Selection and Insertion of Vascular Access Devices in Pediatrics: … · Vascular access devices (VADs) are a common and essential component of pediatric health care.1 Arangeof peripheral

Selection and Insertion of VascularAccess Devices in Pediatrics:A Systematic ReviewRebecca S. Paterson, PhD,a,b Vineet Chopra, MD, MSc,c,d,g Erin Brown, PhD,a,b Tricia M. Kleidon, RN, MNursPrac,a,e

Marie Cooke, RN, PhD,a,f Claire M. Rickard, RN, PhD,a,f Steven J. Bernstein, MD, MPH,c,g Amanda J. Ullman, RN, PhDa,e,f

abstractOBJECTIVE: To critically review the evidence for the selection and insertion of pediatric vascularaccess devices (VADs).

DATA SOURCES: Data were sourced from the US National Library of Medicine, Cumulative Index toNursing and Allied Health, the Cochrane Library databases, Embase, and international clinicaltrial databases.

STUDY SELECTION: Clinical practice guidelines, systematic reviews, cohort designs, randomizedcontrol trials (RCTs), quasi RCTs, before-after trials, or case-control studies that reported oncomplications and/or risk as well as reliability of VADs in patients aged 0 to 18 years wereincluded.

DATA EXTRACTION: Articles were independently reviewed to extract and summarize details on thenumber of patients and catheters, population, age of participants, VAD type, study method,indication, comparators, and the frequency of VAD failure or complications.

RESULTS: VAD selection and insertion decision-making in general hospitalized and somespecialized patient populations were well evidenced. The use of single-lumen devices andultrasound-guided techniques was also broadly supported. There was a lack of RCTs, and forneonates, cardiac patients, patients with difficult venous access, midline catheters, catheter-to-vein ratio, and near-infrared devices, the lack of evidence necessitated broadening thereview scope.

LIMITATIONS: Limitations include the lack of formal assessment of the quality of evidence and thelack of RCTs and systematic reviews. Consequently, clinical decision-making in certainpediatric populations is not guided by strong, evidence-based recommendations.

CONCLUSIONS: This is the first synthesis of available evidence for the selection and insertion ofVADs in pediatric patients and is important for determining the appropriateness of VADs inpediatric patients.

WHAT’S KNOWN ON THIS SUBJECT: Individual studies, systematic reviews, andfocused clinical practice guidelines that evaluate vascular access devices (VADs)in various pediatric populations are available. However, to date, no systematicreview examining the appropriateness, and inappropriateness, of VADs acrosscommon pediatric clinical scenarios exists.

WHAT THIS STUDY ADDS: There is strong evidence to support and facilitateappropriate clinical decision-making in some pediatric indications. However,certain populations, device types and characteristics, and insertion proceduresare poorly evidenced, necessitating the application of clinical judgment for VADdecision-making.

To cite: Paterson RS, Chopra V, Brown E, et al. Selectionand Insertion of Vascular Access Devices in Pediatrics:A Systematic Review. Pediatrics. 2020;145(s3):e20193474H

aAlliance for Vascular Access Teaching and Research, Menzies Health Institute Queensland and fSchool of Nursingand Midwifery, Griffith University, Nathan, Queensland, Australia; bChild Health Research Centre, Faculty ofMedicine, The University of Queensland, Brisbane, Queensland, Australia; cPatient Safety Enhancement Programand Center for Clinical Management Research, Veterans Affair Ann Arbor Healthcare System, Ann Arbor,Michigan; dDivisions of Hospital Medicine and gGeneral Medicine, Department of Internal Medicine, MedicalSchool, University of Michigan, Ann Arbor, Michigan; and eQueensland Children’s Hospital, Brisbane, Queensland,Australia

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Vascular access devices (VADs) area common and essential componentof pediatric health care.1 A range ofperipheral and central venousdevices that provide a route toadminister critical and supportivetherapies such as antibiotics,nutrition, and chemotherapy exists.Poor choice of VAD can lead to theinsertion of an inappropriatedevice, which reduces treatmentefficiency and places the patient atincreased risk of harm.2–5 Cliniciansneed to make device and insertiondecisions that ensure optimumtherapy provision while preventingor reducing VAD-relatedcomplications (such as infection,thrombosis, and vessel damage),patient distress, and treatmentdelays.6

To make VAD choices that mitigatepatient harm and optimize treatmentprovision, clinical decision-makingneeds to reflect current, evidence-based guidance for pediatricpatients. Individual studies,systematic reviews, and focusedclinical practice guidelines (CPGs),which evaluate VADs in variouspediatric populations, areavailable. However, to date, nosystematic review examiningthe appropriateness andinappropriateness of VADs acrosscommon pediatric clinical scenariosexists. Systematic identification ofhigh-quality evidence is necessary,not just to inform clinical decision-making and improve patientoutcomes, but to further identify gapsin evidence that translate to gaps inpractice and increase the risk ofpatient harm. In this review, weaimed to systematically andpragmatically evaluate all availableevidence and guidance for VADs toinform the determination of MichiganAppropriateness Guide forIntravenous Catheters inPediatrics7,8 using the RANDCorporation–University of California,Los Angeles (RAND-UCLA)Appropriateness Method.9

METHODS

A systematic review was undertakento synthesize existing evidence onselection and insertion of pediatricVADs following the RAND-UCLAAppropriateness Method.9 Thesystematic review protocol wasregistered and published with theInternational Prospective Register ofSystematic Reviews (PROSPERO;CRD201994286)10 and is reported inaccordance with the PreferredReporting Items for SystematicReviews and Meta-Analyses(PRISMA) standards.11

Search Strategy

We conducted searches of theUS National Library of Medicine(Medline), Cumulative Index toNursing and Allied Health, CochraneLibrary databases, Embase, andinternational clinical trial databasesfor all studies in which authorsreported VAD use (success andcomplications) in a pediatricpopulation from 2008 to May 16,2018. Search terms were developedin collaboration with an experiencedmedical librarian. We used explodedMedical Subject Headings (MeSH)terms (eg, catheters) and relevantkeywords and their variants (eg,child, pediatrics). Table 1 reveals theelectronic database search strategy.

Eligibility Criteria

Following the RAND-UCLAAppropriateness Method, our goal wasto provide a critical review of theliterature summarizing the scientificevidence available surroundingthe appropriateness of pediatricVAD selection, insertion, andcharacteristics.9 This meant a range ofstudy designs was eligible forinclusion, including existing CPGs,systematic reviews, randomizedcontrol trials (RCTs), quasi RCTs,before-after trials, cohorts, or case-control studies. Additionally, theguidelines and studies must have beenpublished in a peer-reviewed journaland authors must have reported on

complications and/or risk andreliability of VADs in patients agedterm to 18 years in a pediatric hospital.We defined VADs to includeintraosseous devices; midlinecatheters; peripherally inserted centralcatheters (PICCs); short and longperipheral intravenous catheters(PIVCs); tunneled, tunneled-cuffed, andnontunneled central venous accessdevices (CVADs); totally implantablevenous devices; and umbilicalcatheters. We excluded studies thatwere not published in English andconference abstracts, animal studies,NICU studies, n = 1 studies, casereports, case-series reports, andqualitative reports. Although eligibilitycriteria were focused on pediatricstudies (ie, term to 18 years), wedetermined that including pretermneonate and adult studies waspreferential to no evidence.

Outcome Measures

The primary outcomes were defineda priori as (1) device and insertioncharacteristics that impact thesuccess of VAD insertion and (2)device and insertion characteristicsassociated with VAD failure, due tocomplications before the completionof therapy, or successful VADinsertion. Device characteristicsincluded VAD type, device catheter-to-vein ratio, and device lumens.Insertion characteristics includedinsertion site and location and the useof vessel visualization technology.Complications included but were notlimited to central line–associatedbloodstream infection (CLABSI), VAD-associated thrombosis, occlusion,catheter dislodgement, catheter-tipmigration, catheter breakage orrupture, local infection, and phlebitis.

Screening

Title and abstract screening wasperformed independently by 2 reviewauthors (E.B. and A.J.U.), excludingstudies that did not meet eligibilitycriteria when this could bedetermined by the abstract alone.Full-text articles included for

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screening were reviewed by 2 reviewauthors (E.B. and A.J.U.) andindependently assessed against theinclusion or exclusion criteria.Duplicate publications were excluded.When individual studies that hadbeen evaluated in a systematic reviewalso returned in the search, theprimary study was excluded to avoidrepetition, and the systematic reviewwas referred to. Any discrepanciesbetween review authors wereresolved through mutual discussionand, when required, a third,independent review author (M.C.)was consulted.

Data Extraction and Synthesis

All full-text articles that met inclusioncriteria were independently reviewedby 3 review authors (R.S.P., E.B., andA.J.U.) to extract details on thenumber of patients and catheters,population, age of participants, VADtype, study method, indication,comparators, and the frequency ofVAD failure or complications. Thesedetails were summarized in a dataextraction sheet and were cross-checked for accuracy and agreement.Additional relevant references wereidentified by examining referencelists of included studies andguidelines. Hand-searched referenceswere evaluated to ensure that theymet inclusion criteria. Afterscreening, pragmatic inclusion of

wider studies was employed. That is,if no studies identified meetingthe preferential inclusion orexclusion criteria, we included widerstudies (eg, a priori area of deficitincluded neonates outside of theNICU). The extracted data werethen combined by using narrative(descriptive) synthesis by categories(ie, outcome, vascular device,indication).

Study Quality and Risk of Bias

The methodologic quality,transparency, and relevance of allindividual included studies wereindependently assessed by 2 reviewauthors (E.B. and A.J.U.) by usingthe Strengthening the Reportingof Observational Studies inEpidemiology (STROBE) guideline12

and Critical Appraisal Skills Program(CASP) Cohort Study checklist.13

RCTs and systematic reviews werepreferentially included as the goldstandard level of evidence forevaluating VADs. However, whenthis level of evidence did not exist,a pragmatic approach was taken sothat studies outside of the scope ofthe review (eg, laboratory, prematureneonate, or adult studies) and CPGs(which may be limited by the numberor quality of included studies) wereincorporated into the review. Toprovide a synthesis of the availableliterature for the purpose of the

RAND-UCLA AppropriatenessMethod,9 studies were categorizedaccording to their methodology: (1)CPG, (2) systematic review or otherreview, (3) RCT, (4) observationalstudy with comparator, and (5) other(clinical review, pilot study,laboratory study).

RESULTS

Study Selection

The results of the search strategy andstudy selection are summarized inFig 1. Electronic database searchesidentified 7430 articles, and handsearches of the bibliography ofincluded studies and clinicalguidelines identified 30 additionalarticles for potential inclusion.After removal of duplicates andscreening for eligibility, a total of133 studies and CPGs met eligibilitycriteria and were included in dataextraction.

Study Characteristics

The review includes 27 CPGs(20.4%), 11 systematic reviews(8.3%), 10 RCTs (7.6%), 79observational studies (59.8%), 3 pilotstudies (2.3%), 2 clinical reviews(1.5%), and 1 laboratory study(0.8%). These were sourced fromresearch teams based in Africa(1.6%), Asia (9.3%), Europe (31.0%),

TABLE 1 Summary of Search Terms Used for the Electronic Database Search

BooleanVariable

Search Terms

AND Title and abstract terms: pediatric* OR pediatric* OR child* OR youth* OR adolescen* OR neonate* OR toddler* OR baby OR babiesOR MeSH terms: Child OR Adolescent OR Infant OR “Infant, Newborn”

AND Title and abstract terms: vascular access device* OR central venous catheter* OR midline* OR Central venous access device* OR PICC* ORperipherally inserted central catheter* OR peripheral cannula* OR peripheral catheter* OR peripherally inserted OR intravenous access

OR MeSH terms: Vascular Access Devices OR Central Venous Catheters OR Infusions, Intraosseous OR Infusions, Intravenous OR Infusions,Subcutaneous

AND Title and abstract terms: vessel health OR adverse OR complicat* OR appropriat* OR inappropriat* OR indicat* OR guideline* OR unnecessaryOR publication type: guideline OR practice guidelineOR MeSH terms: Guidelines as Topic OR Unnecessary Procedures

NOT Title and abstract terms: abortion OR blood donor* OR caesar* OR obstet* OR pregnan* OR distraction OR immunization OR immunization ORvenipuncture OR venepuncture OR sucrose OR dose OR case report OR case study

OR MeSH terms: Drug dosage calculationsOR publication type: case reports

FILTERS Language: EnglishAND Publication date: from 2008/01/01

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the Middle East 2.3%), North America(40.3%), Oceania (11.6%), and SouthAmerica (3.9%), with the majoritysourced from the United States(n = 34; 37.8%). Subjects within theincluded studies ranged in age, frompremature neonates up to 66 years,and required treatment of oncologicor hematologic conditions, supportduring critical care admission, orvascular access for hemodialysis,postsurgical, or general infusiontherapy or parenteral nutrition (PN).Due to the heterogeneity across ageand conditions in pediatric patients,included articles were divided intospecific clinical subspecialties (eg,hospitalized pediatric patients,hematology or oncology; see Fig 2).Results from individual studies basedon specific hospitalized populations

are presented in Table 2 andinclude key characteristics foreach study.

VAD Selection in HospitalizedPediatric Populations

A total of 3 CPGs and 26 studies wereincluded for general hospitalizedpediatric patients, including 1systematic review, 1 RCT, and 23observational studies. These studiescompared all VADs in hospitalizedadult (n = 3); child (n = 13), infant(n = 2), and neonatal (n = 3); andsurgical (n = 1) populations. With theexception of 1 CPG, no studiesreported on midlines in the pediatricpopulation, so adult studies werealso included.14,43,94

Neonates

Overall, umbilical catheters wereassociated with high rates ofcomplications, including catheter-related bloodstream infection,occlusion, dislodgement, thrombosis,and local infection or phlebitis,with device failure beingcommon.6,15,30,54,57,125,127 Umbilicalcatheter malposition and catheter-tipmigration during treatment alsofrequently occurred,6,142 withconcerns that malpositioned ordislodged umbilical catheters maylead to severe hemorrhage and evendeath if not detected or rectified ina timely manner.58 Despite this, theliterature reviewed indicated thatumbilical catheter placement iscommon practice in neonates up tothe first 7 days of life.23 Evidence forumbilical catheter dwell time wasscarce and supported placement forshort durations only, due to ofincreased risk of device failure.24,57

Consequently, guidance fromavailable CPGs was limited butrecommended placement only for aslong as clinically necessary, or #14days, if managed aseptically.136

Beyond 15 days, ambiguity in theliterature regarding the patency ofthe umbilical vascular system andcatheter for longer durations wasevident.136,142 One CPG did supportreplacing any umbilical catheter witha PICC for central access .7 daysto reduce risk of infection.136

Alternative VADs for neonates includePICCs and CVADs6,34,66,136; however,it was recognized that neonatesfrequently had poor or difficult-to-access venous assets,45,55 were morelikely to have higher risk of insertion-related complications,55 and were athigh risk of blockage across alldevices.6

Infants

PICCs are commonly the first VADchoice for infants.136 Numerousstudies found that PICCs in infantswere associated with a lower risk ofcomplications, particularly

FIGURE 1PRISMA flowchart of study selection. VA, vascular access.


thrombosis,28,122 leading currentCPGs to recommend their use inchildren ,1 year and for therapiesfor longer durations (.7days).56,122,136 Conversely, PIVCshad significantly higher rates ofdysfunction in infants (50%)compared with children .1 yearand for longer dwell times,125

with one CPG only recommendingPIVCs for therapies ,6 days.136 Noneof the included evidence evaluatedthe complications associated withmidline catheters in infants; however,the National Association of NeonatalNurses recommended them asan appropriate alternative forperipherally compatible intravenous(IV) therapy for ,6 to 10 days ininfants.136

Compared to PICCs, tunneled-cuffedCVADs were associated with higherrates of thrombosis (althoughthrombosis tended to occur afterlonger durations in situ), with 60% oftunneled-cuffed CVADs developingdeep vein thrombosis (DVT).67

Tunneled-cuffed CVADs were alsoassociated with higher rates ofinsertion failure in infants and youngchildren.55 Risk of infection in CVADsplaced in infants was high, especiallycompared with toddlers, and waslinked to the use of totally

implantable venous devices.59 Astunneled CVADs and totallyimplantable venous devices restrictthe future use and availability ofaccessed veins and insertion wasrelated to a higher risk ofcomplication, studies and CPGsindicated that their use in infantsshould be limited.97,136

Children and Adolescents

For hospitalized children andadolescents, PIVCs and midlinecatheters were reported asappropriate for short-termperipherally compatible therapies inmultiple studies because of their lowrisk of catheter-related infections andthrombosis in comparison toPICCs.14,43,94,100,127,143 However, inone study, the authors suggested thatthese devices are associated withincreased risk of occlusion withextended dwell times.127 PICCs werereported to have high insertionsuccess rates84 and low failure ratesin children and adolescents,6,59

although one study reported severecomplications in 40.1% of failedPICCs, associated with increasingpatient age.28 PICC insertion wascommonly associated with short-termcomplications such as occlusion,CLABSI, and thrombosis,6,30 with

rates of these events increasing withlonger durations of therapy.30

In comparison, tunneled-cuffedCVADs had high rates of infection(4.8%–19.9%)6 and were associatedwith short-term complications, suchas infection, malfunction, leak, andmalposition,59,134 and high rates ofocclusion (12.1%).6 Although totallyimplantable venous devices had lowrates of infection (0.01–0.28 per 1000catheter days),6 they were associatedwith early complications, such asbleeding, pneumothorax, nervelesions, catheter misplacement,occlusion, and skin damage,97,103 andlong-term complications, such asinfection, thrombosis, catheterfracture or disconnection, secondarydislocation, and skin breakdown overport septum.6,56,103 Overall, tunneled-cuffed CVADs and totally implantablevenous devices had high insertionsuccess rates55,59,87 and low failurerates,1,6 and can be used asalternatives to PICCs in patientsrequiring frequent vascular access.56

Given their high insertion successrate,87 nontunneled CVADs can beplaced after the failed placement ofother CVADs.56

VAD Selection in Special PediatricPopulations

Malignant Hematologic and OncologicalConditions

For patients undergoing treatment ofmalignant hematologic andoncological conditions, infection andthrombotic complications, as well asdisruption to treatment, areimportant considerations for VADselection.25,119 A total of 17 studies,including 1 systematic review and 16observational studies, and 5 CPGswere included. Most studies werefocused on tunneled-cuffed CVADsand totally implantable venousdevices in mixed hematology andoncology (n = 5), PN (n = 1), andleukemia (n = 3) populations. Otherstudies compared PICCs, CVADs, andtotally implantable venous devices in

FIGURE 2Quantity of evidence based on patient subgroup. CVAD includes nontunneled, tunneled, and tunneled-cuffed CVADs.


TABLE2Summaryof

CPGs

andStudiesIncluded

inSystem

aticReview

Study,Year

Participants,n

Design

and/or

Method

Focusand/or

Overview

StudySampleandCharacteristics

Device

Findings

andComments

miniMAGIC

Indication

Adam

set

al,14

2016

—Clinical

review

aClinical

review

ofmidlinecatheter

device

indications

andcomplications

forusein

theED

—Midline

Midlines

have

alowcomplicationrate,longdw

ell

time,andhigh

rateoffirst-attem

ptplacem

ent.

Generalpediatrics

Aiyagariet

al,15

2012

89Observationala

Tocompare

theclinicaloutcom

esforinfantswith

single-

ventriclephysiology

afterum

bilical

catheter

and

femoral

CVAD

placem

ent

Patientswith

single-ventricle

physiology

admitted

totheNICU

(4–13

d)

NontunneledCVAD,u

mbilical

catheter

NontunneledCVADswereassociated

with

higher

ratesof

thrombosisandvein

occlusion.

No

differencewas

seen

amongCLABSI,need

for

transhepaticaccess,and

ultrasound-

documentedthrombusat

theinferior

vena

cava–rightatrial

junction.

Patientswith

nontunneledfemoral

CVAD

for$14

dhad

ahigher

prevalence

ofthrombosisthan

those

for,14

d.No

differencein

theprevalence

of

iliofem

oral

vein

occlusionwas

seen.

Generalpediatrics

Ainsworth

and

McGuire,16

2015

549

System

atic

review

bTo

evaluate

PNdeliveryviaPIVC

orCVAD

inhospitalized

neonates

Included

6RCTs

evaluatingPN

deliveryviaPIVC

or

CVAD

inhospitalized

neonates

PIVC,nontunneled

CVAD

NontunneledCVAD

ledto

asm

allerdeficitof

nutrientsandfewer

catheters;therewas

no

differenceforinvasive

infection.

Long-term

dependent

Altenet

al,17

2012

115

Observationala

Tocompare

USGCVAD

insertionto

landmarktechniques

incritically

illneonates

Retrospectivereview

ofcritically

illneonates

(mean=,14

d)admitted

tothePICU

requiringCVAD

placem

entusingUSGor

landmarktechniques

CVAD

Insertionusingultrasound

guidance

was

associated

with

higher

overallsuccess,first-,

andsecond-attempt

success,andlower

arterial

puncture

rates.

Vessel

visualization

Anilet

al,18

2011

128

Observationala

Toevaluate

complications

associated

with

CVAD

placem

entin

thePICU

Retrospectivereview

ofallpatients(m

edian=21

mo)

admitted

tothePICU

requiringCVAD

placem

ent

CVAD

Therewas

nodifferenceincomplications

forCVAD

insertionat

femoral,subclavian,

orjugular

veins.

Insertionlocation

ANZICS,19

2012

—CPGb

Specificrecommendations

forinsertioncentrallines

for

thepreventionof

CLABSI

—NontunneledCVAD,tunneledCVAD

—Insertionlocation

Allenet

al,20

2008

—Observationala

Todeterm

inetherisk

ofinfectionin

pediatriconcology

patientsrequiringlong-term

vascular

access

12-moprospectivestudyof

pediatriconcology

patients(3

mo–20

yold)

with

aTIVD

or

tunneled-cuffedCVAD

TIVD,tunneled-cuffedCVAD

Therewas

ahigher

rate

ratio

forCLABSIsin

tunneled-cuffedCVAD.

Hematologyand

oncology

ARCandNZRC,21

2010

—CPGb


foraccess

tocirculationin

infantsandchildrenin

thecontextof

cardiorespiratoryarrest

—CVAD,intraosseous,PIVC

—Criticalcare

ARCandNZRC,22

2010

—CPGb

Medicationor

fluids

fortheresuscitationof

the

newborn

infant

—Intraosseous,PICV,um

bilical

catheter


fornewborn

infantsin

thecontextof

resuscitationwereprovided.

Criticalcare

ARCandNZRC,23

2010

—CPGb


forvascular

access

in

pediatricpatientsinthecontextofcardiopulmonary

arrest

—CVAD,intraosseous,PICV

—Generalpediatrics

Arntset

al,24

2014

203

Observationala

Tocompare

theratesof

complications

between

umbilical

cathetersandPIVCsin

newborns

Patientsadmitted

totheNICU

(24–42

wk

gestation)

requiringaPICC

orum

bilical

catheter

PICC,umbilical

catheter

Therewas

nodifferencein

complicationrate

or

dueto

gestationalage.

Generalpediatrics

Athale

etal,25

2012

358

Observationala

Toevaluate

theimpactof

CVAD

on5-yoveralland

event-

free

survival

inchildrenwith

cancer

Childrenwith

non-CNScancer

(#19

yold)

who

required

aCVAD

CVAD

CVAD

dysfunctioncontrolling

for

thromboem

bolism

isassociated

with

poorer

5-yoverallandevent-freesurvival.

Hematologyand

oncology

Avanzini

etal,26

2017

194

Observationala

Todescribe

asingle-centertransitionfrom

CVAD

placem

entviasurgical

cutdow

nto

USGinsertion

techniques

Retrospectivereview

ofpediatricpatients(7

d–18

yold)

who

underw

enttunneled

CVAD

placem

entusingUSGor

surgical

cutdow

n

techniques

Tunneled

CVAD

Double-lumen

PICCswereassociated

with

increasedrisk

ofcomplications,com

paredto

single-lumen

PICCs;complications

were

reported

butnotsignificantlycompared

betweenUSGandsurgical

cutdow

n

techniques.

Device

lumens

Vessel

visualization

Barnwal

etal,27

2016

60Observationala

Tocompare

ECGandlandmarkinsertiontechniques

for

CVAD

placem

ent

Pediatricpatients(0–11

yold)

undergoing

elective

cardiovascular

surgeryrandom

lyassigned

to

CVAD

insertionvialandmarkor

ECG

techniques

CVAD

Therewerefewer

complications

usingUSG

insertiontechniques.

Vessel

visualization

Barrieret

al,28

2012

1280

Observationala

Todeterm

inerisk

factorsforPICC-related

complications

inchildren

Immunocom

prom

ised

children(m

ean=3.2yold;

0–21

yold)

requiringaPICC

PICC

Double-lumen

catheters,PICCsplaced

inthe

femoral

vein

andchildren1–4yold,

comparedwith

olderchildren(5–10

yold,

.10

yold),w

eremoreat

risk

for

complications.

Generalpediatrics

Device

lumens

Insertionlocation

Baskin

etal,29

2019

—CPGb


forcentralvenous

catheters

inchildrenwith

chronicillness

—Midline,PICC,TIVD,

tunneled-cuffedCVAD

—Long-term

dependent

BenAbdelazizet

al,30

2017

215

Observationala

Toexam

inetheincidenceof

PIVC-related

complications

inpediatricpatients

Comparisonof

complications

versus

no

complications

inhospitalized

children

(0.1–18

yold)

requiringaPIVC

PIVC

Longer

durationwas

associated

with

local

complication.

Generalpediatrics

Bezzio

etal,31

2019

205

Observationala

Toinvestigatetherateofandrisk

factorsforinfectionin

childrenundergoing

cardiacsurgeryrequiringCVAD

placem

ent

Prospectivestudyof

pediatricpatients(1

d–25

y

old)

undergoing

cardiacsurgery

CVAD

Infectionrisk

significantlyincreasedwith

increaseddurationof

device

placem

ent;the

SCVvein

was

morelikelyto

developCLABSI.

Congenitalcardiac

Insertionlocation

Blotte

etal,32

2017

162

Observationala

Tocompare

PICC

andCVAD

complications

inpediatric

patientswith

intestinal

failure

Pediatricpatients(1

d–12

yold)

with

intestinal

failure

requiringPN

PICC,tunneled-cuffedCVAD

Tunneled-cuffedCVAD

hadahigher

infectionrate,

andPICCsweremorelikelyto

break.More

Long-term

dependent


TABLE2

Continued

Study,Year

Participants,n

Design

and/or

Method

Focusand/or

Overview


Device

Findings

andComments

miniMAGIC

Indication

tunneled-cuffedCVADshadcentralvenous

thrombosis,whereas

morePICCshadbasilic

vein

thrombosis.

Birhaneet

al,33

2017

178

Observationala

Toassess

factorsthat

impacted

PIVC

lifespan

in

neonates

andinfants

Neonates

andinfants(1

d–11

mo)

requiringPIVC

placem

ent

PIVC

Comparedto

placem

entat

thescalp,hand,orleg,

PIVCsinserted

atthearm

hadalonger

life

span.

Insertionlocation

Bodenham

Chairet

al,34

2016

—CPGb


fortheinsertionof

VADs

in

allpatients

—CVAD,P

IVC

—Criticalcare

Catheter-to-veinratio

Device

lumens

Vessel

visualization

Boeet

al,35

2015

92Observationala

Toevaluate

risk

factorsandcomplications

associated

with

theplacem

entof

transhepaticCVADs

Retrospectivereview

ofcongenitalcardiac

patients(IQ

R=2–10

yold)

undergoing

transhepaticCVAD

placem

ent

Transhepatic

CVAD

Placem

ent$21

dwas

associated

with

increased

transhepaticCVAD

complications.

Criticalcare

Borasino

etal,36

2014

392

Observationala

Todeterm

ineifCVAD

insertioninto

veinsin

theupper

body

isarisk

factor

forchylothorax

Retrospectivereview

ofpediatricpatients(,

1y

old)

undergoing

cardiacsurgery;comparison

amongCVAD

placem

entat

IJVversus

SCV

versus

femoral

vein

CVAD

Insertionat

IJVor

SCVwas

associated

with

ahigher

risk

ofchylothorax.

Insertionlocation

Borettaet

al,37

2018

107

Observationala

Toevaluate

themanagem

entandcomplications

associated

with

PICCsinserted

inpediatriconcology

patients

Pediatriconcology

patients(0–17

yold)

requiring

PICC

placem

ent

PICC

Comparedto

right-sideinsertionlocations,P

ICCs

inserted

ontheleftside

ofthebody

were

associated

with

morecomplications.

Insertionlocation

Bouazizet

al,38

2015

—CPGb


fortheplacem

entof

VADs

underultrasound

guidance

inallpatients

—CVAD,P

IVC

—Vessel

visualization

Bozaan

etal,39

2019

226

Pilotstudya

Toevaluate

theimpact

ofan

interventiondesigned

to

increase

theuseof

single-lumen

PICCs

Pre-andpostinterventio

nof

PICC

placem

entin

hospitalized

adults

(60yold)

PICC

Makingsingle-lumen

PICCsthedefaultoptionand

providingindications

formultilum

endevices

increaseduseof

single-lumen

PICCs.

Device

lumens

Brattonet

al,40

2014

178

Observationala

Toreport

complicationratesof

VADs

inchildren

undergoing

radiotherapy

Retrospectivereview

ofpediatricpatients(1–26

y

old)

undergoing

radiotherapy

who

received

aVAD

PICC,TIVD,

tunneled-cuffedCVAD

TIVDswereassociated

with

lower

infectionand

complicationratesandhadgreaterdurability.

Hematologyand

oncology

Byon

etal,41

2013

98RCTc

Toevaluate

theefficacy

ofUSGSCVcatheterization

Pediatricpatients(0–2.9yold)

undergoing

electivecongenitalcardiacsurgeryor

neurosurgery;randomlyassigned

to

supraclavicularor

infraclavicularapproaches

CVAD

Thesupraclavicularapproach

was

associated

with

shorterpuncture

time,fewer

insertion

attempts,andfewer

misplacem

ents.

Insertionlocation

CamkiranFiratet

al,42

2016

280

RCTc

Tocompare

therate

ofcomplications

associated

with

IJVandSCVCVAD

insertion

Pediatricpatients(16mo–2.2yold)

undergoing

cardiacsurgery;random

lyassigned

toIJVor

SCVinsertion

CVAD

InsertionviatheSCVwas

associated

with

higher

successrates;lower

ratesof

arterial

puncture,catheter-tip

cultures,andCLABSI;

andhigher

ratesofmalposition.Therewas

no

differencein

mechanicalcomplications,ICU

andhospitallength

ofstay,and

in-hospital

mortality.

Insertionlocation

Campagnaet

al,43

2018

1538

Observationala

Todeterm

inethesafety

ofmidlinecathetersused

in

generalhospitalized

adults

Hospitalized

adults

(median=83

yold)

requiring

amidlinecatheter

across

2Italianhospitals

Midline

Atotalof

10%

ofmidlinecathetershadaserious

adverseevent.

Generalpediatrics

Carlsonet

al,44

2015

3846

Observationala

Tocharacterize

procedures

performed

oncritically

ill

childrenby

emergencymedicalservicepersonnelin

out-of-hospitalcontexts

Retrospectivereview


y

old)

requiringout-of-hospitalcriticalcare

CVAD,intraosseous

CVADshadhigher

successratescomparedto

intraosseous

devices.

Criticalcare

Carraroet

al,45

2013

—CPGb


fortheuseof

long-term

centralvenous

access

inpediatrichematologyand

oncology

patients

—TIVD,tunneled-cuffedCVAD

—Hematologyand

oncology

Cesaro

etal,46

2016

1161

Observationala

Toreport

thefrequencyandassociated

risk

factorsfor

centralvenous

catheter–associated

complications

inchildrenwith

hemato-oncologicalconditions

Pediatrichematology-oncology

patients(m

edian=

6.1yold)

requiringatunneled-cuffedCVAD

Tunneled-cuffedCVAD

At,6.1yold,

thereweremoremechanical

complications,m

oremalfunctionor

occlusion;

comparedto

single-lumen

devices,double-

lumen

deviceshadmoremechanical

complications,exit-site

ortunnel

infections,

andmalfunctionor

occlusion.

Hematologyand

oncology

Device

lumens

Chen

etal,47

2020

4405

System

atic

review

bTo

compare

risk

associated

with

PICCsplaced

inthe

upperversus

thelower

extrem

ityin

neonates

Neonates

(,28

dold)

requiringPICC

placem

ent

PICC

Therewas

agreaterrisk

ofnonelectiveremovals

andmalpositionin

PICCsplaced

intheupper

versus

lower

extrem

ity;there

was

alower

risk

ofthrombosisin

PICCsplaced

atthe

upperextrem

ity.There

wereno

differences

in

mechanicalcomplications,PICC-related

infection,

orphlebitis.

Insertionlocation

Choi

etal,48

2017

23Observationala

Todeterm

inethesafetyandaccuracy

ofTIVD

placem

ent

usingultrasound

guidance

comparedto

surgical

cutdow

n

Retrospectivereview

ofpediatric(0–16

yold)

hematology,oncology,and

PNpatients

undergoing

TIVD

placem

ent

TIVD

Therewas

nodifferenceusingultrasound

guidance

ininsertiontim

eor

complication

comparedto

surgical

cutdow

n.

Vessel

visualization

Coolinget

al,49

2017

75Observationala

Toexam

inetheperformance

andsafety

offemoral

CVADs

Retrospectivestudyof

pediatricpatients

undergoing

stem

cellcollection(m

edian=3y

old)

requiringCVAD

placem

ent

CVAD

Comparedto

thoracicCVADs,femoral

CVADshad

fewer

flow

-related

adverseevents.

Insertionlocation

Crocoliet

al,50

2015

—CPGb

CVADsin

pediatricpatientswith

cancer

——


TABLE2

Continued

Study,Year

Participants,n

Design

and/or

Method

Focusand/or

Overview


Device

Findings

andComments

miniMAGIC

Indication

Midline,PICC,nontunneled

CVAD,TIVD,

tunneled

CVAD,tunneled-cuffedCVAD

Hematologyand

oncology

Long-term

dependent


Device

lumens

Vessel

visualization

Debourdeau

etal,51

2009

—CPGb

Preventionofthrombosisassociated

with

centralvenous

cathetersin

patientswith

cancer

—TIVD,tunneledCVAD

—Hematologyand

oncology

Device

lumens

Insertionlocation

DeCarvalho

Onofre

etal,52

2012

42RCTc

Tocompare

theuseof

ultrasound

andpalpation

insertionsuccessforPICC

placem

entin

pediatric

patients

Anypediatricpatient

(1mo–16

yold)

requiringIV

therapyfor.7d;

random

lyassigned

toUSG

PICC

insertionor

palpation

PICC

USGPICC

insertionwas

associated

with

higher

first-attem

ptsuccessrate,b

ettercatheter

positioning

andshorterinsertiontim

e.

Vessel

visualization

deSouzaet

al,53

2018

80RCTc

Todeterm

ineifUSGPICC

placem

entledto

higher

insertionsuccesscomparedto

landmark

techniques

Critically

illpediatricpatients(IQ

R=3mo–1.3y

old)

admitted

tothePICU

requiringPICC

insertionviatheIJV;random

lyassigned

to

USGor

landmarkinsertion

PICC

USGPICC

insertionwas

associated

with

higher

overallsuccessrate,fi

rst-andthird-attempt

successrate,low

erinsertiontim

e,andfewer

hematom

asandarterialpuncturescompared

tolandmark.

Vessel

visualization

DeWitt

etal,54

2015

180

Observationala

Todeterm

ineprocedural

successandfailure

ratesin

umbilical

catheter

placem

ent

Patientswith

congenitalheartdisease,20

hold

versus

.20

holdrequiringan

umbilical

catheter

Umbilical

catheter

Therewas

ahigher

successrate

foryounger

patients.

Generalpediatrics

Dheeret

al,55

2011

103

Observationala

Tocompare

theratesof

immediate

insertion-related

complications

afterCVAD

placem

entin

pediatric

patients

Hospitalized

children(,

12yold)

requiring

aCVAD;com

parisonof

complications

among

neonateversus

infant

versus

.1–12

yold

CVAD

Neonates

wereat

higher

risk

ofimmediate

insertion-relatedcomplications;m

ore

insertionattemptswereassociated

with

insertion-relatedproblems.

Generalpediatrics

Doellman

etal,56

2015

—CPGb


regardingcentralvenous

cathetersthat

accountfortheunique

needsof

pediatricpatients

—Hemodialysiscatheter,P

ICC,nontunneledCVAD,

TIVD,tunneledCVAD


Hematologyand

oncology

Criticalcare

Congenitalcardiac

Long-term

dependent


Device

lumens

Vessel

visualization

Dongaraet

al,57

2017

144

RCTc

Tocompare

successandcomplicationrates,cost,and

insertiontim

ebetweenPICCsandum

bilical

cathetersinserted

intheNICU

Patientsadmitted

totheNICU

(mean=34

wk’

gestation)

requiringaPICC

orum

bilical

catheter

PICC,umbilical

catheter

Therewas

nodifferenceinsuccessrate,time,and

short-term

complications

betweenPICCsand

umbilical

catheters.

Generalpediatrics

Elser,5

82013

—Clinical

review

aClinical

review

ofum

bilical

catheter

placem

ent

Patientsadmitted

totheNICU

requiringan

umbilical

catheter

Umbilical

catheter

Umbilicalcatheter

malpositionor

dislodgementis

associated

with

hemorrhaginganddeath.

Generalpediatrics

Fallonet

al,59

2014

244

Observationala

Todeterm

inedevice-related

complications

ininfants

requiringaVAD

Hospitalized

children(0–3yold)

requiring

acentralvenous

catheter

forprolonged

therapy

TIVD,tunneledCVAD

Infants(#

1yold)

hadhigher

complicationrate,

higher

operativeexchange

rate,h

igher

infectionrate,and

shorterdurationcompared

with

toddlers

(.1yold).

Generalpediatrics

Faustinoet

al,60

2013

101

Observationala

Toexploretheincidenceof

DVTin

PICU

patients

requiringacentralvenous

catheter

Critically

illchildren(0–17

yold)

admitted

tothe

PICU;com

parisons

madeam

ongage(,

1y

oldversus

1–13

yoldversus

13–17

yold)

NontunneledCVAD

Comparedwith

infants(,

1yold),P

ICUpatients

13–17

yoldhadhigher

odds

ofDVT.

Criticalcare

Froehlichet

al,61

2009

93Observationala

Todeterm

ineifCVAD

placem

entusingultrasound

guidance

increasesinsertionsuccessand

decreasescomplications

aftersingle-center

transitionto

USGinsertiontechniques

Prospectivestudyofcritically

illpediatricpatients

(median=2.5yold)

admitted

tothePICU

requiringCVAD

placem

entwith

USGor

landmarktechniques

CVAD

Ultrasound

guidance

was

associated

with

significantlylower

arterial

puncturesand

fewer

No.attem

pts.Therewas

nodifference

insuccessrate

orinsertiontim

ebetween

ultrasound

guidance

andlandmarkgroups.

Vessel

visualization

Frykholm

etal,62

2014

—CPGb

Specificguidelines

forpatientsrequiringcentralvenous

cathetersregardingvascular

approach,u

ltrasound

guidance,andpreventionof

complications

—Dialysiscatheters,nontunneledCVAD,P

ICC,

TIVD,

tunneled-cuffedCVAD

—Long-term

dependent

Device

lumens

Vessel

visualization

Gaballahet

al,63

2014

150

Observationala

Todescribe

complicationratesassociated

with

CVAD

placem

entusingultrasound

guidance

and

fluoroscopicguidance

inneonates

andinfants

Retrospectivereview

ofcritically

illneonates

and

infants(premature–1yold)

requiringCVAD

placem

entwith

USGversus

fluoroscopic

guidance

CVAD

Therewas

nodifferencein

complicationrates.

Insertionlocation

Vessel

visualization

Gallagher

etal,64

2014

168

Observationala

Todeterm

ineifCVAD

placem

entusingUSGtechniques

improved

insertionsuccessin

pediatricED

patients

Retrospectivestudyof

pediatric(3–15

yold)

emergencypatientsrequiringCVAD

placem

entwith

orwithoutultrasound

guidance

CVAD

Therewas

higher

insertionsuccesswhenusing

ultrasound

guidance.

Vessel

visualization

Gonzalez

etal,65

2012

172

Observationala

Todeterm

ineifearlyplacem

entof

TIVDsor

tunneled-

cuffedCVADsin

patientsat

high

risk

ofthrombosis

andinfectionledto

higher

surgical

complications

Retrospectivereview

ofchildrenwith

ALL(4

d–16

yold)

athigh

risk

ofinfectionand

thrombosis

TIVDs,tunneled-cuffedCVADs

Therewas

nodifferencein

infectionrate

between

TIVD

andtunneled-cuffedCVADsandno

differenceinrateofinfectioninsingle-versus

double-lumen

devices.

Hematologyand

oncology

Device

lumens

Gorski

etal,66

2016

—CPGb

——

Criticalcare


TABLE2

Continued

Study,Year

Participants,n

Design

and/or

Method

Focusand/or

Overview


Device

Findings

andComments

miniMAGIC

Indication

Specificpracticerecommendations

foradultand

pediatricpatientsrequiringinfusion

therapy,

includingdevice

selection,

placem

ent,and

complicationprevention

Hemodialysiscatheters,intraosseous,longPIVC,

midline,nontunneledCVAD,P

ICC,shortPIVC,

TIVD,tunneledCVAD,u

mbilical

catheter

Congenitalcardiac

Long-term

dependent


Device

lumens

Vessel

visualization

Gray

etal,67

2012

333

Observationala

Toidentifyrisk

factorsforcatheter-related

DVTininfants

,1yold

Hospitalized

infants(m

ean=34

wk’gestation)

requiringaVAD


Meancatheter

days

before

DVTdiagnosiswere

shorterforPICCsthan

fortunneled-cuffed

CVADs;higher

ratesofDVTwereinmultilum

en

CVADs;themajority

ofDVTwas

infemoral

veins.Femoral

CVADswereassociated

with

greaterDVTratesthan

jugularor

SCVCVADs.

Therewas

moreDVTin

femoral

lines

than

in

sapheno-femoral

tunneled-cuffedCVADs.

Long-term

dependent

Device

lumens

Insertionlocation

Gurien

etal,68

2016

1134

Observationala

Todeterm

inetheincidenceof

complications

associated

with

CVAD

placem

entusingUSGtechniques

Retrospective,multicenterreview

ofpediatric

patients(1.5–12

yold)

who

underw

entCVAD

placem

entwith

landmarkor

USGinsertion

CVAD

Therewas

ahigher

first-attempt

successrate

usingultrasound

guidance

buthigher

risk

of

hemothoraxusingultrasound

guidance.

Vessel

visualization

Habaset

al,69

2018

225

Observationala

Todeterm

inethecomplications

associated

with

CVAD

placem

entat

theBCVinsertionsite

Retrospectivereview

ofpediatricpatients(m

ean

=7yold)

admitted

toPICU

requiringCVAD

placem

ent;BCVinsertionsite

versus

all

others

(fem

oral,subclavian,

jugular)

CVAD

Comparedto

otherinsertionsites,BCVhadfewer

complications.

Insertionlocation

Hamed

etal,70

2013

300

Observationala

Todescribe

insertionsuccessrate

andcomplication

rate

afterdeliveryof

anesthesia

tocritically

ill

infantsandtoddlers

Critically

illinfantsandtoddlers

(21d–1.3yold)

requiringem

ergencysurgery

Intraosseous

Intraosseous

access

was

appropriatefor

unobtainable

peripheral

orcentralaccess.

Criticalcare

Hancock-Howardet

al,71

2010

60Observationala

Todeterm

inethecost-effectivenessof

TIVD

placem

ent

usinginterventionalradiology

Retrospectivereview

ofpediatriconcology

patientsundergoing

placem

entof

aTIVD

usinginterventionalradiology(m

ean=7y

old)

orsurgical

cutdow

n(m

ean=4yold)

techniques

TIVD

Insertiontim

ewas

shorterandresultedin

fewer

complications

usinginterventionalradiology

comparedto

surgical

cutdow

n.

Vessel

visualization

Handrupet

al,72

2010

98Observationala

Toevaluate

theratesof

VAD-relatedcomplications

associated

with

placem

entof

aTIVD

ortunneled-

cuffedCVAD

Retrospectivereview

ofchildrenwith

ALL

(,4–.9yold)

who

received

aTIVD

or

tunneled-cuffedCVAD

over

an8-yperiod


Therewas

ahigher

CLABSI

rate

andnonelective

removal

fortunneled-cuffedCVAD.

Hematologyand

oncology

Hanson

etal,73

2012

1070

Observationala

Toinvestigatetherate

ofandrisk

factorsforVTEin

childrenwith

cardiacdiseaseadmitted

tothePICU

Childrenwith

cardiacdisease(m

edian=10

mo)

admitted

tothePICU;com

parisons

made

among,6moversus

6mo–1yoldversus

1–2yoldversus

2–12

yoldversus

12–18

yold

versus

.18

yold

CVAD

VTEincidencewas

associated

with

increasing

No.

CVAD

days.Inyoungchildren(,

6mo),VTE

incidencewas

significantlyhigher.

Criticalcare

Heinrichset

al,74

2013

1076

System

atic

review

bTo

evaluate

assistivetechnologies,other

than

ultrasound

guidance,inimprovingPIVC

insertion

success

SevenRCTs


yold)

requiringPIVC

insertionusingnovel

interventions

PIVC

Transilluminationwas

associated

with

higher

first-attem

ptsuccesscomparedto

traditional

insertiontechniques;first-attem

ptsuccess

usingNIRandtraditional

methods

was

not

significantlydifferent.There

was

no

differencein

timeor

No.attem

ptsbetween

insertionmethods.

Vessel

visualization

Included

studies

Hosokawa,

2010

Katsogridakis,2008

Nager,1992

Perry,2011

Chapman,2011

Kim,2012

Maynard,1989

Institute

forHealthcare

Improvem

ent,7

52012

—CPGb


forthepreventionof

CLABSI

—CVAD

—Vessel

visualization

IVNN

Z,762012

—CPGb

Specificpracticerecommendations

foradultand

pediatricpatientsrequiringinfusion

therapy,

includingdevice

selection,

placem

ent,and

complicationprevention

—Intraosseous,m

idline,nontunneledCVAD,P

ICC,

TIVD,tunneledCVAD,u

mbilical

catheter

—Criticalcare

Long-term

dependent

Device

lumens

Vessel

visualization

Katsogridakiset

al,77

2008

240

Observationala

Todeterm

ineiftransilluminationincreasesPIVC

insertionsuccessin

pediatricpatients

Pediatricpatients(m

ean=13

yold)

with

difficult

venous

access

admitted

totheED

requiring

nonurgentPIVC

placem

ent;random

ly

assigned

towith

orwithouttransillumination

PIVC

Insertionusingtransilluminationwas

associated

with

higher

first-andsecond-attem

ptsuccess

comparedto

withouttransillumination.

Vessel

visualization

Kim

etal,78

2017

132

RCTc

Tocompare

ultrasound

guidance

tolandmark

techniques

forCVAD

insertionin

children

Pediatriccardiacsurgery,neurosurgery,or

generalsurgical

patients(1

mo–6yold)

requiringCVAD

insertion;

random

lyassigned

toUSGinsertionto

theaxillaryvein

orLM

insertionviatheSCV

CVAD

USG1

axillaryinsertionwas

associated

with

fewer

attemptsandshorterinsertiontim

e.

Therewas

nodifferenceincomplicationrates.

Results

wereconfounded

bylocationand/or

imaging.

Insertionlocation

Vessel

visualization

Kulkarni

etal,79

2014

—System

atic

review

bTIVD,tunneled-cuffedCVAD


TABLE2

Continued

Study,Year

Participants,n

Design

and/or

Method

Focusand/or

Overview


Device

Findings

andComments

miniMAGIC

Indication

Asystem

aticreview

ofTIVDsandtunneled-cuffedCVADs

inadults

andchildrenreceivingchem

otherapy

5RCTs

and25

observationalstudies

ofadultsand

childrenundergoing

chem

otherapy

Tunneled

CVAD

was

associated

with

more

infections,n

oninfectious

complications,and

device

removal.

Hematologyand

oncology

Kulkarni

etal,80

2017

176

Observationala

Todescribe

thecomplications

relatedtoVADinsertionin

infantswith

hemophilia

Infants(0–2yold)

with

hemophilia

requiring

either

aPICC,TIVD,

ortunneled

CVAD

PICC,TIVD,

tunneled

CVAD

TIVDshadthelowestratesof

complications.

Hematologyand

oncology

Lam

etal,81

2018

954

Observationala

Toevaluate

theimpact

ofdefaultingto

single-lumen

PICCs

Hospitalized

adults

(mean=66

yold)

requiring

PICC

placem

ent;comparisonof

single

versus

double

lumens

PICC

Single-lumen

PICCswereassociated

with

lower

complications.

Device

lumens

Lampertiet

al,82

2012

—CPGb


regardingUSGVAD

placem

ent

—CVAD,P

ICC

—Catheter-to-veinratio

Vessel

visualization

LauandCham

berlain,83

2016

760

System

atic

review

bTo

exam

inethesafety

andefficacy

ofCVAD

insertion

usingultrasound

guidance

Atotalof

8RCTs

comparing

theuseof

USGand

landmarkCVAD

placem

entin

pediatric

patients(,

18yold)

CVAD

Ultrasound

guidance

hadahigher

successrate

andfewer

No.insertionattemptscomparedto

landmarktechniques.

Vessel

visualization

Included

studies

Alderson,1993

Verghese,1999

Verghese,2000

Grebenik,2004

Chuan,

2005

Ovezov,2010

Aouad,

2010

Bruzoni,2013

Levy

etal,84

2010

279

Observationala

Todeterm

inetherate

ofandpotentialrisk

factorsfor

infectious

andnoninfectious

complication

associated

with

PICCsin

pediatricpatients

Hospitalized

children(10d–21

yold)

requiring

aPICC

PICC

Olderagewas

associated

with

infectious

complications.

Generalpediatrics

Lindquesteret

al,85

2017

33Observationala

Toexam

inethesafety

andefficacy

oftunneled

CVAD

placem

entat

theinternal

andexternal

jugularin

neonates

andinfants,5kg

Multicenterretrospectivereview

ofhospitalized

infantsweighing,5kg

(0–1yold)

with

atunneled

CVAD

Tunneled

CVAD

Therewas

nodifferencein

complications

associated

with

jugularandfemoral

vein

insertionlocations.

Insertionlocations

Lovedayet

al,86

2014

—CPGb


forthepreventionof

hospital-acquiredinfections

—PICC,TIVD,

tunneled

CVAD

—Long-term

dependent

Device

lumens

Malbezinet

al,87

2013

5435

Observationala

Toprospectivelydeterm

inetheoverallsuccessand

complicationrate

ofCVAD

insertionover

a22-y

period

Hospitalized

children(m

ean=5yold)

requiring

anyCVAD

CVAD

Device

failure

was

morelikelyin

children,3kg.

Generalpediatrics

Marshallet

al,88

2017

19Observationala

Tocompare

transhepaticCVADsto

nontunneledCVADs

asan

alternativeforpreserving

future

central

venous

access

Retrospectivereview

ofinfants(1.8–7.8mo)

with

congenitalheartdiseasewho

underw

ent

placem

entof

1or

moretranshepaticCVADs

NontunneledCVAD,transhepatic

CVAD

TranshepaticCVAD

hadalonger

duration.

There

was

nodifferencein

thrombi,throm

bolytic

burden,orcatheter

sitesrequiringwound

care

consultation.Therewas

ahigher

frequencyof

infectionin

transhepaticCVAD.

Therewas

nodifferencein

therate

of

infection-relatedremoval.

Congenitalcardiac

Marquez

etal,89

2016

175

Observationala

Todeterm

inerisk

factorsforthrombosisafter

placem

entof

nontunneledCVADsin

PICU

patients

Prospective,multicenterstudyof

pediatric

patients(4

mo–8.6yold)

admitted

tothePICU

undergoing

CVAD

placem

ent

NontunneledCVAD

Therewerehigher

ratesof

DVTin

patientswith

right-sidenontunneledCVAD

placem

entand

insertionat

SCV.

Insertionlocation

May

etal,90

2018

912

Observationala

Todeterm

inetheratesof

thrombosis,infection,

and

insertionsite

symptom

safterplacem

entof

PICCs

andTIVDsin

patientswith

cysticfibrosis

Retrospectivereview

ofadultandpediatric

patents(m

ean=7.4yold)

with

cysticfibrosis

PICC,TIVD

Double-lumen

PICCswereassociated

with

greater

ratesof

complications.

Long-term

dependent

Device

lumens

Menéndezet

al,91

2016

256

Observationala

Toevaluate

theincidenceandrisk

factorsforPICC-

relatedthrombosisin

children

Hospitalized

children(IQ

R=2.4–13

yold)

requiringPICC

placem

ent

PICC

Acatheter-to-veinratio

of.0.33

predictedPICC-

relatedsuperficial

vein

thrombosisandDVT.


Mermel

etal,92

2009

—CPGb


forthepreventionof

catheter-related

infection

—CVAD,m

idline,PICC,PIVC,TIVD

—Long-term

dependent

Moonet

al,93

2018

629

Observationala

Todeterm

inerisk

factorsforCLABSI

inchildrenwith

hemato-oncologicaldiseaserequiringlong-term

VADs

Retrospectivereview

ofchildrenwith

hemato-

oncologicdisease(m

edian=6yold;

14

d–17.9yold)

requiringanylong-term

CVAD


Therewas

nodifferencein

therate

ofCLABSI.

Hematologyand

oncology

Mushtaq

etal,94

2018

693

Observationala

Todeterm

inethesafety,specifically

ratesof

CLABSI,

mechanicalcomplications,h

ospitallength

ofstay,

readmission

within90

dof

discharge,andmortality

ofmidlinecatheterscomparedto

CVADsin

adults

admitted

tointensivecare

Adults

.18

yoldadmitted

totheICUor

medical-

surgical

wardwith

either

aCVAD

ormidline

catheter

CVAD,m

idline

CVADswereassociated

with

higher

ratesof

CLABSI,crudemortality,readmission,and

transfer

totheICU.

Midlinecathetershad

moremechanicalcomplications.

Generalpediatrics

Noailly

Charny

etal,2

2018

295

Observationala

Tocompare

therisk

ofthrombosisin

PICCsand

tunneled-cuffedCVADs

Children(,

18yold)

diagnosedwith

leukem

ia

who

received

aPICC

ortunneled-cuffedCVAD


PICCswereassociated

with

anincreasedrisk

of

thrombosis.

Hematologyand

oncology

Nifong

andMcDevitt,95

2011

—Laboratory

studya

Todeterm

inetheeffect

ofcatheter

size

offluidflow

rates

—PICC

Fluidflow

ratedecreasedwith

increasing

catheter

size.


O’Gradyet

al,96

2011

—CPGb


forthepreventionof

intravascularcatheter-related

infections

—Midline,nontunneledCVAD,P

ICC,PIVC,TIVD,

tunneled

CVAD

—Device

lumens

Vessel

visualization

Ohno

etal,97

2016

120

Observationala

Todeterm

inetheratesof

complications

andCLABSI

in

infantsandsm

allinfants(,

1yoldor

,10

kg)

comparedwith

children(.

1yoldor

.10

kg)

Children(4

mo–22

yold)

requiringaTIVD

TIVD

Agewas

notassociated

with

increasedrisk

of

complications.

Generalpediatrics


TABLE2

Continued

Study,Year

Participants,n

Design

and/or

Method

Focusand/or

Overview


Device

Findings

andComments

miniMAGIC

Indication

Oulego-Erroz

etal,98

2016

46Pilotstudya

Todeterm

ineifCVAD

insertionto

theBCVusingUSG

techniques

hadgreaterinsertionsuccesscompared

toinsertionto

theIJV

Prospectivestudyof

critically

illchildren(0.6

mo–13

yold)

requiringurgent

CVAD

insertion;

nonrandom

assignmentto

BCV1

USGor

IJV

insertion

CVAD

BCV1

ultrasound

guidance

hadahigher

first-

attempt

successrate,few

erinsertion

attempts,andlower

insertiontim

ecompared

toIJV.Therewas

nodifferencein

overall

successrates.

Insertionlocation

Vessel

visualization

Oulego-Erroz

etal,99

2018

500

Observationala

Todeterm

ineifCVAD

placem

entoutcom

escanbe

improved

byusingUSGinsertion


allcritically

ill

children(IQ

R=2mo–4.9yold)

requiring

temporary

CVAD

placem

entusingUSGor

landmarktechniques

CVAD

Ultrasound

guidance

hadahigher

first-attem

pt

successrate

andfewer

puncture

attempts

andmechanicalcomplications.

Vessel

visualization

Pacilli

etal,10

02018

18Observationala

Todeterm

inetheappropriatenessof

long

PIVCsin

pediatricpatientsundergoing

surgery

Childrenundergoing

surgery(m

ean=6.3yold)

requiringlong

PIVC

insertion

Long

PIVC

Therewereno

immediatecomplications.Onday3,

removalsweremadebecauseof

3occlusions

and1red/pain.

Generalpediatrics

Paladini

etal,10

12018

40Pilotstudya

Tocompare

thesuccessof

USGlong

PIVC

insertionin

childrenadmitted

totheED

toshortPIVCs

Children.10

yold(m

ean=13

yold)

who

were

admitted

totheED;com

parisonofblindshort

PIVC

versus

USGPIVC

insertion

Long

PIVC,short

PIVC

ShortP

IVCs

hadashorterdw

elltimedurationand

morecomplications

comparedto

long

PIVCs;

ultrasound

guidance

hadalower

risk

of

failure

andcomplications

butresults

confounded.

Criticalcare

Vessel

visualization

Park

etal,10

22016

3832

System

atic

review

bTo

determ

inetheutility

ofNIRlight

devices

Atotalof

11RCTs

ofanypediatricpatient

(,21

y

old)

undergoing

PIVC

placem

entusingNIRor

noassistivedevice

PIVC

Therewas

nooveralldifference

inoverallsuccess

rate

betweenNIRlight

device

andtraditional

methods;however,N

IRlight

deviceshad

ahigher

successrate

forsubsetsdeem

ed

high

risk

offailure.

Vessel

visualization

Included

studies

Chapman,2011

Perry,2011

Kaddoum,2012

Kim,2012

Cuper,2013

Graaff,

2013

Sun,

2013

Szmuk,2013

Woude,2013

Graaff,

2014

Curtis,2015

Pasteuret

al,10

32010

—CPGb


forpatientswith

non-CF

bronchiectasis

—TIVD

—Long-term

dependent

Peterson

etal,10

42012

1399

Observationala

Todeterm

ineifassistivedevicesimprovePIVC

insertion

success

Hospitalized

children(m

ean=1yold)

requiring

PIVC

placem

ent;random

lyassigned

to

unassisted

versus

assisted

(transillum

ination

versus

NIRlight

device–guided)insertion

PIVC

PIVC

insertionsuccesswas

higher

whenno

assistivedevice

was

used

comparedto

assisted

methods.

Vessel

visualization

PerinandScarpa,10

5

2015

—System

atic

review

bTo

review

evidence

relatedto

theassessmentof

catheter-tippositioning

inpediatricpatients

Included

42pediatricstudiesexam

iningoutcom

es

forpatientsundergoing

VADplacem

entusing

vessel

visualizationtechniques

CVAD,P

ICC,

umbilical

catheter

Therewas

insufficienthigh-qualityevidence

to

makespecificrecommendationforusein

pediatricpatients.

Vessel

visualization

Pinonet

al,10

62009

915

Observationala

Todeterm

inetheincidenceandrisk

factorsof

central

venous

catheter-related

complications

inpediatric

hemato-oncologicalandimmunologic

conditions

Single-center,prospectivestudyof

children

(0–19

yold)

with

oncological,hematologic,or

immunologicdiseases

TIVD,tunneledCVAD

Tunneled-cuffedCVADswereassociated

with

more

CLABSI;being#3yoldwas

associated

with

moredislodgements

andmoretunnel

infections;C

LABSIwas

moreprevalentin

double-versus

single-lumen

devices.

Hematologyand

oncology

Device

lumens

Pittirutiet

al,10

72009

—CPGb


forCVADsandcomplication

preventionin

patientsrequiringPN

—Midline,PICC,PIVC,TIVD,tunneledCVAD

—Long-term

dependent

Device

lumens

Vessel

visualization

Polkinghorne

etal,10

8

2013

—CPGb


forvascular

access

in

patientswith

chronicrenaldisease

—NontunneledCVAD,tunneledCVAD

—Vessel

visualization

Qian

etal,10

92014

40Observationala

Toexam

inecomplicationratesinpediatricpatientswith

CFaftertheplacem

entof

along

PIVC

Prospectiveauditof


CF

with

infectiveexacerbation

Long

PIVC

Complicationrateswerehigh;noseriousadverse

outcom

eswerereported.

Long-term

dependent

Ramer

etal,11

02016

53RCTc

Toevaluate

theeffectivenessof

NIRlight

device

technology

forPIVC

placem

entin

pediatric

hematologyandoncology

patients

Pediatrichematologyandoncology

patients

(1–21

yold)

requiringPIVC

placem

ent;

random

lyassigned

toNIRlight

device

or

landmarkinsertiontechniques

PIVC

NIRlight

device

was

associated

with

faster

insertiontim

eandhigher

satisfaction.

Vessel

visualization

Rauthet

al,11

12008

138

Observationala

Toinvestigatetherate

ofinfectionin

infantswhenthe

venous

catheter

isexchangedforatunneled-cuffed

CVAD

afterECMOdecannulation

PICU

patients(m

ean=13

d)requiringCVAD

placem

entafterdecannulationfrom

ECMO

Tunneled-cuffedCVAD

Increasing

thedurationof

ECMOandCVAD

placem

entindependently

predictedCLABSI.

Criticalcare

Revel-Vilk

etal,11

22010

d423

Observationala

Todeterm

inetherate

ofcatheter-related

complications

inchildrenundergoing

chem

otherapy

during

12mo

oftherapy

Single-center,prospectivestudyof

pediatric

patients(29d–28

yold)

undergoing

chem

otherapy


PICCswereassociated

with

ahigher

risk

ofDVT;

tunneled

CVAD

hadahigher

risk

ofocclusion

at1y.

Hematologyand

oncology

Reyet

al,11

32009

825

Observationala

Toidentifyrisk

factorsforearlymechanical

complications

inCVADs

CVAD

Difficultvenous

access

Insertionsite


TABLE2

Continued

Study,Year

Participants,n

Design

and/or

Method

Focusand/or

Overview


Device

Findings

andComments

miniMAGIC

Indication

Pediatricpatients(m

edian=22

mo)

admitted

to

thePICU;com

parisons

amongfemoral,

jugular,andSCVCVAD

insertionsites

SCVandjugularvein,aswellas

increasing

No.

attemptswereassociated

with

significantly

moreearlymechanicalcomplications.

Rivera-Tocancipa

etal,11

4

2018

201

Observationala

Todescribe

theincidenceof

complications

associated

with

USGCVAD

insertionin

childrencomparedto

anatom

iclandmarktechniques

Allhospitalized

children(0–18

yold)

requiring

CVAD

insertionusingUSGor

LMinsertion

techniques

CVAD

Ultrasound

guidance

hadfewer

immediate

complications,no

arterial

punctures,and

higher

ratesof

insertionsuccesscompared

tolandmarktechniques.

Vessel

visualization

Rosado

etal,11

52013

255

Observationala

Toexam

inetherate

ofCVAD-associatedinfectionin

PICU

patients

Prospective,single-centerreview

ofchildren

(majority

,6yold)

admitted

tothePICU

requiringaCVAD

CVAD

CVADsinserted

$7dwereassociated

with

ahigher

risk

ofCLABSI.

Criticalcare

Rossettiet

al,11

62015

309

Observationala

Toinvestigatethesafety

andaccuracy

ofintracavitary

ECG-guided

insertionin

pediatricpatients


hospitalized

pediatricpatients(1

mo–18

yold)

requiring

aVAD;

insertionusingintracavitary

ECG

versus

intracavitary

ECGwith

dedicatedECG

monitorcompared

CVAD,P

ICC

Insertionaccuracy

was

higher

with

adedicated

ECGmonitor.

Vessel

visualization

Schifferet

al,11

72013

—CPGb


forcentralvenous

catheters

inpatientswith

cancer

—NontunneledCVAD,P

ICC,tunneled

CVAD,TIVD

—Hematologyand

oncology

Vessel

visualization

Sharpet

al,11

82015

136

Observationala

Toidentifytheoptim

alratio

cutoffto

reduce

ratesofVTE

Prospectivestudyof

hospitalized

adults

(mean=

57yold)

requiringPICC

insertion,comparison

between#45%versus

$45%catheter-to-vein

ratio

PICC

A.45%

ratio

was

morelikelyto

developVTE.

Catheter-to

vein

ratio

Shenep

etal,11

92017

90Observationala

Todeterm

inetheinteractionbetweenPN

andexternal

centralvenous

devicesin

increasing

risk

of

complications

Ratesof

complications

during

PNandnon-PN

periodsin

pediatriconcology

patients

(median=7.3yold)

requiringcentralvenous

devices

TIVD,tunneledCVAD

Risk

ofCLABSI

was

higher

during

PNforchildren

with

TIVDs.Occlusionrisk

was

higher

for

TIVDs.ComplicationratesforTIVDswere

lower

during

thenon-PN

period

butsimilar

during

thePN

period.

Long-term

dependent

Sibson

etal,12

02018

—CPGb


forpreventingthrombosisin


cancer

—PICC,PIVC,TIVD,tunneledCVAD

—Hematologyand

oncology

Sigaut

etal,12

12009

359

System

atic

review

bTo

evaluate

theadvantages

ofUSGCVAD

placem

entover

anatom

iclandmarktechniques

inpediatricpatients

Children(2

d–8yold)

undergoing

cardiacsurgery

requiringCVAD

CVAD

Forultrasound

guidance,nodifferenceinratesof

artery

puncture,h

ematom

a,hemothorax,

pneumothorax,or

timeto

insert

was

found.

Ultrasound

guidance

hadhigher

success

ratesforsubsetsof

novice

operatorsand

during

intraoperativeuse.

Vessel

visualization

Included

studies

Alderson,1993

Chuan,

2005

Verghese,1999

Verghese,2000

Grabenic,2004

Smitherman

etal,12

2

2015

1135

Observationala

Todeterm

inerisk

factorsforthedevelopm

entof

catheter-associatedVTEin

generalhospitalized

pediatricpatients

Chartreview

ofhospitalized

children(m

ean=8y

old)

requiringaVAD

PICC

Increasing

agewas

relatedtoan

increasedrisk

of

thrombosis;lumen

No.w

asnotassociated

with

thrombosisrisk;insertionsite

(brachial

orcephalic,S

CV,jugular,orfemoral

or

saphenous)

was

notassociated

with

an

increasedrisk

ofthrombosis.

Generalpediatrics

Device

lumens

Insertionlocation

Takeshita

etal,12

32015

96Observationala

Toexam

inethefactorsthat

affect

insertionsuccessfor

invisibleandimpalpableperipheralveinsinchildren

Pediatricpatients(1.1–2.8yold)

with

invisibleor

impalpable

veinsundergoing

electivesurgery

PIVC

PIVC

with

ultrasound

guidance

hadbetter

success

ratescomparedto

PIVC

withoutultrasound

guidance;com

paredto

insertionto

thedorsal

hand

vein,the

cephalicvein

hadahigher

successrate

andshorterinsertiontim

e.

Difficultaccess

Insertionlocation

Vessel

visualization

Takeshita

etal,12

32015

196

RCTc

Toexam

inethefactorsthat

affect

insertionsuccessfor

invisibleandimpalpableperipheralveinsinchildren

Pediatricpatients(10–40

mo)

with

invisibleor

impalpable

veinsundergoing

electivesurgery

PIVC

Comparedto

insertionto

thedorsal

hand

or

saphenousvein,the

cephalicvein

had

ahigher

successrate.

Insertionlocation

TheJointCommission,12

4

2013

—CPGb


forpreventingCLABSI

in

CVADs

—CVAD

—Device

lumens

Tripiet

al,12

52016

108

Observationala

Todeterm

inethefrequencyof

PIVC-related

dysfunction

inpediatricpatients

ComparedPIVC

dysfunctionin

hospitalized

children(0–.12

yold)

over

device

durations

of1–2dversus

2–3dversus

.3d

PIVC

Higher

ratesof

PIVC

dysfunctionwereassociated

with

PIVCsin

placefor.3dor

inserted

in

lower

extrem

ities.

Generalpediatrics

Troianos

etal,12

62011

—CPGb


forVADplacem

entusing

ultrasound

guidance

inpediatricpatients

—CVAD,P

ICC,

PIVC

—Vessel

visualization

Ullman

etal,62015

31933

System

atic

review

bTo

review

theincidenceof

VADfailure

inpediatric

patients

Hospitalized

pediatricpatientsacross

74studies

requiringanyVAD

Hemodialysiscatheter,n

ontunneled

CVAD,P

ICC,

TIVD,tunneledCVAD,u

mbilical

catheter

Hemodialysiscathetersandum

bilical

catheters

hadthehighestfailure

rate;TIVDs

hadthe

lowestfailure

rate.

Generalpediatrics

Ullman

etal,12017

1027

Observationala

Toexam

inetheprevalence,m

anagem

ent,andassociated

complications

ofCVADsin

pediatricpatients

Hospitalized

pediatricpatients(IQ

R=1–12

yold)

requiringanyVAD

Hemodialysiscatheter,n

ontunneled

CVAD,P

ICC,

TIVD,tunneledCVAD,u

mbilical

catheter

PICCshadhigher

proportions

ofCVAD-associated

complications

intheprevious

7d.

Generalpediatrics


TABLE2

Continued

Study,Year

Participants,n

Design

and/or

Method

Focusand/or

Overview


Device

Findings

andComments

miniMAGIC

Indication

Unbeck

etal,12

72015

2032

Observationala

Toidentifyrisk

factorsforPIVC-associatedcomplications

inpediatricpatients

Comparisonof

hospitalized

neonatal

versus

pediatricpatients(0–18

yold)

requiring

aPIVC

PIVC

Occlusionwas

associated

with

longer

dwelltim

e.

Neonatal:P

IVCsurvival

timewas

shorter;

therewas

moreinfiltration.

Insertionat

the

arm

bend

oranklewas

associated

with

higher

ratesof

infiltrationandocclusion.

Generalpediatrics

Insertionlocation

vanGent

etal,12

82017

538

Observationala

Todeterm

inetheratesof

infectionandcomplications

in

pediatrichematology,oncology,and

stem

cell

transplant

patients

Retrospectivereview

ofpediatricpatients(m

ean

=7.8yold)

aftersurgical

placem

entof

any

CVAD


Tunneled-cuffedCVAD

hadalower

risk

ofinfection.

Hematologyand

oncology

Vierboom

etal,12

92018

232

Observationala

Toevaluate

thesafety

oftunneled

CVAD

insertionin

childrenweighing,10

kg

Retrospectivereview

ofallchildren(,

1mo–4y

old)

receivingsurgicalinsertionofatunneled

CVAD

with

ultrasound

guidance

orviasurgical

cutdow

n

Tunneled

CVAD

USGinsertionwas

associated

with

lower

mechanicalblockages,buttherewas

no

differenceinintraoperativeandpostoperative

complications,tim

eto

insert,ordevice

longevity.

Vessel

visualization

Vinograd

etal,13

02018

300

Observationala

Toevaluate

PIVC

insertionsuccessin

patientswith

difficultvenous

access

usingUSGtechniques

Pediatricpatients(m

edian=14

yold)

inan

ED

who

hadafailedPIVC

attempt

viatraditional

insertiontechniques

PIVC

PIVC

usingUSGtechniques

ledto

68%

and87%

first-andsecond-attem

ptsuccessratesafter

failedtraditional

method.

Difficultaccess

Vessel

visualization

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mixed hematology and oncologypopulations (n = 5).

Overall, tunneled-cuffed CVADs andtotally implantable venous deviceshad low rates of insertion-relatedcomplications, device failure, andmalfunction40,65,79,80,119,128 andwere associated with low rates ofthrombosis.2,112,132 Reporting onrates of infection between deviceswas variable. Two studies found thatrates of infection were notstatistically different betweentunneled-cuffed CVADs and totallyimplantable venous devices.79,93 Incontrast, other studies found higherrates of CLABSI in totallyimplantable venous devicescompared to CVADs119 and higherrisk of overall infection in totallyimplantable venous devicescompared to tunneled-cuffedCVADs.128 Additional studies foundthat overall infection rates werehigher in tunneled-cuffed CVADscompared to totally implantablevenous devices.20,40,72,106 Althoughocclusion was common in thispopulation,46,65,112,119 rates were notdifferent between tunneled-cuffedCVAD and totally implantable venousdevices.65,133 Compared to totallyimplantable venous devices andtunneled-cuffed CVADs, PICCs hadhigher rates of device-relatedcomplications as well as overallinfection and CLABSI, thrombosis,and occlusion.2,40,112,138

International guidelines recommendthe use of tunneled-cuffed CVADs forpediatric patients undergoinghematologic and oncologicaltreatment requiring frequent andcontinuous vascular access,particularly for frequent bloodsampling, PN, and complex IVtherapies.50,56 Totally implantablevenous devices may also beappropriate across theseindications,51 especially in patients$10 kg.45 These devices were onlyrecommended for intermittent use,however, due to the increased risk ofinfection and thrombosis.45,50 One

CPG endorsed the use of PICCs forshort- to medium-term treatments,50

although there was insufficientevidence to support their routineuse,117,120 and chemotherapytreatment via peripheral venousaccess was not recommended.50,120

No included studies reported onnontunneled CVADs; however, oneinternational guideline supported theplacement for intrahospital use orshort durations only.50

Critically Ill Patients

Unlike other patient groups, forcritically ill infants, children, andadolescents, choice of VAD may beprioritized by whether the patient isstable or unstable.21,22 Sevenobservational studies, 1 systematicreview, and 1 RCT were includedfor critical care patients andincluded the emergency department(ED) (n = 2), emergency surgery(n = 1), moderate-severe burns(n = 1), out-of-hospital criticalcare (n = 1), and PICU (n = 4)populations. No studies exploredmidline devices in the critical carepopulation, although one studycompared short and long PIVCs.101

Overall, the focus of the studies in thispopulation was on infection andthrombosis and not on outcomes suchas dwell time, occlusion, infiltration,extravasation, or bleedingcomplications.

Stable, Critically Ill Patients

Regarding stable, critically ill patientsrequiring short-term acute therapy, 2CPGs supported the use ofnontunneled CVADs for any type ofinfusion therapy up to 7 to 10 daysdespite risk of infection andthrombosis.34,56 Evidence to supportthe use of PICCs in this populationwas mixed. Whereas the InfusionTherapy Standards of Practicecautioned against the use of PICCs incritically ill patients (adults andpediatrics) because of the risk ofinfection or thrombosis,66 2 otherclinical guidelines recommendedPICCs for both short-34,76 and long-

term34 durations in critically illpatients. This variability may be dueto the scarcity of high-qualityevidence directly comparing thesedevices. PIVCs were frequentlyreported within this population101,137

and were recommended overintraosseous devices in nonemergentsituations.21,22 However, comparedto PICCs, PIVCs were commonlyassociated with obstruction, leakage,and dislodgment,137 with short PIVCsin particular linked to higher ratesof local infections, dislocation,infiltration, occlusion, and thrombosiscompared to long PIVCs.101 Therewere limited studies reporting onnontunneled CVAD use in critically illchildren; however, authors of onestudy reported children .13 yearsold with a nontunneled CVAD were athigher risk of DVT compared withchildren ,1 year.60 Tunneled-cuffedCVADs and totally implantablevenous devices were associatedwith high rates of infection andthrombosis but were reportedas suitable for long-term therapiesin this population.34,73,111,115 Nostudies or CPGs reported on thesuitability of midline devices inthis population specifically, althoughthey were more broadly consideredappropriate for therapies lasting1 to 4 weeks.76

Unstable, Critically Ill Patients

In unstable, critically ill patients,speed of access was prioritized.International guidelines recommendvenous access via PIVC placementunless attempts to cannulate take.60 seconds or $2 attempts.21,22

When IV access was difficult,intraosseous devices wereconsistently reported as fastalternatives for children andadolescents,21,44,66,70,76,131 andumbilical catheter was recommendedfor neonates in the first week ofage.22

Congenital Cardiac Conditions

For patients with congenital cardiacconditions, VAD selection prioritizes


vessel preservation to ensure keyvasculature can be used for futurelife-saving procedures.56 Overall, 3CPGs and 4 observational studiesof pediatric and young adultpatients were included in thesystematic review and encompassedpatients with univentricular andbiventricular physiology andpatients in cardiac surgerysubgroups. Comparisons betweenumbilical catheters, PICCs, tunneledCVADs, and nontunneled CVADsbased on dwell time, occlusion,thrombosis, and infection risk werethe primary focus of the includedstudies.15,31,35,88

Generally, short-term peripheral andnonperipheral compatible therapydelivered via umbilical catheters ininfants can be used.66 PICCs wererecommended for patients withcongenital cardiac conditionsrequiring $7 days of IV therapy.136

because of lower complication rates,PICCs inserted in lower extremityvessels were recommended.136

CVAD (tunneled and nontunneled)use was reported in this population;however, placement $7 days wasassociated with an increased risk ofCLABSI.31,56 None of the includedstudies or guidelines includedevidence to support the use of totallyimplantable venous devices in thispopulation.

Regarding specific use in neonateswith univentricular physiology,umbilical catheters had low rates ofCLABSI, thrombosis, and occlusionwhen compared to other devices,15

and they can be used whenpreventing significant vessel loss forfuture procedures is a prioirity.Although PICCs were generallyrecommended in congenital cardiacpopulations, clinical guidelinesemphasized the need for specialistconsultation for patients with cardiacmalformations.136 Femoralnontunneled CVADs were reported asappropriate for therapies lasting,14 days in single-ventriclepopulations, with $14-day durations

associated with a higher risk ofthrombosis but not occlusion.15

Comparatively, other femoral devices(tunneled, uncuffed) were not relatedto an increased risk of thrombosisor occlusion for therapies lasting$14 days.15

Long-term Vascular Access Dependent

Long-term vascular accessdependency encompassednonmalignant hematologic,respiratory, gastrointestinal,metabolic, and immunologicconditions requiring long-term (.2months) and very long-term (.1year) VAD placement.29 In total, 4studies and 9 CPGs describedthis diverse patient populationacross PN and non-PN therapiesand continuous or intermittenttherapies. Despite the heterogeneityof reported populations, vesselpreservation and complicationprevention were the commonthemes when comparingPICC, short- and long-catheterPIVC, midline, tunneled-cuffed CVAD, and totallyimplantable venous deviceindications.16,32,90,109

Long-term PN Infusates

CLABSI, occlusion, and thrombosiswere common complications of long-term PN therapy across all VADs.16,32

Peripheral devices (PIVCs andmidlines) are unsafe for delivering PNbecause of the risk of venousdamage50,62,66; however, they may beindicated for limited time periodsin hospitalized patients withrestricted dextrose and proteinconcentrations (,10% and/or 5%,respectively).66,76,107 One single-center observational study supportedPICCs for long-term PN,32 andanother CPG recommended PICCs forhome PN107; although totallyimplantable venous devices weregenerally preferred when PN wasrequired for long durations, despitebeing associated with an increasedrisk of infection.16,29,32,50,56,92

Long-term Non-PN Infusates

Evidence for the use of VADsin patients requiring long-termnon-PN infusates was similar.Specifically, except for in oneCPG, all peripheral devices(PIVCs and midlines) wereregarded as inappropriate for long-term–dependent non-PN therapies,especially in patients with chronicrenal failure.56,62,66,76,109 TunneledCVADs and totally implantablevenous devices were insteadpreferred for non-PN therapiesrequired for continuous orintermittent and extended durations,respectively.56,62,66,76,103,109

Difficult Venous Access

For pediatric patients with difficultvenous access, insertion success ratesand the number of attempts arepriority considerations for VADselection. Factors that affect theseinclude patient physiology, pathology,damage caused by VAD, and theprocedural skill of the clinician.144

Five observational studies wereincluded for patients with difficultvenous access in ED (n = 2), electivesurgery (n = 1), PICU (n = 1), andhospitalized children (n = 1)populations. The majority of studiescompared nontunneled CVADs (n = 3)and evaluated the insertion successrates and complications associatedwith the number of insertionattempts. Two studies evaluatedPIVCs with and without ultrasound-guided (USG) techniques in pediatricpopulations.123,130

In patients with difficult vascularaccess, USG PIVC insertion wasassociated with higher overall andfirst- and second-attempt successrates after failed insertion via thelandmark method.130 Up to 17.2% ofCVADs in an ED setting experienceda complication (arterial puncture,hematoma, pneumothorax, andarrhythmia), and $3 attempts weresignificantly related to complicationdevelopment.140 In a studycomparing insertion success in


neonates and nonneonates,nontunneled CVAD failure wascommon (63.1%–76.3%), and thesuccess rate after .1 attempts wassignificantly lower with decreasingpatient age and associated withgreater insertion-relatedcomplications.55 Similarly,nontunneled CVAD placement inPICU patients led to high earlymechanical complications (17.5%)and was associated with moreinsertion attempts and insertionusing the subclavian or jugularapproach.113

Recommendations Regarding DeviceCharacteristics

Catheter-to-Vein Ratio

Determining the appropriatecatheter-to-vein ratio is a difficultbalancing act of optimizing patientand therapy needs while ensuringrisk of catheter-related complications,such as occlusion, is minimized.Although catheter-to-vein ratio wasrecognized as important forpreventing phlebitis, occlusion, andthrombosis,56 few studies reportedon catheter-to-vein ratios in neonateand pediatric patients. Only oneobservational study reported onPICCs in hospitalized children91;therefore the included studies werebroadened to incorporate an adultand laboratory study.95,118 Anadditional 6 CPGs were referred to forguidance.34,50,56,66,82,136

Clinical guidelines emphasizedselecting the smallest practical sizedgauge or French (F) that mettreatment and patientneed.34,56,66,95,136 Inadequatecatheter-to-vein ratio was linked toan increased risk of thrombosis in 2studies, especially in infants withcongenital heart disease, and smallercatheter size was associated withhigher rates of occlusion.50,56 Incontrast, larger catheters hada corresponding increase in rates ofphlebitis.66 For any VAD (PICC, PIVC,midline, CVAD, or totally implantablevenous device) a catheter-to-vein

ratio of ,50% in pediatric patientsand,33% in neonates was generallyrecommended.56,66,136 Specific toPICCs, thrombosis risk increasedwith a catheter-to-vein ratio $0.3391

and $0.45,118 in hospitalizedchildren and adults, respectively.Depending on the patient vessel size,22- to 24-gauge peripheral catheterswere considered appropriate forboth pediatric patients andneonates.66,76 According to thePeripherally Inserted CentralCatheters: Guideline for Practice fromthe National Association of NeonatalNurses, 1.1F to 3F catheters (20–28gauge) were commonly usedcatheter sizes for neonates.136

There were no specificrecommendations or empiricalevidence for the size of CVADs(tunneled or nontunneled), midlinecatheters, or totally implantablevenous devices.

Device Lumens

Choosing the optimum number ofdevice lumens to deliver plannedtherapy while reducing the risk ofcatheter-associated complications,particularly infection, occlusion, andthrombosis, is both complex andimportant.34 Nine studies describedlumen number outcomes inhospitalized adult (n = 2), children(n = 2) and infant (n = 1), immune-competent (n = 1), and hematologyand oncology (n = 3) populations. Anadditional 11 CPG recommendationswere included in the review. Allcompared single- versus double- ormultilumen catheters in CVADs (n =3), tunneled-cuffed CVADs (n = 2),and PICCs (n = 4).

Universally, CPGs recommended theminimum number of lumensnecessary for therapy provision.Because of increased risk of infection,occlusion, and thrombosis,multilumen VADs are onlyappropriate when indicated (ie, forhematopoietic stem cell transplant,critically ill patients, and patientsrequiring concurrent infusion of

noncompatible infusates such asblood and blood product, PN, orchemotherapy).* A dedicated lumenfor PN was also frequentlyendorsed,34,50,86,107 but authors of 2CPGs stated there was insufficientevidence to support thisrecommendation.56,96 Similarly,a dedicated lumen for bloodsampling, through the largest lumen,was recommended by some, but withlimited evidence.66,76

Evidence evaluating multilumen PICCoutcomes was mixed. One studyfound DVT risk increased with $2lumens,67 another study reporteda nonsignificant reduction in CLABSIrisk with single-lumen use,39 whilea number of other studies reportedthat PICC lumen number was notsignificantly associated with the riskof thrombosis81,122 or infection.81

Overall, most studies found occlusionwas the most common complicationassociated with catheter lumennumber, and $2 lumen PICCs wereassociated with the highest risk ofocclusion.28,39,81 Similarly, studiesreported mixed outcomes on thebasis of CVAD lumen number. Twostudies reported no associationbetween single- and double-lumencatheters and rates of infection65 andmajor CVAD-related complications,26

whereas others reported higher ratesof CLABSI,46,106 exit-site or tunnelinfection,46 malfunction orocclusion,46 and complicationsrequiring repositioning26 for double-lumen CVADs.

Recommendations for Insertion

Insertion Locations

Optimal catheter site selection inpediatric patients is more complexthan in adults as pediatric patientstypically have fewer accessible veinsdue to their smaller size.56,124

Determining the appropriateinsertion site is important forminimizing risk of insertion andpreventing post-insertion related

* Refs 34, 50, 51, 56, 62, 66, 76, 86, 107, and 124.


complications19,56,75,86,124; however,only partial evidence for appropriatevessels and insertion locations forVADs was available. A total of 21studies and 12 CPGs were includeddescribing insertion locationoutcomes. Overall, most studies (n =15) compared CVADs in cardiac,neurology, and general surgical (n =5), PICU (n = 4), hospitalized infant(n = 1), oncology (n = 1), and stem cellcollection (n = 1) populations. Fivestudies compared PIVC devicelocation in surgical (n = 3),hospitalized children (n = 1), andneonate and infant(n = 1) populations, and 3 studiesevaluated PICC device location inoncology (n = 1), hospitalizedchildren (n = 1), andimmunocompetent (n = 1)populations.

According to the guidelines reviewed,common insertion sites varied bydevice type. PIVC insertion wasfrequently recommended in the handand upper extremities,66,76 withthe scalp and foot suggested asalternative insertion sites for infantsand toddlers.66 The Infusion TherapyStandards of Practice66 andProvisional Infusion TherapyStandards of Practice76 guidelinesrecommended avoidance of areas offlexion including the wrist. Insertionof PICCs via the basilic vein was thepreferred insertion site, although thebrachial, cephalic, axillary, temporal,and posterior auricular veins wereacceptable alternatives.56,62,66,76,107

For neonates, the best available veinwas recommended without specificguidance as to what constituted thebest vein.66 Infants could also havePICCs inserted at saphenous andpopliteal veins.56,66,76 Similarly, formidline catheter insertion, the basilic,brachial, and cephalic veins weresuggested for neonates, infants, andpediatric patients,76,96 as well asalternative insertion sites such as thescalp and leg.66,76 For PIVCs, theexternal jugular vein wasrecommended only in emergency

settings or if no other vein wasavailable.66 Overall, there were nopreferred insertion sites for tunneledand nontunneled CVADs or totallyimplantable vascular devices inneonates, infants, and pediatricpatients.66,76,82,117,120 No studiesevaluated the insertion locations fortunneled and nontunneled CVADs inchildren; however, in adults, tunneledand nontunneled CVADs werecommonly inserted into the internaland external jugular, subclavian, orfemoral vein, although the subclavianvein was the recommended insertionsite.56,62,76,107

Insertion Success Is Dependent onVessel and Insertion Site

PIVCs had higher success rates wheninserted in the cephalic vein in theproximal forearm under USGtechniques or the antecubitalfossa109,123 and a longer life spanwhen inserted into the arm comparedto scalp, hand, or leg insertion sites.33

CVAD insertion via the axillary veinusing USG techniques resulted infewer insertion attempts andsignificantly shorter time to guide-wire insertion and time tocannulation.78 Similarly, CVADinsertion in the subclavian vein wasassociated with shorter medianpuncture time, less insertionattempts, and significantly less guide-wire misplacement compared toinsertion via the infraclavicularapproach.41 In one study, there washigher overall insertion success forinsertion via the subclavian comparedto the internal jugular vein whenusing the landmark technique.42 Ina sample of critically ill newborns andchildren (0–14 years), USGbrachiocephalic insertion hadsignificantly higher first-attemptsuccess, fewer insertion attempts, anda shorter procedure time comparedto the internal jugular vein.98 Incritically ill neonates and infants,image-guided placement of tunneledCVADs via saphenous or femoralveins using a surgical cutdown was

associated with high placementsuccess.63

Complications Are Associated WithVessel and Insertion Site

In pediatric patients, PIVCs insertedat the bend of the arm or lowerextremities were associated withincreased risk of infiltration,erythema, pain, inability toadminister medications, no or poorflow due to gravity, and kinkedcatheter,125,127 whereas insertion atthe foot, ankle, or scalp wassignificantly associated withincreased risk of occlusion.125,127 Inneonates and infants, PICC insertionat foot or ankle sites was significantlyassociated with an increasedrisk of phlebitis, thrombosis, anddysfunction.47,125,136 Overall, therewas no direct association betweenPICC insertion at brachial, cephalic,or saphenous insertion sites andthrombosis in pediatric patients122;however, left-sided PICC insertionwas associated with higher rates ofPICC-related complications.37 Themajority of studies, with 2exceptions,18,78 found that rates ofinfection and complication variedsignificantly on the basis of CVADinsertion sites.† Generally,complications were similar betweeninternal jugular and subclavianveins.42 One study, however, reportedhigher rates of early mechanicalcomplications in nontunneled CVADsinserted through the subclaviancompared to the jugular or femoralvein.113

Across CVAD types, insertion via theinternal jugular in infants andpediatric patients was associatedwith increased risk of high arterialpuncture,42,113 postoperativechylothorax,36 thrombosis,67,69,89 andinfection.42,69 Insertion through thesubclavian vein was correlated withan increased risk of high arterialpuncture (left-side approaches),42,113

arrhythmias and misplacement

† Refs 31, 36, 42, 49, 67, 69, 85, 89, 113, and 132.


(right-side approaches),113

malposition and occlusion,42

postoperative chylothorax,36 andsepsis.31 In pediatric oncologypatients, subclavian insertion siteshad higher rates of thrombosiscompared to external jugular andcephalic sites, but there was nodifference in rates between right- orleft-side insertion sites.132

Comparatively, brachiocephalicinsertion sites were associated withsignificantly lower CLABSI andthrombosis compared to jugular andsubclavian approaches.69 Overall,CVAD insertion through the femoralvein was linked to higher risk ofthrombosis51,67,89 but lowercomplication and infection rates ininfants ,5 kg.85

Vessel Visualization

Vessel and catheter-tip visualizationtechnologies, including ultrasoundguidance, transillumination, near-infrared (NIR) light device guidance,fluoroscopy, and electrocardiogram(ECG), are commonly used inpediatric clinical practice.34,82 Despitethe variety of available technologies,all vessel visualization technologiesaim to minimize complications andincrease success rates duringcannulation. Overall, 31 studiesdescribing vessel visualizationoutcomes for PIVC, midline, PICC,CVAD, and totally implantable venousdevices and 15 CPGs were included.Among those, 17 studies werefocused on VADs in critically illchildren, neonate, and infant (n = 4);hospitalized children (n = 3); cardiac,neurologic, and general surgical (n =3); mixed cardiac surgical, congenitalheart disease, and PICU (n = 1); ED(n = 1); and neonate (n = 1)populations. Across theseheterogeneous populations, the focuswas on increasing first-attemptsuccess rates and overall successfulinsertion and correct catheter-tippositioning.

Across all CPGs, USG insertion bytrained clinicians was recommended

for all pediatric populations, devicetypes, and insertion sites.‡ It wasindicated in most of the evidencereviewed that USG insertions wereassociated with high insertionsuccess, first-attempt success rates,lower procedure time, fewerattempts, and fewer complications inPIVCs and CVADs.x Only 2 systematicreviews reported no difference inCVAD insertion success rates betweenultrasound guidance and landmarktechniques.121,135 PIVC insertion wasfrequently improved by use of vesselvisualization devices,101,123,130 withfewer complications noted.101 Fewstudies compared visualizationtechniques for totally implantablevenous device placement. One studyreported USG percutaneous punctureof totally implantable venous deviceshad similar success rates, proceduretimes, and complication rates whencompared to surgical cutdownmethods.48 Another study found thatinsertion of totally implantablevenous devices by using ultrasoundguidance was significantly moreeffective in reducing complicationrates, had shorter procedure times,and was more cost-efficient comparedto open surgical cutdowntechniques.71

However, recommendations for othervisualization techniques in pediatricpopulations, including NIR light(vessel visualization) and ECG(catheter-tip confirmation) deviceuse, were scant. Use of NIR lightdevices may be efficacious in selectedhigh-risk subpopulations102 and maymodestly improve first-attemptsuccess rates77,104,110; however, thecurrent evidence does not support anoverall benefit74 or a benefit that isbetter than non–image-guidedmethods.104 Similarly, lowlevels of evidence prevent therecommendation of ECG assistancefor PICC placement105; however, one

study also found higher first-attemptsuccess and correct tip positionsuccess by using intracavitary ECGPICC insertion compared to landmarktechniques.141 Other techniques, suchas ECG techniques, for CVADplacement were reported assuccessful and accurate.27,116 Inparticular, the ECG technique wassignificantly more accurate and wasassociated with fewer complicationswhen compared to landmarktechniques27 and when intracavitaryECG was undertaken by usinga dedicated ECG monitor.116 Anarticle discussed vessel visualizationtechniques for umbilical cathetersand recommended plain radiographsfor confirming catheter course andlocation.142

DISCUSSION

VAD selection and insertion groundedin evidence-based, standardizeddecision-making can reduce risk ofcomplications, pain, length of hospitalstay, and costs and can improveoverall safety and treatmentefficacy.1–6 Despite many individualstudies, systematic reviews, andtargeted CPGs, there is no evidence-based guide to assist clinical decision-making in common pediatricindications. This systematic review isthe first of its kind to evaluate theevidence that informs VAD selectionand insertion for common pediatricindications by using rigorousmethodology and a wide breadth ofscope. Overall, our reviewsynthesized the available high-qualityevidence to inform clinical decision-making, while also highlightingpractices in need of further inquiry.

This systematic review revealedevidence- and guideline-basedrecommendations for VAD selectionand insertion in numerous pediatricpopulations.56,66,76,136 There wasa large quantity of evidence tosupport VAD selection and insertiondecision-making in generalhospitalized pediatric patients and

‡ Refs 34, 38, 50, 56, 62, 66, 75, 76, 82, 96, 107, 108,117, 126, and 136.x Refs 17, 26, 52, 53, 61, 63, 64, 68, 78, 83, 99, 114,129, and 139.


specialized populations, such asmalignant hematologic andoncological and critically ill pediatricpatients. Use of most VADs and theirassociated complications, especiallyfor PICCs, was well evidenced withinthese population groups. Evidence tosupport the use of single-lumendevices unless otherwise indicated(eg, for PN) was broadly supportedwithin the literature and in CPGs.‖

Similarly, evidence to suggest thatVAD insertion assisted by USGtechniques reduced complicationsand improved insertion success wasrepeatedly reported by high-qualitystudies and recommended acrossmultiple CPGs.{ The strength of theevidence for device selection andinsertion in these populationstherefore facilitates theimplementation of quality clinicaldecision-making.

On the other hand, our reviewhighlighted gaps in evidence,especially in the form of RCTs, forsome pediatric populations, devices,and indications. In some pediatricpopulations, evidence was so sparsethat the scope of the review had to bebroadened to include adult andlaboratory studies. Specificpopulations, such as neonates, cardiacpatients, and patients with difficultvenous access, relied on a fewobservational studies, makingrecommendations on device selectionchallenging. Similarly, although therewas a significant proportion of qualityevidence on VADs in patientsdependent on long-term PN, therewas limited evidence for other long-term VAD-dependent populations (eg,cystic fibrosis). Universally, there wasa dearth of evidence evaluatingmidline catheters for the majority ofpediatric indications. The literaturefor recommendations regardingoptimal catheter-to-vein ratio was

also limited; therefore, this reviewhad to be broadened to include adultand laboratory studies. Finally,although there was abundantevidence to support use of USGtechniques for the majority of deviceinsertions, there was a shortage ofevidence for the use of othertechnologies, particularly NIR lightdevices. As such, additional high-quality research evaluating thesepopulations, device typesand characteristics, and insertionprocedures iswarranted.

Although this study undertooka systematic and rigorous review ofthe available literature, the resultsshould be interpreted with cautionand in the context of its limitations.First, we did not undertake formalassessment of the quality of evidence(eg, using the Grading ofRecommendations Assessment,Development and Evaluation[GRADE] approach); however, allindividual included studies wereindependently assessed by 2 reviewauthors, and their quality indicatedby their study methodology, inaccordance with the RAND-UCLAmethodology.9 Additionally, althoughthis study prioritized the review ofRCTs and systematic reviews as thegold standard for evaluating VADs,this level of evidence was rarelyavailable. In accordance with theRAND-UCLA AppropriatenessMethod, the purpose of this reviewwas to include the best availableevidence to provide a synthesis ofinformation to guide panel decision-making.9 To avoid indications forwhich there was no evidence, weincluded evidence from lower-qualitystudies (eg, cross-sectional studies,surveillance studies, consecutivecases) and studies outside the initialscope of this review (NICU, adult, andlaboratory studies). The inclusion ofthese studies for some indicationsmeans that future clinical decision-making in certain pediatricpopulations is not guided by strong,

evidence-based recommendations.However, most of the evidence thatwas broadened beyond the originalscope of the systematic review waswell supported by CPGs, suggestingthat these findings can beimplemented into clinical practicewith confidence.

CONCLUSIONS

In this systematic review, we providethe first synthesis of the breadth ofevidence available for the selectionand insertion of VADs in pediatricpatients to guide clinical decision-making. There was strong evidenceto support and facilitate appropriateclinical decision-making in somepediatric indications. However,certain populations, device typesand characteristics, and insertionprocedures were poorly evidenced,necessitating the application of clinicaljudgment for some indications.Overall, the findings of this review willbe vital to inform criteria using theRAND-UCLA Appropriateness Methodto determine the appropriateness ofVADs in pediatric patients.

ABBREVIATIONS

CPG: clinical practice guidelineCVAD: central venous access

deviceDVT: deep vein thrombosisECG: electrocardiogramED: emergency departmentIV: intravenousMeSH: Medical Subject HeadingsNIR: near-infraredPICC: peripherally inserted central

catheterPIVC: peripheral intravenous

catheterPN: parenteral nutritionRAND-UCLA: RAND Corporation–

University ofCalifornia, LosAngeles

RCT: randomized control trialUSG: ultrasound-guidedVAD: vascular access device

‖ Refs 26, 28, 34, 39, 46, 50, 56, 62, 66, 76, 81, 86,106, 107, and 124.{ Refs 17, 26, 34, 38, 50, 52, 53, 56, 61, 62, 64, 66,68, 75, 76, 78, 82, 83, 96, 99, 107, 108, 114, 117, 126,129, 136, and 139.


Dr Paterson assisted with data extraction and synthesis and drafted the initial manuscript; Dr Brown conducted data collection, article screening, and initial data

extraction and synthesis; Dr Chopra, Ms Kleidon, Prof Cooke, Prof Rickard, and Dr Bernstein assisted with the conception and design of the study; Dr Ullman

conceptualized and designed the study and conducted article screening and data extraction and synthesis; and all authors reviewed and revised the manuscript,

approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.

DOI: https://doi.org/10.1542/peds.2019-3474H

Accepted for publication Jan 21, 2020

Address correspondence to Amanda J. Ullman, RN, PhD, School of Nursing and Midwifery, Menzies Health Institute Queensland, Griffith University, Kessels Rd,

Nathan, QLD 4111, Australia. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2020 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: Dr Paterson reports employment from Griffith University and The University of Queensland. Dr Chopra reports grants from the Agency for

Healthcare Research and Quality, American Hospital Association; book royalties from Oxford University Publishing for The Saint-Chopra Guide to Inpatient Medicine;

and honoraria for invited external talks as visiting professor. Dr Brown reports employment from Griffith University. Ms Kleidon reports employment by Queensland

Health; grants from the Children’s Hospital Foundation, the National Health and Medical Research Council (NHMRC), and Emergency Medicine Foundation; and

investigator-initiated research grants and speaker fees provided to Griffith University from 3M Medical; AngioDynamics; Baxter; BD-Bard; Centurion Medical

Products; Cook Medical; Medical Specialties Australasia, Smiths Medical; and Vygon (unrelated to the current project). Prof Cooke reports employment from Griffith

University and grants from Griffith University, the Children’s Hospital Foundation, Royal Brisbane and Women’s Hospital Foundation, Cancer Council Queensland,

Australasian College for Infection Prevention and Control, and investigator-initiated research grants and speaker fees provided to Griffith University by vascular

access product manufacturers (Baxter, BD, Entrotech Life Sciences) unrelated to this project. Prof Rickard reports a fellowship from Queensland Health;

employment from Griffith University; and grants from NHMRC, Griffith University, the Children’s Hospital Foundation, Princess Alexandra Hospital Foundation, Royal

Brisbane and Women’s Hospital Foundation, American Society for Parenteral and Enteral Nutrition Rhoads Foundation, Cancer Council Queensland, Australasian

College for Infection Prevention and Control, Association for Vascular Access Foundation, Australian College of Nursing, Australian College of Critical Care Nurses,

and Emergency Medicine Foundation; and investigator-initiated research grants and speaker fees provided to Griffith University by vascular access product

manufacturers (3M Medical, AngioDynamics, Baxter, B. Braun Medical, BD-Bard, Medtronic, ResQDevices, Smiths Medical) unrelated to this project. Dr Bernstein

reports grants from the Agency for Healthcare Research and Quality and US Department of Veterans Affairs. Dr Ullman reports fellowships and grants from the

NHMRC; employment from Griffith University; grants by the Children’s Hospital Foundation, Royal Brisbane and Women’s Hospital Foundation, Emergency Medicine

Foundation, and Australian College of Critical Care Nurses; and investigator-initiated research grants and speaker fees provided to Griffith University from 3M

Medical, AngioDynamics, and BD (unrelated to the current project). Dr Ullman also reports investigator-initiated research grants and speaker fees provided to

Griffith University from vascular access product manufacturers (3M Medical, AngioDynamics, BD, Cardinal Health) unrelated to the current project.

FUNDING: Supported by grants from the Association for Vascular Access Foundation, Griffith University, and the University of Michigan.

POTENTIAL CONFLICT OF INTEREST: Dr Chopra reports grants from the Agency for Healthcare Research and Quality, American Hospital Association; book royalties

from Oxford University Publishing for The Saint-Chopra Guide to Inpatient Medicine; and honoraria for invited external talks as visiting professor. Ms Kleidon

reports investigator-initiated research grants and speaker fees provided to Griffith University from 3M Medical; AngioDynamics; Baxter; BD-Bard; Centurion Medical;

Cook Medical; Medical Specialties Australasia; and Vygon (unrelated to the current project). Prof Cooke reports investigator-initiated research grants and speaker

fees provided to Griffith University by vascular access product manufacturers (Baxter, BD, Entrotech Life Sciences) unrelated to this project. Prof Rickard reports

investigator-initiated research grants and speaker fees provided to Griffith University from vascular access product manufacturers (3M Medical; AngioDynamics;

Baxter; B. Braun; BD-Bard; Medtronic; ResQDevices; Smiths Medical) unrelated to this project. Dr Bernstein reports grants from the Agency for Healthcare Research

and Quality and the US Department of Veterans Affairs. Dr Ullman reports investigator-initiated research grants and speaker fees provided to Griffith University

from vascular access product manufacturers (3M Medical, AngioDynamics, and BD) unrelated to the current project. Drs Paterson and Brown have indicated they

have no potential conflicts of interest to disclose.

REFERENCES

1. Ullman AJ, Cooke M, Kleidon T, RickardCM. Road map for improvement:point prevalence audit and surveyof central venous access devicesin paediatric acute care.J Paediatr Child Health. 2017;53(2):123–130

2. Noailly Charny PA, Bleyzac N,Ohannessian R, Aubert E, Bertrand Y,Renard C. Increased risk ofthrombosis associated with

peripherally inserted centralcatheters compared with conventionalcentral venous catheters in childrenwith leukemia. J Pediatr. 2018;198:46–52

3. LaRusso K, Schaack G, Fung T, et al.Should you pick the PICC? Prolongeduse of peripherally inserted centralvenous catheters in children withintestinal failure. J Pediatr Surg. 2019;54(5):999–1004

4. Gibson C, Connolly BL, Moineddin R,Mahant S, Filipescu D, Amaral JG.Peripherally inserted centralcatheters: use at a tertiary carepediatric center. J Vasc Interv Radiol.2013;24(9):1323–1331

5. Noonan PJ, Hanson SJ, Simpson PM,Dasgupta M, Petersen TL. Comparisonof complication rates of centralvenous catheters versus peripherallyinserted central venous catheters in


https://doi.org/10.1542/peds.2019-3474H

mailto:[email protected]

pediatric patients. Pediatr Crit CareMed. 2018;19(12):1097–1105

6. Ullman AJ, Marsh N, Mihala G, CookeM, Rickard CM. Complications ofcentral venous access devices:a systematic review. Pediatrics. 2015;136(5). Available at: www.pediatrics.org/cgi/content/full/136/5/e1331

7. Ullman AJ, Chopra V, Brown E, et al.Developing appropriateness criteriafor pediatric vascular access.Pediatrics. 2020;145(suppl 3):e20193474G

8. Ullman AJ, Bernstein SJ, Brown E, et al.The Michigan Appropriateness Guidefor Intravenous Catheters inPediatrics: miniMAGIC. Pediatrics.2020;145(suppl 3):e20193474I

9. Fitch K, Bernstein SJ, Aguilar MD, et al.The RAND/UCLA AppropriatenessMethod User’s Manual. Santa Monica,CA: RAND Corporation; 2001

10. Brown E, Ullman A. Which vascularaccess devices are most likely topromote function and least likely tocause harm and under whichcircumstances in paediatrics?PROSPERO 2019 CRD42019094286.Available at: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=94286. Accessed April 27,2020

11. Moher D, Liberati A, Tetzlaff J, AltmanDG; PRISMA Group. Preferred reportingitems for systematic reviews and meta-analyses: the PRISMA statement. BMJ.2009;339:b2535

12. von Elm E, Altman DG, Egger M, PocockSJ, Gøtzsche PC, Vandenbroucke JP;STROBE Initiative. Strengthening theReporting of Observational Studies inEpidemiology (STROBE) statement:guidelines for reporting observationalstudies. BMJ. 2007;335(7624):806–808

13. Critical Appraisal Skills Programme.2018. CASP (Cohort Study) Checklist.[Online]. Available at: https://casp-uk.net/wp-content/uploads/2018/01/CASP-Cohort-Study-Checklist_2018.pdf.Accessed June 1, 2018

14. Adams DZ, Little A, Vinsant C,Khandelwal S. The midline catheter:a clinical review. J Emerg Med. 2016;51(3):252–258

15. Aiyagari R, Song JY, Donohue JE, Yu S,Gaies MG. Central venous catheter-

associated complications in infantswith single ventricle: comparison ofumbilical and femoral venous accessroutes. Pediatr Crit Care Med. 2012;13(5):549–553

16. Ainsworth S, McGuire W. Percutaneouscentral venous catheters versusperipheral cannulae for delivery ofparenteral nutrition in neonates.Cochrane Database Syst Rev. 2015;(10):CD004219

17. Alten JA, Borasino S, Gurley WQ, LawMA, Toms R, Dabal RJ. Ultrasound-guided femoral vein catheterization inneonates with cardiac disease. PediatrCrit Care Med. 2012;13(6):654–659

18. Anil AB, Anil M, Kanar B, et al. Theevaluation of central venouscatheterization complications ina pediatric intensive care unit. TurkPediatri Ars. 2011;46:215–219

19. Australian and New Zealand IntensiveCare Society. Central Line Insertion andMaintenance Guideline. Melbourne,Australia: Australian and New ZealandIntensive Care Society Safety andQuality Committee; 2012

20. Allen RC, Holdsworth MT, Johnson CA,et al. Risk determinants for catheter-associated blood stream infections inchildren and young adults withcancer. Pediatr Blood Cancer. 2008;51(1):53–58

21. Australian Resuscitation Council; NewZealand Resuscitation Council.Advanced life support for infants andchildren diagnosis and management.ARC and NZRC Guideline 2010. EmergMed Australas. 2011;23(4):400–402

22. Australian Resuscitation Council; NewZealand Resuscitation Council.Medication or fluids for theresuscitation of the newborn infant.ARC and NZRC Guideline 2010. EmergMed Australas. 2011;23(4):442–444

23. Australian Resuscitation Council; NewZealand Resuscitation Council.Techniques in Paediatric Advanced LifeSupport. ARC and NZRC Guideline 2010.Emerg Med Australas. 2011;23(4):412–416

24. Arnts IJ, Bullens LM, Groenewoud JM,Liem KD. Comparison of complicationrates between umbilical andperipherally inserted central venous

catheters in newborns. J ObstetGynecol Neonatal Nurs. 2014;43:205–215

25. Athale UH, Siciliano S, Cheng J, ThabaneL, Chan AKC. Central venous linedysfunction is an independentpredictor of poor survival in childrenwith cancer. J Pediatr Hematol Oncol.2012;34(3):188–193

26. Avanzini S, Mameli L, Disma N, et al.Brachiocephalic vein for percutaneousultrasound-guided central linepositioning in children: a 20-monthpreliminary experience with 109procedures. Pediatr Blood Cancer. 2017;64(2):330–335

27. Barnwal NK, Dave ST, Dias R. Acomparative study of two techniques(electrocardiogram- and landmark-guided) for correct depth of the centralvenous catheter placement inpaediatric patients undergoing electivecardiovascular surgery. IndianJ Anaesth. 2016;60(7):470–475

28. Barrier A, Williams DJ, Connelly M,Creech CB. Frequency of peripherallyinserted central catheter complicationsin children. Pediatr Infect Dis J. 2012;31(5):519–521

29. Baskin KM, Mermel LA, Saad TF, et al;Venous Access: National Guideline andRegistry Development (VANGUARD)Initiative Affected Persons AdvisoryPanel. Evidence-based strategies andrecommendations for preservation ofcentral venous access in children. JPENJ Parenter Enteral Nutr. 2019;43(5):591–614

30. Ben Abdelaziz R, Hafsi H, Hajji H,et al. Peripheral venous cathetercomplications in children: predisposingfactors in a multicenter prospectivecohort study [published correctionappears in BMC Pediatr. 2018;18(1):307]. BMC Pediatr. 2017;17(1):208

31. Bezzio S, Scolfaro C, Broglia R, et al.Prospective incidence study ofbloodstream infection in infants andchildren with central venous cathetersafter cardiac surgery in Italy. InfectControl Hosp Epidemiol. 2009;30(7):698–701

32. Blotte C, Styers J, Zhu H,Channabasappa N, Piper HG. Acomparison of Broviac® andperipherally inserted central cathetersin children with intestinal failure.J Pediatr Surg. 2017;52(5):768–771


http://www.pediatrics.org/cgi/content/FUll/136/5/e1331

http://www.pediatrics.org/cgi/content/FUll/136/5/e1331

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=94286



https://casp-uk.net/wp-content/uploads/2018/01/CASP-Cohort-Study-Checklist_2018.pdf



33. Birhane E, Kidanu K, Kassa M, et al.Lifespan and associated factors ofperipheral intravenous cannula amonginfants admitted in public hospitals ofMekelle city, Tigray, Ethiopia, 2016. BMCNurs. 2017;16:33

34. Bodenham Chair A, Babu S, Bennett J,et al. Association of Anaesthetists ofGreat Britain and Ireland: safe vascularaccess 2016 [published correctionappears in Anaesthesia. 2016;71(12):1503]. Anaesthesia. 2016;71(5):573–585

35. Boe BA, Zampi JD, Yu S, Donohue JE,Aiyagari R. Transhepatic central venouscatheters in pediatric patients withcongenital heart disease. Pediatr CritCare Med. 2015;16(8):726–732

36. Borasino S, Diaz F, El Masri K, Dabal RJ,Alten JA. Central venous lines are a riskfactor for chylothorax in infants aftercardiac surgery. World J PediatrCongenit Heart Surg. 2014;5(4):522–526

37. Borretta L, MacDonald T, Digout C,Smith N, Fernandez CV, Kulkarni K.Peripherally inserted central cathetersin pediatric oncology patients: a 15-yearpopulation-based review fromMaritimes, Canada. J Pediatr HematolOncol. 2018;40(1):e55–e60

38. Bouaziz H, Zetlaoui PJ, Pierre S, et al.Guidelines on the use of ultrasoundguidance for vascular access. AnaesthCrit Care Pain Med. 2015;34(1):65–69

39. Bozaan D, Skicki D, Brancaccio A,et al. Less lumens-less risk: a pilotintervention to increase the use ofsingle-lumen peripherally insertedcentral catheters. J Hosp Med. 2019;14(1):42–46

40. Bratton J, Johnstone PA, McMullen KP.Outpatient management of vascularaccess devices in children receivingradiotherapy: complications andmorbidity. Pediatr Blood Cancer. 2014;61(3):499–501

41. Byon HJ, Lee GW, Lee JH, et al.Comparison between ultrasound-guided supraclavicular andinfraclavicular approaches forsubclavian venous catheterization inchildren--a randomized trial. BrJ Anaesth. 2013;111(5):788–792

42. Camkiran Firat A, Zeyneloglu P, Ozkan M,Pirat A. A randomized controlledcomparison of the internal jugular veinand the subclavian vein as access sites

for central venous catheterization inpediatric cardiac surgery. Pediatr CritCare Med. 2016;17(9):e413–e419

43. Campagna S, Gonella S, Zerla PA, et al.The risk of adverse events related toextended-dwell peripheral intravenousaccess. Infect Control Hosp Epidemiol.2018;39(7):875–877

44. Carlson JN, Gannon E, Mann NC, et al.Pediatric out-of-hospital criticalprocedures in the United States.Pediatr Crit Care Med. 2015;16(8):e260–e267

45. Carraro F, Cicalese MP, Cesaro S, et al.Guidelines for the use of long-termcentral venous catheter in childrenwith hemato-oncological disorders. Onbehalf of Supportive Therapy WorkingGroup of Italian Association of PediatricHematology and Oncology (AIEOP). AnnHematol. 2013;92(10):1405–1412

46. Cesaro S, Cavaliere M, Pegoraro A,Gamba P, Zadra N, Tridello G. Acomprehensive approach to theprevention of central venous cathetercomplications: results of 10-yearprospective surveillance in pediatrichematology-oncology patients. AnnHematol. 2016;95(5):817–825

47. Chen H, Zhang X, Wang H, Hu X.Complications of upper extremityversus lower extremity placedperipherally inserted central cathetersin neonatal intensive care units:a meta-analysis. Intensive Crit CareNurs. 2020;56:102753

48. Choi JS, Park KM, Jung S, et al.Usefulness of percutaneous puncture ininsertion of totally implantable venousaccess devices in pediatric patients.Vasc Spec Int. 2017;33(3):108–111

49. Cooling L, Hoffmann S, Webb D, YamadaC, Davenport R, Choi SW. Performanceand safety of femoral central venouscatheters in pediatric autologousperipheral blood stem cell collection.J Clin Apher. 2017;32(6):501–516

50. Crocoli A, Tornesello A, Pittiruti M, et al.Central venous access devices inpediatric malignancies: a positionpaper of Italian Association of PediatricHematology and Oncology. J VascAccess. 2015;16(2):130–136

51. Debourdeau P, Kassab Chahmi D, Le GalG, et al; Working Group of the SOR;French National Feberation of Cancer

Centers. 2008 SOR guidelines for theprevention and treatment ofthrombosis associated with centralvenous catheters in patients withcancer: report from the Working Group.Ann Oncol. 2009;20(9):1459–1471

52. de Carvalho Onofre PS, da LuzGonçalves Pedreira M, Peterlini MAS.Placement of peripherally insertedcentral catheters in children guided byultrasound: a prospective randomized,and controlled trial. Pediatr Crit CareMed. 2012;13(5):e282–e287

53. de Souza TH, Brandão MB, Santos TM,Pereira RM, Nogueira RJN. Ultrasoundguidance for internal jugular veincannulation in PICU: a randomisedcontrolled trial. Arch Dis Child. 2018;103(10):952–956

54. DeWitt AG, Zampi JD, Donohue JE, Yu S,Lloyd TR. Fluoroscopy-guided umbilicalvenous catheter placement in infantswith congenital heart disease. CongenitHeart Dis. 2015;10(4):317–325

55. Dheer G, Chaudhry GK, Singh T.Immediate complications ofpercutaneous central venouscannulation in children. J Indian AssocPediatr Surg. 2011;16(4):145–147

56. Doellman D, Buckner JK, HudsonGarrett J Jr., Catudal JP, Frey AM,Lamagna P. Best Practice Guidelines inthe Care and Maintenance of PediatricCentral Venous Catheters, 2nd ed.Herriman, UT: Association for VascularAccess; 2015

57. Dongara AR, Patel DV, Nimbalkar SM,Potana N, Nimbalkar AS. Umbilicalvenous catheter versus peripherallyinserted central catheter in neonates:a randomized controlled trial. J TropPediatr. 2017;63(5):374–379

58. Elser HE. Options for securing umbilicalcatheters. Adv Neonatal Care. 2013;13(6):426–429

59. Fallon SC, Kim ME, Fernandes CJ,Vasudevan SA, Nuchtern JG, Kim ES.Identifying and reducing earlycomplications of surgical central linesin infants and toddlers. J Surg Res.2014;190(1):246–250

60. Faustino EV, Spinella PC, Li S, et al.Incidence and acute complications ofasymptomatic central venous catheter-related deep venous thrombosis in


critically ill children. J Pediatr. 2013;162(2):387–391

61. Froehlich CD, Rigby MR, Rosenberg ES,et al. Ultrasound-guided central venouscatheter placement decreasescomplications and decreasesplacement attempts compared with thelandmark technique in patients ina pediatric intensive care unit. CritCare Med. 2009;37(3):1090–1096

62. Frykholm P, Pikwer A, Hammarskjöld F,et al; Swedish Society ofAnaesthesiology and Intensive CareMedicine. Clinical guidelines on centralvenous catheterisation. ActaAnaesthesiol Scand. 2014;58(5):508–524

63. Gaballah M, Krishnamurthy G, KellerMS, McIntosh A, Munson DA, Cahill AM.US-guided placement and tip positionconfirmation for lower-extremitycentral venous access in neonates andinfants with comparison versusconventional insertion. J Vasc IntervRadiol. 2014;25(4):548–555

64. Gallagher RA, Levy J, Vieira RL,Monuteaux MC, Stack AM. Ultrasoundassistance for central venous catheterplacement in a pediatric emergencydepartment improves placementsuccess rates. Acad Emerg Med. 2014;21(9):981–986

65. Gonzalez G, Davidoff AM, Howard SC,et al. Safety of central venous catheterplacement at diagnosis of acutelymphoblastic leukemia in children.Pediatr Blood Cancer. 2012;58(4):498–502

66. Gorski L, Hadaway L, Hagle M,McGoldrick M, Orr M, Doellman D.Infusion therapy standards of practice.J Infus Nurs. 2016;39:S1–S169

67. Gray BW, Gonzalez R, Warrier KS, et al.Characterization of central venouscatheter-associated deep venousthrombosis in infants. J Pediatr Surg.2012;47(6):1159–1166

68. Gurien LA, Blakely ML, Russell RT, et al;Pediatric Surgery Research (PedSRC)Collaborative. Real-timeultrasonography for placement ofcentral venous catheters in children:a multi-institutional study. Surgery.2016;160(6):1605–1611

69. Habas F, Baleine J, Milési C, et al.Supraclavicular catheterization of thebrachiocephalic vein: a way to prevent

or reduce catheter maintenance-related complications in children. EurJ Pediatr. 2018;177(3):451–459

70. Hamed RK, Hartmans S, Gausche-Hill M.Anesthesia through an intraosseousline using an 18-gauge intravenousneedle for emergency pediatricsurgery. J Clin Anesth. 2013;25(6):447–451

71. Hancock-Howard R, Connolly BL,McMahon M, et al. Cost-effectivenessanalysis of implantable venous accessdevice insertion using interventionalradiologic versus conventionaloperating room methods in pediatricpatients with cancer. J Vasc IntervRadiol. 2010;21(5):677–684

72. Handrup MM, Møller JK, Frydenberg M,Schrøder H. Placing of tunneled centralvenous catheters prior to inductionchemotherapy in children with acutelymphoblastic leukemia. Pediatr BloodCancer. 2010;55(2):309–313

73. Hanson SJ, Punzalan RC, ChristensenMA, Ghanayem NS, Kuhn EM, Havens PL.Incidence and risk factors for venousthromboembolism in critically illchildren with cardiac disease. PediatrCardiol. 2012;33(1):103–108

74. Heinrichs J, Fritze Z, Klassen T, Curtis S.A systematic review and meta-analysisof new interventions for peripheralintravenous cannulation of children.Pediatr Emerg Care. 2013;29(7):858–866

75. Institute for Healthcare Improvement.How-to Guide: Prevent Central Line-Associated Bloodstream Infection(CLABSI). Cambridge, MA: Institute forHealthcare Improvement; 2012

76. Intravenous Nursing New ZealandIncorporated Society. ProvisionalInfusion Therapy Standards of Practice.Auckland, New Zealand: IntravenousNursing New Zealand IncorporatedSociety; 2012

77. Katsogridakis YL, Seshadri R, Sullivan C,Waltzman ML. Veinlite transilluminationin the pediatric emergency department:a therapeutic interventional trial.Pediatr Emerg Care. 2008;24(2):83–88

78. Kim EH, Lee JH, Song IK, et al. Real-timeultrasound-guided axillary veincannulation in children: a randomisedcontrolled trial. Anaesthesia. 2017;72(12):1516–1522

79. Kulkarni S, Wu O, Kasthuri R, Moss JG.Centrally inserted external cathetersand totally implantable ports for thedelivery of chemotherapy: a systematicreview and meta-analysis of device-related complications. CardiovascIntervent Radiol. 2014;37(4):990–1008

80. Kulkarni R, Presley RJ, Lusher JM, et al.Complications of haemophilia in babies(first two years of life): a report fromthe Centers for Disease Control andPrevention Universal Data CollectionSystem. Haemophilia. 2017;23(2):207–214

81. Lam PW, Volling C, Chan T, et al. Impactof defaulting to single-lumenperipherally inserted central catheterson patient outcomes: an interruptedtime series study. Clin Infect Dis. 2018;67(6):954–957

82. Lamperti M, Bodenham AR, Pittiruti M,et al. International evidence-basedrecommendations on ultrasound-guided vascular access. Intensive CareMed. 2012;38(7):1105–1117

83. Lau CS, Chamberlain RS. Ultrasound-guided central venous catheterplacement increases success rates inpediatric patients: a meta-analysis.Pediatr Res. 2016;80(2):178–184

84. Levy I, Bendet M, Samra Z, Shalit I,Katz J. Infectious complications ofperipherally inserted central venouscatheters in children. Pediatr Infect DisJ. 2010;29(5):426–429

85. Lindquester WS, Hawkins CM, MonroeEJ, et al. Single-stick tunneledcentral venous access using thejugular veins in infants weighing lessthan 5 kg. Pediatr Radiol. 2017;47(12):1682–1687

86. Loveday HP, Wilson JA, Pratt RJ, et al; UKDepartment of Health. epic3: nationalevidence-based guidelines forpreventing healthcare-associatedinfections in NHS hospitals in England.J Hosp Infect. 2014;86(suppl 1):S1–S70

87. Malbezin S, Gauss T, Smith I, et al. Areview of 5434 percutaneous pediatriccentral venous catheters inserted byanesthesiologists. Paediatr Anaesth.2013;23(11):974–979

88. Marshall AM, Danford DA, Curzon CL,Anderson V, Delaney JW. Traditionallong-term central venous cathetersversus transhepatic venous catheters


in infants and young children. PediatrCrit Care Med. 2017;18(10):944–948

89. Marquez A, Shabanova V, Faustino EV;Northeast Pediatric Critical CareResearch Consortium. Prediction ofcatheter-associated thrombosis incritically ill children. Pediatr Crit CareMed. 2016;17(11):e521–e528

90. May TL, Gifford AH, Lahiri T, et al.Complications of long and intermediateterm venous catheters in cystic fibrosispatients: a multicenter study. J CystFibros. 2018;17(1):96–104

91. Menéndez JJ, Verdú C, Calderón B, et al.Incidence and risk factors of superficialand deep vein thrombosis associatedwith peripherally inserted centralcatheters in children. J ThrombHaemost. 2016;14(11):2158–2168

92. Mermel LA, Allon M, Bouza E, et al.Clinical practice guidelines for thediagnosis and management ofintravascular catheter-related infection:2009 update by the Infectious DiseasesSociety of America [publishedcorrection appears in Clin Infect Dis.2010;50(7):1079]. Clin Infect Dis. 2009;49(1):1–45

93. Moon HM, Kim S, Yun KW, et al. Clinicalcharacteristics and risk factors of long-term central venous catheter-associated bloodstream infections inchildren. Pediatr Infect Dis J. 2018;37(5):401–406

94. Mushtaq A, Navalkele B, Kaur M, et al.Comparison of complications inmidlines versus central venouscatheters: are midlines safer thancentral venous lines? Am J InfectControl. 2018;46(7):788–792

95. Nifong TP, McDevitt TJ. The effect ofcatheter to vein ratio on blood flowrates in a simulated model ofperipherally inserted central venouscatheters. Chest. 2011;140(1):48–53

96. O’Grady NP, Alexander M, Burns LA, et al;Healthcare Infection Control PracticesAdvisory Committee. Guidelines for theprevention of intravascular catheter-related infections. Am J Infect Control.2011;39(4 suppl 1):S1–S34

97. Ohno K, Nakaoka T, Takama Y, HigashioA, Santo K, Yoneda A. Implantablecentral venous access device in infants:long-term results. Pediatr Int. 2016;58(10):1027–1031

98. Oulego-Erroz I, Muñoz-Lozón A, Alonso-Quintela P, Rodríguez-Nuñez A.Comparison of ultrasound guidedbrachiocephalic and internal jugularvein cannulation in critically ill children.J Crit Care. 2016;35:133–137

99. Oulego-Erroz I, González-Cortes R,García-Soler P, et al; RECANVACollaborative Study. Ultrasound-guidedor landmark techniques for centralvenous catheter placement in criticallyill children. Intensive Care Med. 2018;44(1):61–72

100. Pacilli M, Bradshaw CJ, Clarke SA. Useof 8-cm 22G-long peripheral cannulas inpediatric patients. J Vasc Access. 2018;19(5):496–500

101. Paladini A, Chiaretti A, Sellasie KW,Pittiruti M, Vento G. Ultrasound-guidedplacement of long peripheral cannulasin children over the age of 10 yearsadmitted to the emergency department:a pilot study. BMJ Paediatr Open. 2018;2(1):e000244

102. Park JM, Kim MJ, Yim HW, Lee WC, JeongH, Kim NJ. Utility of near-infrared lightdevices for pediatric peripheralintravenous cannulation: a systematicreview and meta-analysis. Eur J Pediatr.2016;175(12):1975–1988

103. Pasteur MC, Bilton D, Hill AT; BritishThoracic Society Bronchiectasis non-CFGuideline Group. British ThoracicSociety guideline for non-CFbronchiectasis. Thorax. 2010;65(suppl1):i1–i58

104. Peterson KA, Phillips AL, Truemper E,Agrawal S. Does the use of an assistivedevice by nurses impact peripheralintravenous catheter insertion successin children? J Pediatr Nurs. 2012;27(2):134–143

105. Perin G, Scarpa MG. Defining centralvenous line position in children: tips forthe tip. J Vasc Access. 2015;16(2):77–86

106. Pinon M, Bezzio S, Tovo PA, et al. Aprospective 7-year survey on centralvenous catheter-related complicationsat a single pediatric hospital. EurJ Pediatr. 2009;168(12):1505–1512

107. Pittiruti M, Hamilton H, Biffi R, MacFie J,Pertkiewicz M; ESPEN. ESPEN Guidelineson Parenteral Nutrition: central venouscatheters (access, care, diagnosis andtherapy of complications). Clin Nutr.2009;28(4):365–377

108. Polkinghorne KR, Chin GK, MacGinley RJ,et al. KHA-CARI Guideline: vascularaccess - central venous catheters,arteriovenous fistulae andarteriovenous grafts [publishedcorrection appears in Nephrology(Carlton). 2014;19(1):64]. Nephrology(Carlton). 2013;18(11):701–705

109. Qian SY, Horn MT, Barnes R, ArmstrongD. The use of 8-cm 22G Seldingercatheters for intravenous access inchildren with cystic fibrosis. J VascAccess. 2014;15(5):415–417

110. Ramer L, Hunt P, Ortega E, Knowlton J,Briggs R, Hirokawa S. Effect ofintravenous (IV) assistive device(VeinViewer) on IV access attempts,procedural time, and patient and nursesatisfaction. J Pediatr Oncol Nurs. 2016;33(4):273–281

111. Rauth TP, Scott BP, Thomason CK,Bartilson RE, Hann TM, Pietsch JB.Central venous catheter placement atthe time of extracorporeal membraneoxygenation decannulation: is it safe?J Pediatr Surg. 2008;43(1):53–57;discussion 58

112. Revel-Vilk S, Yacobovich J, Tamary H,et al. Risk factors for central venouscatheter thrombotic complications inchildren and adolescents with cancer.Cancer. 2010;116(17):4197–4205

113. Rey C, Alvarez F, De La Rua V, et al.Mechanical complications duringcentral venous cannulations inpediatric patients. Intensive Care Med.2009;35(8):1438–1443

114. Rivera-Tocancipá D, Díaz-Sánchez E,Montalvo-Arce CA. Ultrasound versusanatomical landmarks: immediatecomplications in the central venouscatheterization in children under18 years of age. Rev Esp AnestesiolReanim. 2018;65(7):366–372

115. Rosado V, Camargos PA, Clemente WT,Romanelli RM. Incidence of infectiouscomplications associated with centralvenous catheters in pediatricpopulation. Am J Infect Control. 2013;41(9):e81–e84

116. Rossetti F, Pittiruti M, Lamperti M,Graziano U, Celentano D, Capozzoli G.The intracavitary ECG method forpositioning the tip of central venousaccess devices in pediatric patients:results of an Italian multicenter study.J Vasc Access. 2015;16(2):137–143


117. Schiffer CA, Mangu PB, Wade JC, et al.Central venous catheter care for thepatient with cancer: American Societyof Clinical Oncology clinical practiceguideline. J Clin Oncol. 2013;31(10):1357–1370

118. Sharp R, Cummings M, Fielder A,Mikocka-Walus A, Grech C, Esterman A.The catheter to vein ratio andrates of symptomatic venousthromboembolism in patients witha peripherally inserted centralcatheter (PICC): a prospective cohortstudy. Int J Nurs Stud. 2015;52(3):677–685

119. Shenep MA, Tanner MR, Sun Y, et al.Catheter-related complications inchildren with cancer receivingparenteral nutrition: change in risk ismoderated by catheter type. JPENJ Parenter Enteral Nutr. 2017;41(6):1063–1071

120. Sibson KR, Biss TT, Furness CL, et al;British Society for Haematology. BSHGuideline: management of thromboticand haemostatic issues in paediatricmalignancy. Br J Haematol. 2018;180(4):511–525

121. Sigaut S, Skhiri A, Stany I, et al.Ultrasound guided internal jugular veinaccess in children and infant: a meta-analysis of published studies. PaediatrAnaesth. 2009;19(12):1199–1206

122. Smitherman AB, Alexander T, ConnellyM, et al. The incidence of catheter-associated venous thrombosis innoncritically ill children. Hosp Pediatr.2015;5(2):59–66

123. Takeshita J, Nakayama Y, Nakajima Y,et al. Optimal site for ultrasound-guidedvenous catheterisation in paediatricpatients: an observational study toinvestigate predictors forcatheterisation success anda randomised controlled study todetermine the most successful site. CritCare. 2015;19:15–23

124. The Joint Commission. Central line-associated bloodstream infectionstoolkit and monograph: preventingcentral line–associated bloodstreaminfections. With useful tools and aninternational perspective. 2013.Available at: www.jointcommission.org/CLABSIToolkit. Accessed June, 2018

125. Tripi PA, Thomas S, Clebone A,Goldfinger MM, Tobias JD. Peripheral

intravenous catheter problems ininfants and children presenting foranesthesia and surgery. Middle EastJ Anaesthesiol. 2016;23(4):411–414

126. Troianos CA, Hartman GS, Glas KE, et al;Councils on IntraoperativeEchocardiography and VascularUltrasound of the American Societyof Echocardiography. Guidelinesfor performing ultrasoundguided vascular cannulation:recommendations of the AmericanSociety of Echocardiography and theSociety of CardiovascularAnesthesiologists. J Am SocEchocardiogr. 2011;24(12):1291–1318

127. Unbeck M, Förberg U, Ygge BM,Ehrenberg A, Petzold M, Johansson E.Peripheral venous catheterrelated complications are commonamong paediatric and neonatalpatients. Acta Paediatr. 2015;104(6):566–574

128. van Gent MB, van der Made WJ,Marang-van de Mheen PJ, van der BogtKE. Contemporary insertion of centralvenous access catheters in pediatricpatients: a retrospective record reviewstudy of 538 catheters in a singlecenter. Surg Infect (Larchmt). 2017;18(2):105–111

129. Vierboom L, Darani A, Langusch C,Soundappan S, Karpelowsky J.Tunnelled central venous accessdevices in small children: a comparisonof open vs. ultrasound-guidedpercutaneous insertion in childrenweighing ten kilograms or less.J Pediatr Surg. 2018;53(9):1832–1838

130. Vinograd AM, Zorc JJ, Dean AJ,Abbadessa MKF, Chen AE. First-attempt success, longevity, andcomplication rates of ultrasound-guided peripheral intravenouscatheters in children. Pediatr EmergCare. 2018;34(6):376–380

131. Voigt J, Waltzman M, Lottenberg L.Intraosseous vascular access for in-hospital emergency use: a systematicclinical review of the literature andanalysis. Pediatr Emerg Care. 2012;28(2):185–199

132. Wiegering V, Schmid S, Andres O, et al.Thrombosis as a complication ofcentral venous access in pediatricpatients with malignancies: a 5-year

single-center experience. BMC Hematol.2014;14(1):18

133. White AD, Othman D, Dawrant MJ,Sohrabi S, Young AL, Squire R.Implantable versus cuffed externalcentral venous catheters for themanagement of children andadolescents with acute lymphoblasticleukaemia. Pediatr Surg Int. 2012;28(12):1195–1199

134. Wragg RC, Blundell S, Bader M, et al.Patency of neck veins followingultrasound-guided percutaneousHickman line insertion. Pediatr SurgInt. 2014;30(3):301–304

135. Wu SY, Ling Q, Cao LH, Wang J, Xu MX,Zeng WA. Real-time two-dimensionalultrasound guidance for centralvenous cannulation: a meta-analysis. Anesthesiology. 2013;118(2):361–375

136. Wyckoff MM, Sharpe EL. PeripherallyInserted Central Catheters: Guidelinefor Practice, 3rd ed. Chicago, IL:National Association of NeonatalNurses; 2015

137. Xia Y, Wu Y, Zhang W, et al. Applicationof peripherally inserted centralcatheter via femoral vein for pediatricburns. Int J Clin Exp Med. 2016;9:20105–20108

138. Yacobovich J, Ben-Ami T, Abdalla T,et al. Patient and central venouscatheter related risk factors forblood stream infections in childrenreceiving chemotherapy. PediatrBlood Cancer. 2015;62(3):471–476

139. Zanolla GR, Baldisserotto M, Piva J. Howuseful is ultrasound guidance for internaljugular venous access in children?J Pediatr Surg. 2018;53(4):789–793

140. Zengin Y, Içer M, Gündüz E, Dursun R,Durgun HM, Gülo�glu C. Assessment ofcentral venous catheters applied inpediatric patients at emergencydepartment. J Exp Clin Med (Turkey).2013;30:345–348

141. Zhou L, Xu H, Liang J, Xu M, Yu J.Effectiveness of intracavitaryelectrocardiogram guidance inperipherally inserted centralcatheter tip placement in neonates.J Perinat Neonatal Nurs. 2017;31(4):326–331


www.jointcommission.org/CLABSIToolkit

www.jointcommission.org/CLABSIToolkit

142. Oestreich AE. Umbilical veincatheterization--appropriateand inappropriate placement.Pediatr Radiol. 2010;40(12):1941–1949

143. DeVries M, Lee J, Hoffman L. Infectionfree midline catheter implementation ata community hospital (2 years).Am J Infect Control. 2019;47(9):1118–1121

144. Kleidon TM, Cattanach P, Mihala G, UllmanAJ. Implementation of a paediatricperipheral intravenous catheter care bundle:a quality improvement initiative. J PaediatrChild Health. 2019;55(10):1214–1223


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Selection and Insertion of Vascular Access Devices in Pediatrics: … · Vascular access devices (VADs) are a common and essential component of pediatric health care.1 Arangeof peripheral