Vascular access in pediatric cardiac patients is an inherently complex topic. Many clinicians struggle to understand the “plumbing,” let alone the implications that particular cardiovascular anatomic and physiologic derangements and our strategies of palliation have for children, both for the present and the future. Each choice a clinician makes regarding where and how to place a vascular access device (VAD), the length and diameter of the catheter, the surveillance and maintenance practices for the catheter, the duration the catheter is left indwelling, the types of therapies administered through the catheter, the blood sampled through the catheter, and the decision to remove the catheter can have major implications for a child’s future candidacy for additional catheterization and surgery. Simultaneously accounting for all of these factors can result in an incomprehensible morass. Through the Michigan Appropriateness Guide for Intravenous Catheters in pediatrics (miniMAGIC), we have employed the use of an expert panel and the RAND Corporation and University of California, Los Angeles appropriateness methodology (which is similar to the approach that was used in the development of the Michigan Appropriateness Guide for Intravenous Catheters)1  in an attempt to distil the multitude of patient-, catheter-, and condition-related factors into a reasonable and straightforward framework. miniMAGIC2  provides a starting point for the multidisciplinary discussions that necessarily precede the individualized decisions surrounding vascular access in the congenital cardiac population. These recommendations do not necessarily reflect policy of the American Academy of Pediatrics (Table 1).

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

TABLE 1

Key Points for Pediatric Cardiology and Cardiac Surgery Practice

Key Points
Understand the cardiac diagnosis and strategy of palliation or treatment fully before deciding what VAD to place and where to place it 
Choose devices and sites that minimize long-term vessel damage 
Use intraprocedural vascular ultrasound anytime it is feasible 
Minimize number of VAD lumens and do not dedicate lumens for blood draws 
Do not forget about unusual or nonstandard routes of access 
Avoid placing an upper extremity CVAD in patients with functionally univentricular physiology, especially in neonates and infants 
Key Points
Understand the cardiac diagnosis and strategy of palliation or treatment fully before deciding what VAD to place and where to place it 
Choose devices and sites that minimize long-term vessel damage 
Use intraprocedural vascular ultrasound anytime it is feasible 
Minimize number of VAD lumens and do not dedicate lumens for blood draws 
Do not forget about unusual or nonstandard routes of access 
Avoid placing an upper extremity CVAD in patients with functionally univentricular physiology, especially in neonates and infants 

In neonates and infants who require vascular access, it is critical to choose devices and insertion sites that minimize the likelihood of long-term vessel damage, thrombosis, and occlusion.

For children with complex congenital heart disease, it is important to understand the long-term trajectory of their palliation strategy (ie, functionally univentricular physiology versus biventricular circulation) as well as their stage of palliation if functionally univentricular. For example, such understanding is critical in deciding whether to place a peripherally inserted central catheter in the arm or the leg of an infant or whether to place a femoral or jugular short-term central venous access device (CVAD) in the operating room before cardiac surgery. In general, a strategy that preserves the patency of upper extremity veins for patients with functionally univentricular physiology undergoing staged palliation is paramount.

Patients undergoing biventricular repair generally have fewer risks associated with upper extremity catheters, and the known issues of thrombosis and infection inherent to femoral VADs should be taken into account.3  In patients who require future cardiac catheterization through femoral veins, these vessels should be preserved when possible (eg, patients with Tetralogy of Fallot with pulmonary atresia and patients receiving cardiac transplant who will need multiple endomyocardial biopsies).

Although data on many unusual routes of access (ie, intracardiac and transthoracic, umbilical, transhepatic, and translumbar routes) are sparse, these routes should be considered as options. In particular, the umbilical vein can provide a free CVAD route for neonates requiring several days of central access without jeopardizing any longer-term access sites, but care must be taken to ensure such catheters remain central and to remove them promptly when they are no longer needed. Similarly, the use of transthoracic intracardiac right atrial or common atrial lines can help preserve both upper and lower extremity veins.

Vessel visualization with ultrasound should be employed whenever achievable to minimize vessel trauma and the number of access attempts.

It is usually inappropriate to dedicate additional lumens of a central venous line for blood sampling because of the risks posed by additional lumens.4 

Totally implantable venous devices do not have much of a role in the congenital cardiac population.

  • • Many of us who trained in earlier eras became accustomed to placing peripheral and central VADs using landmark techniques. Today, with the availability and extremely high quality of vascular ultrasound machines, we have a need to modernize and use them intraprocedurally when it is feasible to do so.

  • • At many centers, special effort is made to place a central umbilical venous catheter (under fluoroscopic guidance, if necessary) in the neonate prenatally diagnosed with a functionally univentricular heart within the first 24 hours after birth to postpone the use of femoral CVADs and peripherally inserted central catheters in these patients.

  • • We necessarily left many choices in the table as uncertain. This underscores the importance of having multidisciplinary discussions between cardiologists, surgeons, nurses, anesthesiologists, radiologists, and other allied health professionals when trying to balance risks and benefits for an individual patient for whom there is no clear correct answer for VAD selection.

  • • Finally, recommendations do not particularly help when they only exist in the electronic ether; we plan to employ both low-technology decision support (printing out the relevant tables and mounting them to our clipboards for easy viewing) and high-technology decision support (displaying the relevant tables in the electronic health record system as adjunctive information to the ordering clinician and posting these protocols on the Internet so that they can be accessed at the bedside from mobile devices) to bring the knowledge to the bedside.

We thank Vineet Chopra, Amanda Ullman, and the entire miniMAGIC panel, from whom we learned a tremendous amount during the process of creating and disseminating these guidelines.

All authors drafted the manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.

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

CVAD

central venous access device

miniMAGIC

Michigan Appropriateness Guide for Intravenous Catheters in pediatrics

VAD

vascular access device

1
Chopra
V
,
Flanders
SA
,
Saint
S
, et al;
Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) Panel
.
The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): results from a multispecialty panel using the RAND/UCLA Appropriateness Method
.
Ann Intern Med
.
2015
;
163
(
suppl 6
):
S1
S40
2
Ullman
AJ
,
Bernstein
SJ
,
Brown
E
, et al
.
The Michigan Appropriateness Guide for Intravenous Catheters in pediatrics: miniMAGIC
.
Pediatrics
.
2020
;
145
(
suppl 3
):
e20193474I
3
Aiyagari
R
,
Song
JY
,
Donohue
JE
,
Yu
S
,
Gaies
MG
.
Central venous catheter-associated complications in infants with single ventricle: comparison of umbilical and femoral venous access routes
.
Pediatr Crit Care Med
.
2012
;
13
(
5
):
549
553
4
Bozaan
D
,
Skicki
D
,
Brancaccio
A
, et al
.
Less lumens-less risk: a pilot intervention to increase the use of single-lumen peripherally inserted central catheters
.
J Hosp Med
.
2019
;
14
(
1
):
42
46

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.