs as uncertain, owing largely to a lack of credible evidence supporting this practice. Although some panelists had substantial experience in using midline catheters for this purpose and reported few untoward events, the lack of evidence to support this practice and the potential risk of complications limited recommendations. When considering medium-duration (8–14 days) treatment, PICCs; tunneled, cuffed CVADs; and totally implanted venous devices were rated as appropriate.

Difficult Venous Access

Difficult venous access is caused by a variety of factors in pediatrics, including physiology, pathology, VAD damage, and clinician procedural skill.³⁶ Appropriateness criteria for difficult venous access are focused on the number of insertion attempts, intramuscular (IM) therapy substitution, and escalation of VAD types. Each of these criteria provided a pathway to minimize vessel damage and patient distress without impacting treatment provision.

In agreement with the Infusion Nurses Society guidelines, the panel rated ≥3 attempts at PIVC insertion by a single clinician as inappropriate.¹⁵ In parallel, the panel rated 0 to 2 attempts by one individual as appropriate but recommended early escalation to a more experienced PIVC inserter for children with difficult venous access.

It is not uncommon in pediatrics for a child to need an additional day of IV treatment only to lose reliable IV access. In such situations, the panel rated it appropriate to substitute an antibiotic that may be delivered via alternative routes (eg, IM ceftriaxone) with a non-IV injection on the final day of therapy when advanced insertion staff are not available or after ≥2 insertion attempts are unsuccessful. The panel rated this approach as uncertain with 0 to 1 attempts but also indicated that it was reasonable to attempt to insert a PIVC for completion of IV therapy. Underlying the panel’s recommendation was the understanding (1) that the efficacy of IV and IM administration for the antibiotic in question is similar and (2) that IM injections can be painful, and often multiple doses are required, thus making it less ideal.³⁷ When transitioning from IV to IM treatment, consultation with an infectious diseases specialist was recommended. Additionally, the panel advised considering oral antibiotic therapy in all such situations, including before IV therapy is commenced.³⁸

The panel rated placement of a PICC as appropriate for a child who does not need central access or access for extended periods but who, despite appropriate escalation with skilled inserters and technology (eg, ultrasound), has required ≥2 PIVC insertion attempts. For this indication, the panel balanced the risk associated with delays to treatment and distressing repeated PIVC insertion procedures with device complications and sequelae.

Catheter-to-Vein Ratio

Although thrombosis risk is generally considered to be lower in pediatrics than in adults, the size of the vessel should be considered carefully when choosing the size of a catheter.¹⁶ In agreement with the Infusion Nurses Society guidelines and adult literature, the panel rated a catheter-to-vein ratio of ≤45% as appropriate for PIVCs and PICCs. The panel rated a catheter-to-vein ratio of 50% as uncertain and a ratio of ≥60% as inappropriate.^15,23 For nontunneled CVADs, tunneled CVADs, and totally implanted venous devices, the panel’s catheter-to-vessel ratio of appropriateness ratings were more conservative, with ≤40% appropriate, 45% to 50% uncertain, and ≥60% inappropriate. Although the panel recognized the lack of pediatric-specific literature in this area of practice, these ratings were an instance in which findings from the adult literature were felt to be applicable to pediatric patients. The panel did recommend this a priority for future inquiry.

Device Lumens

In agreement with MAGIC⁸ and multiple national and international guidelines,^15,30,39 the panel rated it appropriate to routinely place a single-lumen device, unless there were specific reasons for a multilumen device (eg, incompatible infusions that could not be separated in time).^8,30 Within this domain, the panel also rated it inappropriate to place a multilumen device with dedicated lumens for blood transfusions and sampling. However, the appropriateness of dedicating lumens for lipid emulsions and PN was rated as uncertain. This rating reflected a lack of evidence regarding risks and benefits with respect to infectious complications from PN and lipid emulsions versus risks and benefits with respect to a multilumen device. Therefore, the panel recommended collaboration with a pharmacist and/or VAD insertion clinician to ensure device characteristic suitability (ie, lumen number and size) as appropriate.

Insertion Locations

The locations into which VADs are inserted directly impact the success of the procedure and risk of complications.^15,39–41 Vessels suitable for VAD insertion in a neonate may become difficult and/or inappropriate to access (eg, scalp vessels) or lead to an increased risk of complications (eg, lower-body PICCs in a mobilizing patient) later in life. Devices inserted into areas of flexion are associated with an increased risk of postinsertion complications, including infiltration, phlebitis, and thrombosis.⁴² Recommendations for the appropriateness of VAD insertion vessels and sites are described in Fig 7.

Vessel Visualization

Vessel visualization technologies, such as ultrasound, near infrared light, and fluoroscopy, are used with increasing frequency in pediatric clinical practice.⁴³ High-quality evidence is available to support the use of vessel visualization techniques during the insertion of several devices, including PIVCs, PICCs, and nontunneled CVADs, to promote insertion success and prevent insertion and postinsertion complications.^43–46 In agreement with previous guidelines,^15,43 panelists rated it appropriate to insert all devices by using ultrasound guidance. Similarly, panelists rated placement of PIVCs in patients with difficult venous access and placement of nonemergent central devices without image guidance as inappropriate. The appropriateness of near infrared light to guide PIVC and midline catheter insertion was rated as uncertain because of limited evidence. Similarly, electrocardiographically guided insertion of PICCs across populations was rated as uncertain because (unlike in the adult population) the evidence in pediatrics for a benefit of this technology is limited. Evaluation of the venous anatomy using ultrasound before placement of all central devices, and placement of VADs in neonates and pediatric patients with long-term vascular access–dependent conditions, was rated as appropriate by the panel.