Achieving reliable vascular access (VA) for children devoid of pain, anxiety, and complication is the goal of pediatric VA specialists. VA prevails across various settings, both inpatient and outpatient. In addition, VA spans acute and chronic medical requirements, ranging from the seemingly simple, one-time infusion to the complex, prolonged treatments requiring multiple, frequent infusions and sometimes a lifelong dependency. Regardless of the motive, selection of a vascular access device (VAD) should be driven by the individual’s treatment (medication properties and treatment duration and frequency) and pathophysiology (age, acute and/or chronic disease, existing vessel health, diagnosis, and individual risk factors) with the primary aim of avoiding patient harm. At the heart of achieving this is choosing the right VAD from the beginning. Most health care facilities attempt to achieve this by publishing local VA decision trees. Unfortunately, these are often generic, lack an evidence base, and do not provide direction for nonstandard VA needs.

Globally, the realization of VA as a specialty is variable. Even within the same country, the scope and recognition of VA specialists differ.1  In Australia, pediatric VA as a specialty is in its infancy with few, poorly resourced VA teams. This health service model relies heavily on medical practitioners to choose the most appropriate device, undertake the insertion if it is a “simple” peripheral intravenous catheter insertion, or refer to the appropriate medical practitioner (anesthetist, surgeon, or interventional radiologist) if a more permanent device is required. In the United States, pediatric vascular access teams have evolved in many tertiary hospitals, to include VAD insertion, complication management, data collection, and education.2  The use of technology (ultrasound and tip location) has been a driving force in improving device outcomes and the patient and family experience. Ambiguity still exists surrounding the selection of the most appropriate device.

In part, the lack of consistent device terminology may be responsible for this uncertainty.3 

Choice of a central or peripheral catheter is more complex than length of treatment, although this is how VAD choices are often made. Additionally, the use of multilumen catheters to avoid drug-drug incompatibilities is often the default rather than consultation with interdisciplinary health care professionals who can provide knowledge surrounding the judicious use of multilumen catheters. Use of Michigan Appropriateness Guide for Intravenous Catheters in pediatrics (miniMAGIC) to guide consultation with a conversant specialist is appropriate, and it is recommended that skilled pharmacists participate in decisions about incompatibility.

Non-VA specialists often do not understand the nuances of various VADs, for example, the difference between a peripheral intravenous catheter and a midline, assuming they recognize a midline to be a peripheral device. Although the definition of nonperipherally compatible infusates is unsettled, the fact remains that certain drugs can damage the vascular endothelium.4  Use of the general categories (peripherally compatible and nonperipherally compatible) intentionally avoids assignment of individual drug risk. The selection of a VAD for nonperipherally compatible drug infusates is based on current best practices and will be modified as the exact interplay between drugs and catheter type becomes available (Table 1).

TABLE 1

Key Points for VA Specialists

Key Points
Interdisciplinary collaboration is imperative to ensure due consideration of thorough patient assessment, insertion factors, and future VA needs. 
The combination of the miniMAGIC device selection and knowledge of nonperipherally compatible infusates can prevent drug-induced phlebitis. 
Opportunities to advance pediatric VA are evident in the areas of uncertainty or disagreement and represent variance in practice and gaps in the literature. 
Integration of miniMAGIC into the electronic ordering system may support guidance on the appropriate devices at the time of order entry. 
Key Points
Interdisciplinary collaboration is imperative to ensure due consideration of thorough patient assessment, insertion factors, and future VA needs. 
The combination of the miniMAGIC device selection and knowledge of nonperipherally compatible infusates can prevent drug-induced phlebitis. 
Opportunities to advance pediatric VA are evident in the areas of uncertainty or disagreement and represent variance in practice and gaps in the literature. 
Integration of miniMAGIC into the electronic ordering system may support guidance on the appropriate devices at the time of order entry. 

Although the content provided in miniMAGIC provides a comprehensive resource for device selection, many health care providers and leaders must seek realistic solutions for integration into practice. With the implementation and advancement of the adult Michigan Appropriateness Guide for Intravenous Catheters, the research team integrated some of the decision components directly into the electronic ordering sets for peripherally inserted central catheters. This order set allowed for real-time clinical monitoring and provider feedback.5  For clinicians seeking to integrate miniMAGIC into pediatric practice, the use of digital integration into the electronic health system may improve compliance with appropriate device selection.

There are many evidence gaps in the literature specific to pediatric VA and device selection. These voids become more evident in miniMAGIC, specifically where there are areas of “uncertainty.” Of the total 1234 scenarios reviewed by the panelists in the second round, the panel concluded with 137 uncertain scenarios (18.2%) and disagreed on 18 clinical scenarios (2.4%). These areas of uncertainty represent practice variance and may help identify opportunities for further research for VA clinicians. On the basis of ratings of uncertainty and/or a lack of appropriate options, areas of consideration for future research and/or product development by VA specialists include midline use, device options for patients requiring frequent blood draws, device selection for children with congenital heart conditions, and site selection by age and device.

The implementation of miniMAGIC into pediatric facilities will provide health services without VA specialists with the evidence and tools to choose the most appropriate device on the basis of infusion properties, patient characteristics, length of treatment, and current vessel health. In health services where pediatric VA specialists are recognized, miniMAGIC will guide all interdisciplinary device planning conversations. miniMAGIC provides the most comprehensive and realistic opportunity to guide device selection to reduce unnecessary insertion attempts and complications during treatment. These recommendations do not necessarily reflect the policy of the American Academy of Pediatrics.

We acknowledge the facilitators of miniMAGIC, Drs Amanda Ullman, Steven Bernstein, and Vineet Chopra, whose efforts to explain the methodology and moderate the discussion made the development of this guide possible and enjoyable.

Ms Kleidon, Ms Doellman, Ms Pitts, and Mr Stranz conceptualized and designed the study, drafted the initial manuscript, and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

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

     
  • miniMAGIC

    Michigan Appropriateness Guide for Intravenous Catheters in pediatrics

  •  
  • VA

    vascular access

  •  
  • VAD

    vascular access device

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Competing Interests

POTENTIAL CONFLICTS OF INTEREST: Ms Kleidon reports investigator-initiated research grants and speaker fees provided to Griffith University from 3M Medical, AngioDynamics, Baxter International, Becton Dickinson Bard, Centurion, Cook Medical, Medical Specialties Australasia, and Vygon (unrelated to the current project). Ms Pitts reports employment by B. Braun Medical and St Joseph’s Children’s Hospital in Tampa, previous employment and stockholder status with AngioDynamics, and board membership at Navi Medical Technologies; the other authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: Ms Kleidon reports grants from the National Health and Medical Research Council, employment by Griffith University, grants from the Children’s Hospital Foundation and Emergency Medicine Foundation, and investigator-initiated research grants and speaker fees provided to Griffith University from 3M Medical, AngioDynamics, Becton Dickinson, and Medical Specialties Australasia (unrelated to the current project). Ms Doellman is on the speaker’s bureau of Genentech and Lineus Medical and is a consultant for Teleflex Medical; the other authors have indicated they have no financial relationships relevant to this article to disclose.