OBJECTIVE:

To critically review the evidence for the selection and insertion of pediatric vascular access devices (VADs).

DATA SOURCES:

Data were sourced from the US National Library of Medicine, Cumulative Index to Nursing and Allied Health, the Cochrane Library databases, Embase, and international clinical trial databases.

STUDY SELECTION:

Clinical practice guidelines, systematic reviews, cohort designs, randomized control trials (RCTs), quasi RCTs, before-after trials, or case-control studies that reported on complications and/or risk as well as reliability of VADs in patients aged 0 to 18 years were included.

DATA EXTRACTION:

Articles were independently reviewed to extract and summarize details on the number 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 some specialized patient populations were well evidenced. The use of single-lumen devices and ultrasound-guided techniques was also broadly supported. There was a lack of RCTs, and for neonates, cardiac patients, patients with difficult venous access, midline catheters, catheter-to-vein ratio, and near-infrared devices, the lack of evidence necessitated broadening the review scope.

LIMITATIONS:

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

CONCLUSIONS:

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

What’s Known on This Subject:

Individual studies, systematic reviews, and focused clinical practice guidelines that evaluate vascular access devices (VADs) in various pediatric populations are available. However, to date, no systematic review examining the appropriateness, and inappropriateness, of VADs across common pediatric clinical scenarios exists.

What This Study Adds:

There is strong evidence to support and facilitate appropriate clinical decision-making in some pediatric indications. However, certain populations, device types and characteristics, and insertion procedures are poorly evidenced, necessitating the application of clinical judgment for VAD decision-making.

Vascular access devices (VADs) are a common and essential component of pediatric health care.1  A range of peripheral and central venous devices that provide a route to administer critical and supportive therapies such as antibiotics, nutrition, and chemotherapy exists. Poor choice of VAD can lead to the insertion of an inappropriate device, which reduces treatment efficiency and places the patient at increased risk of harm.25  Clinicians need to make device and insertion decisions that ensure optimum therapy provision while preventing or reducing VAD-related complications (such as infection, thrombosis, and vessel damage), patient distress, and treatment delays.6 

To make VAD choices that mitigate patient harm and optimize treatment provision, clinical decision-making needs to reflect current, evidence-based guidance for pediatric patients. Individual studies, systematic reviews, and focused clinical practice guidelines (CPGs), which evaluate VADs in various pediatric populations, are available. However, to date, no systematic review examining the appropriateness and inappropriateness of VADs across common pediatric clinical scenarios exists. Systematic identification of high-quality evidence is necessary, not just to inform clinical decision-making and improve patient outcomes, but to further identify gaps in evidence that translate to gaps in practice and increase the risk of patient harm. In this review, we aimed to systematically and pragmatically evaluate all available evidence and guidance for VADs to inform the determination of Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics7,8  using the RAND Corporation–University of California, Los Angeles (RAND-UCLA) Appropriateness Method.9 

A systematic review was undertaken to synthesize existing evidence on selection and insertion of pediatric VADs following the RAND-UCLA Appropriateness Method.9  The systematic review protocol was registered and published with the International Prospective Register of Systematic Reviews (PROSPERO; CRD201994286)10  and is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards.11 

We conducted searches of the US National Library of Medicine (Medline), Cumulative Index to Nursing and Allied Health, Cochrane Library databases, Embase, and international clinical trial databases for all studies in which authors reported VAD use (success and complications) in a pediatric population from 2008 to May 16, 2018. Search terms were developed in collaboration with an experienced medical librarian. We used exploded Medical Subject Headings (MeSH) terms (eg, catheters) and relevant keywords and their variants (eg, child, pediatrics). Table 1 reveals the electronic database search strategy.

TABLE 1

Summary of Search Terms Used for the Electronic Database Search

Boolean VariableSearch Terms
AND Title and abstract terms: pediatric* OR pediatric* OR child* OR youth* OR adolescen* OR neonate* OR toddler* OR baby OR babies 
OR 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* OR peripherally 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 unnecessary 
OR publication type: guideline OR practice guideline 
OR 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 OR venipuncture OR venepuncture OR sucrose OR dose OR case report OR case study 
OR MeSH terms: Drug dosage calculations 
OR publication type: case reports 
FILTERS Language: English 
AND Publication date: from 2008/01/01 
Boolean VariableSearch Terms
AND Title and abstract terms: pediatric* OR pediatric* OR child* OR youth* OR adolescen* OR neonate* OR toddler* OR baby OR babies 
OR 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* OR peripherally 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 unnecessary 
OR publication type: guideline OR practice guideline 
OR 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 OR venipuncture OR venepuncture OR sucrose OR dose OR case report OR case study 
OR MeSH terms: Drug dosage calculations 
OR publication type: case reports 
FILTERS Language: English 
AND Publication date: from 2008/01/01 

Following the RAND-UCLA Appropriateness Method, our goal was to provide a critical review of the literature summarizing the scientific evidence available surrounding the appropriateness of pediatric VAD selection, insertion, and characteristics.9  This meant a range of study designs was eligible for inclusion, including existing CPGs, systematic reviews, randomized control trials (RCTs), quasi RCTs, before-after trials, cohorts, or case-control studies. Additionally, the guidelines and studies must have been published in a peer-reviewed journal and authors must have reported on complications and/or risk and reliability of VADs in patients aged term to 18 years in a pediatric hospital. We defined VADs to include intraosseous devices; midline catheters; peripherally inserted central catheters (PICCs); short and long peripheral intravenous catheters (PIVCs); tunneled, tunneled-cuffed, and nontunneled central venous access devices (CVADs); totally implantable venous devices; and umbilical catheters. We excluded studies that were not published in English and conference abstracts, animal studies, NICU studies, n = 1 studies, case reports, case-series reports, and qualitative reports. Although eligibility criteria were focused on pediatric studies (ie, term to 18 years), we determined that including preterm neonate and adult studies was preferential to no evidence.

The primary outcomes were defined a priori as (1) device and insertion characteristics that impact the success of VAD insertion and (2) device and insertion characteristics associated with VAD failure, due to complications before the completion of therapy, or successful VAD insertion. Device characteristics included VAD type, device catheter-to-vein ratio, and device lumens. Insertion characteristics included insertion site and location and the use of vessel visualization technology. Complications included but were not limited to central line–associated bloodstream infection (CLABSI), VAD-associated thrombosis, occlusion, catheter dislodgement, catheter-tip migration, catheter breakage or rupture, local infection, and phlebitis.

Title and abstract screening was performed independently by 2 review authors (E.B. and A.J.U.), excluding studies that did not meet eligibility criteria when this could be determined by the abstract alone. Full-text articles included for screening were reviewed by 2 review authors (E.B. and A.J.U.) and independently assessed against the inclusion or exclusion criteria. Duplicate publications were excluded. When individual studies that had been evaluated in a systematic review also returned in the search, the primary study was excluded to avoid repetition, and the systematic review was referred to. Any discrepancies between review authors were resolved through mutual discussion and, when required, a third, independent review author (M.C.) was consulted.

All full-text articles that met inclusion criteria were independently reviewed by 3 review authors (R.S.P., E.B., and A.J.U.) to extract details on the number of patients and catheters, population, age of participants, VAD type, study method, indication, comparators, and the frequency of VAD failure or complications. These details were summarized in a data extraction sheet and were cross-checked for accuracy and agreement. Additional relevant references were identified by examining reference lists of included studies and guidelines. Hand-searched references were evaluated to ensure that they met inclusion criteria. After screening, pragmatic inclusion of wider studies was employed. That is, if no studies identified meeting the preferential inclusion or exclusion criteria, we included wider studies (eg, a priori area of deficit included neonates outside of the NICU). The extracted data were then combined by using narrative (descriptive) synthesis by categories (ie, outcome, vascular device, indication).

The methodologic quality, transparency, and relevance of all individual included studies were independently assessed by 2 review authors (E.B. and A.J.U.) by using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline12  and Critical Appraisal Skills Program (CASP) Cohort Study checklist.13  RCTs and systematic reviews were preferentially included as the gold standard level of evidence for evaluating VADs. However, when this level of evidence did not exist, a pragmatic approach was taken so that studies outside of the scope of the review (eg, laboratory, premature neonate, or adult studies) and CPGs (which may be limited by the number or quality of included studies) were incorporated into the review. To provide a synthesis of the available literature for the purpose of the RAND-UCLA Appropriateness Method,9  studies were categorized according to their methodology: (1) CPG, (2) systematic review or other review, (3) RCT, (4) observational study with comparator, and (5) other (clinical review, pilot study, laboratory study).

The results of the search strategy and study selection are summarized in Fig 1. Electronic database searches identified 7430 articles, and hand searches of the bibliography of included studies and clinical guidelines identified 30 additional articles for potential inclusion. After removal of duplicates and screening for eligibility, a total of 133 studies and CPGs met eligibility criteria and were included in data extraction.

FIGURE 1

PRISMA flowchart of study selection. VA, vascular access.

FIGURE 1

PRISMA flowchart of study selection. VA, vascular access.

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The review includes 27 CPGs (20.4%), 11 systematic reviews (8.3%), 10 RCTs (7.6%), 79 observational studies (59.8%), 3 pilot studies (2.3%), 2 clinical reviews (1.5%), and 1 laboratory study (0.8%). These were sourced from research teams based in Africa (1.6%), Asia (9.3%), Europe (31.0%), the Middle East 2.3%), North America (40.3%), Oceania (11.6%), and South America (3.9%), with the majority sourced from the United States (n = 34; 37.8%). Subjects within the included studies ranged in age, from premature neonates up to 66 years, and required treatment of oncologic or hematologic conditions, support during critical care admission, or vascular access for hemodialysis, postsurgical, or general infusion therapy or parenteral nutrition (PN). Due to the heterogeneity across age and conditions in pediatric patients, included articles were divided into specific clinical subspecialties (eg, hospitalized pediatric patients, hematology or oncology; see Fig 2). Results from individual studies based on specific hospitalized populations are presented in Table 2 and include key characteristics for each study.

FIGURE 2

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

FIGURE 2

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

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TABLE 2

Summary of CPGs and Studies Included in Systematic Review

Study, YearParticipants, nDesign and/or MethodFocus and/or OverviewStudy Sample and CharacteristicsDeviceFindings and CommentsminiMAGIC Indication
Adams et al,14  2016 — Clinical reviewa Clinical review of midline catheter device indications and complications for use in the ED — Midline Midlines have a low complication rate, long dwell time, and high rate of first-attempt placement. General pediatrics 
Aiyagari et al,15  2012 89 Observationala To compare the clinical outcomes for infants with single-ventricle physiology after umbilical catheter and femoral CVAD placement Patients with single-ventricle physiology admitted to the NICU (4–13 d) Nontunneled CVAD, umbilical catheter Nontunneled CVADs were associated with higher rates of thrombosis and vein occlusion. No difference was seen among CLABSI, need for transhepatic access, and ultrasound-documented thrombus at the inferior vena cava–right atrial junction. Patients with nontunneled femoral CVAD for ≥14 d had a higher prevalence of thrombosis than those for <14 d. No difference in the prevalence of iliofemoral vein occlusion was seen. General pediatrics 
Ainsworth and McGuire,16  2015 549 Systematic reviewb To evaluate PN delivery via PIVC or CVAD in hospitalized neonates Included 6 RCTs evaluating PN delivery via PIVC or CVAD in hospitalized neonates PIVC, nontunneled CVAD Nontunneled CVAD led to a smaller deficit of nutrients and fewer catheters; there was no difference for invasive infection. Long-term dependent 
Alten et al,17  2012 115 Observationala To compare USG CVAD insertion to landmark techniques in critically ill neonates Retrospective review of critically ill neonates (mean = <14 d) admitted to the PICU requiring CVAD placement using USG or landmark techniques CVAD Insertion using ultrasound guidance was associated with higher overall success, first-, and second- attempt success, and lower arterial puncture rates. Vessel visualization 
Anil et al,18  2011 128 Observationala To evaluate complications associated with CVAD placement in the PICU Retrospective review of all patients (median = 21 mo) admitted to the PICU requiring CVAD placement CVAD There was no difference in complications for CVAD insertion at femoral, subclavian, or jugular veins. Insertion location 
ANZICS,19  2012 — CPGb Specific recommendations for insertion central lines for the prevention of CLABSI — Nontunneled CVAD, tunneled CVAD — Insertion location 
Allen et al,20  2008 — Observationala To determine the risk of infection in pediatric oncology patients requiring long-term vascular access 12-mo prospective study of pediatric oncology patients (3 mo–20 y old) with a TIVD or tunneled-cuffed CVAD TIVD, tunneled-cuffed CVAD There was a higher rate ratio for CLABSIs in tunneled-cuffed CVAD. Hematology and oncology 
ARC and NZRC,21  2010 — CPGb Specific recommendations for access to circulation in infants and children in the context of cardiorespiratory arrest — CVAD, intraosseous, PIVC — Critical care 
ARC and NZRC,22  2010 — CPGb Medication or fluids for the resuscitation of the newborn infant — Intraosseous, PICV, umbilical catheter Specific recommendations for newborn infants in the context of resuscitation were provided. Critical care 
ARC and NZRC,23  2010 — CPGb Specific recommendations for vascular access in pediatric patients in the context of cardiopulmonary arrest — CVAD, intraosseous, PICV — General pediatrics 
Arnts et al,24  2014 203 Observationala To compare the rates of complications between umbilical catheters and PIVCs in newborns Patients admitted to the NICU (24–42 wk gestation) requiring a PICC or umbilical catheter PICC, umbilical catheter There was no difference in complication rate or due to gestational age. General pediatrics 
Athale et al,25  2012 358 Observationala To evaluate the impact of CVAD on 5-y overall and event-free survival in children with cancer Children with non-CNS cancer (≤19 y old) who required a CVAD CVAD CVAD dysfunction controlling for thromboembolism is associated with poorer 5-y overall and event-free survival. Hematology and oncology 
Avanzini et al,26  2017 194 Observationala To describe a single-center transition from CVAD placement via surgical cutdown to USG insertion techniques Retrospective review of pediatric patients (7 d–18 y old) who underwent tunneled CVAD placement using USG or surgical cutdown techniques Tunneled CVAD Double-lumen PICCs were associated with increased risk of complications, compared to single-lumen PICCs; complications were reported but not significantly compared between USG and surgical cutdown techniques. Device lumens 
Vessel visualization 
Barnwal et al,27  2016 60 Observationala To compare ECG and landmark insertion techniques for CVAD placement Pediatric patients (0–11 y old) undergoing elective cardiovascular surgery randomly assigned to CVAD insertion via landmark or ECG techniques CVAD There were fewer complications using USG insertion techniques. Vessel visualization 
Barrier et al,28  2012 1280 Observationala To determine risk factors for PICC-related complications in children Immunocompromised children (mean = 3.2 y old; 0–21 y old) requiring a PICC PICC Double-lumen catheters, PICCs placed in the femoral vein and children 1–4 y old, compared with older children (5–10 y old, >10 y old), were more at risk for complications. General pediatrics 
Device lumens 
Insertion location 
Baskin et al,29  2019 — CPGb Specific recommendations for central venous catheters in children with chronic illness — Midline, PICC, TIVD, tunneled-cuffed CVAD — Long-term dependent 
Ben Abdelaziz et al,30  2017 215 Observationala To examine the incidence of PIVC-related complications in pediatric patients Comparison of complications versus no complications in hospitalized children (0.1–18 y old) requiring a PIVC PIVC Longer duration was associated with local complication. General pediatrics 
Bezzio et al,31  2019 205 Observationala To investigate the rate of and risk factors for infection in children undergoing cardiac surgery requiring CVAD placement Prospective study of pediatric patients (1 d–25 y old) undergoing cardiac surgery CVAD Infection risk significantly increased with increased duration of device placement; the SCV vein was more likely to develop CLABSI. Congenital cardiac 
Insertion location 
Blotte et al,32  2017 162 Observationala To compare PICC and CVAD complications in pediatric patients with intestinal failure Pediatric patients (1 d–12 y old) with intestinal failure requiring PN PICC, tunneled-cuffed CVAD Tunneled-cuffed CVAD had a higher infection rate, and PICCs were more likely to break. More tunneled-cuffed CVADs had central venous thrombosis, whereas more PICCs had basilic vein thrombosis. Long-term dependent 
Birhane et al,33  2017 178 Observationala To assess factors that impacted PIVC life span in neonates and infants Neonates and infants (1 d–11 mo) requiring PIVC placement PIVC Compared to placement at the scalp, hand, or leg, PIVCs inserted at the arm had a longer life span. Insertion location 
Bodenham Chair et al,34  2016 — CPGb Specific recommendations for the insertion of VADs in all patients — CVAD, PIVC — Critical care 
Catheter-to-vein ratio 
Device lumens 
Vessel visualization 
Boe et al,35  2015 92 Observationala To evaluate risk factors and complications associated with the placement of transhepatic CVADs Retrospective review of congenital cardiac patients (IQR = 2–10 y old) undergoing transhepatic CVAD placement Transhepatic CVAD Placement ≥21 d was associated with increased transhepatic CVAD complications. Critical care 
Borasino et al,36  2014 392 Observationala To determine if CVAD insertion into veins in the upper body is a risk factor for chylothorax Retrospective review of pediatric patients (<1 y old) undergoing cardiac surgery; comparison among CVAD placement at IJV versus SCV versus femoral vein CVAD Insertion at IJV or SCV was associated with a higher risk of chylothorax. Insertion location 
Boretta et al,37  2018 107 Observationala To evaluate the management and complications associated with PICCs inserted in pediatric oncology patients Pediatric oncology patients (0–17 y old) requiring PICC placement PICC Compared to right-side insertion locations, PICCs inserted on the left side of the body were associated with more complications. Insertion location 
Bouaziz et al,38  2015 — CPGb Specific recommendations for the placement of VADs under ultrasound guidance in all patients — CVAD, PIVC — Vessel visualization 
Bozaan et al,39  2019 226 Pilot studya To evaluate the impact of an intervention designed to increase the use of single-lumen PICCs Pre- and postintervention of PICC placement in hospitalized adults (60 y old) PICC Making single-lumen PICCs the default option and providing indications for multilumen devices increased use of single-lumen PICCs. Device lumens 
Bratton et al,40  2014 178 Observationala To report complication rates of VADs in children undergoing radiotherapy Retrospective review of pediatric patients (1–26 y old) undergoing radiotherapy who received a VAD PICC, TIVD, tunneled-cuffed CVAD TIVDs were associated with lower infection and complication rates and had greater durability. Hematology and oncology 
Byon et al,41  2013 98 RCTc To evaluate the efficacy of USG SCV catheterization Pediatric patients (0–2.9 y old) undergoing elective congenital cardiac surgery or neurosurgery; randomly assigned to supraclavicular or infraclavicular approaches CVAD The supraclavicular approach was associated with shorter puncture time, fewer insertion attempts, and fewer misplacements. Insertion location 
Camkiran Firat et al,42  2016 280 RCTc To compare the rate of complications associated with IJV and SCV CVAD insertion Pediatric patients (16 mo–2.2 y old) undergoing cardiac surgery; randomly assigned to IJV or SCV insertion CVAD Insertion via the SCV was associated with higher success rates; lower rates of arterial puncture, catheter-tip cultures, and CLABSI; and higher rates of malposition. There was no difference in mechanical complications, ICU and hospital length of stay, and in-hospital mortality. Insertion location 
Campagna et al,43  2018 1538 Observationala To determine the safety of midline catheters used in general hospitalized adults Hospitalized adults (median = 83 y old) requiring a midline catheter across 2 Italian hospitals Midline A total of 10% of midline catheters had a serious adverse event. General pediatrics 
Carlson et al,44  2015 3846 Observationala To characterize procedures performed on critically ill children by emergency medical service personnel in out-of-hospital contexts Retrospective review of pediatric patients (0–17 y old) requiring out-of-hospital critical care CVAD, intraosseous CVADs had higher success rates compared to intraosseous devices. Critical care 
Carraro et al,45  2013 — CPGb Specific recommendations for the use of long-term central venous access in pediatric hematology and oncology patients — TIVD, tunneled-cuffed CVAD — Hematology and oncology 
Cesaro et al,46  2016 1161 Observationala To report the frequency and associated risk factors for central venous catheter–associated complications in children with hemato-oncological conditions Pediatric hematology-oncology patients (median = 6.1 y old) requiring a tunneled-cuffed CVAD Tunneled-cuffed CVAD At <6.1 y old, there were more mechanical complications, more malfunction or occlusion; compared to single-lumen devices, double-lumen devices had more mechanical complications, exit-site or tunnel infections, and malfunction or occlusion. Hematology and oncology 
Device lumens 
Chen et al,47  2020 4405 Systematic reviewb To compare risk associated with PICCs placed in the upper versus the lower extremity in neonates Neonates (<28 d old) requiring PICC placement PICC There was a greater risk of nonelective removals and malposition in PICCs placed in the upper versus lower extremity; there was a lower risk of thrombosis in PICCs placed at the upper extremity. There were no differences in mechanical complications, PICC-related infection, or phlebitis. Insertion location 
Choi et al,48  2017 23 Observationala To determine the safety and accuracy of TIVD placement using ultrasound guidance compared to surgical cutdown Retrospective review of pediatric (0–16 y old) hematology, oncology, and PN patients undergoing TIVD placement TIVD There was no difference using ultrasound guidance in insertion time or complication compared to surgical cutdown. Vessel visualization 
Cooling et al,49  2017 75 Observationala To examine the performance and safety of femoral CVADs Retrospective study of pediatric patients undergoing stem cell collection (median = 3 y old) requiring CVAD placement CVAD Compared to thoracic CVADs, femoral CVADs had fewer flow-related adverse events. Insertion location 
Crocoli et al,50  2015 — CPGb CVADs in pediatric patients with cancer — Midline, PICC, nontunneled CVAD, TIVD, tunneled CVAD, tunneled-cuffed CVAD — Hematology and oncology 
Long-term dependent 
Catheter-to-vein ratio 
Device lumens 
Vessel visualization 
Debourdeau et al,51  2009 — CPGb Prevention of thrombosis associated with central venous catheters in patients with cancer — TIVD, tunneled CVAD — Hematology and oncology 
Device lumens 
Insertion location 
De Carvalho Onofre et al,52  2012 42 RCTc To compare the use of ultrasound and palpation insertion success for PICC placement in pediatric patients Any pediatric patient (1 mo–16 y old) requiring IV therapy for >7 d; randomly assigned to USG PICC insertion or palpation PICC USG PICC insertion was associated with higher first-attempt success rate, better catheter positioning and shorter insertion time. Vessel visualization 
de Souza et al,53  2018 80 RCTc To determine if USG PICC placement led to higher insertion success compared to landmark techniques Critically ill pediatric patients (IQR = 3 mo–1.3 y old) admitted to the PICU requiring PICC insertion via the IJV; randomly assigned to USG or landmark insertion PICC USG PICC insertion was associated with higher overall success rate, first- and third-attempt success rate, lower insertion time, and fewer hematomas and arterial punctures compared to landmark. Vessel visualization 
DeWitt et al,54  2015 180 Observationala To determine procedural success and failure rates in umbilical catheter placement Patients with congenital heart disease <20 h old versus >20 h old requiring an umbilical catheter Umbilical catheter There was a higher success rate for younger patients. General pediatrics 
Dheer et al,55  2011 103 Observationala To compare the rates of immediate insertion-related complications after CVAD placement in pediatric patients Hospitalized children (<12 y old) requiring a CVAD; comparison of complications among neonate versus infant versus >1–12 y old CVAD Neonates were at higher risk of immediate insertion-related complications; more insertion attempts were associated with insertion-related problems. General pediatrics 
Doellman et al,56  2015 — CPGb Specific recommendations regarding central venous catheters that account for the unique needs of pediatric patients — Hemodialysis catheter, PICC, nontunneled CVAD, TIVD, tunneled CVAD — General pediatrics 
Hematology and oncology 
Critical care 
Congenital cardiac 
Long-term dependent 
Catheter-to-vein ratio 
Device lumens 
Vessel visualization 
Dongara et al,57  2017 144 RCTc To compare success and complication rates, cost, and insertion time between PICCs and umbilical catheters inserted in the NICU Patients admitted to the NICU (mean = 34 wk’ gestation) requiring a PICC or umbilical catheter PICC, umbilical catheter There was no difference in success rate, time, and short-term complications between PICCs and umbilical catheters. General pediatrics 
Elser,58  2013 — Clinical reviewa Clinical review of umbilical catheter placement Patients admitted to the NICU requiring an umbilical catheter Umbilical catheter Umbilical catheter malposition or dislodgement is associated with hemorrhaging and death. General pediatrics 
Fallon et al,59  2014 244 Observationala To determine device-related complications in infants requiring a VAD Hospitalized children (0–3 y old) requiring a central venous catheter for prolonged therapy TIVD, tunneled CVAD Infants (≤1 y old) had higher complication rate, higher operative exchange rate, higher infection rate, and shorter duration compared with toddlers (>1 y old). General pediatrics 
Faustino et al,60  2013 101 Observationala To explore the incidence of DVT in PICU patients requiring a central venous catheter Critically ill children (0–17 y old) admitted to the PICU; comparisons made among age (<1 y old versus 1–13 y old versus 13–17 y old) Nontunneled CVAD Compared with infants (<1 y old), PICU patients 13–17 y old had higher odds of DVT. Critical care 
Froehlich et al,61  2009 93 Observationala To determine if CVAD placement using ultrasound guidance increases insertion success and decreases complications after single-center transition to USG insertion techniques Prospective study of critically ill pediatric patients (median = 2.5 y old) admitted to the PICU requiring CVAD placement with USG or landmark techniques CVAD Ultrasound guidance was associated with significantly lower arterial punctures and fewer No. attempts. There was no difference in success rate or insertion time between ultrasound guidance and landmark groups. Vessel visualization 
Frykholm et al,62  2014 — CPGb Specific guidelines for patients requiring central venous catheters regarding vascular approach, ultrasound guidance, and prevention of complications — Dialysis catheters, nontunneled CVAD, PICC, TIVD, tunneled-cuffed CVAD — Long-term dependent 
Device lumens 
Vessel visualization 
Gaballah et al,63  2014 150 Observationala To describe complication rates associated with CVAD placement using ultrasound guidance and fluoroscopic guidance in neonates and infants Retrospective review of critically ill neonates and infants (premature–1 y old) requiring CVAD placement with USG versus fluoroscopic guidance CVAD There was no difference in complication rates. Insertion location 
Vessel visualization 
Gallagher et al,64  2014 168 Observationala To determine if CVAD placement using USG techniques improved insertion success in pediatric ED patients Retrospective study of pediatric (3–15 y old) emergency patients requiring CVAD placement with or without ultrasound guidance CVAD There was higher insertion success when using ultrasound guidance. Vessel visualization 
Gonzalez et al,65  2012 172 Observationala To determine if early placement of TIVDs or tunneled-cuffed CVADs in patients at high risk of thrombosis and infection led to higher surgical complications Retrospective review of children with ALL (4 d–16 y old) at high risk of infection and thrombosis TIVDs, tunneled-cuffed CVADs There was no difference in infection rate between TIVD and tunneled-cuffed CVADs and no difference in rate of infection in single- versus double-lumen devices. Hematology and oncology 
Device lumens 
Gorski et al,66  2016 — CPGb Specific practice recommendations for adult and pediatric patients requiring infusion therapy, including device selection, placement, and complication prevention — Hemodialysis catheters, intraosseous, long PIVC, midline, nontunneled CVAD, PICC, short PIVC, TIVD, tunneled CVAD, umbilical catheter — Critical care 
Congenital cardiac 
Long-term dependent 
Catheter-to-vein ratio 
Device lumens 
Vessel visualization 
Gray et al,67  2012 333 Observationala To identify risk factors for catheter-related DVT in infants <1 y old Hospitalized infants (mean = 34 wk’ gestation) requiring a VAD PICC, tunneled-cuffed CVAD Mean catheter days before DVT diagnosis were shorter for PICCs than for tunneled-cuffed CVADs; higher rates of DVT were in multilumen CVADs; the majority of DVT was in femoral veins. Femoral CVADs were associated with greater DVT rates than jugular or SCV CVADs. There was more DVT in femoral lines than in sapheno-femoral tunneled-cuffed CVADs. Long-term dependent 
Device lumens 
Insertion location 
Gurien et al,68  2016 1134 Observationala To determine the incidence of complications associated with CVAD placement using USG techniques Retrospective, multicenter review of pediatric patients (1.5–12 y old) who underwent CVAD placement with landmark or USG insertion CVAD There was a higher first- attempt success rate using ultrasound guidance but higher risk of hemothorax using ultrasound guidance. Vessel visualization 
Habas et al,69  2018 225 Observationala To determine the complications associated with CVAD placement at the BCV insertion site Retrospective review of pediatric patients (mean = 7 y old) admitted to PICU requiring CVAD placement; BCV insertion site versus all others (femoral, subclavian, jugular) CVAD Compared to other insertion sites, BCV had fewer complications. Insertion location 
Hamed et al,70  2013 300 Observationala To describe insertion success rate and complication rate after delivery of anesthesia to critically ill infants and toddlers Critically ill infants and toddlers (21 d–1.3 y old) requiring emergency surgery Intraosseous Intraosseous access was appropriate for unobtainable peripheral or central access. Critical care 
Hancock-Howard et al,71  2010 60 Observationala To determine the cost-effectiveness of TIVD placement using interventional radiology Retrospective review of pediatric oncology patients undergoing placement of a TIVD using interventional radiology (mean = 7 y old) or surgical cutdown (mean = 4 y old) techniques TIVD Insertion time was shorter and resulted in fewer complications using interventional radiology compared to surgical cutdown. Vessel visualization 
Handrup et al,72  2010 98 Observationala To evaluate the rates of VAD-related complications associated with placement of a TIVD or tunneled-cuffed CVAD Retrospective review of children with ALL (<4–>9 y old) who received a TIVD or tunneled-cuffed CVAD over an 8-y period TIVD, tunneled-cuffed CVAD There was a higher CLABSI rate and nonelective removal for tunneled-cuffed CVAD. Hematology and oncology 
Hanson et al,73  2012 1070 Observationala To investigate the rate of and risk factors for VTE in children with cardiac disease admitted to the PICU Children with cardiac disease (median = 10 mo) admitted to the PICU; comparisons made among <6 mo versus 6 mo–1 y old versus 1–2 y old versus 2–12 y old versus 12–18 y old versus >18 y old CVAD VTE incidence was associated with increasing No. CVAD days. In young children (<6 mo), VTE incidence was significantly higher. Critical care 
Heinrichs et al,74  2013 1076 Systematic reviewb To evaluate assistive technologies, other than ultrasound guidance, in improving PIVC insertion success Seven RCTs of pediatric patients (0–21 y old) requiring PIVC insertion using novel interventions PIVC Transillumination was associated with higher first-attempt success compared to traditional insertion techniques; first-attempt success using NIR and traditional methods was not significantly different. There was no difference in time or No. attempts between insertion methods. Vessel visualization 
Included studies 
Hosokawa, 2010 
Katsogridakis, 2008 
Nager, 1992 
Perry, 2011 
Chapman, 2011 
Kim, 2012 
Maynard, 1989 
Institute for Healthcare Improvement,75  2012 — CPGb Specific recommendations for the prevention of CLABSI — CVAD — Vessel visualization 
IVNNZ,76  2012 — CPGb Specific practice recommendations for adult and pediatric patients requiring infusion therapy, including device selection, placement, and complication prevention — Intraosseous, midline, nontunneled CVAD, PICC, TIVD, tunneled CVAD, umbilical catheter — Critical care 
Long-term dependent 
Device lumens 
Vessel visualization 
Katsogridakis et al,77  2008 240 Observationala To determine if transillumination increases PIVC insertion success in pediatric patients Pediatric patients (mean = 13 y old) with difficult venous access admitted to the ED requiring nonurgent PIVC placement; randomly assigned to with or without transillumination PIVC Insertion using transillumination was associated with higher first- and second-attempt success compared to without transillumination. Vessel visualization 
Kim et al,78  2017 132 RCTc To compare ultrasound guidance to landmark techniques for CVAD insertion in children Pediatric cardiac surgery, neurosurgery, or general surgical patients (1 mo–6 y old) requiring CVAD insertion; randomly assigned to USG insertion to the axillary vein or LM insertion via the SCV CVAD USG + axillary insertion was associated with fewer attempts and shorter insertion time. There was no difference in complication rates. Results were confounded by location and/or imaging. Insertion location 
Vessel visualization 
Kulkarni et al,79  2014 — Systematic reviewb A systematic review of TIVDs and tunneled-cuffed CVADs in adults and children receiving chemotherapy 5 RCTs and 25 observational studies of adults and children undergoing chemotherapy TIVD, tunneled-cuffed CVAD Tunneled CVAD was associated with more infections, noninfectious complications, and device removal. Hematology and oncology 
Kulkarni et al,80  2017 176 Observationala To describe the complications related to VAD insertion in infants with hemophilia Infants (0–2 y old) with hemophilia requiring either a PICC, TIVD, or tunneled CVAD PICC, TIVD, tunneled CVAD TIVDs had the lowest rates of complications. Hematology and oncology 
Lam et al,81  2018 954 Observationala To evaluate the impact of defaulting to single-lumen PICCs Hospitalized adults (mean = 66 y old) requiring PICC placement; comparison of single versus double lumens PICC Single-lumen PICCs were associated with lower complications. Device lumens 
Lamperti et al,82  2012 — CPGb Specific recommendations regarding USG VAD placement — CVAD, PICC — Catheter-to-vein ratio 
Vessel visualization 
Lau and Chamberlain,83  2016 760 Systematic reviewb To examine the safety and efficacy of CVAD insertion using ultrasound guidance A total of 8 RCTs comparing the use of USG and landmark CVAD placement in pediatric patients (<18 y old) CVAD Ultrasound guidance had a higher success rate and fewer No. insertion attempts compared to landmark techniques. Vessel visualization 
Included studies 
Alderson, 1993 
Verghese, 1999 
Verghese, 2000 
Grebenik, 2004 
Chuan, 2005 
Ovezov, 2010 
Aouad, 2010 
Bruzoni, 2013 
Levy et al,84  2010 279 Observationala To determine the rate of and potential risk factors for infectious and noninfectious complication associated with PICCs in pediatric patients Hospitalized children (10 d–21 y old) requiring a PICC PICC Older age was associated with infectious complications. General pediatrics 
Lindquester et al,85  2017 33 Observationala To examine the safety and efficacy of tunneled CVAD placement at the internal and external jugular in neonates and infants <5 kg Multicenter retrospective review of hospitalized infants weighing <5 kg (0–1 y old) with a tunneled CVAD Tunneled CVAD There was no difference in complications associated with jugular and femoral vein insertion locations. Insertion locations 
Loveday et al,86  2014 — CPGb Specific recommendations for the prevention of hospital-acquired infections — PICC, TIVD, tunneled CVAD — Long-term dependent 
Device lumens 
Malbezin et al,87  2013 5435 Observationala To prospectively determine the overall success and complication rate of CVAD insertion over a 22-y period Hospitalized children (mean = 5 y old) requiring any CVAD CVAD Device failure was more likely in children <3 kg. General pediatrics 
Marshall et al,88  2017 19 Observationala To compare transhepatic CVADs to nontunneled CVADs as an alternative for preserving future central venous access Retrospective review of infants (1.8–7.8 mo) with congenital heart disease who underwent placement of 1 or more transhepatic CVADs Nontunneled CVAD, transhepatic CVAD Transhepatic CVAD had a longer duration. There was no difference in thrombi, thrombolytic burden, or catheter sites requiring wound care consultation. There was a higher frequency of infection in transhepatic CVAD. There was no difference in the rate of infection-related removal. Congenital cardiac 
Marquez et al,89  2016 175 Observationala To determine risk factors for thrombosis after placement of nontunneled CVADs in PICU patients Prospective, multicenter study of pediatric patients (4 mo–8.6 y old) admitted to the PICU undergoing CVAD placement Nontunneled CVAD There were higher rates of DVT in patients with right-side nontunneled CVAD placement and insertion at SCV. Insertion location 
May et al,90  2018 912 Observationala To determine the rates of thrombosis, infection, and insertion site symptoms after placement of PICCs and TIVDs in patients with cystic fibrosis Retrospective review of adult and pediatric patents (mean = 7.4 y old) with cystic fibrosis PICC, TIVD Double-lumen PICCs were associated with greater rates of complications. Long-term dependent 
Device lumens 
Menéndez et al,91  2016 256 Observationala To evaluate the incidence and risk factors for PICC-related thrombosis in children Hospitalized children (IQR = 2.4–13 y old) requiring PICC placement PICC A catheter-to-vein ratio of >0.33 predicted PICC-related superficial vein thrombosis and DVT. Catheter-to-vein ratio 
Mermel et al,92  2009 — CPGb Specific recommendations for the prevention of catheter-related infection — CVAD, midline, PICC, PIVC, TIVD — Long-term dependent 
Moon et al,93  2018 629 Observationala To determine risk factors for CLABSI in children with hemato-oncological disease requiring long-term VADs Retrospective review of children with hemato-oncologic disease (median = 6 y old; 14 d–17.9 y old) requiring any long-term CVAD TIVD, tunneled-cuffed CVAD There was no difference in the rate of CLABSI. Hematology and oncology 
Mushtaq et al,94  2018 693 Observationala To determine the safety, specifically rates of CLABSI, mechanical complications, hospital length of stay, readmission within 90 d of discharge, and mortality of midline catheters compared to CVADs in adults admitted to intensive care Adults >18 y old admitted to the ICU or medical-surgical ward with either a CVAD or midline catheter CVAD, midline CVADs were associated with higher rates of CLABSI, crude mortality, readmission, and transfer to the ICU. Midline catheters had more mechanical complications. General pediatrics 
Noailly Charny et al,2  2018 295 Observationala To compare the risk of thrombosis in PICCs and tunneled-cuffed CVADs Children (<18 y old) diagnosed with leukemia who received a PICC or tunneled-cuffed CVAD PICC, tunneled-cuffed CVAD PICCs were associated with an increased risk of thrombosis. Hematology and oncology 
Nifong and McDevitt,95  2011 — Laboratory studya To determine the effect of catheter size of fluid flow rates — PICC Fluid flow rate decreased with increasing catheter size. Catheter-to-vein ratio 
O’Grady et al,96  2011 — CPGb Specific recommendations for the prevention of intravascular catheter-related infections — Midline, nontunneled CVAD, PICC, PIVC, TIVD, tunneled CVAD — Device lumens 
Vessel visualization 
Ohno et al,97  2016 120 Observationala To determine the rates of complications and CLABSI in infants and small infants (<1 y old or <10 kg) compared with children (>1 y old or >10 kg) Children (4 mo–22 y old) requiring a TIVD TIVD Age was not associated with increased risk of complications. General pediatrics 
Oulego-Erroz et al,98  2016 46 Pilot studya To determine if CVAD insertion to the BCV using USG techniques had greater insertion success compared to insertion to the IJV Prospective study of critically ill children (0.6 mo–13 y old) requiring urgent CVAD insertion; nonrandom assignment to BCV + USG or IJV insertion CVAD BCV + ultrasound guidance had a higher first-attempt success rate, fewer insertion attempts, and lower insertion time compared to IJV. There was no difference in overall success rates. Insertion location 
Vessel visualization 
Oulego-Erroz et al,99  2018 500 Observationala To determine if CVAD placement outcomes can be improved by using USG insertion Prospective, multicenter study of all critically ill children (IQR = 2 mo–4.9 y old) requiring temporary CVAD placement using USG or landmark techniques CVAD Ultrasound guidance had a higher first-attempt success rate and fewer puncture attempts and mechanical complications. Vessel visualization 
Pacilli et al,100  2018 18 Observationala To determine the appropriateness of long PIVCs in pediatric patients undergoing surgery Children undergoing surgery (mean = 6.3 y old) requiring long PIVC insertion Long PIVC There were no immediate complications. On day 3, removals were made because of 3 occlusions and 1 red/pain. General pediatrics 
Paladini et al,101  2018 40 Pilot studya To compare the success of USG long PIVC insertion in children admitted to the ED to short PIVCs Children >10 y old (mean = 13 y old) who were admitted to the ED; comparison of blind short PIVC versus USG PIVC insertion Long PIVC, short PIVC Short PIVCs had a shorter dwell time duration and more complications compared to long PIVCs; ultrasound guidance had a lower risk of failure and complications but results confounded. Critical care 
Vessel visualization 
Park et al,102  2016 3832 Systematic reviewb To determine the utility of NIR light devices A total of 11 RCTs of any pediatric patient (<21 y old) undergoing PIVC placement using NIR or no assistive device PIVC There was no overall difference in overall success rate between NIR light device and traditional methods; however, NIR light devices had a higher success rate for subsets deemed high risk of failure. 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 
Pasteur et al,103  2010 — CPGb Specific recommendations for patients with non-CF bronchiectasis — TIVD — Long-term dependent 
Peterson et al,104  2012 1399 Observationala To determine if assistive devices improve PIVC insertion success Hospitalized children (mean = 1 y old) requiring PIVC placement; randomly assigned to unassisted versus assisted (transillumination versus NIR light device–guided) insertion PIVC PIVC insertion success was higher when no assistive device was used compared to assisted methods. Vessel visualization 
Perin and Scarpa,105  2015 — Systematic reviewb To review evidence related to the assessment of catheter-tip positioning in pediatric patients Included 42 pediatric studies examining outcomes for patients undergoing VAD placement using vessel visualization techniques CVAD, PICC, umbilical catheter There was insufficient high-quality evidence to make specific recommendation for use in pediatric patients. Vessel visualization 
Pinon et al,106  2009 915 Observationala To determine the incidence and risk factors of central venous catheter-related complications in pediatric hemato-oncological and immunologic conditions Single-center, prospective study of children (0–19 y old) with oncological, hematologic, or immunologic diseases TIVD, tunneled CVAD Tunneled-cuffed CVADs were associated with more CLABSI; being ≤3 y old was associated with more dislodgements and more tunnel infections; CLABSI was more prevalent in double- versus single-lumen devices. Hematology and oncology 
Device lumens 
Pittiruti et al,107  2009 — CPGb Specific recommendations for CVADs and complication prevention in patients requiring PN — Midline, PICC, PIVC, TIVD, tunneled CVAD — Long-term dependent 
Device lumens 
Vessel visualization 
Polkinghorne et al,108  2013 — CPGb Specific recommendations for vascular access in patients with chronic renal disease — Nontunneled CVAD, tunneled CVAD — Vessel visualization 
Qian et al,109  2014 40 Observationala To examine complication rates in pediatric patients with CF after the placement of a long PIVC Prospective audit of pediatric patients with CF with infective exacerbation Long PIVC Complication rates were high; no serious adverse outcomes were reported. Long-term dependent 
Ramer et al,110  2016 53 RCTc To evaluate the effectiveness of NIR light device technology for PIVC placement in pediatric hematology and oncology patients Pediatric hematology and oncology patients (1–21 y old) requiring PIVC placement; randomly assigned to NIR light device or landmark insertion techniques PIVC NIR light device was associated with faster insertion time and higher satisfaction. Vessel visualization 
Rauth et al,111  2008 138 Observationala To investigate the rate of infection in infants when the venous catheter is exchanged for a tunneled-cuffed CVAD after ECMO decannulation PICU patients (mean = 13 d) requiring CVAD placement after decannulation from ECMO Tunneled-cuffed CVAD Increasing the duration of ECMO and CVAD placement independently predicted CLABSI. Critical care 
Revel-Vilk et al,112  2010d 423 Observationala To determine the rate of catheter-related complications in children undergoing chemotherapy during 12 mo of therapy Single-center, prospective study of pediatric patients (29 d–28 y old) undergoing chemotherapy PICC, tunneled-cuffed CVAD PICCs were associated with a higher risk of DVT; tunneled CVAD had a higher risk of occlusion at 1 y. Hematology and oncology 
Rey et al,113  2009 825 Observationala To identify risk factors for early mechanical complications in CVADs Pediatric patients (median = 22 mo) admitted to the PICU; comparisons among femoral, jugular, and SCV CVAD insertion sites CVAD SCV and jugular vein, as well as increasing No. attempts were associated with significantly more early mechanical complications. Difficult venous access 
Insertion site 
Rivera-Tocancipa et al,114  2018 201 Observationala To describe the incidence of complications associated with USG CVAD insertion in children compared to anatomic landmark techniques All hospitalized children (0–18 y old) requiring CVAD insertion using USG or LM insertion techniques CVAD Ultrasound guidance had fewer immediate complications, no arterial punctures, and higher rates of insertion success compared to landmark techniques. Vessel visualization 
Rosado et al,115  2013 255 Observationala To examine the rate of CVAD-associated infection in PICU patients Prospective, single-center review of children (majority <6 y old) admitted to the PICU requiring a CVAD CVAD CVADs inserted ≥7 d were associated with a higher risk of CLABSI. Critical care 
Rossetti et al,116  2015 309 Observationala To investigate the safety and accuracy of intracavitary ECG-guided insertion in pediatric patients Prospective, multicenter study of hospitalized pediatric patients (1 mo–18 y old) requiring a VAD; insertion using intracavitary ECG versus intracavitary ECG with dedicated ECG monitor compared CVAD, PICC Insertion accuracy was higher with a dedicated ECG monitor. Vessel visualization 
Schiffer et al,117  2013 — CPGb Specific recommendations for central venous catheters in patients with cancer — Nontunneled CVAD, PICC, tunneled CVAD, TIVD — Hematology and oncology 
Vessel visualization 
Sharp et al,118  2015 136 Observationala To identify the optimal ratio cutoff to reduce rates of VTE Prospective study of hospitalized adults (mean = 57 y old) requiring PICC insertion, comparison between ≤45% versus ≥45% catheter-to-vein ratio PICC A >45% ratio was more likely to develop VTE. Catheter-to vein ratio 
Shenep et al,119  2017 90 Observationala To determine the interaction between PN and external central venous devices in increasing risk of complications Rates of complications during PN and non-PN periods in pediatric oncology patients (median = 7.3 y old) requiring central venous devices TIVD, tunneled CVAD Risk of CLABSI was higher during PN for children with TIVDs. Occlusion risk was higher for TIVDs. Complication rates for TIVDs were lower during the non-PN period but similar during the PN period. Long-term dependent 
Sibson et al,120  2018 — CPGb Specific recommendations for preventing thrombosis in pediatric patients with cancer — PICC, PIVC, TIVD, tunneled CVAD — Hematology and oncology 
Sigaut et al,121  2009 359 Systematic reviewb To evaluate the advantages of USG CVAD placement over anatomic landmark techniques in pediatric patients Children (2 d–8 y old) undergoing cardiac surgery requiring CVAD CVAD For ultrasound guidance, no difference in rates of artery puncture, hematoma, hemothorax, pneumothorax, or time to insert was found. Ultrasound guidance had higher success rates for subsets of novice operators and during intraoperative use. Vessel visualization 
Included studies 
Alderson, 1993 
Chuan, 2005 
Verghese, 1999 
Verghese, 2000 
Grabenic, 2004 
Smitherman et al,122  2015 1135 Observationala To determine risk factors for the development of catheter-associated VTE in general hospitalized pediatric patients Chart review of hospitalized children (mean = 8 y old) requiring a VAD PICC Increasing age was related to an increased risk of thrombosis; lumen No. was not associated with thrombosis risk; insertion site (brachial or cephalic, SCV, jugular, or femoral or saphenous) was not associated with an increased risk of thrombosis. General pediatrics 
Device lumens 
Insertion location 
Takeshita et al,123  2015 96 Observationala To examine the factors that affect insertion success for invisible and impalpable peripheral veins in children Pediatric patients (1.1–2.8 y old) with invisible or impalpable veins undergoing elective surgery PIVC PIVC with ultrasound guidance had better success rates compared to PIVC without ultrasound guidance; compared to insertion to the dorsal hand vein, the cephalic vein had a higher success rate and shorter insertion time. Difficult access 
Insertion location 
Vessel visualization 
Takeshita et al,123  2015 196 RCTc To examine the factors that affect insertion success for invisible and impalpable peripheral veins in children Pediatric patients (10–40 mo) with invisible or impalpable veins undergoing elective surgery PIVC Compared to insertion to the dorsal hand or saphenous vein, the cephalic vein had a higher success rate. Insertion location 
The Joint Commission,124  2013 — CPGb Specific recommendations for preventing CLABSI in CVADs — CVAD — Device lumens 
Tripi et al,125  2016 108 Observationala To determine the frequency of PIVC-related dysfunction in pediatric patients Compared PIVC dysfunction in hospitalized children (0–>12 y old) over device durations of 1–2 d versus 2–3 d versus >3 d PIVC Higher rates of PIVC dysfunction were associated with PIVCs in place for >3 d or inserted in lower extremities. General pediatrics 
Troianos et al,126  2011 — CPGb Specific recommendations for VAD placement using ultrasound guidance in pediatric patients — CVAD, PICC, PIVC — Vessel visualization 
Ullman et al,6  2015 31 933 Systematic reviewb To review the incidence of VAD failure in pediatric patients Hospitalized pediatric patients across 74 studies requiring any VAD Hemodialysis catheter, nontunneled CVAD, PICC, TIVD, tunneled CVAD, umbilical catheter Hemodialysis catheters and umbilical catheters had the highest failure rate; TIVDs had the lowest failure rate. General pediatrics 
Ullman et al,1  2017 1027 Observationala To examine the prevalence, management, and associated complications of CVADs in pediatric patients Hospitalized pediatric patients (IQR = 1–12 y old) requiring any VAD Hemodialysis catheter, nontunneled CVAD, PICC, TIVD, tunneled CVAD, umbilical catheter PICCs had higher proportions of CVAD-associated complications in the previous 7 d. General pediatrics 
Unbeck et al,127  2015 2032 Observationala To identify risk factors for PIVC-associated complications in pediatric patients Comparison of hospitalized neonatal versus pediatric patients (0–18 y old) requiring a PIVC PIVC Occlusion was associated with longer dwell time. Neonatal: PIVC survival time was shorter; there was more infiltration. Insertion at the arm bend or ankle was associated with higher rates of infiltration and occlusion. General pediatrics 
Insertion location 
van Gent et al,128  2017 538 Observationala To determine the rates of infection and complications in pediatric hematology, oncology, and stem cell transplant patients Retrospective review of pediatric patients (mean = 7.8 y old) after surgical placement of any CVAD TIVD, tunneled-cuffed CVAD Tunneled-cuffed CVAD had a lower risk of infection. Hematology and oncology 
Vierboom et al,129  2018 232 Observationala To evaluate the safety of tunneled CVAD insertion in children weighing <10 kg Retrospective review of all children (<1 mo–4 y old) receiving surgical insertion of a tunneled CVAD with ultrasound guidance or via surgical cutdown Tunneled CVAD USG insertion was associated with lower mechanical blockages, but there was no difference in intraoperative and postoperative complications, time to insert, or device longevity. Vessel visualization 
Vinograd et al,130  2018 300 Observationala To evaluate PIVC insertion success in patients with difficult venous access using USG techniques Pediatric patients (median = 14 y old) in an ED who had a failed PIVC attempt via traditional insertion techniques PIVC PIVC using USG techniques led to 68% and 87% first- and second-attempt success rates after failed traditional method. Difficult access 
Vessel visualization 
Voigt et al,131  2012 — Systematic reviewb To review the evidence for the use of intraosseous devices in emergent contexts Studies evaluating intraosseous devices in patients requiring emergent vascular access or nonhuman randomized prospective studies Intraosseous Compared to alternative access, there was no difference in complications using intraosseous devices. Critical care 
Wiegering et al,132  2014 43 Observationala To determine the incidence of catheter-related thrombosis in pediatric oncology patients Single-center retrospective review of pediatric oncology patients (mean = 9.4 y old) requiring central venous access TIVD, tunneled-cuffed CVAD TIVDs showed an earlier peak of thrombosis occurrence than that of tunneled-cuffed CVAD catheters; the highest incidence of thrombosis occurred in the SCV, followed by external jugular and cephalic sites. There was no difference in complications between insertion at the left and right side. Hematology and oncology 
Insertion location 
White et al,133  2012 322 Observationala To compare the rate of complications and early removal between TIVDs and tunneled-cuffed CVADs Retrospective review of children (1 mo–19 y old) with ALL requiring a TIVD or a tunneled-cuffed CVAD TIVD, tunneled-cuffed CVAD TIVDs had less complications. Hematology and oncology 
Wragg et al,134  2014 100 Observationala To determine the rate of occlusion associated with tunneled-cuffed CVAD insertion under ultrasound guidance Children (21 d–16 y old) requiring elective or emergency removal of a tunneled-cuffed CVAD Tunneled-cuffed CVAD Complete venous occlusion was associated with younger age. General pediatrics 
Vessel visualization 
Wu et al,135  2013 508 Systematic reviewb To evaluate whether USG CVAD insertion was more successful compared to anatomic landmark techniques Meta-analysis of RCTs comparing USG versus landmark CVAD insertion in pediatric patients (mean = 0.5–<8 y old) CVAD There were few pediatric studies (n = 2), which limited analysis. For ultrasound guidance, there was no reduction in the risk of cannulation failure, arterial puncture, hematoma, pneumothorax, and hemothorax in children or infants. Vessel visualization 
Wyckoff and Sharpe,136  2015 — CPGb Specific recommendations for vascular access in neonates and infants — Midline, PICC, PIVC, TIVD, tunneled CVAD, umbilical catheter — General pediatrics 
Congenital cardiac 
Catheter-to-vein ratio 
Vessel visualization 
Xia et al,137  2016 48 RCTc To determine the efficacy and rate of complications in pediatric patients with moderate-to-severe burn injuries Pediatric patients (mean = 2.2 y old) with moderate-to-severe burn injuries PICC, PIVC There was a higher 1-time puncture success rate, longer retention duration, and more complication for PICCs compared to PIVCs Critical care 
Yacobovich et al,138  2015d 423 Observationala To determine patient- and catheter-related risk factors for CLABSI in children receiving chemotherapy Prospective study of pediatric patients (29 d–28 y old) receiving chemotherapy requiring a VAD PICC, TIVD, tunneled-cuffed CVAD Tunneled-cuffed CVADs and PICCs had a higher risk for CLABSI in the group of diseases with lower rate of infection. In diseases with high rate of infection, there was no difference. Hematology and oncology 
Zanolla et al,139  2018 51 RCTc To determine if USG techniques reduce the No. puncture attempts, procedure time, and complication rates during CVAD insertion via the IJV in children Prospective study of any child (11 mo–9 y old) requiring CVAD insertion via the IJV; randomly assigned to USG versus landmark insertion groups CVAD USG techniques required fewer attempts, took less time, and resulted in fewer complications, compared to landmark techniques. Vessel visualization 
Zengin et al,140  2013 64 Observationala To determine risk factors for CVAD-related complications in children admitted to the ED Retrospective review of pediatric patients (2–16 y old) admitted to the ED Nontunneled CVAD More complications were associated with >3 attempts. Difficult venous access 
Zhou et al,141  2017 281 Observationala To evaluate the feasibility and safety of intracavitary ECG technique in guiding PICC placement in neonates Hospitalized neonates (27–41 wk) requiring PICC placement using landmark techniques or intracavitary ECG guidance PICC Intracavitary ECG-guided PICC placement had a higher correct tip position on the first attempt compared to landmark techniques. Vessel visualization 
Study, YearParticipants, nDesign and/or MethodFocus and/or OverviewStudy Sample and CharacteristicsDeviceFindings and CommentsminiMAGIC Indication
Adams et al,14  2016 — Clinical reviewa Clinical review of midline catheter device indications and complications for use in the ED — Midline Midlines have a low complication rate, long dwell time, and high rate of first-attempt placement. General pediatrics 
Aiyagari et al,15  2012 89 Observationala To compare the clinical outcomes for infants with single-ventricle physiology after umbilical catheter and femoral CVAD placement Patients with single-ventricle physiology admitted to the NICU (4–13 d) Nontunneled CVAD, umbilical catheter Nontunneled CVADs were associated with higher rates of thrombosis and vein occlusion. No difference was seen among CLABSI, need for transhepatic access, and ultrasound-documented thrombus at the inferior vena cava–right atrial junction. Patients with nontunneled femoral CVAD for ≥14 d had a higher prevalence of thrombosis than those for <14 d. No difference in the prevalence of iliofemoral vein occlusion was seen. General pediatrics 
Ainsworth and McGuire,16  2015 549 Systematic reviewb To evaluate PN delivery via PIVC or CVAD in hospitalized neonates Included 6 RCTs evaluating PN delivery via PIVC or CVAD in hospitalized neonates PIVC, nontunneled CVAD Nontunneled CVAD led to a smaller deficit of nutrients and fewer catheters; there was no difference for invasive infection. Long-term dependent 
Alten et al,17  2012 115 Observationala To compare USG CVAD insertion to landmark techniques in critically ill neonates Retrospective review of critically ill neonates (mean = <14 d) admitted to the PICU requiring CVAD placement using USG or landmark techniques CVAD Insertion using ultrasound guidance was associated with higher overall success, first-, and second- attempt success, and lower arterial puncture rates. Vessel visualization 
Anil et al,18  2011 128 Observationala To evaluate complications associated with CVAD placement in the PICU Retrospective review of all patients (median = 21 mo) admitted to the PICU requiring CVAD placement CVAD There was no difference in complications for CVAD insertion at femoral, subclavian, or jugular veins. Insertion location 
ANZICS,19  2012 — CPGb Specific recommendations for insertion central lines for the prevention of CLABSI — Nontunneled CVAD, tunneled CVAD — Insertion location 
Allen et al,20  2008 — Observationala To determine the risk of infection in pediatric oncology patients requiring long-term vascular access 12-mo prospective study of pediatric oncology patients (3 mo–20 y old) with a TIVD or tunneled-cuffed CVAD TIVD, tunneled-cuffed CVAD There was a higher rate ratio for CLABSIs in tunneled-cuffed CVAD. Hematology and oncology 
ARC and NZRC,21  2010 — CPGb Specific recommendations for access to circulation in infants and children in the context of cardiorespiratory arrest — CVAD, intraosseous, PIVC — Critical care 
ARC and NZRC,22  2010 — CPGb Medication or fluids for the resuscitation of the newborn infant — Intraosseous, PICV, umbilical catheter Specific recommendations for newborn infants in the context of resuscitation were provided. Critical care 
ARC and NZRC,23  2010 — CPGb Specific recommendations for vascular access in pediatric patients in the context of cardiopulmonary arrest — CVAD, intraosseous, PICV — General pediatrics 
Arnts et al,24  2014 203 Observationala To compare the rates of complications between umbilical catheters and PIVCs in newborns Patients admitted to the NICU (24–42 wk gestation) requiring a PICC or umbilical catheter PICC, umbilical catheter There was no difference in complication rate or due to gestational age. General pediatrics 
Athale et al,25  2012 358 Observationala To evaluate the impact of CVAD on 5-y overall and event-free survival in children with cancer Children with non-CNS cancer (≤19 y old) who required a CVAD CVAD CVAD dysfunction controlling for thromboembolism is associated with poorer 5-y overall and event-free survival. Hematology and oncology 
Avanzini et al,26  2017 194 Observationala To describe a single-center transition from CVAD placement via surgical cutdown to USG insertion techniques Retrospective review of pediatric patients (7 d–18 y old) who underwent tunneled CVAD placement using USG or surgical cutdown techniques Tunneled CVAD Double-lumen PICCs were associated with increased risk of complications, compared to single-lumen PICCs; complications were reported but not significantly compared between USG and surgical cutdown techniques. Device lumens 
Vessel visualization 
Barnwal et al,27  2016 60 Observationala To compare ECG and landmark insertion techniques for CVAD placement Pediatric patients (0–11 y old) undergoing elective cardiovascular surgery randomly assigned to CVAD insertion via landmark or ECG techniques CVAD There were fewer complications using USG insertion techniques. Vessel visualization 
Barrier et al,28  2012 1280 Observationala To determine risk factors for PICC-related complications in children Immunocompromised children (mean = 3.2 y old; 0–21 y old) requiring a PICC PICC Double-lumen catheters, PICCs placed in the femoral vein and children 1–4 y old, compared with older children (5–10 y old, >10 y old), were more at risk for complications. General pediatrics 
Device lumens 
Insertion location 
Baskin et al,29  2019 — CPGb Specific recommendations for central venous catheters in children with chronic illness — Midline, PICC, TIVD, tunneled-cuffed CVAD — Long-term dependent 
Ben Abdelaziz et al,30  2017 215 Observationala To examine the incidence of PIVC-related complications in pediatric patients Comparison of complications versus no complications in hospitalized children (0.1–18 y old) requiring a PIVC PIVC Longer duration was associated with local complication. General pediatrics 
Bezzio et al,31  2019 205 Observationala To investigate the rate of and risk factors for infection in children undergoing cardiac surgery requiring CVAD placement Prospective study of pediatric patients (1 d–25 y old) undergoing cardiac surgery CVAD Infection risk significantly increased with increased duration of device placement; the SCV vein was more likely to develop CLABSI. Congenital cardiac 
Insertion location 
Blotte et al,32  2017 162 Observationala To compare PICC and CVAD complications in pediatric patients with intestinal failure Pediatric patients (1 d–12 y old) with intestinal failure requiring PN PICC, tunneled-cuffed CVAD Tunneled-cuffed CVAD had a higher infection rate, and PICCs were more likely to break. More tunneled-cuffed CVADs had central venous thrombosis, whereas more PICCs had basilic vein thrombosis. Long-term dependent 
Birhane et al,33  2017 178 Observationala To assess factors that impacted PIVC life span in neonates and infants Neonates and infants (1 d–11 mo) requiring PIVC placement PIVC Compared to placement at the scalp, hand, or leg, PIVCs inserted at the arm had a longer life span. Insertion location 
Bodenham Chair et al,34  2016 — CPGb Specific recommendations for the insertion of VADs in all patients — CVAD, PIVC — Critical care 
Catheter-to-vein ratio 
Device lumens 
Vessel visualization 
Boe et al,35  2015 92 Observationala To evaluate risk factors and complications associated with the placement of transhepatic CVADs Retrospective review of congenital cardiac patients (IQR = 2–10 y old) undergoing transhepatic CVAD placement Transhepatic CVAD Placement ≥21 d was associated with increased transhepatic CVAD complications. Critical care 
Borasino et al,36  2014 392 Observationala To determine if CVAD insertion into veins in the upper body is a risk factor for chylothorax Retrospective review of pediatric patients (<1 y old) undergoing cardiac surgery; comparison among CVAD placement at IJV versus SCV versus femoral vein CVAD Insertion at IJV or SCV was associated with a higher risk of chylothorax. Insertion location 
Boretta et al,37  2018 107 Observationala To evaluate the management and complications associated with PICCs inserted in pediatric oncology patients Pediatric oncology patients (0–17 y old) requiring PICC placement PICC Compared to right-side insertion locations, PICCs inserted on the left side of the body were associated with more complications. Insertion location 
Bouaziz et al,38  2015 — CPGb Specific recommendations for the placement of VADs under ultrasound guidance in all patients — CVAD, PIVC — Vessel visualization 
Bozaan et al,39  2019 226 Pilot studya To evaluate the impact of an intervention designed to increase the use of single-lumen PICCs Pre- and postintervention of PICC placement in hospitalized adults (60 y old) PICC Making single-lumen PICCs the default option and providing indications for multilumen devices increased use of single-lumen PICCs. Device lumens 
Bratton et al,40  2014 178 Observationala To report complication rates of VADs in children undergoing radiotherapy Retrospective review of pediatric patients (1–26 y old) undergoing radiotherapy who received a VAD PICC, TIVD, tunneled-cuffed CVAD TIVDs were associated with lower infection and complication rates and had greater durability. Hematology and oncology 
Byon et al,41  2013 98 RCTc To evaluate the efficacy of USG SCV catheterization Pediatric patients (0–2.9 y old) undergoing elective congenital cardiac surgery or neurosurgery; randomly assigned to supraclavicular or infraclavicular approaches CVAD The supraclavicular approach was associated with shorter puncture time, fewer insertion attempts, and fewer misplacements. Insertion location 
Camkiran Firat et al,42  2016 280 RCTc To compare the rate of complications associated with IJV and SCV CVAD insertion Pediatric patients (16 mo–2.2 y old) undergoing cardiac surgery; randomly assigned to IJV or SCV insertion CVAD Insertion via the SCV was associated with higher success rates; lower rates of arterial puncture, catheter-tip cultures, and CLABSI; and higher rates of malposition. There was no difference in mechanical complications, ICU and hospital length of stay, and in-hospital mortality. Insertion location 
Campagna et al,43  2018 1538 Observationala To determine the safety of midline catheters used in general hospitalized adults Hospitalized adults (median = 83 y old) requiring a midline catheter across 2 Italian hospitals Midline A total of 10% of midline catheters had a serious adverse event. General pediatrics 
Carlson et al,44  2015 3846 Observationala To characterize procedures performed on critically ill children by emergency medical service personnel in out-of-hospital contexts Retrospective review of pediatric patients (0–17 y old) requiring out-of-hospital critical care CVAD, intraosseous CVADs had higher success rates compared to intraosseous devices. Critical care 
Carraro et al,45  2013 — CPGb Specific recommendations for the use of long-term central venous access in pediatric hematology and oncology patients — TIVD, tunneled-cuffed CVAD — Hematology and oncology 
Cesaro et al,46  2016 1161 Observationala To report the frequency and associated risk factors for central venous catheter–associated complications in children with hemato-oncological conditions Pediatric hematology-oncology patients (median = 6.1 y old) requiring a tunneled-cuffed CVAD Tunneled-cuffed CVAD At <6.1 y old, there were more mechanical complications, more malfunction or occlusion; compared to single-lumen devices, double-lumen devices had more mechanical complications, exit-site or tunnel infections, and malfunction or occlusion. Hematology and oncology 
Device lumens 
Chen et al,47  2020 4405 Systematic reviewb To compare risk associated with PICCs placed in the upper versus the lower extremity in neonates Neonates (<28 d old) requiring PICC placement PICC There was a greater risk of nonelective removals and malposition in PICCs placed in the upper versus lower extremity; there was a lower risk of thrombosis in PICCs placed at the upper extremity. There were no differences in mechanical complications, PICC-related infection, or phlebitis. Insertion location 
Choi et al,48  2017 23 Observationala To determine the safety and accuracy of TIVD placement using ultrasound guidance compared to surgical cutdown Retrospective review of pediatric (0–16 y old) hematology, oncology, and PN patients undergoing TIVD placement TIVD There was no difference using ultrasound guidance in insertion time or complication compared to surgical cutdown. Vessel visualization 
Cooling et al,49  2017 75 Observationala To examine the performance and safety of femoral CVADs Retrospective study of pediatric patients undergoing stem cell collection (median = 3 y old) requiring CVAD placement CVAD Compared to thoracic CVADs, femoral CVADs had fewer flow-related adverse events. Insertion location 
Crocoli et al,50  2015 — CPGb CVADs in pediatric patients with cancer — Midline, PICC, nontunneled CVAD, TIVD, tunneled CVAD, tunneled-cuffed CVAD — Hematology and oncology 
Long-term dependent 
Catheter-to-vein ratio 
Device lumens 
Vessel visualization 
Debourdeau et al,51  2009 — CPGb Prevention of thrombosis associated with central venous catheters in patients with cancer — TIVD, tunneled CVAD — Hematology and oncology 
Device lumens 
Insertion location 
De Carvalho Onofre et al,52  2012 42 RCTc To compare the use of ultrasound and palpation insertion success for PICC placement in pediatric patients Any pediatric patient (1 mo–16 y old) requiring IV therapy for >7 d; randomly assigned to USG PICC insertion or palpation PICC USG PICC insertion was associated with higher first-attempt success rate, better catheter positioning and shorter insertion time. Vessel visualization 
de Souza et al,53  2018 80 RCTc To determine if USG PICC placement led to higher insertion success compared to landmark techniques Critically ill pediatric patients (IQR = 3 mo–1.3 y old) admitted to the PICU requiring PICC insertion via the IJV; randomly assigned to USG or landmark insertion PICC USG PICC insertion was associated with higher overall success rate, first- and third-attempt success rate, lower insertion time, and fewer hematomas and arterial punctures compared to landmark. Vessel visualization 
DeWitt et al,54  2015 180 Observationala To determine procedural success and failure rates in umbilical catheter placement Patients with congenital heart disease <20 h old versus >20 h old requiring an umbilical catheter Umbilical catheter There was a higher success rate for younger patients. General pediatrics 
Dheer et al,55  2011 103 Observationala To compare the rates of immediate insertion-related complications after CVAD placement in pediatric patients Hospitalized children (<12 y old) requiring a CVAD; comparison of complications among neonate versus infant versus >1–12 y old CVAD Neonates were at higher risk of immediate insertion-related complications; more insertion attempts were associated with insertion-related problems. General pediatrics 
Doellman et al,56  2015 — CPGb Specific recommendations regarding central venous catheters that account for the unique needs of pediatric patients — Hemodialysis catheter, PICC, nontunneled CVAD, TIVD, tunneled CVAD — General pediatrics 
Hematology and oncology 
Critical care 
Congenital cardiac 
Long-term dependent 
Catheter-to-vein ratio 
Device lumens 
Vessel visualization 
Dongara et al,57  2017 144 RCTc To compare success and complication rates, cost, and insertion time between PICCs and umbilical catheters inserted in the NICU Patients admitted to the NICU (mean = 34 wk’ gestation) requiring a PICC or umbilical catheter PICC, umbilical catheter There was no difference in success rate, time, and short-term complications between PICCs and umbilical catheters. General pediatrics 
Elser,58  2013 — Clinical reviewa Clinical review of umbilical catheter placement Patients admitted to the NICU requiring an umbilical catheter Umbilical catheter Umbilical catheter malposition or dislodgement is associated with hemorrhaging and death. General pediatrics 
Fallon et al,59  2014 244 Observationala To determine device-related complications in infants requiring a VAD Hospitalized children (0–3 y old) requiring a central venous catheter for prolonged therapy TIVD, tunneled CVAD Infants (≤1 y old) had higher complication rate, higher operative exchange rate, higher infection rate, and shorter duration compared with toddlers (>1 y old). General pediatrics 
Faustino et al,60  2013 101 Observationala To explore the incidence of DVT in PICU patients requiring a central venous catheter Critically ill children (0–17 y old) admitted to the PICU; comparisons made among age (<1 y old versus 1–13 y old versus 13–17 y old) Nontunneled CVAD Compared with infants (<1 y old), PICU patients 13–17 y old had higher odds of DVT. Critical care 
Froehlich et al,61  2009 93 Observationala To determine if CVAD placement using ultrasound guidance increases insertion success and decreases complications after single-center transition to USG insertion techniques Prospective study of critically ill pediatric patients (median = 2.5 y old) admitted to the PICU requiring CVAD placement with USG or landmark techniques CVAD Ultrasound guidance was associated with significantly lower arterial punctures and fewer No. attempts. There was no difference in success rate or insertion time between ultrasound guidance and landmark groups. Vessel visualization 
Frykholm et al,62  2014 — CPGb Specific guidelines for patients requiring central venous catheters regarding vascular approach, ultrasound guidance, and prevention of complications — Dialysis catheters, nontunneled CVAD, PICC, TIVD, tunneled-cuffed CVAD — Long-term dependent 
Device lumens 
Vessel visualization 
Gaballah et al,63  2014 150 Observationala To describe complication rates associated with CVAD placement using ultrasound guidance and fluoroscopic guidance in neonates and infants Retrospective review of critically ill neonates and infants (premature–1 y old) requiring CVAD placement with USG versus fluoroscopic guidance CVAD There was no difference in complication rates. Insertion location 
Vessel visualization 
Gallagher et al,64  2014 168 Observationala To determine if CVAD placement using USG techniques improved insertion success in pediatric ED patients Retrospective study of pediatric (3–15 y old) emergency patients requiring CVAD placement with or without ultrasound guidance CVAD There was higher insertion success when using ultrasound guidance. Vessel visualization 
Gonzalez et al,65  2012 172 Observationala To determine if early placement of TIVDs or tunneled-cuffed CVADs in patients at high risk of thrombosis and infection led to higher surgical complications Retrospective review of children with ALL (4 d–16 y old) at high risk of infection and thrombosis TIVDs, tunneled-cuffed CVADs There was no difference in infection rate between TIVD and tunneled-cuffed CVADs and no difference in rate of infection in single- versus double-lumen devices. Hematology and oncology 
Device lumens 
Gorski et al,66  2016 — CPGb Specific practice recommendations for adult and pediatric patients requiring infusion therapy, including device selection, placement, and complication prevention — Hemodialysis catheters, intraosseous, long PIVC, midline, nontunneled CVAD, PICC, short PIVC, TIVD, tunneled CVAD, umbilical catheter — Critical care 
Congenital cardiac 
Long-term dependent 
Catheter-to-vein ratio 
Device lumens 
Vessel visualization 
Gray et al,67  2012 333 Observationala To identify risk factors for catheter-related DVT in infants <1 y old Hospitalized infants (mean = 34 wk’ gestation) requiring a VAD PICC, tunneled-cuffed CVAD Mean catheter days before DVT diagnosis were shorter for PICCs than for tunneled-cuffed CVADs; higher rates of DVT were in multilumen CVADs; the majority of DVT was in femoral veins. Femoral CVADs were associated with greater DVT rates than jugular or SCV CVADs. There was more DVT in femoral lines than in sapheno-femoral tunneled-cuffed CVADs. Long-term dependent 
Device lumens 
Insertion location 
Gurien et al,68  2016 1134 Observationala To determine the incidence of complications associated with CVAD placement using USG techniques Retrospective, multicenter review of pediatric patients (1.5–12 y old) who underwent CVAD placement with landmark or USG insertion CVAD There was a higher first- attempt success rate using ultrasound guidance but higher risk of hemothorax using ultrasound guidance. Vessel visualization 
Habas et al,69  2018 225 Observationala To determine the complications associated with CVAD placement at the BCV insertion site Retrospective review of pediatric patients (mean = 7 y old) admitted to PICU requiring CVAD placement; BCV insertion site versus all others (femoral, subclavian, jugular) CVAD Compared to other insertion sites, BCV had fewer complications. Insertion location 
Hamed et al,70  2013 300 Observationala To describe insertion success rate and complication rate after delivery of anesthesia to critically ill infants and toddlers Critically ill infants and toddlers (21 d–1.3 y old) requiring emergency surgery Intraosseous Intraosseous access was appropriate for unobtainable peripheral or central access. Critical care 
Hancock-Howard et al,71  2010 60 Observationala To determine the cost-effectiveness of TIVD placement using interventional radiology Retrospective review of pediatric oncology patients undergoing placement of a TIVD using interventional radiology (mean = 7 y old) or surgical cutdown (mean = 4 y old) techniques TIVD Insertion time was shorter and resulted in fewer complications using interventional radiology compared to surgical cutdown. Vessel visualization 
Handrup et al,72  2010 98 Observationala To evaluate the rates of VAD-related complications associated with placement of a TIVD or tunneled-cuffed CVAD Retrospective review of children with ALL (<4–>9 y old) who received a TIVD or tunneled-cuffed CVAD over an 8-y period TIVD, tunneled-cuffed CVAD There was a higher CLABSI rate and nonelective removal for tunneled-cuffed CVAD. Hematology and oncology 
Hanson et al,73  2012 1070 Observationala To investigate the rate of and risk factors for VTE in children with cardiac disease admitted to the PICU Children with cardiac disease (median = 10 mo) admitted to the PICU; comparisons made among <6 mo versus 6 mo–1 y old versus 1–2 y old versus 2–12 y old versus 12–18 y old versus >18 y old CVAD VTE incidence was associated with increasing No. CVAD days. In young children (<6 mo), VTE incidence was significantly higher. Critical care 
Heinrichs et al,74  2013 1076 Systematic reviewb To evaluate assistive technologies, other than ultrasound guidance, in improving PIVC insertion success Seven RCTs of pediatric patients (0–21 y old) requiring PIVC insertion using novel interventions PIVC Transillumination was associated with higher first-attempt success compared to traditional insertion techniques; first-attempt success using NIR and traditional methods was not significantly different. There was no difference in time or No. attempts between insertion methods. Vessel visualization 
Included studies 
Hosokawa, 2010 
Katsogridakis, 2008 
Nager, 1992 
Perry, 2011 
Chapman, 2011 
Kim, 2012 
Maynard, 1989 
Institute for Healthcare Improvement,75  2012 — CPGb Specific recommendations for the prevention of CLABSI — CVAD — Vessel visualization 
IVNNZ,76  2012 — CPGb Specific practice recommendations for adult and pediatric patients requiring infusion therapy, including device selection, placement, and complication prevention — Intraosseous, midline, nontunneled CVAD, PICC, TIVD, tunneled CVAD, umbilical catheter — Critical care 
Long-term dependent 
Device lumens 
Vessel visualization 
Katsogridakis et al,77  2008 240 Observationala To determine if transillumination increases PIVC insertion success in pediatric patients Pediatric patients (mean = 13 y old) with difficult venous access admitted to the ED requiring nonurgent PIVC placement; randomly assigned to with or without transillumination PIVC Insertion using transillumination was associated with higher first- and second-attempt success compared to without transillumination. Vessel visualization 
Kim et al,78  2017 132 RCTc To compare ultrasound guidance to landmark techniques for CVAD insertion in children Pediatric cardiac surgery, neurosurgery, or general surgical patients (1 mo–6 y old) requiring CVAD insertion; randomly assigned to USG insertion to the axillary vein or LM insertion via the SCV CVAD USG + axillary insertion was associated with fewer attempts and shorter insertion time. There was no difference in complication rates. Results were confounded by location and/or imaging. Insertion location 
Vessel visualization 
Kulkarni et al,79  2014 — Systematic reviewb A systematic review of TIVDs and tunneled-cuffed CVADs in adults and children receiving chemotherapy 5 RCTs and 25 observational studies of adults and children undergoing chemotherapy TIVD, tunneled-cuffed CVAD Tunneled CVAD was associated with more infections, noninfectious complications, and device removal. Hematology and oncology 
Kulkarni et al,80  2017 176 Observationala To describe the complications related to VAD insertion in infants with hemophilia Infants (0–2 y old) with hemophilia requiring either a PICC, TIVD, or tunneled CVAD PICC, TIVD, tunneled CVAD TIVDs had the lowest rates of complications. Hematology and oncology 
Lam et al,81  2018 954 Observationala To evaluate the impact of defaulting to single-lumen PICCs Hospitalized adults (mean = 66 y old) requiring PICC placement; comparison of single versus double lumens PICC Single-lumen PICCs were associated with lower complications. Device lumens 
Lamperti et al,82  2012 — CPGb Specific recommendations regarding USG VAD placement — CVAD, PICC — Catheter-to-vein ratio 
Vessel visualization 
Lau and Chamberlain,83  2016 760 Systematic reviewb To examine the safety and efficacy of CVAD insertion using ultrasound guidance A total of 8 RCTs comparing the use of USG and landmark CVAD placement in pediatric patients (<18 y old) CVAD Ultrasound guidance had a higher success rate and fewer No. insertion attempts compared to landmark techniques. Vessel visualization 
Included studies 
Alderson, 1993 
Verghese, 1999 
Verghese, 2000 
Grebenik, 2004 
Chuan, 2005 
Ovezov, 2010 
Aouad, 2010 
Bruzoni, 2013 
Levy et al,84  2010 279 Observationala To determine the rate of and potential risk factors for infectious and noninfectious complication associated with PICCs in pediatric patients Hospitalized children (10 d–21 y old) requiring a PICC PICC Older age was associated with infectious complications. General pediatrics 
Lindquester et al,85  2017 33 Observationala To examine the safety and efficacy of tunneled CVAD placement at the internal and external jugular in neonates and infants <5 kg Multicenter retrospective review of hospitalized infants weighing <5 kg (0–1 y old) with a tunneled CVAD Tunneled CVAD There was no difference in complications associated with jugular and femoral vein insertion locations. Insertion locations 
Loveday et al,86  2014 — CPGb Specific recommendations for the prevention of hospital-acquired infections — PICC, TIVD, tunneled CVAD — Long-term dependent 
Device lumens 
Malbezin et al,87  2013 5435 Observationala To prospectively determine the overall success and complication rate of CVAD insertion over a 22-y period Hospitalized children (mean = 5 y old) requiring any CVAD CVAD Device failure was more likely in children <3 kg. General pediatrics 
Marshall et al,88  2017 19 Observationala To compare transhepatic CVADs to nontunneled CVADs as an alternative for preserving future central venous access Retrospective review of infants (1.8–7.8 mo) with congenital heart disease who underwent placement of 1 or more transhepatic CVADs Nontunneled CVAD, transhepatic CVAD Transhepatic CVAD had a longer duration. There was no difference in thrombi, thrombolytic burden, or catheter sites requiring wound care consultation. There was a higher frequency of infection in transhepatic CVAD. There was no difference in the rate of infection-related removal. Congenital cardiac 
Marquez et al,89  2016 175 Observationala To determine risk factors for thrombosis after placement of nontunneled CVADs in PICU patients Prospective, multicenter study of pediatric patients (4 mo–8.6 y old) admitted to the PICU undergoing CVAD placement Nontunneled CVAD There were higher rates of DVT in patients with right-side nontunneled CVAD placement and insertion at SCV. Insertion location 
May et al,90  2018 912 Observationala To determine the rates of thrombosis, infection, and insertion site symptoms after placement of PICCs and TIVDs in patients with cystic fibrosis Retrospective review of adult and pediatric patents (mean = 7.4 y old) with cystic fibrosis PICC, TIVD Double-lumen PICCs were associated with greater rates of complications. Long-term dependent 
Device lumens 
Menéndez et al,91  2016 256 Observationala To evaluate the incidence and risk factors for PICC-related thrombosis in children Hospitalized children (IQR = 2.4–13 y old) requiring PICC placement PICC A catheter-to-vein ratio of >0.33 predicted PICC-related superficial vein thrombosis and DVT. Catheter-to-vein ratio 
Mermel et al,92  2009 — CPGb Specific recommendations for the prevention of catheter-related infection — CVAD, midline, PICC, PIVC, TIVD — Long-term dependent 
Moon et al,93  2018 629 Observationala To determine risk factors for CLABSI in children with hemato-oncological disease requiring long-term VADs Retrospective review of children with hemato-oncologic disease (median = 6 y old; 14 d–17.9 y old) requiring any long-term CVAD TIVD, tunneled-cuffed CVAD There was no difference in the rate of CLABSI. Hematology and oncology 
Mushtaq et al,94  2018 693 Observationala To determine the safety, specifically rates of CLABSI, mechanical complications, hospital length of stay, readmission within 90 d of discharge, and mortality of midline catheters compared to CVADs in adults admitted to intensive care Adults >18 y old admitted to the ICU or medical-surgical ward with either a CVAD or midline catheter CVAD, midline CVADs were associated with higher rates of CLABSI, crude mortality, readmission, and transfer to the ICU. Midline catheters had more mechanical complications. General pediatrics 
Noailly Charny et al,2  2018 295 Observationala To compare the risk of thrombosis in PICCs and tunneled-cuffed CVADs Children (<18 y old) diagnosed with leukemia who received a PICC or tunneled-cuffed CVAD PICC, tunneled-cuffed CVAD PICCs were associated with an increased risk of thrombosis. Hematology and oncology 
Nifong and McDevitt,95  2011 — Laboratory studya To determine the effect of catheter size of fluid flow rates — PICC Fluid flow rate decreased with increasing catheter size. Catheter-to-vein ratio 
O’Grady et al,96  2011 — CPGb Specific recommendations for the prevention of intravascular catheter-related infections — Midline, nontunneled CVAD, PICC, PIVC, TIVD, tunneled CVAD — Device lumens 
Vessel visualization 
Ohno et al,97  2016 120 Observationala To determine the rates of complications and CLABSI in infants and small infants (<1 y old or <10 kg) compared with children (>1 y old or >10 kg) Children (4 mo–22 y old) requiring a TIVD TIVD Age was not associated with increased risk of complications. General pediatrics 
Oulego-Erroz et al,98  2016 46 Pilot studya To determine if CVAD insertion to the BCV using USG techniques had greater insertion success compared to insertion to the IJV Prospective study of critically ill children (0.6 mo–13 y old) requiring urgent CVAD insertion; nonrandom assignment to BCV + USG or IJV insertion CVAD BCV + ultrasound guidance had a higher first-attempt success rate, fewer insertion attempts, and lower insertion time compared to IJV. There was no difference in overall success rates. Insertion location 
Vessel visualization 
Oulego-Erroz et al,99  2018 500 Observationala To determine if CVAD placement outcomes can be improved by using USG insertion Prospective, multicenter study of all critically ill children (IQR = 2 mo–4.9 y old) requiring temporary CVAD placement using USG or landmark techniques CVAD Ultrasound guidance had a higher first-attempt success rate and fewer puncture attempts and mechanical complications. Vessel visualization 
Pacilli et al,100  2018 18 Observationala To determine the appropriateness of long PIVCs in pediatric patients undergoing surgery Children undergoing surgery (mean = 6.3 y old) requiring long PIVC insertion Long PIVC There were no immediate complications. On day 3, removals were made because of 3 occlusions and 1 red/pain. General pediatrics 
Paladini et al,101  2018 40 Pilot studya To compare the success of USG long PIVC insertion in children admitted to the ED to short PIVCs Children >10 y old (mean = 13 y old) who were admitted to the ED; comparison of blind short PIVC versus USG PIVC insertion Long PIVC, short PIVC Short PIVCs had a shorter dwell time duration and more complications compared to long PIVCs; ultrasound guidance had a lower risk of failure and complications but results confounded. Critical care 
Vessel visualization 
Park et al,102  2016 3832 Systematic reviewb To determine the utility of NIR light devices A total of 11 RCTs of any pediatric patient (<21 y old) undergoing PIVC placement using NIR or no assistive device PIVC There was no overall difference in overall success rate between NIR light device and traditional methods; however, NIR light devices had a higher success rate for subsets deemed high risk of failure. 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 
Pasteur et al,103  2010 — CPGb Specific recommendations for patients with non-CF bronchiectasis — TIVD — Long-term dependent 
Peterson et al,104  2012 1399 Observationala To determine if assistive devices improve PIVC insertion success Hospitalized children (mean = 1 y old) requiring PIVC placement; randomly assigned to unassisted versus assisted (transillumination versus NIR light device–guided) insertion PIVC PIVC insertion success was higher when no assistive device was used compared to assisted methods. Vessel visualization 
Perin and Scarpa,105  2015 — Systematic reviewb To review evidence related to the assessment of catheter-tip positioning in pediatric patients Included 42 pediatric studies examining outcomes for patients undergoing VAD placement using vessel visualization techniques CVAD, PICC, umbilical catheter There was insufficient high-quality evidence to make specific recommendation for use in pediatric patients. Vessel visualization 
Pinon et al,106  2009 915 Observationala To determine the incidence and risk factors of central venous catheter-related complications in pediatric hemato-oncological and immunologic conditions Single-center, prospective study of children (0–19 y old) with oncological, hematologic, or immunologic diseases TIVD, tunneled CVAD Tunneled-cuffed CVADs were associated with more CLABSI; being ≤3 y old was associated with more dislodgements and more tunnel infections; CLABSI was more prevalent in double- versus single-lumen devices. Hematology and oncology 
Device lumens 
Pittiruti et al,107  2009 — CPGb Specific recommendations for CVADs and complication prevention in patients requiring PN — Midline, PICC, PIVC, TIVD, tunneled CVAD — Long-term dependent 
Device lumens 
Vessel visualization 
Polkinghorne et al,108  2013 — CPGb Specific recommendations for vascular access in patients with chronic renal disease — Nontunneled CVAD, tunneled CVAD — Vessel visualization 
Qian et al,109  2014 40 Observationala To examine complication rates in pediatric patients with CF after the placement of a long PIVC Prospective audit of pediatric patients with CF with infective exacerbation Long PIVC Complication rates were high; no serious adverse outcomes were reported. Long-term dependent 
Ramer et al,110  2016 53 RCTc To evaluate the effectiveness of NIR light device technology for PIVC placement in pediatric hematology and oncology patients Pediatric hematology and oncology patients (1–21 y old) requiring PIVC placement; randomly assigned to NIR light device or landmark insertion techniques PIVC NIR light device was associated with faster insertion time and higher satisfaction. Vessel visualization 
Rauth et al,111  2008 138 Observationala To investigate the rate of infection in infants when the venous catheter is exchanged for a tunneled-cuffed CVAD after ECMO decannulation PICU patients (mean = 13 d) requiring CVAD placement after decannulation from ECMO Tunneled-cuffed CVAD Increasing the duration of ECMO and CVAD placement independently predicted CLABSI. Critical care 
Revel-Vilk et al,112  2010d 423 Observationala To determine the rate of catheter-related complications in children undergoing chemotherapy during 12 mo of therapy Single-center, prospective study of pediatric patients (29 d–28 y old) undergoing chemotherapy PICC, tunneled-cuffed CVAD PICCs were associated with a higher risk of DVT; tunneled CVAD had a higher risk of occlusion at 1 y. Hematology and oncology 
Rey et al,113  2009 825 Observationala To identify risk factors for early mechanical complications in CVADs Pediatric patients (median = 22 mo) admitted to the PICU; comparisons among femoral, jugular, and SCV CVAD insertion sites CVAD SCV and jugular vein, as well as increasing No. attempts were associated with significantly more early mechanical complications. Difficult venous access 
Insertion site 
Rivera-Tocancipa et al,114  2018 201 Observationala To describe the incidence of complications associated with USG CVAD insertion in children compared to anatomic landmark techniques All hospitalized children (0–18 y old) requiring CVAD insertion using USG or LM insertion techniques CVAD Ultrasound guidance had fewer immediate complications, no arterial punctures, and higher rates of insertion success compared to landmark techniques. Vessel visualization 
Rosado et al,115  2013 255 Observationala To examine the rate of CVAD-associated infection in PICU patients Prospective, single-center review of children (majority <6 y old) admitted to the PICU requiring a CVAD CVAD CVADs inserted ≥7 d were associated with a higher risk of CLABSI. Critical care 
Rossetti et al,116  2015 309 Observationala To investigate the safety and accuracy of intracavitary ECG-guided insertion in pediatric patients Prospective, multicenter study of hospitalized pediatric patients (1 mo–18 y old) requiring a VAD; insertion using intracavitary ECG versus intracavitary ECG with dedicated ECG monitor compared CVAD, PICC Insertion accuracy was higher with a dedicated ECG monitor. Vessel visualization 
Schiffer et al,117  2013 — CPGb Specific recommendations for central venous catheters in patients with cancer — Nontunneled CVAD, PICC, tunneled CVAD, TIVD — Hematology and oncology 
Vessel visualization 
Sharp et al,118  2015 136 Observationala To identify the optimal ratio cutoff to reduce rates of VTE Prospective study of hospitalized adults (mean = 57 y old) requiring PICC insertion, comparison between ≤45% versus ≥45% catheter-to-vein ratio PICC A >45% ratio was more likely to develop VTE. Catheter-to vein ratio 
Shenep et al,119  2017 90 Observationala To determine the interaction between PN and external central venous devices in increasing risk of complications Rates of complications during PN and non-PN periods in pediatric oncology patients (median = 7.3 y old) requiring central venous devices TIVD, tunneled CVAD Risk of CLABSI was higher during PN for children with TIVDs. Occlusion risk was higher for TIVDs. Complication rates for TIVDs were lower during the non-PN period but similar during the PN period. Long-term dependent 
Sibson et al,120  2018 — CPGb Specific recommendations for preventing thrombosis in pediatric patients with cancer — PICC, PIVC, TIVD, tunneled CVAD — Hematology and oncology 
Sigaut et al,121  2009 359 Systematic reviewb To evaluate the advantages of USG CVAD placement over anatomic landmark techniques in pediatric patients Children (2 d–8 y old) undergoing cardiac surgery requiring CVAD CVAD For ultrasound guidance, no difference in rates of artery puncture, hematoma, hemothorax, pneumothorax, or time to insert was found. Ultrasound guidance had higher success rates for subsets of novice operators and during intraoperative use. Vessel visualization 
Included studies 
Alderson, 1993 
Chuan, 2005 
Verghese, 1999 
Verghese, 2000 
Grabenic, 2004 
Smitherman et al,122  2015 1135 Observationala To determine risk factors for the development of catheter-associated VTE in general hospitalized pediatric patients Chart review of hospitalized children (mean = 8 y old) requiring a VAD PICC Increasing age was related to an increased risk of thrombosis; lumen No. was not associated with thrombosis risk; insertion site (brachial or cephalic, SCV, jugular, or femoral or saphenous) was not associated with an increased risk of thrombosis. General pediatrics 
Device lumens 
Insertion location 
Takeshita et al,123  2015 96 Observationala To examine the factors that affect insertion success for invisible and impalpable peripheral veins in children Pediatric patients (1.1–2.8 y old) with invisible or impalpable veins undergoing elective surgery PIVC PIVC with ultrasound guidance had better success rates compared to PIVC without ultrasound guidance; compared to insertion to the dorsal hand vein, the cephalic vein had a higher success rate and shorter insertion time. Difficult access 
Insertion location 
Vessel visualization 
Takeshita et al,123  2015 196 RCTc To examine the factors that affect insertion success for invisible and impalpable peripheral veins in children Pediatric patients (10–40 mo) with invisible or impalpable veins undergoing elective surgery PIVC Compared to insertion to the dorsal hand or saphenous vein, the cephalic vein had a higher success rate. Insertion location 
The Joint Commission,124  2013 — CPGb Specific recommendations for preventing CLABSI in CVADs — CVAD — Device lumens 
Tripi et al,125  2016 108 Observationala To determine the frequency of PIVC-related dysfunction in pediatric patients Compared PIVC dysfunction in hospitalized children (0–>12 y old) over device durations of 1–2 d versus 2–3 d versus >3 d PIVC Higher rates of PIVC dysfunction were associated with PIVCs in place for >3 d or inserted in lower extremities. General pediatrics 
Troianos et al,126  2011 — CPGb Specific recommendations for VAD placement using ultrasound guidance in pediatric patients — CVAD, PICC, PIVC — Vessel visualization 
Ullman et al,6  2015 31 933 Systematic reviewb To review the incidence of VAD failure in pediatric patients Hospitalized pediatric patients across 74 studies requiring any VAD Hemodialysis catheter, nontunneled CVAD, PICC, TIVD, tunneled CVAD, umbilical catheter Hemodialysis catheters and umbilical catheters had the highest failure rate; TIVDs had the lowest failure rate. General pediatrics 
Ullman et al,1  2017 1027 Observationala To examine the prevalence, management, and associated complications of CVADs in pediatric patients Hospitalized pediatric patients (IQR = 1–12 y old) requiring any VAD Hemodialysis catheter, nontunneled CVAD, PICC, TIVD, tunneled CVAD, umbilical catheter PICCs had higher proportions of CVAD-associated complications in the previous 7 d. General pediatrics 
Unbeck et al,127  2015 2032 Observationala To identify risk factors for PIVC-associated complications in pediatric patients Comparison of hospitalized neonatal versus pediatric patients (0–18 y old) requiring a PIVC PIVC Occlusion was associated with longer dwell time. Neonatal: PIVC survival time was shorter; there was more infiltration. Insertion at the arm bend or ankle was associated with higher rates of infiltration and occlusion. General pediatrics 
Insertion location 
van Gent et al,128  2017 538 Observationala To determine the rates of infection and complications in pediatric hematology, oncology, and stem cell transplant patients Retrospective review of pediatric patients (mean = 7.8 y old) after surgical placement of any CVAD TIVD, tunneled-cuffed CVAD Tunneled-cuffed CVAD had a lower risk of infection. Hematology and oncology 
Vierboom et al,129  2018 232 Observationala To evaluate the safety of tunneled CVAD insertion in children weighing <10 kg Retrospective review of all children (<1 mo–4 y old) receiving surgical insertion of a tunneled CVAD with ultrasound guidance or via surgical cutdown Tunneled CVAD USG insertion was associated with lower mechanical blockages, but there was no difference in intraoperative and postoperative complications, time to insert, or device longevity. Vessel visualization 
Vinograd et al,130  2018 300 Observationala To evaluate PIVC insertion success in patients with difficult venous access using USG techniques Pediatric patients (median = 14 y old) in an ED who had a failed PIVC attempt via traditional insertion techniques PIVC PIVC using USG techniques led to 68% and 87% first- and second-attempt success rates after failed traditional method. Difficult access 
Vessel visualization 
Voigt et al,131  2012 — Systematic reviewb To review the evidence for the use of intraosseous devices in emergent contexts Studies evaluating intraosseous devices in patients requiring emergent vascular access or nonhuman randomized prospective studies Intraosseous Compared to alternative access, there was no difference in complications using intraosseous devices. Critical care 
Wiegering et al,132  2014 43 Observationala To determine the incidence of catheter-related thrombosis in pediatric oncology patients Single-center retrospective review of pediatric oncology patients (mean = 9.4 y old) requiring central venous access TIVD, tunneled-cuffed CVAD TIVDs showed an earlier peak of thrombosis occurrence than that of tunneled-cuffed CVAD catheters; the highest incidence of thrombosis occurred in the SCV, followed by external jugular and cephalic sites. There was no difference in complications between insertion at the left and right side. Hematology and oncology 
Insertion location 
White et al,133  2012 322 Observationala To compare the rate of complications and early removal between TIVDs and tunneled-cuffed CVADs Retrospective review of children (1 mo–19 y old) with ALL requiring a TIVD or a tunneled-cuffed CVAD TIVD, tunneled-cuffed CVAD TIVDs had less complications. Hematology and oncology 
Wragg et al,134  2014 100 Observationala To determine the rate of occlusion associated with tunneled-cuffed CVAD insertion under ultrasound guidance Children (21 d–16 y old) requiring elective or emergency removal of a tunneled-cuffed CVAD Tunneled-cuffed CVAD Complete venous occlusion was associated with younger age. General pediatrics 
Vessel visualization 
Wu et al,135  2013 508 Systematic reviewb To evaluate whether USG CVAD insertion was more successful compared to anatomic landmark techniques Meta-analysis of RCTs comparing USG versus landmark CVAD insertion in pediatric patients (mean = 0.5–<8 y old) CVAD There were few pediatric studies (n = 2), which limited analysis. For ultrasound guidance, there was no reduction in the risk of cannulation failure, arterial puncture, hematoma, pneumothorax, and hemothorax in children or infants. Vessel visualization 
Wyckoff and Sharpe,136  2015 — CPGb Specific recommendations for vascular access in neonates and infants — Midline, PICC, PIVC, TIVD, tunneled CVAD, umbilical catheter — General pediatrics 
Congenital cardiac 
Catheter-to-vein ratio 
Vessel visualization 
Xia et al,137  2016 48 RCTc To determine the efficacy and rate of complications in pediatric patients with moderate-to-severe burn injuries Pediatric patients (mean = 2.2 y old) with moderate-to-severe burn injuries PICC, PIVC There was a higher 1-time puncture success rate, longer retention duration, and more complication for PICCs compared to PIVCs Critical care 
Yacobovich et al,138  2015d 423 Observationala To determine patient- and catheter-related risk factors for CLABSI in children receiving chemotherapy Prospective study of pediatric patients (29 d–28 y old) receiving chemotherapy requiring a VAD PICC, TIVD, tunneled-cuffed CVAD Tunneled-cuffed CVADs and PICCs had a higher risk for CLABSI in the group of diseases with lower rate of infection. In diseases with high rate of infection, there was no difference. Hematology and oncology 
Zanolla et al,139  2018 51 RCTc To determine if USG techniques reduce the No. puncture attempts, procedure time, and complication rates during CVAD insertion via the IJV in children Prospective study of any child (11 mo–9 y old) requiring CVAD insertion via the IJV; randomly assigned to USG versus landmark insertion groups CVAD USG techniques required fewer attempts, took less time, and resulted in fewer complications, compared to landmark techniques. Vessel visualization 
Zengin et al,140  2013 64 Observationala To determine risk factors for CVAD-related complications in children admitted to the ED Retrospective review of pediatric patients (2–16 y old) admitted to the ED Nontunneled CVAD More complications were associated with >3 attempts. Difficult venous access 
Zhou et al,141  2017 281 Observationala To evaluate the feasibility and safety of intracavitary ECG technique in guiding PICC placement in neonates Hospitalized neonates (27–41 wk) requiring PICC placement using landmark techniques or intracavitary ECG guidance PICC Intracavitary ECG-guided PICC placement had a higher correct tip position on the first attempt compared to landmark techniques. Vessel visualization 

ALL, acute lymphoblastic leukemia; ANZICS, Australian and New Zealand Intensive Care Society; ARC, Australian Resuscitation Council; BCV, brachiocephalic vein; CF, Cystic Fibrosis; CNS, Central Nervous System; ECMO, Extracorproeal membrane oxygenation; IJV, internal jugular vein; IQR, interquartile range; IVNNZ, Intravenous Nursing New Zealand Incorporated Society; LM, Landmark; miniMAGIC, Michigan Appropriateness Guide for Intravascular Catheters in Pediatrics; mo, months old; NZRC, New Zealand Resuscitation Council; SCV, subclavian vein; TIVD, totally implantable venous device; VTE, venous thromboembolism; —, not applicable.

a

Low strength of evidence: observational study (with comparator) and other (eg, clinical review or pilot study).

b

High strength of evidence: CPG, systematic review.

c

Moderate strength of evidence: RCT.

d

Same sample.

A total of 3 CPGs and 26 studies were included for general hospitalized pediatric patients, including 1 systematic review, 1 RCT, and 23 observational studies. These studies compared all VADs in hospitalized adult (n = 3); child (n = 13), infant (n = 2), and neonatal (n = 3); and surgical (n = 1) populations. With the exception of 1 CPG, no studies reported on midlines in the pediatric population, so adult studies were also included.14,43,94 

Neonates

Overall, umbilical catheters were associated with high rates of complications, including catheter-related bloodstream infection, occlusion, dislodgement, thrombosis, and local infection or phlebitis, with device failure being common.6,15,30,54,57,125,127  Umbilical catheter malposition and catheter-tip migration during treatment also frequently occurred,6,142  with concerns that malpositioned or dislodged umbilical catheters may lead to severe hemorrhage and even death if not detected or rectified in a timely manner.58  Despite this, the literature reviewed indicated that umbilical catheter placement is common practice in neonates up to the first 7 days of life.23  Evidence for umbilical catheter dwell time was scarce and supported placement for short durations only, due to of increased risk of device failure.24,57  Consequently, guidance from available CPGs was limited but recommended placement only for as long as clinically necessary, or ≤14 days, if managed aseptically.136  Beyond 15 days, ambiguity in the literature regarding the patency of the umbilical vascular system and catheter for longer durations was evident.136,142  One CPG did support replacing any umbilical catheter with a PICC for central access >7 days to reduce risk of infection.136  Alternative VADs for neonates include PICCs and CVADs6,34,66,136 ; however, it was recognized that neonates frequently had poor or difficult-to-access venous assets,45,55  were more likely to have higher risk of insertion-related complications,55  and were at high risk of blockage across all devices.6 

Infants

PICCs are commonly the first VAD choice for infants.136  Numerous studies found that PICCs in infants were associated with a lower risk of complications, particularly thrombosis,28,122  leading current CPGs to recommend their use in children <1 year and for therapies for longer durations (>7 days).56,122,136  Conversely, PIVCs had significantly higher rates of dysfunction in infants (50%) compared with children >1 year and for longer dwell times,125  with one CPG only recommending PIVCs for therapies <6 days.136  None of the included evidence evaluated the complications associated with midline catheters in infants; however, the National Association of Neonatal Nurses recommended them as an appropriate alternative for peripherally compatible intravenous (IV) therapy for <6 to 10 days in infants.136 

Compared to PICCs, tunneled-cuffed CVADs were associated with higher rates of thrombosis (although thrombosis tended to occur after longer durations in situ), with 60% of tunneled-cuffed CVADs developing deep vein thrombosis (DVT).67  Tunneled-cuffed CVADs were also associated with higher rates of insertion failure in infants and young children.55  Risk of infection in CVADs placed in infants was high, especially compared with toddlers, and was linked to the use of totally implantable venous devices.59  As tunneled CVADs and totally implantable venous devices restrict the future use and availability of accessed veins and insertion was related to a higher risk of complication, studies and CPGs indicated that their use in infants should be limited.97,136 

Children and Adolescents

For hospitalized children and adolescents, PIVCs and midline catheters were reported as appropriate for short-term peripherally compatible therapies in multiple studies because of their low risk of catheter-related infections and thrombosis in comparison to PICCs.14,43,94,100,127,143  However, in one study, the authors suggested that these devices are associated with increased risk of occlusion with extended dwell times.127  PICCs were reported to have high insertion success rates84  and low failure rates in children and adolescents,6,59  although one study reported severe complications in 40.1% of failed PICCs, associated with increasing patient age.28  PICC insertion was commonly associated with short-term complications such as occlusion, CLABSI, and thrombosis,6,30  with rates of these events increasing with longer durations of therapy.30 

In comparison, tunneled-cuffed CVADs had high rates of infection (4.8%–19.9%)6  and were associated with short-term complications, such as infection, malfunction, leak, and malposition,59,134  and high rates of occlusion (12.1%).6  Although totally implantable venous devices had low rates of infection (0.01–0.28 per 1000 catheter days),6  they were associated with early complications, such as bleeding, pneumothorax, nerve lesions, catheter misplacement, occlusion, and skin damage,97,103  and long-term complications, such as infection, thrombosis, catheter fracture or disconnection, secondary dislocation, and skin breakdown over port septum.6,56,103  Overall, tunneled-cuffed CVADs and totally implantable venous devices had high insertion success rates55,59,87  and low failure rates,1,6  and can be used as alternatives to PICCs in patients requiring frequent vascular access.56  Given their high insertion success rate,87  nontunneled CVADs can be placed after the failed placement of other CVADs.56 

Malignant Hematologic and Oncological Conditions

For patients undergoing treatment of malignant hematologic and oncological conditions, infection and thrombotic complications, as well as disruption to treatment, are important considerations for VAD selection.25,119  A total of 17 studies, including 1 systematic review and 16 observational studies, and 5 CPGs were included. Most studies were focused on tunneled-cuffed CVADs and totally implantable venous devices in mixed hematology and oncology (n = 5), PN (n = 1), and leukemia (n = 3) populations. Other studies compared PICCs, CVADs, and totally implantable venous devices in mixed hematology and oncology populations (n = 5).

Overall, tunneled-cuffed CVADs and totally implantable venous devices had low rates of insertion-related complications, device failure, and malfunction40,65,79,80,119,128  and were associated with low rates of thrombosis.2,112,132  Reporting on rates of infection between devices was variable. Two studies found that rates of infection were not statistically different between tunneled-cuffed CVADs and totally implantable venous devices.79,93  In contrast, other studies found higher rates of CLABSI in totally implantable venous devices compared to CVADs119  and higher risk of overall infection in totally implantable venous devices compared to tunneled-cuffed CVADs.128  Additional studies found that overall infection rates were higher in tunneled-cuffed CVADs compared to totally implantable venous devices.20,40,72,106  Although occlusion was common in this population,46,65,112,119  rates were not different between tunneled-cuffed CVAD and totally implantable venous devices.65,133  Compared to totally implantable venous devices and tunneled-cuffed CVADs, PICCs had higher rates of device-related complications as well as overall infection and CLABSI, thrombosis, and occlusion.2,40,112,138 

International guidelines recommend the use of tunneled-cuffed CVADs for pediatric patients undergoing hematologic and oncological treatment requiring frequent and continuous vascular access, particularly for frequent blood sampling, PN, and complex IV therapies.50,56  Totally implantable venous devices may also be appropriate across these indications,51  especially in patients ≥10 kg.45  These devices were only recommended for intermittent use, however, due to the increased risk of infection and thrombosis.45,50  One CPG endorsed the use of PICCs for short- to medium-term treatments,50  although there was insufficient evidence to support their routine use,117,120  and chemotherapy treatment via peripheral venous access was not recommended.50,120  No included studies reported on nontunneled CVADs; however, one international guideline supported the placement for intrahospital use or short durations only.50 

Critically Ill Patients

Unlike other patient groups, for critically ill infants, children, and adolescents, choice of VAD may be prioritized by whether the patient is stable or unstable.21,22  Seven observational studies, 1 systematic review, and 1 RCT were included for critical care patients and included the emergency department (ED) (n = 2), emergency surgery (n = 1), moderate-severe burns (n = 1), out-of-hospital critical care (n = 1), and PICU (n = 4) populations. No studies explored midline devices in the critical care population, although one study compared short and long PIVCs.101  Overall, the focus of the studies in this population was on infection and thrombosis and not on outcomes such as dwell time, occlusion, infiltration, extravasation, or bleeding complications.

Stable, Critically Ill Patients

Regarding stable, critically ill patients requiring short-term acute therapy, 2 CPGs supported the use of nontunneled CVADs for any type of infusion therapy up to 7 to 10 days despite risk of infection and thrombosis.34,56  Evidence to support the use of PICCs in this population was mixed. Whereas the Infusion Therapy Standards of Practice cautioned against the use of PICCs in critically ill patients (adults and pediatrics) because of the risk of infection or thrombosis,66  2 other clinical guidelines recommended PICCs for both short-34,76  and long-term34  durations in critically ill patients. This variability may be due to the scarcity of high-quality evidence directly comparing these devices. PIVCs were frequently reported within this population101,137  and were recommended over intraosseous devices in nonemergent situations.21,22  However, compared to PICCs, PIVCs were commonly associated with obstruction, leakage, and dislodgment,137  with short PIVCs in particular linked to higher rates of local infections, dislocation, infiltration, occlusion, and thrombosis compared to long PIVCs.101  There were limited studies reporting on nontunneled CVAD use in critically ill children; however, authors of one study reported children >13 years old with a nontunneled CVAD were at higher risk of DVT compared with children <1 year.60  Tunneled-cuffed CVADs and totally implantable venous devices were associated with high rates of infection and thrombosis but were reported as suitable for long-term therapies in this population.34,73,111,115  No studies or CPGs reported on the suitability of midline devices in this population specifically, although they were more broadly considered appropriate for therapies lasting 1 to 4 weeks.76 

Unstable, Critically Ill Patients

In unstable, critically ill patients, speed of access was prioritized. International guidelines recommend venous access via PIVC placement unless attempts to cannulate take >60 seconds or ≥2 attempts.21,22  When IV access was difficult, intraosseous devices were consistently reported as fast alternatives for children and adolescents,21,44,66,70,76,131  and umbilical catheter was recommended for neonates in the first week of age.22 

Congenital Cardiac Conditions

For patients with congenital cardiac conditions, VAD selection prioritizes vessel preservation to ensure key vasculature can be used for future life-saving procedures.56  Overall, 3 CPGs and 4 observational studies of pediatric and young adult patients were included in the systematic review and encompassed patients with univentricular and biventricular physiology and patients in cardiac surgery subgroups. Comparisons between umbilical catheters, PICCs, tunneled CVADs, and nontunneled CVADs based on dwell time, occlusion, thrombosis, and infection risk were the primary focus of the included studies.15,31,35,88 

Generally, short-term peripheral and nonperipheral compatible therapy delivered via umbilical catheters in infants can be used.66  PICCs were recommended for patients with congenital cardiac conditions requiring ≥7 days of IV therapy.136  because of lower complication rates, PICCs inserted in lower extremity vessels were recommended.136  CVAD (tunneled and nontunneled) use was reported in this population; however, placement ≥7 days was associated with an increased risk of CLABSI.31,56  None of the included studies or guidelines included evidence to support the use of totally implantable venous devices in this population.

Regarding specific use in neonates with univentricular physiology, umbilical catheters had low rates of CLABSI, thrombosis, and occlusion when compared to other devices,15  and they can be used when preventing significant vessel loss for future procedures is a prioirity. Although PICCs were generally recommended in congenital cardiac populations, clinical guidelines emphasized the need for specialist consultation for patients with cardiac malformations.136  Femoral nontunneled CVADs were reported as appropriate for therapies lasting <14 days in single-ventricle populations, with ≥14-day durations associated with a higher risk of thrombosis but not occlusion.15  Comparatively, other femoral devices (tunneled, uncuffed) were not related to an increased risk of thrombosis or occlusion for therapies lasting ≥14 days.15 

Long-term Vascular Access Dependent

Long-term vascular access dependency encompassed nonmalignant hematologic, respiratory, gastrointestinal, metabolic, and immunologic conditions requiring long-term (>2 months) and very long-term (>1 year) VAD placement.29  In total, 4 studies and 9 CPGs described this diverse patient population across PN and non-PN therapies and continuous or intermittent therapies. Despite the heterogeneity of reported populations, vessel preservation and complication prevention were the common themes when comparing PICC, short- and long-catheter PIVC, midline, tunneled-cuffed CVAD, and totally implantable venous device indications.16,32,90,109 

Long-term PN Infusates

CLABSI, occlusion, and thrombosis were common complications of long-term PN therapy across all VADs.16,32  Peripheral devices (PIVCs and midlines) are unsafe for delivering PN because of the risk of venous damage50,62,66 ; however, they may be indicated for limited time periods in hospitalized patients with restricted dextrose and protein concentrations (<10% and/or 5%, respectively).66,76,107  One single-center observational study supported PICCs for long-term PN,32  and another CPG recommended PICCs for home PN107 ; although totally implantable venous devices were generally preferred when PN was required for long durations, despite being associated with an increased risk of infection.16,29,32,50,56,92 

Long-term Non-PN Infusates

Evidence for the use of VADs in patients requiring long-term non-PN infusates was similar. Specifically, except for in one CPG, all peripheral devices (PIVCs and midlines) were regarded as inappropriate for long-term–dependent non-PN therapies, especially in patients with chronic renal failure.56,62,66,76,109  Tunneled CVADs and totally implantable venous devices were instead preferred for non-PN therapies required for continuous or intermittent and extended durations, respectively.56,62,66,76,103,109 

Difficult Venous Access

For pediatric patients with difficult venous access, insertion success rates and the number of attempts are priority considerations for VAD selection. Factors that affect these include patient physiology, pathology, damage caused by VAD, and the procedural skill of the clinician.144  Five observational studies were included for patients with difficult venous access in ED (n = 2), elective surgery (n = 1), PICU (n = 1), and hospitalized children (n = 1) populations. The majority of studies compared nontunneled CVADs (n = 3) and evaluated the insertion success rates and complications associated with the number of insertion attempts. Two studies evaluated PIVCs with and without ultrasound-guided (USG) techniques in pediatric populations.123,130 

In patients with difficult vascular access, USG PIVC insertion was associated with higher overall and first- and second-attempt success rates after failed insertion via the landmark method.130  Up to 17.2% of CVADs in an ED setting experienced a complication (arterial puncture, hematoma, pneumothorax, and arrhythmia), and ≥3 attempts were significantly related to complication development.140  In a study comparing insertion success in neonates and nonneonates, nontunneled CVAD failure was common (63.1%–76.3%), and the success rate after >1 attempts was significantly lower with decreasing patient age and associated with greater insertion-related complications.55  Similarly, nontunneled CVAD placement in PICU patients led to high early mechanical complications (17.5%) and was associated with more insertion attempts and insertion using the subclavian or jugular approach.113 

Catheter-to-Vein Ratio

Determining the appropriate catheter-to-vein ratio is a difficult balancing act of optimizing patient and therapy needs while ensuring risk of catheter-related complications, such as occlusion, is minimized. Although catheter-to-vein ratio was recognized as important for preventing phlebitis, occlusion, and thrombosis,56  few studies reported on catheter-to-vein ratios in neonate and pediatric patients. Only one observational study reported on PICCs in hospitalized children91 ; therefore the included studies were broadened to incorporate an adult and laboratory study.95,118  An additional 6 CPGs were referred to for guidance.34,50,56,66,82,136 

Clinical guidelines emphasized selecting the smallest practical sized gauge or French (F) that met treatment and patient need.34,56,66,95,136  Inadequate catheter-to-vein ratio was linked to an increased risk of thrombosis in 2 studies, especially in infants with congenital heart disease, and smaller catheter size was associated with higher rates of occlusion.50,56  In contrast, larger catheters had a corresponding increase in rates of phlebitis.66  For any VAD (PICC, PIVC, midline, CVAD, or totally implantable venous device) a catheter-to-vein ratio of <50% in pediatric patients and <33% in neonates was generally recommended.56,66,136  Specific to PICCs, thrombosis risk increased with a catheter-to-vein ratio ≥0.3391  and ≥0.45,118  in hospitalized children and adults, respectively. Depending on the patient vessel size, 22- to 24-gauge peripheral catheters were considered appropriate for both pediatric patients and neonates.66,76  According to the Peripherally Inserted Central Catheters: Guideline for Practice from the National Association of Neonatal Nurses, 1.1F to 3F catheters (20–28 gauge) were commonly used catheter sizes for neonates.136  There were no specific recommendations or empirical evidence for the size of CVADs (tunneled or nontunneled), midline catheters, or totally implantable venous devices.

Device Lumens

Choosing the optimum number of device lumens to deliver planned therapy while reducing the risk of catheter-associated complications, particularly infection, occlusion, and thrombosis, is both complex and important.34  Nine studies described lumen number outcomes in hospitalized adult (n = 2), children (n = 2) and infant (n = 1), immune-competent (n = 1), and hematology and oncology (n = 3) populations. An additional 11 CPG recommendations were included in the review. All compared single- versus double- or multilumen catheters in CVADs (n = 3), tunneled-cuffed CVADs (n = 2), and PICCs (n = 4).

Universally, CPGs recommended the minimum number of lumens necessary for therapy provision. Because of increased risk of infection, occlusion, and thrombosis, multilumen VADs are only appropriate when indicated (ie, for hematopoietic stem cell transplant, critically ill patients, and patients requiring concurrent infusion of noncompatible infusates such as blood and blood product, PN, or chemotherapy).* A dedicated lumen for PN was also frequently endorsed,34,50,86,107  but authors of 2 CPGs stated there was insufficient evidence to support this recommendation.56,96  Similarly, a dedicated lumen for blood sampling, through the largest lumen, was recommended by some, but with limited evidence.66,76 

Evidence evaluating multilumen PICC outcomes was mixed. One study found DVT risk increased with ≥2 lumens,67  another study reported a nonsignificant reduction in CLABSI risk with single-lumen use,39  while a number of other studies reported that PICC lumen number was not significantly associated with the risk of thrombosis81,122  or infection.81  Overall, most studies found occlusion was the most common complication associated with catheter lumen number, and ≥2 lumen PICCs were associated with the highest risk of occlusion.28,39,81  Similarly, studies reported mixed outcomes on the basis of CVAD lumen number. Two studies reported no association between single- and double-lumen catheters and rates of infection65  and major CVAD-related complications,26  whereas others reported higher rates of CLABSI,46,106  exit-site or tunnel infection,46  malfunction or occlusion,46  and complications requiring repositioning26  for double-lumen CVADs.

Insertion Locations

Optimal catheter site selection in pediatric patients is more complex than in adults as pediatric patients typically have fewer accessible veins due to their smaller size.56,124  Determining the appropriate insertion site is important for minimizing risk of insertion and preventing post-insertion related complications19,56,75,86,124 ; however, only partial evidence for appropriate vessels and insertion locations for VADs was available. A total of 21 studies and 12 CPGs were included describing insertion location outcomes. 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 cell collection (n = 1) populations. Five studies compared PIVC device location in surgical (n = 3), hospitalized children (n = 1), and neonate and infant (n = 1) populations, and 3 studies evaluated PICC device location in oncology (n = 1), hospitalized children (n = 1), and immunocompetent (n = 1) populations.

According to the guidelines reviewed, common insertion sites varied by device type. PIVC insertion was frequently recommended in the hand and upper extremities,66,76  with the scalp and foot suggested as alternative insertion sites for infants and toddlers.66  The Infusion Therapy Standards of Practice66  and Provisional Infusion Therapy Standards of Practice76  guidelines recommended avoidance of areas of flexion including the wrist. Insertion of PICCs via the basilic vein was the preferred insertion site, although the brachial, cephalic, axillary, temporal, and posterior auricular veins were acceptable alternatives.56,62,66,76,107  For neonates, the best available vein was recommended without specific guidance as to what constituted the best vein.66  Infants could also have PICCs inserted at saphenous and popliteal veins.56,66,76  Similarly, for midline catheter insertion, the basilic, brachial, and cephalic veins were suggested for neonates, infants, and pediatric patients,76,96  as well as alternative insertion sites such as the scalp and leg.66,76  For PIVCs, the external jugular vein was recommended only in emergency settings or if no other vein was available.66  Overall, there were no preferred insertion sites for tunneled and nontunneled CVADs or totally implantable vascular devices in neonates, infants, and pediatric patients.66,76,82,117,120  No studies evaluated the insertion locations for tunneled and nontunneled CVADs in children; however, in adults, tunneled and nontunneled CVADs were commonly inserted into the internal and external jugular, subclavian, or femoral vein, although the subclavian vein was the recommended insertion site.56,62,76,107 

Insertion Success Is Dependent on Vessel and Insertion Site

PIVCs had higher success rates when inserted in the cephalic vein in the proximal forearm under USG techniques or the antecubital fossa109,123  and a longer life span when inserted into the arm compared to scalp, hand, or leg insertion sites.33  CVAD insertion via the axillary vein using USG techniques resulted in fewer insertion attempts and significantly shorter time to guide-wire insertion and time to cannulation.78  Similarly, CVAD insertion in the subclavian vein was associated with shorter median puncture time, less insertion attempts, and significantly less guide-wire misplacement compared to insertion via the infraclavicular approach.41  In one study, there was higher overall insertion success for insertion via the subclavian compared to the internal jugular vein when using the landmark technique.42  In a sample of critically ill newborns and children (0–14 years), USG brachiocephalic insertion had significantly higher first-attempt success, fewer insertion attempts, and a shorter procedure time compared to the internal jugular vein.98  In critically ill neonates and infants, image-guided placement of tunneled CVADs via saphenous or femoral veins using a surgical cutdown was associated with high placement success.63 

Complications Are Associated With Vessel and Insertion Site

In pediatric patients, PIVCs inserted at the bend of the arm or lower extremities were associated with increased risk of infiltration, erythema, pain, inability to administer medications, no or poor flow due to gravity, and kinked catheter,125,127  whereas insertion at the foot, ankle, or scalp was significantly associated with increased risk of occlusion.125,127  In neonates and infants, PICC insertion at foot or ankle sites was significantly associated with an increased risk of phlebitis, thrombosis, and dysfunction.47,125,136  Overall, there was no direct association between PICC insertion at brachial, cephalic, or saphenous insertion sites and thrombosis in pediatric patients122 ; however, left-sided PICC insertion was associated with higher rates of PICC-related complications.37  The majority of studies, with 2 exceptions,18,78  found that rates of infection and complication varied significantly on the basis of CVAD insertion sites. Generally, complications were similar between internal jugular and subclavian veins.42  One study, however, reported higher rates of early mechanical complications in nontunneled CVADs inserted through the subclavian compared to the jugular or femoral vein.113 

Across CVAD types, insertion via the internal jugular in infants and pediatric patients was associated with increased risk of high arterial puncture,42,113  postoperative chylothorax,36  thrombosis,67,69,89  and infection.42,69  Insertion through the subclavian vein was correlated with an increased risk of high arterial puncture (left-side approaches),42,113  arrhythmias and misplacement (right-side approaches),113  malposition and occlusion,42  postoperative chylothorax,36  and sepsis.31  In pediatric oncology patients, subclavian insertion sites had higher rates of thrombosis compared to external jugular and cephalic sites, but there was no difference in rates between right- or left-side insertion sites.132  Comparatively, brachiocephalic insertion sites were associated with significantly lower CLABSI and thrombosis compared to jugular and subclavian approaches.69  Overall, CVAD insertion through the femoral vein was linked to higher risk of thrombosis51,67,89  but lower complication and infection rates in infants <5 kg.85 

Vessel Visualization

Vessel and catheter-tip visualization technologies, including ultrasound guidance, transillumination, near-infrared (NIR) light device guidance, fluoroscopy, and electrocardiogram (ECG), are commonly used in pediatric clinical practice.34,82  Despite the variety of available technologies, all vessel visualization technologies aim to minimize complications and increase success rates during cannulation. Overall, 31 studies describing vessel visualization outcomes for PIVC, midline, PICC, CVAD, and totally implantable venous devices and 15 CPGs were included. Among those, 17 studies were focused on VADs in critically ill children, neonate, and infant (n = 4); hospitalized children (n = 3); cardiac, neurologic, and general surgical (n = 3); mixed cardiac surgical, congenital heart disease, and PICU (n = 1); ED (n = 1); and neonate (n = 1) populations. Across these heterogeneous populations, the focus was on increasing first-attempt success rates and overall successful insertion and correct catheter-tip positioning.

Across all CPGs, USG insertion by trained clinicians was recommended for all pediatric populations, device types, and insertion sites. It was indicated in most of the evidence reviewed that USG insertions were associated with high insertion success, first-attempt success rates, lower procedure time, fewer attempts, and fewer complications in PIVCs and CVADs.§ Only 2 systematic reviews reported no difference in CVAD insertion success rates between ultrasound guidance and landmark techniques.121,135  PIVC insertion was frequently improved by use of vessel visualization devices,101,123,130  with fewer complications noted.101  Few studies compared visualization techniques for totally implantable venous device placement. One study reported USG percutaneous puncture of totally implantable venous devices had similar success rates, procedure times, and complication rates when compared to surgical cutdown methods.48  Another study found that insertion of totally implantable venous devices by using ultrasound guidance was significantly more effective in reducing complication rates, had shorter procedure times, and was more cost-efficient compared to open surgical cutdown techniques.71 

However, recommendations for other visualization techniques in pediatric populations, including NIR light (vessel visualization) and ECG (catheter-tip confirmation) device use, were scant. Use of NIR light devices may be efficacious in selected high-risk subpopulations102  and may modestly improve first-attempt success rates77,104,110 ; however, the current evidence does not support an overall benefit74  or a benefit that is better than non–image-guided methods.104  Similarly, low levels of evidence prevent the recommendation of ECG assistance for PICC placement105 ; however, one study also found higher first-attempt success and correct tip position success by using intracavitary ECG PICC insertion compared to landmark techniques.141  Other techniques, such as ECG techniques, for CVAD placement were reported as successful and accurate.27,116  In particular, the ECG technique was significantly more accurate and was associated with fewer complications when compared to landmark techniques27  and when intracavitary ECG was undertaken by using a dedicated ECG monitor.116  An article discussed vessel visualization techniques for umbilical catheters and recommended plain radiographs for confirming catheter course and location.142 

VAD selection and insertion grounded in evidence-based, standardized decision-making can reduce risk of complications, pain, length of hospital stay, and costs and can improve overall safety and treatment efficacy.16  Despite many individual studies, systematic reviews, and targeted CPGs, there is no evidence-based guide to assist clinical decision-making in common pediatric indications. This systematic review is the first of its kind to evaluate the evidence that informs VAD selection and insertion for common pediatric indications by using rigorous methodology and a wide breadth of scope. Overall, our review synthesized the available high-quality evidence to inform clinical decision-making, while also highlighting practices in need of further inquiry.

This systematic review revealed evidence- and guideline-based recommendations for VAD selection and insertion in numerous pediatric populations.56,66,76,136  There was a large quantity of evidence to support VAD selection and insertion decision-making in general hospitalized pediatric patients and specialized populations, such as malignant hematologic and oncological and critically ill pediatric patients. Use of most VADs and their associated complications, especially for PICCs, was well evidenced within these population groups. Evidence to support the use of single-lumen devices unless otherwise indicated (eg, for PN) was broadly supported within the literature and in CPGs. Similarly, evidence to suggest that VAD insertion assisted by USG techniques reduced complications and improved insertion success was repeatedly reported by high-quality studies and recommended across multiple CPGs. The strength of the evidence for device selection and insertion in these populations therefore facilitates the implementation of quality clinical decision-making.

On the other hand, our review highlighted gaps in evidence, especially in the form of RCTs, for some pediatric populations, devices, and indications. In some pediatric populations, evidence was so sparse that the scope of the review had to be broadened to include adult and laboratory studies. Specific populations, such as neonates, cardiac patients, and patients with difficult venous access, relied on a few observational studies, making recommendations on device selection challenging. Similarly, although there was a significant proportion of quality evidence on VADs in patients dependent on long-term PN, there was limited evidence for other long-term VAD-dependent populations (eg, cystic fibrosis). Universally, there was a dearth of evidence evaluating midline catheters for the majority of pediatric indications. The literature for recommendations regarding optimal catheter-to-vein ratio was also limited; therefore, this review had to be broadened to include adult and laboratory studies. Finally, although there was abundant evidence to support use of USG techniques for the majority of device insertions, there was a shortage of evidence for the use of other technologies, particularly NIR light devices. As such, additional high-quality research evaluating these populations, device types and characteristics, and insertion procedures is warranted.

Although this study undertook a systematic and rigorous review of the available literature, the results should be interpreted with caution and in the context of its limitations. First, we did not undertake formal assessment of the quality of evidence (eg, using the Grading of Recommendations Assessment, Development and Evaluation [GRADE] approach); however, all individual included studies were independently assessed by 2 review authors, and their quality indicated by their study methodology, in accordance with the RAND-UCLA methodology.9  Additionally, although this study prioritized the review of RCTs and systematic reviews as the gold standard for evaluating VADs, this level of evidence was rarely available. In accordance with the RAND-UCLA Appropriateness Method, the purpose of this review was to include the best available evidence to provide a synthesis of information to guide panel decision-making.9  To avoid indications for which there was no evidence, we included evidence from lower-quality studies (eg, cross-sectional studies, surveillance studies, consecutive cases) and studies outside the initial scope of this review (NICU, adult, and laboratory studies). The inclusion of these studies for some indications means that future clinical decision-making in certain pediatric populations is not guided by strong, evidence-based recommendations. However, most of the evidence that was broadened beyond the original scope of the systematic review was well supported by CPGs, suggesting that these findings can be implemented into clinical practice with confidence.

In this systematic review, we provide the first synthesis of the breadth of evidence available for the selection and insertion of VADs in pediatric patients to guide clinical decision-making. There was strong evidence to support and facilitate appropriate clinical decision-making in some pediatric indications. However, certain populations, device types and characteristics, and insertion procedures were poorly evidenced, necessitating the application of clinical judgment for some indications. Overall, the findings of this review will be vital to inform criteria using the RAND-UCLA Appropriateness Method to determine the appropriateness of VADs in pediatric patients.

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.

*

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

Refs 13650,56,62,66,75,76,82,96,107,108,11738.

Refs 28,34,39,46,50,56,62,66,76,86,106,107,12426.

§

Refs 13626,50,56,62,66,75,76,78,82,96,107,108,11783.

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

§

Refs 17, 26, 52, 53, 61, 63, 64, 68, 78, 83, 99, 114, 129, and 139.

*

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

Refs 34, 38, 50, 56, 62, 66, 75, 76, 82, 96, 107, 108, 117, 126, and 136.

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.

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

     
  • CPG

    clinical practice guideline

  •  
  • CVAD

    central venous access device

  •  
  • DVT

    deep vein thrombosis

  •  
  • ECG

    electrocardiogram

  •  
  • ED

    emergency department

  •  
  • IV

    intravenous

  •  
  • MeSH

    Medical Subject Headings

  •  
  • NIR

    near-infrared

  •  
  • PICC

    peripherally inserted central catheter

  •  
  • PIVC

    peripheral intravenous catheter

  •  
  • PN

    parenteral nutrition

  •  
  • RAND-UCLA

    RAND Corporation–University of California, Los Angeles

  •  
  • RCT

    randomized control trial

  •  
  • USG

    ultrasound-guided

  •  
  • VAD

    vascular access device

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Competing Interests

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.

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.