Vascular access devices (VADs) are commonly inserted, often in a time sensitive manner, in critically ill children to provide life-sustaining therapy, including but not limited to fluid resuscitation, antibiotics, vasopressors, or parenteral nutrition, and for hemodynamic monitoring. Among children admitted to the pediatric emergency department (PED), VAD selection is limited to peripheral intravenous catheter (PIVC), intraosseous device, and nontunneled central vascular access device (NTCVAD). VAD selection is more varied in the PICU and includes peripherally inserted central catheter (PICC), midline catheter, tunneled cuffed central VAD, and totally implanted venous device in addition to those that are available in the PED. Regardless of setting of care, currently there is no evidence-based guidance for VAD selection. In general, PIVCs are the mainstay for critically ill children in the PED, and PIVC and NTCVAD are the mainstays for those in the PICU. However, given the concerns of central line–associated bloodstream infections and catheter-associated deep venous thrombosis, intensivists have been advocating for early transition to PICC despite paucity of evidence of its safety.1 

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

The Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics (miniMAGIC)2  provides a decision aid for VAD selection across the pediatric population, including critically ill children. This guide is built on evidence and expert consensus where evidence was lacking. Implementation of this tool and its ongoing evaluation for effectiveness and impact will help drive change, reduce practice pattern variation, and promote best practices across emergency departments (EDs) and PICUs globally. These recommendations do not necessarily reflect policy of the American Academy of Pediatrics.

It is important to note that the miniMAGIC panelists recommended VAD selection on the basis of illness severity (ie, physiologically unstable versus stable) rather than setting of care (ie, PICU versus PED) or other patient and/or clinical characteristics. Clinical providers will encounter critically ill children outside of the PICU or ED, but the rationale for VAD selection will likely be the same as for these 2 settings of care. For the unstable critically ill child, speed of vascular access is priority. Thus, panelists rated it inappropriate to attempt PIVC access for ≥120 seconds (or ≥2 attempts), which is consistent with national guidelines on resuscitation.3  For these children, PIVC, intraosseous device, and NTCVAD are appropriate. Importantly, the intraosseous device is increasingly being used in ED and even prehospital settings in the context of pediatric cardiopulmonary resuscitation, and their use has been endorsed by the American Heart Association.3  For stable critically ill children, VAD selection should be based on infusate characteristics and monitoring requirements. NTCVADs were rated appropriate for up to 14 days of non–peripherally compatible therapy and for hemodynamic monitoring. PICCs were rated as appropriate for 8 or more days of peripherally compatible therapies and all durations of non–peripherally compatible therapies. Despite minimal data, midline catheters were rated by the panel as appropriate for all durations of peripherally compatible therapies. The panelists preferred PIVCs over intraosseous devices for peripherally compatible therapy for 14 or fewer days (Table 1).

TABLE 1

Key Points for Critical Care and Emergency Medicine

Key Points
For unstable critically ill children, speed of vascular access is priority. 
For stable critically ill children, VAD selection is based on infusate characteristics and monitoring requirements. 
VAD selection, particularly for long-term access, requires a multidisciplinary approach and should include the family, if appropriate. 
Studies are needed to compare prolonged use of NTCVAD versus early transition to PICC or midline catheter. 
Key Points
For unstable critically ill children, speed of vascular access is priority. 
For stable critically ill children, VAD selection is based on infusate characteristics and monitoring requirements. 
VAD selection, particularly for long-term access, requires a multidisciplinary approach and should include the family, if appropriate. 
Studies are needed to compare prolonged use of NTCVAD versus early transition to PICC or midline catheter. 

One area that may need further clarification is the use of VAD for blood draws. The use of arterial catheters specifically for blood draws is not commented on. Likely, there is great variation among institutions and insufficient evidence, but it would be important to address the risks and potential benefits of using arterial catheters in critically ill children rather than a VAD.

There are many take-home points from miniMAGIC for critically ill children. The first point is the need for maintenance of technical skills training of providers in insertion and management of VADs. The second is support for midline vascular access because this is likely an underused VAD, particularly in the PICU. Although it varies across institutions, it is not part of the routine training for fellowships or credentialing for intensivists; thus, intensivists may not be familiar with this type of VAD. Most institutions who use midline catheters have dedicated venous access teams. The third point is the need for a multidisciplinary approach to VAD selection, which includes involvement of patients and caregivers in VAD selection. Although many institutions have dedicated vascular access teams, they likely function within silos from the intensivists, interventional radiologists, or surgical teams. To truly ensure that the most appropriate VAD will be used, there is a need for a multispecialty vascular access team that will act as a consultative team beyond the technical procedure. A consultation visit needs to include input from subspecialists and family as well as a vascular evaluation and history before any VAD placement, particularly for long-term access.

miniMAGIC is a much needed tool to guide VAD selection in children, including those who are critically ill. In unstable critically ill children, VAD selection is dictated by the speed by which vascular access can be obtained. However, for stable critically ill children, a multidisciplinary approach to VAD selection is essential.

Drs Kandil and Faustino drafted the initial manuscript; 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.

FUNDING: No external funding.

ED

emergency department

miniMAGIC

Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics

NTCVAD

nontunneled central vascular access device

PED

pediatric emergency department

PICC

peripherally inserted central catheter

PIVC

peripheral intravenous catheter

VAD

vascular access device

1
Chopra
V
,
Flanders
SA
,
Saint
S
.
The problem with peripherally inserted central catheters
.
JAMA
.
2012
;
308
(
15
):
1527
1528
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
Kleinman
ME
,
Chameides
L
,
Schexnayder
SM
, et al
.
Part 14: pediatric advanced life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care
.
Circulation
.
2010
;
122
(
18
suppl 3
):
S876
S908

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.