Vascular Access for Children Needing Procedures

Interventional radiologists, nurse practitioners, anesthesiologists, and surgeons are often involved in securing vascular access for children. Traditionally our roles have been focused on central venous access, but increasingly we are called on for patients with difficult intravenous access or to provide longer-term peripheral access. At times, decisions to involve us occur as a “plan B,” after repeated failure to secure other access or after early failure of multiple peripheral intravenous lines. Vascular access decisions are often left to junior staff, occur after hours, and can be seen by treating teams as inconsequential and unimportant. Traditional silos of practice have not helped in this approach. Pediatric vascular access is often an orphan child, with no coordinating family of practitioners. Vascular access is emerging as a subspecialty domain, involving nursing, surgical, anesthetic, and interventional radiologic skills. Who those practitioners are is less important than ensuring they have the necessary skills to perform their tasks and the structural support of an institution to continue to work toward improvements in device selection, insertion, and care through ongoing research.¹ 

The Michigan Appropriateness Guide for Intravenous Catheters in pediatrics (miniMAGIC) provides the basis for a conversation between senior members of the treating team(s) and proceduralists regarding the most appropriate intravascular access for a child.²  Prudent practice would involve team-based discussion of device selection, as skilled and risk free a placement as possible, and impeccable postplacement care to reduce infectious or other complications that would shorten line days.¹  Collectively, these efforts combine to minimize consumption of valuable venous access sites and to maximize the dwell time of the selected vascular access device. The earlier those conversations can be considered and initiated, the more potential access points we as proceduralists will have when our skills are called on. Proceduralists are sometimes viewed as technicians only, without an opinion regarding the line. This leads to late or poor decisions regarding intravascular access for many patients.

The technology of vascular access is continually advancing. Midline catheters are not in common use in all centers, and thus miniMAGIC rated the benefit as uncertain in many cases regarding midline catheters. miniMAGIC’s focus is not on specific product technologies, such as subcutaneous chamber or line tip design, or on bundles of care to promote line survival. As inserting proceduralists, we are ideally placed to undertake prospective research into such areas, to add to the corpus of knowledge, and to decrease the risk of children requiring multiple lines because of device failure before treatment is completed.

Complications start with poor or delayed decisions regarding insertion. Risk increases with substandard insertion techniques and with indifferent aftercare. Lack of coordination between these aspects of vascular access further increases the risk of early line failure. It is time to embrace the concept of a coordinated and hospital-wide approach to vascular access for children; one that does not just involve insertion but also postinsertion care.

The later parts of miniMAGIC revolve around choices of sites, device sizes, the number of lumens, and insertion techniques.²  Home teams are sometimes in the habit of asking for more lumens than are strictly required "just in case." Such practices are not supported by evidence³  and should be challenged. As proceduralists, but also as specialists in our own right, we have a duty of care to these patients to engage home teams in a conversation to determine the principles behind their requests rather than simply inserting whatever line is requested (Table 1).

Many of our procedural colleagues learned their insertion techniques in an era predating the widespread use of image-guided percutaneous techniques. Although there is no doubting their skills, there is evidence that open cutdown or landmark-guided (or “blind”) insertion techniques should no longer be taught as routine to our trainees. If we are to be guided by the evidence, including miniMAGIC, it is time to recognize pediatric vascular access as a subspecialty discipline that crosses traditional team boundaries.