At the interface of clinical practice and medical science, evidence emerges. In domains of clinical practice that lack adequate evidence, clinical decisions are guided by a combination of clinical experience, clinician intuition, and resource availability (material and personnel). Consequently, where evidence gaps exist, clinical care can feel autonomous and innovative but is often inconsistent and may generate adverse outcomes for patients who are underappreciated.
For children with serious illness, clinical decisions regarding achieving and sustaining venous access predominantly occur without much evidence, resulting in more variability than predictability in selecting central venous access devices (CVADs). In this supplement, an international group of pediatric experts propose a way forward using the Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics (miniMAGIC) evidence framework,1 which used the RAND Corporation–University of California, Los Angeles Appropriateness Method. miniMAGIC follows on the forward-thinking Michigan Appropriateness Guide for Intravenous Catheters (MAGIC), which aimed to decrease inappropriate peripherally inserted central catheter (PICC) use in adult patients, along with offering an approach to vascular access line selection.2 MAGIC offers standardization of clinical practice, which in turn has prompted subsequent studies to evaluate the effects of implementation on patient outcomes. Peer-reviewed studies have suggested that following the MAGIC approach led to reduction in infections secondary to midline catheter use among adults3 and suggest that reductions in PICC-associated complications are achieved among adults when evidence-based clinically inappropriate PICC use decreases.4,5
miniMAGIC holds the same promise focusing on children, with the greatest short-term promise being the opportunity for clinical standardization across institutions to study the complications of different CVADs in distinct patient populations. Institutional quality and safety officers can focus their attention on miniMAGIC recommendations with an appropriate or inappropriate rating. Such recommendations can be considered “ready for implementation” through the use of a standardized approach with careful measurement to monitor adoption, outcomes such as infection rates and device associated complications, and balancing factors such as timeliness of device placement. Key areas ready for such implementation work include the following:
differentiating the use of CVADs for peripherally versus nonperipherally compatible indications;
decreasing PICC use for peripherally compatible indications <15 days in hospitalized patients (with the notable exception of patients with cardiac conditions);
midline catheter programs, especially for use in hospitalized children that need peripherally compatible infusates for <15 days or stable critically ill patient <31 days;
placement of PICC, tunneled CVAD and/or totally implanted venous devices for pediatric patients who need infusion therapies for >31 days; and
use of tunneled CVAD for children with long-term (>2 months) vascular access dependence including parenteral nutrition and other continuous therapies.
Although identifying areas ready for change is important, the tremendous long-term potential of miniMAGIC lies in focusing attention to a research agenda examining benefits and risks of CVADs for children. Specifically, some miniMAGIC indications have uncertain recommendations, and variation among the panel for the following scenarios represent areas ripe for future study:
The role of totally implanted venous devices for continuous long-term (>2 months) parenteral therapy remains unclear. However, the panel rated these devices as appropriate for continuous long-term nonparenteral therapy, along with both nonperipherally compatible and peripherally compatible infusates >31 days.
Uncertainty remains in selecting the appropriate CVAD for frequent blood draws in neonates, hospitalized infants, and children. Although miniMAGIC defines frequent blood draws as >1 per day, variation in this definition in practice may change these findings. Research into complications of intermittent direct venous access versus central access is needed.
The use of midline catheters for short-term peripherally compatible infusates in the neonatal and infant populations remains uncertain. Further research in these patient populations could reduce central access while still allowing for stable access.
Nontunneled venous access devices were found to be uncertain in all clinical scenarios of peripherally compatible infusions in the stable critically ill child. Therefore, in institutions that do not offer midline catheters, the options for CVAD are narrow and in need of further inquiry.
Although not directly addressed, further research into timely removal of CVADs is needed to understand the postintervention monitoring period in many chronic conditions (eg, posttransplant, postdiscontinuation of parenteral therapy, postdialysis) as maintaining central access “just in case” poses risks.
These recommendations do not necessarily reflect policy of the American Academy of Pediatrics.
With ever-improving survival of children with chronic health needs, it is likely that pediatricians’ clinical decisions about central venous access for a child may have echoes years or even decades in the future. Ultimately, we hope that use of miniMAGIC will stimulate greater institutional attention to decision-making and quality improvement efforts focused on venous access and foster greater scientific innovations regarding safer and better tailored intravenous devices for young patients. In this supplement, that story begins.
Drs Schroeder and Davis conceptualized the manuscript, 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.
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.