Children with disorders of blood and cancer frequently require long-term central venous access devices (CVADs) for recurrent blood draws, blood transfusions, and infusion of caustic medications, such as chemotherapy, immunotherapy, and biological agents. Their diagnosis puts them at increased risk for other comorbidities, such as systemic infection from neutropenia, along with thrombosis secondary to malignancy, immobility, chemotherapeutic agents (eg, steroids and asparaginase), or the underlying thrombogenic state of sickle cell disease.13  Therefore, careful consideration is needed when choosing a CVAD that is best for these patients.

The guidelines/recommendations in this article are not American Academy of Pediatrics policy, and publication herein does not imply endorsement.

CVAD selection and placement guidelines through Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics (miniMAGIC) are helpful for clinicians treating this diverse patient population, which ranges from children with benign hematologic diagnoses (eg, sickle cell disease, thalassemia, and hemophilia) to those with cancer or requiring a bone marrow transplant. Challenging clinical situations that require a CVAD include a newly diagnosed patient with a malignancy requiring immediate chemotherapy or a male infant with hemophilia requiring frequent factor infusions. Having a data-driven framework, such as miniMAGIC,4  will improve the safety of CVADs chosen for these patients in addition to providing consistency between clinicians and institutions. These recommendations do not necessarily reflect policy of the American Academy of Pediatrics.

Key recommendations from miniMAGIC surround CVAD selection for urgent initiation of chemotherapy as well as for nonmalignant hematology patients requiring CVADs for long-term, intermittent access.

Historically, there has been a clinical dilemma on which CVAD to place initially for patients who require urgent treatment of their malignancy. Depending on the clinical situation and institutional procedures, one can either place a peripherally inserted central catheter (PICC) initially and later replace it with a tunneled, cuffed CVAD or totally implanted device or place the tunneled, cuffed CVAD or totally implanted venous device immediately. The miniMAGIC panel rated it appropriate to place a tunneled, cuffed CVAD or totally implanted venous device in patients ≥10 kg instead of a PICC in patients requiring nonurgent chemotherapy. However, in urgent situations, the panel deemed it appropriate to place a PICC and later replace it with a more definitive device.

Another key recommendation was for patients with nonmalignant hematologic conditions who require intermittent access, such as those with sickle cell disease or thalassemia on chronic transfusions. The panelists rated placing tunneled, cuffed CVADs for all populations and totally implanted venous devices in children and adolescents as appropriate and the use of peripheral devices as inappropriate. The roles of PICCs as well as totally implanted venous devices for neonates and infants were rated by the group as uncertain. These recommendations reflect the importance of thinking longitudinally about vascular access, rather than within moments of acute hospitalization (Table 1).

TABLE 1

Key Points for Children With Blood Disorders or Cancer

Key Points
miniMAGIC includes recommendations for diverse populations who have wide-ranging indications for central venous access. 
Evidence suggests increased risk of thrombosis with certain devices, which should be considered when making decisions. 
Diagnosis, urgency, duration of need, and intermittent versus continuous access can help inform what device is most appropriate. 
Unless medically urgent therapy is needed, PICC is discouraged given risks of complications. 
Key Points
miniMAGIC includes recommendations for diverse populations who have wide-ranging indications for central venous access. 
Evidence suggests increased risk of thrombosis with certain devices, which should be considered when making decisions. 
Diagnosis, urgency, duration of need, and intermittent versus continuous access can help inform what device is most appropriate. 
Unless medically urgent therapy is needed, PICC is discouraged given risks of complications. 

miniMAGIC will be beneficial for this diverse patient population in which there are conflicting practices surrounding CVAD selection and placement. These guidelines will inform how best to weigh the risks and benefits of each CVAD type for specific patients with their individual diagnoses, treatment plans, comorbidities, and age. The CVAD needs of this particular population vary from requiring intensive treatment of a short duration of time to more intermediate treatment needed for years or lifelong. Thus, it is of great importance to individualize and to carefully consider the most appropriate CVAD for the patient.

In some acute instances, a PICC may be most appropriate and the most available form of CVAD to place, but we appreciate that miniMAGIC supports removing PICCs in this patient population as soon as a more permanent device can be placed. Although the convenience of placing a PICC at bedside by skilled nurses instead of in a surgical suite with a surgeon is tempting, we will now be placing PICCs in our hematology, oncology, and bone marrow transplant patients with a little more caution after miniMAGIC.

Drs Jaffray and Mody 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: No external funding.

CVAD

central venous access device

miniMAGIC

Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics

PICC

peripherally inserted central catheter

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.