Consider this scenario: an 8-month-old infant with osteomyelitis needs intravenous (IV) access for 3 weeks of antibiotics; what device will best ensure successful therapy and low risk of complications? Or consider this: a teenager with cystic fibrosis is hospitalized for the third time this year with an acute exacerbation. Despite multiple efforts by experienced clinicians, an IV catheter cannot be successfully placed in a peripheral vein. Frustrated, the nurse says, “Let’s just put in a peripherally inserted central catheter.” Is this the best choice for the patient?
These scenarios, and many more like them, occur for hundreds of pediatric patients in hospitals every day. Yet, the approach to these decisions is far from consistent.1 Ask a provider why they choose a specific device or consult a certain specialist for an IV access procedure, and you may hear, “That’s how I have always done it,” or “This is how I was trained.” In part, these monocentric styles have evolved as a result of evidence gaps in pediatric vascular access. Compared with adult populations, the evidence base for risk, benefits, and alternatives of IV access devices in pediatrics is limited and largely informed by single-center, observational studies. This evidence gap has important implications. For example, when managing acutely ill pediatric patients or those with complex chronic conditions, decisions around which device to use, which vessel to insert it into, and how to insert them vary widely across centers.2,3 Choices are also often made with a limited time horizon: what will get them through this admission, rather than what is the best long-term strategy for a child. The painful truth is that we rely more on device availability than device appropriateness and on the culture of our practice, rather than evidence, when selecting an IV device for pediatric patients.
A lackadaisical approach to choosing IV catheters has consequences. Many children with chronic conditions transition into the adult world with permanent vessel damage, limiting treatment options.4 Reports of significant infections, extravasation injuries, and procedural harm by IV devices are common.5 Growing concerns about inappropriate use of IV devices (especially peripherally inserted central catheters) also abound in the literature.2,6 Thus, for all the above reasons, the need for a tool to inform decision-making related to IV devices had reached a deafening crescendo. And this tool, the mini Michigan Appropriateness Guide for Intravenous Catheters (miniMAGIC), is what we created to answer this call.
miniMAGIC was not born out of a whim. Its adult forerunner, the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC),7 was created in 2015 and has served to address the gaps in decision-making for IV access in hospitalized adult patients. The impact of MAGIC has been substantial: hospitals all over the United States, professional societies, guidelines, and health systems in many parts of the world have adopted MAGIC as policy.8–10 The medical device industry has been affected, leading to innovations and emphasis on less-invasive alternatives.11 And in early evidence from clinical studies, it is suggested that MAGIC not only improves IV device selection but also leads to a reduction in morbid and costly complications.12,13 The desire to replicate this success for pediatrics was too strong to resist.
To create miniMAGIC, we began with a systematic review of the literature to understand what is currently known about vascular access devices in pediatrics. Armed with this evidence, we created scenarios for use of various devices with the input of experts so as to delineate the most common and most challenging decisions in pediatric vascular access. We established an outstanding team of panelists (leaders in the field that represented virtually every discipline related to insertion, management, and use of pediatric IV devices) to help define what makes sense, what does not, and where the gaps lie. With support from the Association for Vascular Access Foundation, the University of Michigan and Griffith University, we spent countless hours refining and distilling the key recommendations and wisdom of our experts into tangible, concrete, and measurable appropriateness criteria. The task was challenging, but the labor was one of love.
What happens next, however, lies not in the hands of those who created miniMAGIC but with those that will use it for clinical decisions. With this document, we place the combined science, expertise of the panel, and evidence into your hands. As with MAGIC, we know what we have established represents the first iteration of a living document. Important gaps remain, and areas of uncertainty within miniMAGIC need clarity. These are not shortcomings but rather key opportunities for clinicians, researchers, funders, and policy makers to improve decisions for children all over the world. Whether it is an acute, complex, or chronic health condition, we hope no child will ever need to receive an IV without miniMAGIC in some way informing that choice.
That is a future we will look forward to. For our children and theirs.
Both authors reviewed and revised the manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.
FUNDING: Supported by grants from the Association for Vascular Access Foundation, Griffith University, and the University of Michigan.
POTENTIAL CONFLICT OF INTEREST: Dr Ullman reports investigator-initiated research grants and speaker fees provided to Griffith University from vascular access product manufacturers (3M Medical, Angiodynamics, and Becton Dickinson), unrelated to the current project. Dr Chopra reports grants from AHRQ and 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.
FINANCIAL DISCLOSURE: Dr Ullman reports fellowships and grants from the National Health and Medical Research Council; employment by Griffith University; grants from the Children’s Hospital Foundation, the Royal Brisbane and Women’s Hospital Foundation, Emergency Medicine Foundation, and the Australian College of Critical Care Nursing; and investigator-initiated research grants and speaker fees provided to Griffith University from 3M Medical, Angiodynamics, and Becton Dickinson (unrelated to the current project). Dr Chopra reports grants from the Agency for Healthcare Research and Quality and 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.