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TABLE 2

Summary of CPGs and Studies Included in Systematic Review

Study, YearParticipants, nDesign and/or MethodFocus and/or OverviewStudy Sample and CharacteristicsDeviceFindings and CommentsminiMAGIC Indication
Adams et al,14  2016 — Clinical reviewa Clinical review of midline catheter device indications and complications for use in the ED — Midline Midlines have a low complication rate, long dwell time, and high rate of first-attempt placement. General pediatrics 
Aiyagari et al,15  2012 89 Observationala To compare the clinical outcomes for infants with single-ventricle physiology after umbilical catheter and femoral CVAD placement Patients with single-ventricle physiology admitted to the NICU (4–13 d) Nontunneled CVAD, umbilical catheter Nontunneled CVADs were associated with higher rates of thrombosis and vein occlusion. No difference was seen among CLABSI, need for transhepatic access, and ultrasound-documented thrombus at the inferior vena cava–right atrial junction. Patients with nontunneled femoral CVAD for ≥14 d had a higher prevalence of thrombosis than those for <14 d. No difference in the prevalence of iliofemoral vein occlusion was seen. General pediatrics 
Ainsworth and McGuire,16  2015 549 Systematic reviewb To evaluate PN delivery via PIVC or CVAD in hospitalized neonates Included 6 RCTs evaluating PN delivery via PIVC or CVAD in hospitalized neonates PIVC, nontunneled CVAD Nontunneled CVAD led to a smaller deficit of nutrients and fewer catheters; there was no difference for invasive infection. Long-term dependent 
Alten et al,17  2012 115 Observationala To compare USG CVAD insertion to landmark techniques in critically ill neonates Retrospective review of critically ill neonates (mean = <14 d) admitted to the PICU requiring CVAD placement using USG or landmark techniques CVAD Insertion using ultrasound guidance was associated with higher overall success, first-, and second- attempt success, and lower arterial puncture rates. Vessel visualization 
Anil et al,18  2011 128 Observationala To evaluate complications associated with CVAD placement in the PICU Retrospective review of all patients (median = 21 mo) admitted to the PICU requiring CVAD placement CVAD There was no difference in complications for CVAD insertion at femoral, subclavian, or jugular veins. Insertion location 
ANZICS,19  2012 — CPGb Specific recommendations for insertion central lines for the prevention of CLABSI — Nontunneled CVAD, tunneled CVAD — Insertion location 
Allen et al,20  2008 — Observationala To determine the risk of infection in pediatric oncology patients requiring long-term vascular access 12-mo prospective study of pediatric oncology patients (3 mo–20 y old) with a TIVD or tunneled-cuffed CVAD TIVD, tunneled-cuffed CVAD There was a higher rate ratio for CLABSIs in tunneled-cuffed CVAD. Hematology and oncology 
ARC and NZRC,21  2010 — CPGb Specific recommendations for access to circulation in infants and children in the context of cardiorespiratory arrest — CVAD, intraosseous, PIVC — Critical care 
ARC and NZRC,22  2010 — CPGb Medication or fluids for the resuscitation of the newborn infant — Intraosseous, PICV, umbilical catheter Specific recommendations for newborn infants in the context of resuscitation were provided. Critical care 
ARC and NZRC,23  2010 — CPGb Specific recommendations for vascular access in pediatric patients in the context of cardiopulmonary arrest — CVAD, intraosseous, PICV — General pediatrics 
Arnts et al,24  2014 203 Observationala To compare the rates of complications between umbilical catheters and PIVCs in newborns Patients admitted to the NICU (24–42 wk gestation) requiring a PICC or umbilical catheter PICC, umbilical catheter There was no difference in complication rate or due to gestational age. General pediatrics 
Athale et al,25  2012 358 Observationala To evaluate the impact of CVAD on 5-y overall and event-free survival in children with cancer Children with non-CNS cancer (≤19 y old) who required a CVAD CVAD CVAD dysfunction controlling for thromboembolism is associated with poorer 5-y overall and event-free survival. Hematology and oncology 
Avanzini et al,26  2017 194 Observationala To describe a single-center transition from CVAD placement via surgical cutdown to USG insertion techniques Retrospective review of pediatric patients (7 d–18 y old) who underwent tunneled CVAD placement using USG or surgical cutdown techniques Tunneled CVAD Double-lumen PICCs were associated with increased risk of complications, compared to single-lumen PICCs; complications were reported but not significantly compared between USG and surgical cutdown techniques. Device lumens 
Vessel visualization 
Barnwal et al,27  2016 60 Observationala To compare ECG and landmark insertion techniques for CVAD placement Pediatric patients (0–11 y old) undergoing elective cardiovascular surgery randomly assigned to CVAD insertion via landmark or ECG techniques CVAD There were fewer complications using USG insertion techniques. Vessel visualization 
Barrier et al,28  2012 1280 Observationala To determine risk factors for PICC-related complications in children Immunocompromised children (mean = 3.2 y old; 0–21 y old) requiring a PICC PICC Double-lumen catheters, PICCs placed in the femoral vein and children 1–4 y old, compared with older children (5–10 y old, >10 y old), were more at risk for complications. General pediatrics 
Device lumens 
Insertion location 
Baskin et al,29  2019 — CPGb Specific recommendations for central venous catheters in children with chronic illness — Midline, PICC, TIVD, tunneled-cuffed CVAD — Long-term dependent 
Ben Abdelaziz et al,30  2017 215 Observationala To examine the incidence of PIVC-related complications in pediatric patients Comparison of complications versus no complications in hospitalized children (0.1–18 y old) requiring a PIVC PIVC Longer duration was associated with local complication. General pediatrics 
Bezzio et al,31  2019 205 Observationala To investigate the rate of and risk factors for infection in children undergoing cardiac surgery requiring CVAD placement Prospective study of pediatric patients (1 d–25 y old) undergoing cardiac surgery CVAD Infection risk significantly increased with increased duration of device placement; the SCV vein was more likely to develop CLABSI. Congenital cardiac 
Insertion location 
Blotte et al,32  2017 162 Observationala To compare PICC and CVAD complications in pediatric patients with intestinal failure Pediatric patients (1 d–12 y old) with intestinal failure requiring PN PICC, tunneled-cuffed CVAD Tunneled-cuffed CVAD had a higher infection rate, and PICCs were more likely to break. More tunneled-cuffed CVADs had central venous thrombosis, whereas more PICCs had basilic vein thrombosis. Long-term dependent 
Birhane et al,33  2017 178 Observationala To assess factors that impacted PIVC life span in neonates and infants Neonates and infants (1 d–11 mo) requiring PIVC placement PIVC Compared to placement at the scalp, hand, or leg, PIVCs inserted at the arm had a longer life span. Insertion location 
Bodenham Chair et al,34  2016 — CPGb Specific recommendations for the insertion of VADs in all patients — CVAD, PIVC — Critical care 
Catheter-to-vein ratio 
Device lumens 
Vessel visualization 
Boe et al,35  2015 92 Observationala To evaluate risk factors and complications associated with the placement of transhepatic CVADs Retrospective review of congenital cardiac patients (IQR = 2–10 y old) undergoing transhepatic CVAD placement Transhepatic CVAD Placement ≥21 d was associated with increased transhepatic CVAD complications. Critical care 
Borasino et al,36  2014 392 Observationala To determine if CVAD insertion into veins in the upper body is a risk factor for chylothorax Retrospective review of pediatric patients (<1 y old) undergoing cardiac surgery; comparison among CVAD placement at IJV versus SCV versus femoral vein CVAD Insertion at IJV or SCV was associated with a higher risk of chylothorax. Insertion location 
Boretta et al,37  2018 107 Observationala To evaluate the management and complications associated with PICCs inserted in pediatric oncology patients Pediatric oncology patients (0–17 y old) requiring PICC placement PICC Compared to right-side insertion locations, PICCs inserted on the left side of the body were associated with more complications. Insertion location 
Bouaziz et al,38  2015 — CPGb Specific recommendations for the placement of VADs under ultrasound guidance in all patients — CVAD, PIVC — Vessel visualization 
Bozaan et al,39  2019 226 Pilot studya To evaluate the impact of an intervention designed to increase the use of single-lumen PICCs Pre- and postintervention of PICC placement in hospitalized adults (60 y old) PICC Making single-lumen PICCs the default option and providing indications for multilumen devices increased use of single-lumen PICCs. Device lumens 
Bratton et al,40  2014 178 Observationala To report complication rates of VADs in children undergoing radiotherapy Retrospective review of pediatric patients (1–26 y old) undergoing radiotherapy who received a VAD PICC, TIVD, tunneled-cuffed CVAD TIVDs were associated with lower infection and complication rates and had greater durability. Hematology and oncology 
Byon et al,41  2013 98 RCTc To evaluate the efficacy of USG SCV catheterization Pediatric patients (0–2.9 y old) undergoing elective congenital cardiac surgery or neurosurgery; randomly assigned to supraclavicular or infraclavicular approaches CVAD The supraclavicular approach was associated with shorter puncture time, fewer insertion attempts, and fewer misplacements. Insertion location 
Camkiran Firat et al,42  2016 280 RCTc To compare the rate of complications associated with IJV and SCV CVAD insertion Pediatric patients (16 mo–2.2 y old) undergoing cardiac surgery; randomly assigned to IJV or SCV insertion CVAD Insertion via the SCV was associated with higher success rates; lower rates of arterial puncture, catheter-tip cultures, and CLABSI; and higher rates of malposition. There was no difference in mechanical complications, ICU and hospital length of stay, and in-hospital mortality. Insertion location 
Campagna et al,43  2018 1538 Observationala To determine the safety of midline catheters used in general hospitalized adults Hospitalized adults (median = 83 y old) requiring a midline catheter across 2 Italian hospitals Midline A total of 10% of midline catheters had a serious adverse event. General pediatrics 
Carlson et al,44  2015 3846 Observationala To characterize procedures performed on critically ill children by emergency medical service personnel in out-of-hospital contexts Retrospective review of pediatric patients (0–17 y old) requiring out-of-hospital critical care CVAD, intraosseous CVADs had higher success rates compared to intraosseous devices. Critical care 
Carraro et al,45  2013 — CPGb Specific recommendations for the use of long-term central venous access in pediatric hematology and oncology patients — TIVD, tunneled-cuffed CVAD — Hematology and oncology 
Cesaro et al,46  2016 1161 Observationala To report the frequency and associated risk factors for central venous catheter–associated complications in children with hemato-oncological conditions Pediatric hematology-oncology patients (median = 6.1 y old) requiring a tunneled-cuffed CVAD Tunneled-cuffed CVAD At <6.1 y old, there were more mechanical complications, more malfunction or occlusion; compared to single-lumen devices, double-lumen devices had more mechanical complications, exit-site or tunnel infections, and malfunction or occlusion. Hematology and oncology 
Device lumens 
Chen et al,47  2020 4405 Systematic reviewb To compare risk associated with PICCs placed in the upper versus the lower extremity in neonates Neonates (<28 d old) requiring PICC placement PICC There was a greater risk of nonelective removals and malposition in PICCs placed in the upper versus lower extremity; there was a lower risk of thrombosis in PICCs placed at the upper extremity. There were no differences in mechanical complications, PICC-related infection, or phlebitis. Insertion location 
Choi et al,48  2017 23 Observationala To determine the safety and accuracy of TIVD placement using ultrasound guidance compared to surgical cutdown Retrospective review of pediatric (0–16 y old) hematology, oncology, and PN patients undergoing TIVD placement TIVD There was no difference using ultrasound guidance in insertion time or complication compared to surgical cutdown. Vessel visualization 
Cooling et al,49  2017 75 Observationala To examine the performance and safety of femoral CVADs Retrospective study of pediatric patients undergoing stem cell collection (median = 3 y old) requiring CVAD placement CVAD Compared to thoracic CVADs, femoral CVADs had fewer flow-related adverse events. Insertion location 
Crocoli et al,50  2015 — CPGb CVADs in pediatric patients with cancer — Midline, PICC, nontunneled CVAD, TIVD, tunneled CVAD, tunneled-cuffed CVAD — Hematology and oncology 
Long-term dependent 
Catheter-to-vein ratio 
Device lumens 
Vessel visualization 
Debourdeau et al,51  2009 — CPGb Prevention of thrombosis associated with central venous catheters in patients with cancer — TIVD, tunneled CVAD — Hematology and oncology 
Device lumens 
Insertion location 
De Carvalho Onofre et al,52  2012 42 RCTc To compare the use of ultrasound and palpation insertion success for PICC placement in pediatric patients Any pediatric patient (1 mo–16 y old) requiring IV therapy for >7 d; randomly assigned to USG PICC insertion or palpation PICC USG PICC insertion was associated with higher first-attempt success rate, better catheter positioning and shorter insertion time. Vessel visualization 
de Souza et al,53  2018 80 RCTc To determine if USG PICC placement led to higher insertion success compared to landmark techniques Critically ill pediatric patients (IQR = 3 mo–1.3 y old) admitted to the PICU requiring PICC insertion via the IJV; randomly assigned to USG or landmark insertion PICC USG PICC insertion was associated with higher overall success rate, first- and third-attempt success rate, lower insertion time, and fewer hematomas and arterial punctures compared to landmark. Vessel visualization 
DeWitt et al,54  2015 180 Observationala To determine procedural success and failure rates in umbilical catheter placement Patients with congenital heart disease <20 h old versus >20 h old requiring an umbilical catheter Umbilical catheter There was a higher success rate for younger patients. General pediatrics 
Dheer et al,55  2011 103 Observationala To compare the rates of immediate insertion-related complications after CVAD placement in pediatric patients Hospitalized children (<12 y old) requiring a CVAD; comparison of complications among neonate versus infant versus >1–12 y old CVAD Neonates were at higher risk of immediate insertion-related complications; more insertion attempts were associated with insertion-related problems. General pediatrics 
Doellman et al,56  2015 — CPGb Specific recommendations regarding central venous catheters that account for the unique needs of pediatric patients — Hemodialysis catheter, PICC, nontunneled CVAD, TIVD, tunneled CVAD — General pediatrics 
Hematology and oncology 
Critical care 
Congenital cardiac 
Long-term dependent 
Catheter-to-vein ratio 
Device lumens 
Vessel visualization 
Dongara et al,57  2017 144 RCTc To compare success and complication rates, cost, and insertion time between PICCs and umbilical catheters inserted in the NICU Patients admitted to the NICU (mean = 34 wk’ gestation) requiring a PICC or umbilical catheter PICC, umbilical catheter There was no difference in success rate, time, and short-term complications between PICCs and umbilical catheters. General pediatrics 
Elser,58  2013 — Clinical reviewa Clinical review of umbilical catheter placement Patients admitted to the NICU requiring an umbilical catheter Umbilical catheter Umbilical catheter malposition or dislodgement is associated with hemorrhaging and death. General pediatrics 
Fallon et al,59  2014 244 Observationala To determine device-related complications in infants requiring a VAD Hospitalized children (0–3 y old) requiring a central venous catheter for prolonged therapy TIVD, tunneled CVAD Infants (≤1 y old) had higher complication rate, higher operative exchange rate, higher infection rate, and shorter duration compared with toddlers (>1 y old). General pediatrics 
Faustino et al,60  2013 101 Observationala To explore the incidence of DVT in PICU patients requiring a central venous catheter Critically ill children (0–17 y old) admitted to the PICU; comparisons made among age (<1 y old versus 1–13 y old versus 13–17 y old) Nontunneled CVAD Compared with infants (<1 y old), PICU patients 13–17 y old had higher odds of DVT. Critical care 
Froehlich et al,61  2009 93 Observationala To determine if CVAD placement using ultrasound guidance increases insertion success and decreases complications after single-center transition to USG insertion techniques Prospective study of critically ill pediatric patients (median = 2.5 y old) admitted to the PICU requiring CVAD placement with USG or landmark techniques CVAD Ultrasound guidance was associated with significantly lower arterial punctures and fewer No. attempts. There was no difference in success rate or insertion time between ultrasound guidance and landmark groups. Vessel visualization 
Frykholm et al,62  2014 — CPGb Specific guidelines for patients requiring central venous catheters regarding vascular approach, ultrasound guidance, and prevention of complications — Dialysis catheters, nontunneled CVAD, PICC, TIVD, tunneled-cuffed CVAD — Long-term dependent 
Device lumens 
Vessel visualization 
Gaballah et al,63  2014 150 Observationala To describe complication rates associated with CVAD placement using ultrasound guidance and fluoroscopic guidance in neonates and infants Retrospective review of critically ill neonates and infants (premature–1 y old) requiring CVAD placement with USG versus fluoroscopic guidance CVAD There was no difference in complication rates. Insertion location 
Vessel visualization 
Gallagher et al,64  2014 168 Observationala To determine if CVAD placement using USG techniques improved insertion success in pediatric ED patients Retrospective study of pediatric (3–15 y old) emergency patients requiring CVAD placement with or without ultrasound guidance CVAD There was higher insertion success when using ultrasound guidance. Vessel visualization 
Gonzalez et al,65  2012 172 Observationala To determine if early placement of TIVDs or tunneled-cuffed CVADs in patients at high risk of thrombosis and infection led to higher surgical complications Retrospective review of children with ALL (4 d–16 y old) at high risk of infection and thrombosis TIVDs, tunneled-cuffed CVADs There was no difference in infection rate between TIVD and tunneled-cuffed CVADs and no difference in rate of infection in single- versus double-lumen devices. Hematology and oncology 
Device lumens 
Gorski et al,66  2016 — CPGb Specific practice recommendations for adult and pediatric patients requiring infusion therapy, including device selection, placement, and complication prevention — Hemodialysis catheters, intraosseous, long PIVC, midline, nontunneled CVAD, PICC, short PIVC, TIVD, tunneled CVAD, umbilical catheter — Critical care 
Congenital cardiac 
Long-term dependent 
Catheter-to-vein ratio 
Device lumens 
Vessel visualization 
Gray et al,67  2012 333 Observationala To identify risk factors for catheter-related DVT in infants <1 y old Hospitalized infants (mean = 34 wk’ gestation) requiring a VAD PICC, tunneled-cuffed CVAD Mean catheter days before DVT diagnosis were shorter for PICCs than for tunneled-cuffed CVADs; higher rates of DVT were in multilumen CVADs; the majority of DVT was in femoral veins. Femoral CVADs were associated with greater DVT rates than jugular or SCV CVADs. There was more DVT in femoral lines than in sapheno-femoral tunneled-cuffed CVADs. Long-term dependent 
Device lumens 
Insertion location 
Gurien et al,68  2016 1134 Observationala To determine the incidence of complications associated with CVAD placement using USG techniques Retrospective, multicenter review of pediatric patients (1.5–12 y old) who underwent CVAD placement with landmark or USG insertion CVAD There was a higher first- attempt success rate using ultrasound guidance but higher risk of hemothorax using ultrasound guidance. Vessel visualization 
Habas et al,69  2018 225 Observationala To determine the complications associated with CVAD placement at the BCV insertion site Retrospective review of pediatric patients (mean = 7 y old) admitted to PICU requiring CVAD placement; BCV insertion site versus all others (femoral, subclavian, jugular) CVAD Compared to other insertion sites, BCV had fewer complications. Insertion location 
Hamed et al,70  2013 300 Observationala To describe insertion success rate and complication rate after delivery of anesthesia to critically ill infants and toddlers Critically ill infants and toddlers (21 d–1.3 y old) requiring emergency surgery Intraosseous Intraosseous access was appropriate for unobtainable peripheral or central access. Critical care 
Hancock-Howard et al,71  2010 60 Observationala To determine the cost-effectiveness of TIVD placement using interventional radiology Retrospective review of pediatric oncology patients undergoing placement of a TIVD using interventional radiology (mean = 7 y old) or surgical cutdown (mean = 4 y old) techniques TIVD Insertion time was shorter and resulted in fewer complications using interventional radiology compared to surgical cutdown. Vessel visualization 
Handrup et al,72  2010 98 Observationala To evaluate the rates of VAD-related complications associated with placement of a TIVD or tunneled-cuffed CVAD Retrospective review of children with ALL (<4–>9 y old) who received a TIVD or tunneled-cuffed CVAD over an 8-y period TIVD, tunneled-cuffed CVAD There was a higher CLABSI rate and nonelective removal for tunneled-cuffed CVAD. Hematology and oncology 
Hanson et al,73  2012 1070 Observationala To investigate the rate of and risk factors for VTE in children with cardiac disease admitted to the PICU Children with cardiac disease (median = 10 mo) admitted to the PICU; comparisons made among <6 mo versus 6 mo–1 y old versus 1–2 y old versus 2–12 y old versus 12–18 y old versus >18 y old CVAD VTE incidence was associated with increasing No. CVAD days. In young children (<6 mo), VTE incidence was significantly higher. Critical care 
Heinrichs et al,74  2013 1076 Systematic reviewb To evaluate assistive technologies, other than ultrasound guidance, in improving PIVC insertion success Seven RCTs of pediatric patients (0–21 y old) requiring PIVC insertion using novel interventions PIVC Transillumination was associated with higher first-attempt success compared to traditional insertion techniques; first-attempt success using NIR and traditional methods was not significantly different. There was no difference in time or No. attempts between insertion methods. Vessel visualization 
Included studies 
Hosokawa, 2010 
Katsogridakis, 2008 
Nager, 1992 
Perry, 2011 
Chapman, 2011 
Kim, 2012 
Maynard, 1989 
Institute for Healthcare Improvement,75  2012 — CPGb Specific recommendations for the prevention of CLABSI — CVAD — Vessel visualization 
IVNNZ,76  2012 — CPGb Specific practice recommendations for adult and pediatric patients requiring infusion therapy, including device selection, placement, and complication prevention — Intraosseous, midline, nontunneled CVAD, PICC, TIVD, tunneled CVAD, umbilical catheter — Critical care 
Long-term dependent 
Device lumens 
Vessel visualization 
Katsogridakis et al,77  2008 240 Observationala To determine if transillumination increases PIVC insertion success in pediatric patients Pediatric patients (mean = 13 y old) with difficult venous access admitted to the ED requiring nonurgent PIVC placement; randomly assigned to with or without transillumination PIVC Insertion using transillumination was associated with higher first- and second-attempt success compared to without transillumination. Vessel visualization 
Kim et al,78  2017 132 RCTc To compare ultrasound guidance to landmark techniques for CVAD insertion in children Pediatric cardiac surgery, neurosurgery, or general surgical patients (1 mo–6 y old) requiring CVAD insertion; randomly assigned to USG insertion to the axillary vein or LM insertion via the SCV CVAD USG + axillary insertion was associated with fewer attempts and shorter insertion time. There was no difference in complication rates. Results were confounded by location and/or imaging. Insertion location 
Vessel visualization 
Kulkarni et al,79  2014 — Systematic reviewb A systematic review of TIVDs and tunneled-cuffed CVADs in adults and children receiving chemotherapy 5 RCTs and 25 observational studies of adults and children undergoing chemotherapy TIVD, tunneled-cuffed CVAD Tunneled CVAD was associated with more infections, noninfectious complications, and device removal. Hematology and oncology 
Kulkarni et al,80  2017 176 Observationala To describe the complications related to VAD insertion in infants with hemophilia Infants (0–2 y old) with hemophilia requiring either a PICC, TIVD, or tunneled CVAD PICC, TIVD, tunneled CVAD TIVDs had the lowest rates of complications. Hematology and oncology 
Lam et al,81  2018 954 Observationala To evaluate the impact of defaulting to single-lumen PICCs Hospitalized adults (mean = 66 y old) requiring PICC placement; comparison of single versus double lumens PICC Single-lumen PICCs were associated with lower complications. Device lumens 
Lamperti et al,82  2012 — CPGb Specific recommendations regarding USG VAD placement — CVAD, PICC — Catheter-to-vein ratio 
Vessel visualization 
Lau and Chamberlain,83  2016 760 Systematic reviewb To examine the safety and efficacy of CVAD insertion using ultrasound guidance A total of 8 RCTs comparing the use of USG and landmark CVAD placement in pediatric patients (<18 y old) CVAD Ultrasound guidance had a higher success rate and fewer No. insertion attempts compared to landmark techniques. Vessel visualization 
Included studies 
Alderson, 1993 
Verghese, 1999 
Verghese, 2000 
Grebenik, 2004 
Chuan, 2005 
Ovezov, 2010 
Aouad, 2010 
Bruzoni, 2013 
Levy et al,84  2010 279 Observationala To determine the rate of and potential risk factors for infectious and noninfectious complication associated with PICCs in pediatric patients Hospitalized children (10 d–21 y old) requiring a PICC PICC Older age was associated with infectious complications. General pediatrics 
Lindquester et al,85  2017 33 Observationala To examine the safety and efficacy of tunneled CVAD placement at the internal and external jugular in neonates and infants <5 kg Multicenter retrospective review of hospitalized infants weighing <5 kg (0–1 y old) with a tunneled CVAD Tunneled CVAD There was no difference in complications associated with jugular and femoral vein insertion locations. Insertion locations 
Loveday et al,86  2014 — CPGb Specific recommendations for the prevention of hospital-acquired infections — PICC, TIVD, tunneled CVAD — Long-term dependent 
Device lumens 
Malbezin et al,87  2013 5435 Observationala To prospectively determine the overall success and complication rate of CVAD insertion over a 22-y period Hospitalized children (mean = 5 y old) requiring any CVAD CVAD Device failure was more likely in children <3 kg. General pediatrics 
Marshall et al,88  2017 19 Observationala To compare transhepatic CVADs to nontunneled CVADs as an alternative for preserving future central venous access Retrospective review of infants (1.8–7.8 mo) with congenital heart disease who underwent placement of 1 or more transhepatic CVADs Nontunneled CVAD, transhepatic CVAD Transhepatic CVAD had a longer duration. There was no difference in thrombi, thrombolytic burden, or catheter sites requiring wound care consultation. There was a higher frequency of infection in transhepatic CVAD. There was no difference in the rate of infection-related removal. Congenital cardiac 
Marquez et al,89  2016 175 Observationala To determine risk factors for thrombosis after placement of nontunneled CVADs in PICU patients Prospective, multicenter study of pediatric patients (4 mo–8.6 y old) admitted to the PICU undergoing CVAD placement Nontunneled CVAD There were higher rates of DVT in patients with right-side nontunneled CVAD placement and insertion at SCV. Insertion location 
May et al,90  2018 912 Observationala To determine the rates of thrombosis, infection, and insertion site symptoms after placement of PICCs and TIVDs in patients with cystic fibrosis Retrospective review of adult and pediatric patents (mean = 7.4 y old) with cystic fibrosis PICC, TIVD Double-lumen PICCs were associated with greater rates of complications. Long-term dependent 
Device lumens 
Menéndez et al,91  2016 256 Observationala To evaluate the incidence and risk factors for PICC-related thrombosis in children Hospitalized children (IQR = 2.4–13 y old) requiring PICC placement PICC A catheter-to-vein ratio of >0.33 predicted PICC-related superficial vein thrombosis and DVT. Catheter-to-vein ratio 
Mermel et al,92  2009 — CPGb Specific recommendations for the prevention of catheter-related infection — CVAD, midline, PICC, PIVC, TIVD — Long-term dependent 
Moon et al,93  2018 629 Observationala To determine risk factors for CLABSI in children with hemato-oncological disease requiring long-term VADs Retrospective review of children with hemato-oncologic disease (median = 6 y old; 14 d–17.9 y old) requiring any long-term CVAD TIVD, tunneled-cuffed CVAD There was no difference in the rate of CLABSI. Hematology and oncology 
Mushtaq et al,94  2018 693 Observationala To determine the safety, specifically rates of CLABSI, mechanical complications, hospital length of stay, readmission within 90 d of discharge, and mortality of midline catheters compared to CVADs in adults admitted to intensive care Adults >18 y old admitted to the ICU or medical-surgical ward with either a CVAD or midline catheter CVAD, midline CVADs were associated with higher rates of CLABSI, crude mortality, readmission, and transfer to the ICU. Midline catheters had more mechanical complications. General pediatrics 
Noailly Charny et al,2  2018 295 Observationala To compare the risk of thrombosis in PICCs and tunneled-cuffed CVADs Children (<18 y old) diagnosed with leukemia who received a PICC or tunneled-cuffed CVAD PICC, tunneled-cuffed CVAD PICCs were associated with an increased risk of thrombosis. Hematology and oncology 
Nifong and McDevitt,95  2011 — Laboratory studya To determine the effect of catheter size of fluid flow rates — PICC Fluid flow rate decreased with increasing catheter size. Catheter-to-vein ratio 
O’Grady et al,96  2011 — CPGb Specific recommendations for the prevention of intravascular catheter-related infections — Midline, nontunneled CVAD, PICC, PIVC, TIVD, tunneled CVAD — Device lumens 
Vessel visualization 
Ohno et al,97  2016 120 Observationala To determine the rates of complications and CLABSI in infants and small infants (<1 y old or <10 kg) compared with children (>1 y old or >10 kg) Children (4 mo–22 y old) requiring a TIVD TIVD Age was not associated with increased risk of complications. General pediatrics 
Oulego-Erroz et al,98  2016 46 Pilot studya To determine if CVAD insertion to the BCV using USG techniques had greater insertion success compared to insertion to the IJV Prospective study of critically ill children (0.6 mo–13 y old) requiring urgent CVAD insertion; nonrandom assignment to BCV + USG or IJV insertion CVAD BCV + ultrasound guidance had a higher first-attempt success rate, fewer insertion attempts, and lower insertion time compared to IJV. There was no difference in overall success rates. Insertion location 
Vessel visualization 
Oulego-Erroz et al,99  2018 500 Observationala To determine if CVAD placement outcomes can be improved by using USG insertion Prospective, multicenter study of all critically ill children (IQR = 2 mo–4.9 y old) requiring temporary CVAD placement using USG or landmark techniques CVAD Ultrasound guidance had a higher first-attempt success rate and fewer puncture attempts and mechanical complications. Vessel visualization 
Pacilli et al,100  2018 18 Observationala To determine the appropriateness of long PIVCs in pediatric patients undergoing surgery Children undergoing surgery (mean = 6.3 y old) requiring long PIVC insertion Long PIVC There were no immediate complications. On day 3, removals were made because of 3 occlusions and 1 red/pain. General pediatrics 
Paladini et al,101  2018 40 Pilot studya To compare the success of USG long PIVC insertion in children admitted to the ED to short PIVCs Children >10 y old (mean = 13 y old) who were admitted to the ED; comparison of blind short PIVC versus USG PIVC insertion Long PIVC, short PIVC Short PIVCs had a shorter dwell time duration and more complications compared to long PIVCs; ultrasound guidance had a lower risk of failure and complications but results confounded. Critical care 
Vessel visualization 
Park et al,102  2016 3832 Systematic reviewb To determine the utility of NIR light devices A total of 11 RCTs of any pediatric patient (<21 y old) undergoing PIVC placement using NIR or no assistive device PIVC There was no overall difference in overall success rate between NIR light device and traditional methods; however, NIR light devices had a higher success rate for subsets deemed high risk of failure. Vessel visualization 
Included studies 
Chapman, 2011 
Perry, 2011 
Kaddoum, 2012 
Kim, 2012 
Cuper, 2013 
Graaff, 2013 
Sun, 2013 
Szmuk, 2013 
Woude, 2013 
Graaff, 2014 
Curtis, 2015 
Pasteur et al,103  2010 — CPGb Specific recommendations for patients with non-CF bronchiectasis — TIVD — Long-term dependent 
Peterson et al,104  2012 1399 Observationala To determine if assistive devices improve PIVC insertion success Hospitalized children (mean = 1 y old) requiring PIVC placement; randomly assigned to unassisted versus assisted (transillumination versus NIR light device–guided) insertion PIVC PIVC insertion success was higher when no assistive device was used compared to assisted methods. Vessel visualization 
Perin and Scarpa,105  2015 — Systematic reviewb To review evidence related to the assessment of catheter-tip positioning in pediatric patients Included 42 pediatric studies examining outcomes for patients undergoing VAD placement using vessel visualization techniques CVAD, PICC, umbilical catheter There was insufficient high-quality evidence to make specific recommendation for use in pediatric patients. Vessel visualization 
Pinon et al,106  2009 915 Observationala To determine the incidence and risk factors of central venous catheter-related complications in pediatric hemato-oncological and immunologic conditions Single-center, prospective study of children (0–19 y old) with oncological, hematologic, or immunologic diseases TIVD, tunneled CVAD Tunneled-cuffed CVADs were associated with more CLABSI; being ≤3 y old was associated with more dislodgements and more tunnel infections; CLABSI was more prevalent in double- versus single-lumen devices. Hematology and oncology 
Device lumens 
Pittiruti et al,107  2009 — CPGb Specific recommendations for CVADs and complication prevention in patients requiring PN — Midline, PICC, PIVC, TIVD, tunneled CVAD — Long-term dependent 
Device lumens 
Vessel visualization 
Polkinghorne et al,108  2013 — CPGb Specific recommendations for vascular access in patients with chronic renal disease — Nontunneled CVAD, tunneled CVAD — Vessel visualization 
Qian et al,109  2014 40 Observationala To examine complication rates in pediatric patients with CF after the placement of a long PIVC Prospective audit of pediatric patients with CF with infective exacerbation Long PIVC Complication rates were high; no serious adverse outcomes were reported. Long-term dependent 
Ramer et al,110  2016 53 RCTc To evaluate the effectiveness of NIR light device technology for PIVC placement in pediatric hematology and oncology patients Pediatric hematology and oncology patients (1–21 y old) requiring PIVC placement; randomly assigned to NIR light device or landmark insertion techniques PIVC NIR light device was associated with faster insertion time and higher satisfaction. Vessel visualization 
Rauth et al,111  2008 138 Observationala To investigate the rate of infection in infants when the venous catheter is exchanged for a tunneled-cuffed CVAD after ECMO decannulation PICU patients (mean = 13 d) requiring CVAD placement after decannulation from ECMO Tunneled-cuffed CVAD Increasing the duration of ECMO and CVAD placement independently predicted CLABSI. Critical care 
Revel-Vilk et al,112  2010d 423 Observationala To determine the rate of catheter-related complications in children undergoing chemotherapy during 12 mo of therapy Single-center, prospective study of pediatric patients (29 d–28 y old) undergoing chemotherapy PICC, tunneled-cuffed CVAD PICCs were associated with a higher risk of DVT; tunneled CVAD had a higher risk of occlusion at 1 y. Hematology and oncology 
Rey et al,113  2009 825 Observationala To identify risk factors for early mechanical complications in CVADs Pediatric patients (median = 22 mo) admitted to the PICU; comparisons among femoral, jugular, and SCV CVAD insertion sites CVAD SCV and jugular vein, as well as increasing No. attempts were associated with significantly more early mechanical complications. Difficult venous access 
Insertion site 
Rivera-Tocancipa et al,114  2018 201 Observationala To describe the incidence of complications associated with USG CVAD insertion in children compared to anatomic landmark techniques All hospitalized children (0–18 y old) requiring CVAD insertion using USG or LM insertion techniques CVAD Ultrasound guidance had fewer immediate complications, no arterial punctures, and higher rates of insertion success compared to landmark techniques. Vessel visualization 
Rosado et al,115  2013 255 Observationala To examine the rate of CVAD-associated infection in PICU patients Prospective, single-center review of children (majority <6 y old) admitted to the PICU requiring a CVAD CVAD CVADs inserted ≥7 d were associated with a higher risk of CLABSI. Critical care 
Rossetti et al,116  2015 309 Observationala To investigate the safety and accuracy of intracavitary ECG-guided insertion in pediatric patients Prospective, multicenter study of hospitalized pediatric patients (1 mo–18 y old) requiring a VAD; insertion using intracavitary ECG versus intracavitary ECG with dedicated ECG monitor compared CVAD, PICC Insertion accuracy was higher with a dedicated ECG monitor. Vessel visualization 
Schiffer et al,117  2013 — CPGb Specific recommendations for central venous catheters in patients with cancer — Nontunneled CVAD, PICC, tunneled CVAD, TIVD — Hematology and oncology 
Vessel visualization 
Sharp et al,118  2015 136 Observationala To identify the optimal ratio cutoff to reduce rates of VTE Prospective study of hospitalized adults (mean = 57 y old) requiring PICC insertion, comparison between ≤45% versus ≥45% catheter-to-vein ratio PICC A >45% ratio was more likely to develop VTE. Catheter-to vein ratio 
Shenep et al,119  2017 90 Observationala To determine the interaction between PN and external central venous devices in increasing risk of complications Rates of complications during PN and non-PN periods in pediatric oncology patients (median = 7.3 y old) requiring central venous devices TIVD, tunneled CVAD Risk of CLABSI was higher during PN for children with TIVDs. Occlusion risk was higher for TIVDs. Complication rates for TIVDs were lower during the non-PN period but similar during the PN period. Long-term dependent 
Sibson et al,120  2018 — CPGb Specific recommendations for preventing thrombosis in pediatric patients with cancer — PICC, PIVC, TIVD, tunneled CVAD — Hematology and oncology 
Sigaut et al,121  2009 359 Systematic reviewb To evaluate the advantages of USG CVAD placement over anatomic landmark techniques in pediatric patients Children (2 d–8 y old) undergoing cardiac surgery requiring CVAD CVAD For ultrasound guidance, no difference in rates of artery puncture, hematoma, hemothorax, pneumothorax, or time to insert was found. Ultrasound guidance had higher success rates for subsets of novice operators and during intraoperative use. Vessel visualization 
Included studies 
Alderson, 1993 
Chuan, 2005 
Verghese, 1999 
Verghese, 2000 
Grabenic, 2004 
Smitherman et al,122  2015 1135 Observationala To determine risk factors for the development of catheter-associated VTE in general hospitalized pediatric patients Chart review of hospitalized children (mean = 8 y old) requiring a VAD PICC Increasing age was related to an increased risk of thrombosis; lumen No. was not associated with thrombosis risk; insertion site (brachial or cephalic, SCV, jugular, or femoral or saphenous) was not associated with an increased risk of thrombosis. General pediatrics 
Device lumens 
Insertion location 
Takeshita et al,123  2015 96 Observationala To examine the factors that affect insertion success for invisible and impalpable peripheral veins in children Pediatric patients (1.1–2.8 y old) with invisible or impalpable veins undergoing elective surgery PIVC PIVC with ultrasound guidance had better success rates compared to PIVC without ultrasound guidance; compared to insertion to the dorsal hand vein, the cephalic vein had a higher success rate and shorter insertion time. Difficult access 
Insertion location 
Vessel visualization 
Takeshita et al,123  2015 196 RCTc To examine the factors that affect insertion success for invisible and impalpable peripheral veins in children Pediatric patients (10–40 mo) with invisible or impalpable veins undergoing elective surgery PIVC Compared to insertion to the dorsal hand or saphenous vein, the cephalic vein had a higher success rate. Insertion location 
The Joint Commission,124  2013 — CPGb Specific recommendations for preventing CLABSI in CVADs — CVAD — Device lumens 
Tripi et al,125  2016 108 Observationala To determine the frequency of PIVC-related dysfunction in pediatric patients Compared PIVC dysfunction in hospitalized children (0–>12 y old) over device durations of 1–2 d versus 2–3 d versus >3 d PIVC Higher rates of PIVC dysfunction were associated with PIVCs in place for >3 d or inserted in lower extremities. General pediatrics 
Troianos et al,126  2011 — CPGb Specific recommendations for VAD placement using ultrasound guidance in pediatric patients — CVAD, PICC, PIVC — Vessel visualization 
Ullman et al,6  2015 31 933 Systematic reviewb To review the incidence of VAD failure in pediatric patients Hospitalized pediatric patients across 74 studies requiring any VAD Hemodialysis catheter, nontunneled CVAD, PICC, TIVD, tunneled CVAD, umbilical catheter Hemodialysis catheters and umbilical catheters had the highest failure rate; TIVDs had the lowest failure rate. General pediatrics 
Ullman et al,1  2017 1027 Observationala To examine the prevalence, management, and associated complications of CVADs in pediatric patients Hospitalized pediatric patients (IQR = 1–12 y old) requiring any VAD Hemodialysis catheter, nontunneled CVAD, PICC, TIVD, tunneled CVAD, umbilical catheter PICCs had higher proportions of CVAD-associated complications in the previous 7 d. General pediatrics 
Unbeck et al,127  2015 2032 Observationala To identify risk factors for PIVC-associated complications in pediatric patients Comparison of hospitalized neonatal versus pediatric patients (0–18 y old) requiring a PIVC PIVC Occlusion was associated with longer dwell time. Neonatal: PIVC survival time was shorter; there was more infiltration. Insertion at the arm bend or ankle was associated with higher rates of infiltration and occlusion. General pediatrics 
Insertion location 
van Gent et al,128  2017 538 Observationala To determine the rates of infection and complications in pediatric hematology, oncology, and stem cell transplant patients Retrospective review of pediatric patients (mean = 7.8 y old) after surgical placement of any CVAD TIVD, tunneled-cuffed CVAD Tunneled-cuffed CVAD had a lower risk of infection. Hematology and oncology 
Vierboom et al,129  2018 232 Observationala To evaluate the safety of tunneled CVAD insertion in children weighing <10 kg Retrospective review of all children (<1 mo–4 y old) receiving surgical insertion of a tunneled CVAD with ultrasound guidance or via surgical cutdown Tunneled CVAD USG insertion was associated with lower mechanical blockages, but there was no difference in intraoperative and postoperative complications, time to insert, or device longevity. Vessel visualization 
Vinograd et al,130  2018 300 Observationala To evaluate PIVC insertion success in patients with difficult venous access using USG techniques Pediatric patients (median = 14 y old) in an ED who had a failed PIVC attempt via traditional insertion techniques PIVC PIVC using USG techniques led to 68% and 87% first- and second-attempt success rates after failed traditional method. Difficult access 
Vessel visualization 
Voigt et al,131  2012 — Systematic reviewb To review the evidence for the use of intraosseous devices in emergent contexts Studies evaluating intraosseous devices in patients requiring emergent vascular access or nonhuman randomized prospective studies Intraosseous Compared to alternative access, there was no difference in complications using intraosseous devices. Critical care 
Wiegering et al,132  2014 43 Observationala To determine the incidence of catheter-related thrombosis in pediatric oncology patients Single-center retrospective review of pediatric oncology patients (mean = 9.4 y old) requiring central venous access TIVD, tunneled-cuffed CVAD TIVDs showed an earlier peak of thrombosis occurrence than that of tunneled-cuffed CVAD catheters; the highest incidence of thrombosis occurred in the SCV, followed by external jugular and cephalic sites. There was no difference in complications between insertion at the left and right side. Hematology and oncology 
Insertion location 
White et al,133  2012 322 Observationala To compare the rate of complications and early removal between TIVDs and tunneled-cuffed CVADs Retrospective review of children (1 mo–19 y old) with ALL requiring a TIVD or a tunneled-cuffed CVAD TIVD, tunneled-cuffed CVAD TIVDs had less complications. Hematology and oncology 
Wragg et al,134  2014 100 Observationala To determine the rate of occlusion associated with tunneled-cuffed CVAD insertion under ultrasound guidance Children (21 d–16 y old) requiring elective or emergency removal of a tunneled-cuffed CVAD Tunneled-cuffed CVAD Complete venous occlusion was associated with younger age. General pediatrics 
Vessel visualization 
Wu et al,135  2013 508 Systematic reviewb To evaluate whether USG CVAD insertion was more successful compared to anatomic landmark techniques Meta-analysis of RCTs comparing USG versus landmark CVAD insertion in pediatric patients (mean = 0.5–<8 y old) CVAD There were few pediatric studies (n = 2), which limited analysis. For ultrasound guidance, there was no reduction in the risk of cannulation failure, arterial puncture, hematoma, pneumothorax, and hemothorax in children or infants. Vessel visualization 
Wyckoff and Sharpe,136  2015 — CPGb Specific recommendations for vascular access in neonates and infants — Midline, PICC, PIVC, TIVD, tunneled CVAD, umbilical catheter — General pediatrics 
Congenital cardiac 
Catheter-to-vein ratio 
Vessel visualization 
Xia et al,137  2016 48 RCTc To determine the efficacy and rate of complications in pediatric patients with moderate-to-severe burn injuries Pediatric patients (mean = 2.2 y old) with moderate-to-severe burn injuries PICC, PIVC There was a higher 1-time puncture success rate, longer retention duration, and more complication for PICCs compared to PIVCs Critical care 
Yacobovich et al,138  2015d 423 Observationala To determine patient- and catheter-related risk factors for CLABSI in children receiving chemotherapy Prospective study of pediatric patients (29 d–28 y old) receiving chemotherapy requiring a VAD PICC, TIVD, tunneled-cuffed CVAD Tunneled-cuffed CVADs and PICCs had a higher risk for CLABSI in the group of diseases with lower rate of infection. In diseases with high rate of infection, there was no difference. Hematology and oncology 
Zanolla et al,139  2018 51 RCTc To determine if USG techniques reduce the No. puncture attempts, procedure time, and complication rates during CVAD insertion via the IJV in children Prospective study of any child (11 mo–9 y old) requiring CVAD insertion via the IJV; randomly assigned to USG versus landmark insertion groups CVAD USG techniques required fewer attempts, took less time, and resulted in fewer complications, compared to landmark techniques. Vessel visualization 
Zengin et al,140  2013 64 Observationala To determine risk factors for CVAD-related complications in children admitted to the ED Retrospective review of pediatric patients (2–16 y old) admitted to the ED Nontunneled CVAD More complications were associated with >3 attempts. Difficult venous access 
Zhou et al,141  2017 281 Observationala To evaluate the feasibility and safety of intracavitary ECG technique in guiding PICC placement in neonates Hospitalized neonates (27–41 wk) requiring PICC placement using landmark techniques or intracavitary ECG guidance PICC Intracavitary ECG-guided PICC placement had a higher correct tip position on the first attempt compared to landmark techniques. Vessel visualization 
Study, YearParticipants, nDesign and/or MethodFocus and/or OverviewStudy Sample and CharacteristicsDeviceFindings and CommentsminiMAGIC Indication
Adams et al,14  2016 — Clinical reviewa Clinical review of midline catheter device indications and complications for use in the ED — Midline Midlines have a low complication rate, long dwell time, and high rate of first-attempt placement. General pediatrics 
Aiyagari et al,15  2012 89 Observationala To compare the clinical outcomes for infants with single-ventricle physiology after umbilical catheter and femoral CVAD placement Patients with single-ventricle physiology admitted to the NICU (4–13 d) Nontunneled CVAD, umbilical catheter Nontunneled CVADs were associated with higher rates of thrombosis and vein occlusion. No difference was seen among CLABSI, need for transhepatic access, and ultrasound-documented thrombus at the inferior vena cava–right atrial junction. Patients with nontunneled femoral CVAD for ≥14 d had a higher prevalence of thrombosis than those for <14 d. No difference in the prevalence of iliofemoral vein occlusion was seen. General pediatrics 
Ainsworth and McGuire,16  2015 549 Systematic reviewb To evaluate PN delivery via PIVC or CVAD in hospitalized neonates Included 6 RCTs evaluating PN delivery via PIVC or CVAD in hospitalized neonates PIVC, nontunneled CVAD Nontunneled CVAD led to a smaller deficit of nutrients and fewer catheters; there was no difference for invasive infection. Long-term dependent 
Alten et al,17  2012 115 Observationala To compare USG CVAD insertion to landmark techniques in critically ill neonates Retrospective review of critically ill neonates (mean = <14 d) admitted to the PICU requiring CVAD placement using USG or landmark techniques CVAD Insertion using ultrasound guidance was associated with higher overall success, first-, and second- attempt success, and lower arterial puncture rates. Vessel visualization 
Anil et al,18  2011 128 Observationala To evaluate complications associated with CVAD placement in the PICU Retrospective review of all patients (median = 21 mo) admitted to the PICU requiring CVAD placement CVAD There was no difference in complications for CVAD insertion at femoral, subclavian, or jugular veins. Insertion location 
ANZICS,19  2012 — CPGb Specific recommendations for insertion central lines for the prevention of CLABSI — Nontunneled CVAD, tunneled CVAD — Insertion location 
Allen et al,20  2008 — Observationala To determine the risk of infection in pediatric oncology patients requiring long-term vascular access 12-mo prospective study of pediatric oncology patients (3 mo–20 y old) with a TIVD or tunneled-cuffed CVAD TIVD, tunneled-cuffed CVAD There was a higher rate ratio for CLABSIs in tunneled-cuffed CVAD. Hematology and oncology 
ARC and NZRC,21  2010 — CPGb Specific recommendations for access to circulation in infants and children in the context of cardiorespiratory arrest — CVAD, intraosseous, PIVC — Critical care 
ARC and NZRC,22  2010 — CPGb Medication or fluids for the resuscitation of the newborn infant — Intraosseous, PICV, umbilical catheter Specific recommendations for newborn infants in the context of resuscitation were provided. Critical care 
ARC and NZRC,23  2010 — CPGb Specific recommendations for vascular access in pediatric patients in the context of cardiopulmonary arrest — CVAD, intraosseous, PICV — General pediatrics 
Arnts et al,24  2014 203 Observationala To compare the rates of complications between umbilical catheters and PIVCs in newborns Patients admitted to the NICU (24–42 wk gestation) requiring a PICC or umbilical catheter PICC, umbilical catheter There was no difference in complication rate or due to gestational age. General pediatrics 
Athale et al,25  2012 358 Observationala To evaluate the impact of CVAD on 5-y overall and event-free survival in children with cancer Children with non-CNS cancer (≤19 y old) who required a CVAD CVAD CVAD dysfunction controlling for thromboembolism is associated with poorer 5-y overall and event-free survival. Hematology and oncology 
Avanzini et al,26  2017 194 Observationala To describe a single-center transition from CVAD placement via surgical cutdown to USG insertion techniques Retrospective review of pediatric patients (7 d–18 y old) who underwent tunneled CVAD placement using USG or surgical cutdown techniques Tunneled CVAD Double-lumen PICCs were associated with increased risk of complications, compared to single-lumen PICCs; complications were reported but not significantly compared between USG and surgical cutdown techniques. Device lumens 
Vessel visualization 
Barnwal et al,27  2016 60 Observationala To compare ECG and landmark insertion techniques for CVAD placement Pediatric patients (0–11 y old) undergoing elective cardiovascular surgery randomly assigned to CVAD insertion via landmark or ECG techniques CVAD There were fewer complications using USG insertion techniques. Vessel visualization 
Barrier et al,28  2012 1280 Observationala To determine risk factors for PICC-related complications in children Immunocompromised children (mean = 3.2 y old; 0–21 y old) requiring a PICC PICC Double-lumen catheters, PICCs placed in the femoral vein and children 1–4 y old, compared with older children (5–10 y old, >10 y old), were more at risk for complications. General pediatrics 
Device lumens 
Insertion location 
Baskin et al,29  2019 — CPGb Specific recommendations for central venous catheters in children with chronic illness — Midline, PICC, TIVD, tunneled-cuffed CVAD — Long-term dependent 
Ben Abdelaziz et al,30  2017 215 Observationala To examine the incidence of PIVC-related complications in pediatric patients Comparison of complications versus no complications in hospitalized children (0.1–18 y old) requiring a PIVC PIVC Longer duration was associated with local complication. General pediatrics 
Bezzio et al,31  2019 205 Observationala To investigate the rate of and risk factors for infection in children undergoing cardiac surgery requiring CVAD placement Prospective study of pediatric patients (1 d–25 y old) undergoing cardiac surgery CVAD Infection risk significantly increased with increased duration of device placement; the SCV vein was more likely to develop CLABSI. Congenital cardiac 
Insertion location 
Blotte et al,32  2017 162 Observationala To compare PICC and CVAD complications in pediatric patients with intestinal failure Pediatric patients (1 d–12 y old) with intestinal failure requiring PN PICC, tunneled-cuffed CVAD Tunneled-cuffed CVAD had a higher infection rate, and PICCs were more likely to break. More tunneled-cuffed CVADs had central venous thrombosis, whereas more PICCs had basilic vein thrombosis. Long-term dependent 
Birhane et al,33  2017 178 Observationala To assess factors that impacted PIVC life span in neonates and infants Neonates and infants (1 d–11 mo) requiring PIVC placement PIVC Compared to placement at the scalp, hand, or leg, PIVCs inserted at the arm had a longer life span. Insertion location 
Bodenham Chair et al,34  2016 — CPGb Specific recommendations for the insertion of VADs in all patients — CVAD, PIVC — Critical care 
Catheter-to-vein ratio 
Device lumens 
Vessel visualization 
Boe et al,35  2015 92 Observationala To evaluate risk factors and complications associated with the placement of transhepatic CVADs Retrospective review of congenital cardiac patients (IQR = 2–10 y old) undergoing transhepatic CVAD placement Transhepatic CVAD Placement ≥21 d was associated with increased transhepatic CVAD complications. Critical care 
Borasino et al,36  2014 392 Observationala To determine if CVAD insertion into veins in the upper body is a risk factor for chylothorax Retrospective review of pediatric patients (<1 y old) undergoing cardiac surgery; comparison among CVAD placement at IJV versus SCV versus femoral vein CVAD Insertion at IJV or SCV was associated with a higher risk of chylothorax. Insertion location 
Boretta et al,37  2018 107 Observationala To evaluate the management and complications associated with PICCs inserted in pediatric oncology patients Pediatric oncology patients (0–17 y old) requiring PICC placement PICC Compared to right-side insertion locations, PICCs inserted on the left side of the body were associated with more complications. Insertion location 
Bouaziz et al,38  2015 — CPGb Specific recommendations for the placement of VADs under ultrasound guidance in all patients — CVAD, PIVC — Vessel visualization 
Bozaan et al,39  2019 226 Pilot studya To evaluate the impact of an intervention designed to increase the use of single-lumen PICCs Pre- and postintervention of PICC placement in hospitalized adults (60 y old) PICC Making single-lumen PICCs the default option and providing indications for multilumen devices increased use of single-lumen PICCs. Device lumens 
Bratton et al,40  2014 178 Observationala To report complication rates of VADs in children undergoing radiotherapy Retrospective review of pediatric patients (1–26 y old) undergoing radiotherapy who received a VAD PICC, TIVD, tunneled-cuffed CVAD TIVDs were associated with lower infection and complication rates and had greater durability. Hematology and oncology 
Byon et al,41  2013 98 RCTc To evaluate the efficacy of USG SCV catheterization Pediatric patients (0–2.9 y old) undergoing elective congenital cardiac surgery or neurosurgery; randomly assigned to supraclavicular or infraclavicular approaches CVAD The supraclavicular approach was associated with shorter puncture time, fewer insertion attempts, and fewer misplacements. Insertion location 
Camkiran Firat et al,42  2016 280 RCTc To compare the rate of complications associated with IJV and SCV CVAD insertion Pediatric patients (16 mo–2.2 y old) undergoing cardiac surgery; randomly assigned to IJV or SCV insertion CVAD Insertion via the SCV was associated with higher success rates; lower rates of arterial puncture, catheter-tip cultures, and CLABSI; and higher rates of malposition. There was no difference in mechanical complications, ICU and hospital length of stay, and in-hospital mortality. Insertion location 
Campagna et al,43  2018 1538 Observationala To determine the safety of midline catheters used in general hospitalized adults Hospitalized adults (median = 83 y old) requiring a midline catheter across 2 Italian hospitals Midline A total of 10% of midline catheters had a serious adverse event. General pediatrics 
Carlson et al,44  2015 3846 Observationala To characterize procedures performed on critically ill children by emergency medical service personnel in out-of-hospital contexts Retrospective review of pediatric patients (0–17 y old) requiring out-of-hospital critical care CVAD, intraosseous CVADs had higher success rates compared to intraosseous devices. Critical care 
Carraro et al,45  2013 — CPGb Specific recommendations for the use of long-term central venous access in pediatric hematology and oncology patients — TIVD, tunneled-cuffed CVAD — Hematology and oncology 
Cesaro et al,46  2016 1161 Observationala To report the frequency and associated risk factors for central venous catheter–associated complications in children with hemato-oncological conditions Pediatric hematology-oncology patients (median = 6.1 y old) requiring a tunneled-cuffed CVAD Tunneled-cuffed CVAD At <6.1 y old, there were more mechanical complications, more malfunction or occlusion; compared to single-lumen devices, double-lumen devices had more mechanical complications, exit-site or tunnel infections, and malfunction or occlusion. Hematology and oncology 
Device lumens 
Chen et al,47  2020 4405 Systematic reviewb To compare risk associated with PICCs placed in the upper versus the lower extremity in neonates Neonates (<28 d old) requiring PICC placement PICC There was a greater risk of nonelective removals and malposition in PICCs placed in the upper versus lower extremity; there was a lower risk of thrombosis in PICCs placed at the upper extremity. There were no differences in mechanical complications, PICC-related infection, or phlebitis. Insertion location 
Choi et al,48  2017 23 Observationala To determine the safety and accuracy of TIVD placement using ultrasound guidance compared to surgical cutdown Retrospective review of pediatric (0–16 y old) hematology, oncology, and PN patients undergoing TIVD placement TIVD There was no difference using ultrasound guidance in insertion time or complication compared to surgical cutdown. Vessel visualization 
Cooling et al,49  2017 75 Observationala To examine the performance and safety of femoral CVADs Retrospective study of pediatric patients undergoing stem cell collection (median = 3 y old) requiring CVAD placement CVAD Compared to thoracic CVADs, femoral CVADs had fewer flow-related adverse events. Insertion location 
Crocoli et al,50  2015 — CPGb CVADs in pediatric patients with cancer — Midline, PICC, nontunneled CVAD, TIVD, tunneled CVAD, tunneled-cuffed CVAD — Hematology and oncology 
Long-term dependent 
Catheter-to-vein ratio 
Device lumens 
Vessel visualization 
Debourdeau et al,51  2009 — CPGb Prevention of thrombosis associated with central venous catheters in patients with cancer — TIVD, tunneled CVAD — Hematology and oncology 
Device lumens 
Insertion location 
De Carvalho Onofre et al,52  2012 42 RCTc To compare the use of ultrasound and palpation insertion success for PICC placement in pediatric patients Any pediatric patient (1 mo–16 y old) requiring IV therapy for >7 d; randomly assigned to USG PICC insertion or palpation PICC USG PICC insertion was associated with higher first-attempt success rate, better catheter positioning and shorter insertion time. Vessel visualization 
de Souza et al,53  2018 80 RCTc To determine if USG PICC placement led to higher insertion success compared to landmark techniques Critically ill pediatric patients (IQR = 3 mo–1.3 y old) admitted to the PICU requiring PICC insertion via the IJV; randomly assigned to USG or landmark insertion PICC USG PICC insertion was associated with higher overall success rate, first- and third-attempt success rate, lower insertion time, and fewer hematomas and arterial punctures compared to landmark. Vessel visualization 
DeWitt et al,54  2015 180 Observationala To determine procedural success and failure rates in umbilical catheter placement Patients with congenital heart disease <20 h old versus >20 h old requiring an umbilical catheter Umbilical catheter There was a higher success rate for younger patients. General pediatrics 
Dheer et al,55  2011 103 Observationala To compare the rates of immediate insertion-related complications after CVAD placement in pediatric patients Hospitalized children (<12 y old) requiring a CVAD; comparison of complications among neonate versus infant versus >1–12 y old CVAD Neonates were at higher risk of immediate insertion-related complications; more insertion attempts were associated with insertion-related problems. General pediatrics 
Doellman et al,56  2015 — CPGb Specific recommendations regarding central venous catheters that account for the unique needs of pediatric patients — Hemodialysis catheter, PICC, nontunneled CVAD, TIVD, tunneled CVAD — General pediatrics 
Hematology and oncology 
Critical care 
Congenital cardiac 
Long-term dependent 
Catheter-to-vein ratio 
Device lumens 
Vessel visualization 
Dongara et al,57  2017 144 RCTc To compare success and complication rates, cost, and insertion time between PICCs and umbilical catheters inserted in the NICU Patients admitted to the NICU (mean = 34 wk’ gestation) requiring a PICC or umbilical catheter PICC, umbilical catheter There was no difference in success rate, time, and short-term complications between PICCs and umbilical catheters. General pediatrics 
Elser,58  2013 — Clinical reviewa Clinical review of umbilical catheter placement Patients admitted to the NICU requiring an umbilical catheter Umbilical catheter Umbilical catheter malposition or dislodgement is associated with hemorrhaging and death. General pediatrics 
Fallon et al,59  2014 244 Observationala To determine device-related complications in infants requiring a VAD Hospitalized children (0–3 y old) requiring a central venous catheter for prolonged therapy TIVD, tunneled CVAD Infants (≤1 y old) had higher complication rate, higher operative exchange rate, higher infection rate, and shorter duration compared with toddlers (>1 y old). General pediatrics 
Faustino et al,60  2013 101 Observationala To explore the incidence of DVT in PICU patients requiring a central venous catheter Critically ill children (0–17 y old) admitted to the PICU; comparisons made among age (<1 y old versus 1–13 y old versus 13–17 y old) Nontunneled CVAD Compared with infants (<1 y old), PICU patients 13–17 y old had higher odds of DVT. Critical care 
Froehlich et al,61  2009 93 Observationala To determine if CVAD placement using ultrasound guidance increases insertion success and decreases complications after single-center transition to USG insertion techniques Prospective study of critically ill pediatric patients (median = 2.5 y old) admitted to the PICU requiring CVAD placement with USG or landmark techniques CVAD Ultrasound guidance was associated with significantly lower arterial punctures and fewer No. attempts. There was no difference in success rate or insertion time between ultrasound guidance and landmark groups. Vessel visualization 
Frykholm et al,62  2014 — CPGb Specific guidelines for patients requiring central venous catheters regarding vascular approach, ultrasound guidance, and prevention of complications — Dialysis catheters, nontunneled CVAD, PICC, TIVD, tunneled-cuffed CVAD — Long-term dependent 
Device lumens 
Vessel visualization 
Gaballah et al,63  2014 150 Observationala To describe complication rates associated with CVAD placement using ultrasound guidance and fluoroscopic guidance in neonates and infants Retrospective review of critically ill neonates and infants (premature–1 y old) requiring CVAD placement with USG versus fluoroscopic guidance CVAD There was no difference in complication rates. Insertion location 
Vessel visualization 
Gallagher et al,64  2014 168 Observationala To determine if CVAD placement using USG techniques improved insertion success in pediatric ED patients Retrospective study of pediatric (3–15 y old) emergency patients requiring CVAD placement with or without ultrasound guidance CVAD There was higher insertion success when using ultrasound guidance. Vessel visualization 
Gonzalez et al,65  2012 172 Observationala To determine if early placement of TIVDs or tunneled-cuffed CVADs in patients at high risk of thrombosis and infection led to higher surgical complications Retrospective review of children with ALL (4 d–16 y old) at high risk of infection and thrombosis TIVDs, tunneled-cuffed CVADs There was no difference in infection rate between TIVD and tunneled-cuffed CVADs and no difference in rate of infection in single- versus double-lumen devices. Hematology and oncology 
Device lumens 
Gorski et al,66  2016 — CPGb Specific practice recommendations for adult and pediatric patients requiring infusion therapy, including device selection, placement, and complication prevention — Hemodialysis catheters, intraosseous, long PIVC, midline, nontunneled CVAD, PICC, short PIVC, TIVD, tunneled CVAD, umbilical catheter — Critical care 
Congenital cardiac 
Long-term dependent 
Catheter-to-vein ratio 
Device lumens 
Vessel visualization 
Gray et al,67  2012 333 Observationala To identify risk factors for catheter-related DVT in infants <1 y old Hospitalized infants (mean = 34 wk’ gestation) requiring a VAD PICC, tunneled-cuffed CVAD Mean catheter days before DVT diagnosis were shorter for PICCs than for tunneled-cuffed CVADs; higher rates of DVT were in multilumen CVADs; the majority of DVT was in femoral veins. Femoral CVADs were associated with greater DVT rates than jugular or SCV CVADs. There was more DVT in femoral lines than in sapheno-femoral tunneled-cuffed CVADs. Long-term dependent 
Device lumens 
Insertion location 
Gurien et al,68  2016 1134 Observationala To determine the incidence of complications associated with CVAD placement using USG techniques Retrospective, multicenter review of pediatric patients (1.5–12 y old) who underwent CVAD placement with landmark or USG insertion CVAD There was a higher first- attempt success rate using ultrasound guidance but higher risk of hemothorax using ultrasound guidance. Vessel visualization 
Habas et al,69  2018 225 Observationala To determine the complications associated with CVAD placement at the BCV insertion site Retrospective review of pediatric patients (mean = 7 y old) admitted to PICU requiring CVAD placement; BCV insertion site versus all others (femoral, subclavian, jugular) CVAD Compared to other insertion sites, BCV had fewer complications. Insertion location 
Hamed et al,70  2013 300 Observationala To describe insertion success rate and complication rate after delivery of anesthesia to critically ill infants and toddlers Critically ill infants and toddlers (21 d–1.3 y old) requiring emergency surgery Intraosseous Intraosseous access was appropriate for unobtainable peripheral or central access. Critical care 
Hancock-Howard et al,71  2010 60 Observationala To determine the cost-effectiveness of TIVD placement using interventional radiology Retrospective review of pediatric oncology patients undergoing placement of a TIVD using interventional radiology (mean = 7 y old) or surgical cutdown (mean = 4 y old) techniques TIVD Insertion time was shorter and resulted in fewer complications using interventional radiology compared to surgical cutdown. Vessel visualization 
Handrup et al,72  2010 98 Observationala To evaluate the rates of VAD-related complications associated with placement of a TIVD or tunneled-cuffed CVAD Retrospective review of children with ALL (<4–>9 y old) who received a TIVD or tunneled-cuffed CVAD over an 8-y period TIVD, tunneled-cuffed CVAD There was a higher CLABSI rate and nonelective removal for tunneled-cuffed CVAD. Hematology and oncology 
Hanson et al,73  2012 1070 Observationala To investigate the rate of and risk factors for VTE in children with cardiac disease admitted to the PICU Children with cardiac disease (median = 10 mo) admitted to the PICU; comparisons made among <6 mo versus 6 mo–1 y old versus 1–2 y old versus 2–12 y old versus 12–18 y old versus >18 y old CVAD VTE incidence was associated with increasing No. CVAD days. In young children (<6 mo), VTE incidence was significantly higher. Critical care 
Heinrichs et al,74  2013 1076 Systematic reviewb To evaluate assistive technologies, other than ultrasound guidance, in improving PIVC insertion success Seven RCTs of pediatric patients (0–21 y old) requiring PIVC insertion using novel interventions PIVC Transillumination was associated with higher first-attempt success compared to traditional insertion techniques; first-attempt success using NIR and traditional methods was not significantly different. There was no difference in time or No. attempts between insertion methods. Vessel visualization 
Included studies 
Hosokawa, 2010 
Katsogridakis, 2008 
Nager, 1992 
Perry, 2011 
Chapman, 2011 
Kim, 2012 
Maynard, 1989 
Institute for Healthcare Improvement,75  2012 — CPGb Specific recommendations for the prevention of CLABSI — CVAD — Vessel visualization 
IVNNZ,76  2012 — CPGb Specific practice recommendations for adult and pediatric patients requiring infusion therapy, including device selection, placement, and complication prevention — Intraosseous, midline, nontunneled CVAD, PICC, TIVD, tunneled CVAD, umbilical catheter — Critical care 
Long-term dependent 
Device lumens 
Vessel visualization 
Katsogridakis et al,77  2008 240 Observationala To determine if transillumination increases PIVC insertion success in pediatric patients Pediatric patients (mean = 13 y old) with difficult venous access admitted to the ED requiring nonurgent PIVC placement; randomly assigned to with or without transillumination PIVC Insertion using transillumination was associated with higher first- and second-attempt success compared to without transillumination. Vessel visualization 
Kim et al,78  2017 132 RCTc To compare ultrasound guidance to landmark techniques for CVAD insertion in children Pediatric cardiac surgery, neurosurgery, or general surgical patients (1 mo–6 y old) requiring CVAD insertion; randomly assigned to USG insertion to the axillary vein or LM insertion via the SCV CVAD USG + axillary insertion was associated with fewer attempts and shorter insertion time. There was no difference in complication rates. Results were confounded by location and/or imaging. Insertion location 
Vessel visualization 
Kulkarni et al,79  2014 — Systematic reviewb A systematic review of TIVDs and tunneled-cuffed CVADs in adults and children receiving chemotherapy 5 RCTs and 25 observational studies of adults and children undergoing chemotherapy TIVD, tunneled-cuffed CVAD Tunneled CVAD was associated with more infections, noninfectious complications, and device removal. Hematology and oncology 
Kulkarni et al,80  2017 176 Observationala To describe the complications related to VAD insertion in infants with hemophilia Infants (0–2 y old) with hemophilia requiring either a PICC, TIVD, or tunneled CVAD PICC, TIVD, tunneled CVAD TIVDs had the lowest rates of complications. Hematology and oncology 
Lam et al,81  2018 954 Observationala To evaluate the impact of defaulting to single-lumen PICCs Hospitalized adults (mean = 66 y old) requiring PICC placement; comparison of single versus double lumens PICC Single-lumen PICCs were associated with lower complications. Device lumens 
Lamperti et al,82  2012 — CPGb Specific recommendations regarding USG VAD placement — CVAD, PICC — Catheter-to-vein ratio 
Vessel visualization 
Lau and Chamberlain,83  2016 760 Systematic reviewb To examine the safety and efficacy of CVAD insertion using ultrasound guidance A total of 8 RCTs comparing the use of USG and landmark CVAD placement in pediatric patients (<18 y old) CVAD Ultrasound guidance had a higher success rate and fewer No. insertion attempts compared to landmark techniques. Vessel visualization 
Included studies 
Alderson, 1993 
Verghese, 1999 
Verghese, 2000 
Grebenik, 2004 
Chuan, 2005 
Ovezov, 2010 
Aouad, 2010 
Bruzoni, 2013 
Levy et al,84  2010 279 Observationala To determine the rate of and potential risk factors for infectious and noninfectious complication associated with PICCs in pediatric patients Hospitalized children (10 d–21 y old) requiring a PICC PICC Older age was associated with infectious complications. General pediatrics 
Lindquester et al,85  2017 33 Observationala To examine the safety and efficacy of tunneled CVAD placement at the internal and external jugular in neonates and infants <5 kg Multicenter retrospective review of hospitalized infants weighing <5 kg (0–1 y old) with a tunneled CVAD Tunneled CVAD There was no difference in complications associated with jugular and femoral vein insertion locations. Insertion locations 
Loveday et al,86  2014 — CPGb Specific recommendations for the prevention of hospital-acquired infections — PICC, TIVD, tunneled CVAD — Long-term dependent 
Device lumens 
Malbezin et al,87  2013 5435 Observationala To prospectively determine the overall success and complication rate of CVAD insertion over a 22-y period Hospitalized children (mean = 5 y old) requiring any CVAD CVAD Device failure was more likely in children <3 kg. General pediatrics 
Marshall et al,88  2017 19 Observationala To compare transhepatic CVADs to nontunneled CVADs as an alternative for preserving future central venous access Retrospective review of infants (1.8–7.8 mo) with congenital heart disease who underwent placement of 1 or more transhepatic CVADs Nontunneled CVAD, transhepatic CVAD Transhepatic CVAD had a longer duration. There was no difference in thrombi, thrombolytic burden, or catheter sites requiring wound care consultation. There was a higher frequency of infection in transhepatic CVAD. There was no difference in the rate of infection-related removal. Congenital cardiac 
Marquez et al,89  2016 175 Observationala To determine risk factors for thrombosis after placement of nontunneled CVADs in PICU patients Prospective, multicenter study of pediatric patients (4 mo–8.6 y old) admitted to the PICU undergoing CVAD placement Nontunneled CVAD There were higher rates of DVT in patients with right-side nontunneled CVAD placement and insertion at SCV. Insertion location 
May et al,90  2018 912 Observationala To determine the rates of thrombosis, infection, and insertion site symptoms after placement of PICCs and TIVDs in patients with cystic fibrosis Retrospective review of adult and pediatric patents (mean = 7.4 y old) with cystic fibrosis PICC, TIVD Double-lumen PICCs were associated with greater rates of complications. Long-term dependent 
Device lumens 
Menéndez et al,91  2016 256 Observationala To evaluate the incidence and risk factors for PICC-related thrombosis in children Hospitalized children (IQR = 2.4–13 y old) requiring PICC placement PICC A catheter-to-vein ratio of >0.33 predicted PICC-related superficial vein thrombosis and DVT. Catheter-to-vein ratio 
Mermel et al,92  2009 — CPGb Specific recommendations for the prevention of catheter-related infection — CVAD, midline, PICC, PIVC, TIVD — Long-term dependent 
Moon et al,93  2018 629 Observationala To determine risk factors for CLABSI in children with hemato-oncological disease requiring long-term VADs Retrospective review of children with hemato-oncologic disease (median = 6 y old; 14 d–17.9 y old) requiring any long-term CVAD TIVD, tunneled-cuffed CVAD There was no difference in the rate of CLABSI. Hematology and oncology 
Mushtaq et al,94  2018 693 Observationala To determine the safety, specifically rates of CLABSI, mechanical complications, hospital length of stay, readmission within 90 d of discharge, and mortality of midline catheters compared to CVADs in adults admitted to intensive care Adults >18 y old admitted to the ICU or medical-surgical ward with either a CVAD or midline catheter CVAD, midline CVADs were associated with higher rates of CLABSI, crude mortality, readmission, and transfer to the ICU. Midline catheters had more mechanical complications. General pediatrics 
Noailly Charny et al,2  2018 295 Observationala To compare the risk of thrombosis in PICCs and tunneled-cuffed CVADs Children (<18 y old) diagnosed with leukemia who received a PICC or tunneled-cuffed CVAD PICC, tunneled-cuffed CVAD PICCs were associated with an increased risk of thrombosis. Hematology and oncology 
Nifong and McDevitt,95  2011 — Laboratory studya To determine the effect of catheter size of fluid flow rates — PICC Fluid flow rate decreased with increasing catheter size. Catheter-to-vein ratio 
O’Grady et al,96  2011 — CPGb Specific recommendations for the prevention of intravascular catheter-related infections — Midline, nontunneled CVAD, PICC, PIVC, TIVD, tunneled CVAD — Device lumens 
Vessel visualization 
Ohno et al,97  2016 120 Observationala To determine the rates of complications and CLABSI in infants and small infants (<1 y old or <10 kg) compared with children (>1 y old or >10 kg) Children (4 mo–22 y old) requiring a TIVD TIVD Age was not associated with increased risk of complications. General pediatrics 
Oulego-Erroz et al,98  2016 46 Pilot studya To determine if CVAD insertion to the BCV using USG techniques had greater insertion success compared to insertion to the IJV Prospective study of critically ill children (0.6 mo–13 y old) requiring urgent CVAD insertion; nonrandom assignment to BCV + USG or IJV insertion CVAD BCV + ultrasound guidance had a higher first-attempt success rate, fewer insertion attempts, and lower insertion time compared to IJV. There was no difference in overall success rates. Insertion location 
Vessel visualization 
Oulego-Erroz et al,99  2018 500 Observationala To determine if CVAD placement outcomes can be improved by using USG insertion Prospective, multicenter study of all critically ill children (IQR = 2 mo–4.9 y old) requiring temporary CVAD placement using USG or landmark techniques CVAD Ultrasound guidance had a higher first-attempt success rate and fewer puncture attempts and mechanical complications. Vessel visualization 
Pacilli et al,100  2018 18 Observationala To determine the appropriateness of long PIVCs in pediatric patients undergoing surgery Children undergoing surgery (mean = 6.3 y old) requiring long PIVC insertion Long PIVC There were no immediate complications. On day 3, removals were made because of 3 occlusions and 1 red/pain. General pediatrics 
Paladini et al,101  2018 40 Pilot studya To compare the success of USG long PIVC insertion in children admitted to the ED to short PIVCs Children >10 y old (mean = 13 y old) who were admitted to the ED; comparison of blind short PIVC versus USG PIVC insertion Long PIVC, short PIVC Short PIVCs had a shorter dwell time duration and more complications compared to long PIVCs; ultrasound guidance had a lower risk of failure and complications but results confounded. Critical care 
Vessel visualization 
Park et al,102  2016 3832 Systematic reviewb To determine the utility of NIR light devices A total of 11 RCTs of any pediatric patient (<21 y old) undergoing PIVC placement using NIR or no assistive device PIVC There was no overall difference in overall success rate between NIR light device and traditional methods; however, NIR light devices had a higher success rate for subsets deemed high risk of failure. Vessel visualization 
Included studies 
Chapman, 2011 
Perry, 2011 
Kaddoum, 2012 
Kim, 2012 
Cuper, 2013 
Graaff, 2013 
Sun, 2013 
Szmuk, 2013 
Woude, 2013 
Graaff, 2014 
Curtis, 2015 
Pasteur et al,103  2010 — CPGb Specific recommendations for patients with non-CF bronchiectasis — TIVD — Long-term dependent 
Peterson et al,104  2012 1399 Observationala To determine if assistive devices improve PIVC insertion success Hospitalized children (mean = 1 y old) requiring PIVC placement; randomly assigned to unassisted versus assisted (transillumination versus NIR light device–guided) insertion PIVC PIVC insertion success was higher when no assistive device was used compared to assisted methods. Vessel visualization 
Perin and Scarpa,105  2015 — Systematic reviewb To review evidence related to the assessment of catheter-tip positioning in pediatric patients Included 42 pediatric studies examining outcomes for patients undergoing VAD placement using vessel visualization techniques CVAD, PICC, umbilical catheter There was insufficient high-quality evidence to make specific recommendation for use in pediatric patients. Vessel visualization 
Pinon et al,106  2009 915 Observationala To determine the incidence and risk factors of central venous catheter-related complications in pediatric hemato-oncological and immunologic conditions Single-center, prospective study of children (0–19 y old) with oncological, hematologic, or immunologic diseases TIVD, tunneled CVAD Tunneled-cuffed CVADs were associated with more CLABSI; being ≤3 y old was associated with more dislodgements and more tunnel infections; CLABSI was more prevalent in double- versus single-lumen devices. Hematology and oncology 
Device lumens 
Pittiruti et al,107  2009 — CPGb Specific recommendations for CVADs and complication prevention in patients requiring PN — Midline, PICC, PIVC, TIVD, tunneled CVAD — Long-term dependent 
Device lumens 
Vessel visualization 
Polkinghorne et al,108  2013 — CPGb Specific recommendations for vascular access in patients with chronic renal disease — Nontunneled CVAD, tunneled CVAD — Vessel visualization 
Qian et al,109  2014 40 Observationala To examine complication rates in pediatric patients with CF after the placement of a long PIVC Prospective audit of pediatric patients with CF with infective exacerbation Long PIVC Complication rates were high; no serious adverse outcomes were reported. Long-term dependent 
Ramer et al,110  2016 53 RCTc To evaluate the effectiveness of NIR light device technology for PIVC placement in pediatric hematology and oncology patients Pediatric hematology and oncology patients (1–21 y old) requiring PIVC placement; randomly assigned to NIR light device or landmark insertion techniques PIVC NIR light device was associated with faster insertion time and higher satisfaction. Vessel visualization 
Rauth et al,111  2008 138 Observationala To investigate the rate of infection in infants when the venous catheter is exchanged for a tunneled-cuffed CVAD after ECMO decannulation PICU patients (mean = 13 d) requiring CVAD placement after decannulation from ECMO Tunneled-cuffed CVAD Increasing the duration of ECMO and CVAD placement independently predicted CLABSI. Critical care 
Revel-Vilk et al,112  2010d 423 Observationala To determine the rate of catheter-related complications in children undergoing chemotherapy during 12 mo of therapy Single-center, prospective study of pediatric patients (29 d–28 y old) undergoing chemotherapy PICC, tunneled-cuffed CVAD PICCs were associated with a higher risk of DVT; tunneled CVAD had a higher risk of occlusion at 1 y. Hematology and oncology 
Rey et al,113  2009 825 Observationala To identify risk factors for early mechanical complications in CVADs Pediatric patients (median = 22 mo) admitted to the PICU; comparisons among femoral, jugular, and SCV CVAD insertion sites CVAD SCV and jugular vein, as well as increasing No. attempts were associated with significantly more early mechanical complications. Difficult venous access 
Insertion site 
Rivera-Tocancipa et al,114  2018 201 Observationala To describe the incidence of complications associated with USG CVAD insertion in children compared to anatomic landmark techniques All hospitalized children (0–18 y old) requiring CVAD insertion using USG or LM insertion techniques CVAD Ultrasound guidance had fewer immediate complications, no arterial punctures, and higher rates of insertion success compared to landmark techniques. Vessel visualization 
Rosado et al,115  2013 255 Observationala To examine the rate of CVAD-associated infection in PICU patients Prospective, single-center review of children (majority <6 y old) admitted to the PICU requiring a CVAD CVAD CVADs inserted ≥7 d were associated with a higher risk of CLABSI. Critical care 
Rossetti et al,116  2015 309 Observationala To investigate the safety and accuracy of intracavitary ECG-guided insertion in pediatric patients Prospective, multicenter study of hospitalized pediatric patients (1 mo–18 y old) requiring a VAD; insertion using intracavitary ECG versus intracavitary ECG with dedicated ECG monitor compared CVAD, PICC Insertion accuracy was higher with a dedicated ECG monitor. Vessel visualization 
Schiffer et al,117  2013 — CPGb Specific recommendations for central venous catheters in patients with cancer — Nontunneled CVAD, PICC, tunneled CVAD, TIVD — Hematology and oncology 
Vessel visualization 
Sharp et al,118  2015 136 Observationala To identify the optimal ratio cutoff to reduce rates of VTE Prospective study of hospitalized adults (mean = 57 y old) requiring PICC insertion, comparison between ≤45% versus ≥45% catheter-to-vein ratio PICC A >45% ratio was more likely to develop VTE. Catheter-to vein ratio 
Shenep et al,119  2017 90 Observationala To determine the interaction between PN and external central venous devices in increasing risk of complications Rates of complications during PN and non-PN periods in pediatric oncology patients (median = 7.3 y old) requiring central venous devices TIVD, tunneled CVAD Risk of CLABSI was higher during PN for children with TIVDs. Occlusion risk was higher for TIVDs. Complication rates for TIVDs were lower during the non-PN period but similar during the PN period. Long-term dependent 
Sibson et al,120  2018 — CPGb Specific recommendations for preventing thrombosis in pediatric patients with cancer — PICC, PIVC, TIVD, tunneled CVAD — Hematology and oncology 
Sigaut et al,121  2009 359 Systematic reviewb To evaluate the advantages of USG CVAD placement over anatomic landmark techniques in pediatric patients Children (2 d–8 y old) undergoing cardiac surgery requiring CVAD CVAD For ultrasound guidance, no difference in rates of artery puncture, hematoma, hemothorax, pneumothorax, or time to insert was found. Ultrasound guidance had higher success rates for subsets of novice operators and during intraoperative use. Vessel visualization 
Included studies 
Alderson, 1993 
Chuan, 2005 
Verghese, 1999 
Verghese, 2000 
Grabenic, 2004 
Smitherman et al,122  2015 1135 Observationala To determine risk factors for the development of catheter-associated VTE in general hospitalized pediatric patients Chart review of hospitalized children (mean = 8 y old) requiring a VAD PICC Increasing age was related to an increased risk of thrombosis; lumen No. was not associated with thrombosis risk; insertion site (brachial or cephalic, SCV, jugular, or femoral or saphenous) was not associated with an increased risk of thrombosis. General pediatrics 
Device lumens 
Insertion location 
Takeshita et al,123  2015 96 Observationala To examine the factors that affect insertion success for invisible and impalpable peripheral veins in children Pediatric patients (1.1–2.8 y old) with invisible or impalpable veins undergoing elective surgery PIVC PIVC with ultrasound guidance had better success rates compared to PIVC without ultrasound guidance; compared to insertion to the dorsal hand vein, the cephalic vein had a higher success rate and shorter insertion time. Difficult access 
Insertion location 
Vessel visualization 
Takeshita et al,123  2015 196 RCTc To examine the factors that affect insertion success for invisible and impalpable peripheral veins in children Pediatric patients (10–40 mo) with invisible or impalpable veins undergoing elective surgery PIVC Compared to insertion to the dorsal hand or saphenous vein, the cephalic vein had a higher success rate. Insertion location 
The Joint Commission,124  2013 — CPGb Specific recommendations for preventing CLABSI in CVADs — CVAD — Device lumens 
Tripi et al,125  2016 108 Observationala To determine the frequency of PIVC-related dysfunction in pediatric patients Compared PIVC dysfunction in hospitalized children (0–>12 y old) over device durations of 1–2 d versus 2–3 d versus >3 d PIVC Higher rates of PIVC dysfunction were associated with PIVCs in place for >3 d or inserted in lower extremities. General pediatrics 
Troianos et al,126  2011 — CPGb Specific recommendations for VAD placement using ultrasound guidance in pediatric patients — CVAD, PICC, PIVC — Vessel visualization 
Ullman et al,6  2015 31 933 Systematic reviewb To review the incidence of VAD failure in pediatric patients Hospitalized pediatric patients across 74 studies requiring any VAD Hemodialysis catheter, nontunneled CVAD, PICC, TIVD, tunneled CVAD, umbilical catheter Hemodialysis catheters and umbilical catheters had the highest failure rate; TIVDs had the lowest failure rate. General pediatrics 
Ullman et al,1  2017 1027 Observationala To examine the prevalence, management, and associated complications of CVADs in pediatric patients Hospitalized pediatric patients (IQR = 1–12 y old) requiring any VAD Hemodialysis catheter, nontunneled CVAD, PICC, TIVD, tunneled CVAD, umbilical catheter PICCs had higher proportions of CVAD-associated complications in the previous 7 d. General pediatrics 
Unbeck et al,127  2015 2032 Observationala To identify risk factors for PIVC-associated complications in pediatric patients Comparison of hospitalized neonatal versus pediatric patients (0–18 y old) requiring a PIVC PIVC Occlusion was associated with longer dwell time. Neonatal: PIVC survival time was shorter; there was more infiltration. Insertion at the arm bend or ankle was associated with higher rates of infiltration and occlusion. General pediatrics 
Insertion location 
van Gent et al,128  2017 538 Observationala To determine the rates of infection and complications in pediatric hematology, oncology, and stem cell transplant patients Retrospective review of pediatric patients (mean = 7.8 y old) after surgical placement of any CVAD TIVD, tunneled-cuffed CVAD Tunneled-cuffed CVAD had a lower risk of infection. Hematology and oncology 
Vierboom et al,129  2018 232 Observationala To evaluate the safety of tunneled CVAD insertion in children weighing <10 kg Retrospective review of all children (<1 mo–4 y old) receiving surgical insertion of a tunneled CVAD with ultrasound guidance or via surgical cutdown Tunneled CVAD USG insertion was associated with lower mechanical blockages, but there was no difference in intraoperative and postoperative complications, time to insert, or device longevity. Vessel visualization 
Vinograd et al,130  2018 300 Observationala To evaluate PIVC insertion success in patients with difficult venous access using USG techniques Pediatric patients (median = 14 y old) in an ED who had a failed PIVC attempt via traditional insertion techniques PIVC PIVC using USG techniques led to 68% and 87% first- and second-attempt success rates after failed traditional method. Difficult access 
Vessel visualization 
Voigt et al,131  2012 — Systematic reviewb To review the evidence for the use of intraosseous devices in emergent contexts Studies evaluating intraosseous devices in patients requiring emergent vascular access or nonhuman randomized prospective studies Intraosseous Compared to alternative access, there was no difference in complications using intraosseous devices. Critical care 
Wiegering et al,132  2014 43 Observationala To determine the incidence of catheter-related thrombosis in pediatric oncology patients Single-center retrospective review of pediatric oncology patients (mean = 9.4 y old) requiring central venous access TIVD, tunneled-cuffed CVAD TIVDs showed an earlier peak of thrombosis occurrence than that of tunneled-cuffed CVAD catheters; the highest incidence of thrombosis occurred in the SCV, followed by external jugular and cephalic sites. There was no difference in complications between insertion at the left and right side. Hematology and oncology 
Insertion location 
White et al,133  2012 322 Observationala To compare the rate of complications and early removal between TIVDs and tunneled-cuffed CVADs Retrospective review of children (1 mo–19 y old) with ALL requiring a TIVD or a tunneled-cuffed CVAD TIVD, tunneled-cuffed CVAD TIVDs had less complications. Hematology and oncology 
Wragg et al,134  2014 100 Observationala To determine the rate of occlusion associated with tunneled-cuffed CVAD insertion under ultrasound guidance Children (21 d–16 y old) requiring elective or emergency removal of a tunneled-cuffed CVAD Tunneled-cuffed CVAD Complete venous occlusion was associated with younger age. General pediatrics 
Vessel visualization 
Wu et al,135  2013 508 Systematic reviewb To evaluate whether USG CVAD insertion was more successful compared to anatomic landmark techniques Meta-analysis of RCTs comparing USG versus landmark CVAD insertion in pediatric patients (mean = 0.5–<8 y old) CVAD There were few pediatric studies (n = 2), which limited analysis. For ultrasound guidance, there was no reduction in the risk of cannulation failure, arterial puncture, hematoma, pneumothorax, and hemothorax in children or infants. Vessel visualization 
Wyckoff and Sharpe,136  2015 — CPGb Specific recommendations for vascular access in neonates and infants — Midline, PICC, PIVC, TIVD, tunneled CVAD, umbilical catheter — General pediatrics 
Congenital cardiac 
Catheter-to-vein ratio 
Vessel visualization 
Xia et al,137  2016 48 RCTc To determine the efficacy and rate of complications in pediatric patients with moderate-to-severe burn injuries Pediatric patients (mean = 2.2 y old) with moderate-to-severe burn injuries PICC, PIVC There was a higher 1-time puncture success rate, longer retention duration, and more complication for PICCs compared to PIVCs Critical care 
Yacobovich et al,138  2015d 423 Observationala To determine patient- and catheter-related risk factors for CLABSI in children receiving chemotherapy Prospective study of pediatric patients (29 d–28 y old) receiving chemotherapy requiring a VAD PICC, TIVD, tunneled-cuffed CVAD Tunneled-cuffed CVADs and PICCs had a higher risk for CLABSI in the group of diseases with lower rate of infection. In diseases with high rate of infection, there was no difference. Hematology and oncology 
Zanolla et al,139  2018 51 RCTc To determine if USG techniques reduce the No. puncture attempts, procedure time, and complication rates during CVAD insertion via the IJV in children Prospective study of any child (11 mo–9 y old) requiring CVAD insertion via the IJV; randomly assigned to USG versus landmark insertion groups CVAD USG techniques required fewer attempts, took less time, and resulted in fewer complications, compared to landmark techniques. Vessel visualization 
Zengin et al,140  2013 64 Observationala To determine risk factors for CVAD-related complications in children admitted to the ED Retrospective review of pediatric patients (2–16 y old) admitted to the ED Nontunneled CVAD More complications were associated with >3 attempts. Difficult venous access 
Zhou et al,141  2017 281 Observationala To evaluate the feasibility and safety of intracavitary ECG technique in guiding PICC placement in neonates Hospitalized neonates (27–41 wk) requiring PICC placement using landmark techniques or intracavitary ECG guidance PICC Intracavitary ECG-guided PICC placement had a higher correct tip position on the first attempt compared to landmark techniques. Vessel visualization 

ALL, acute lymphoblastic leukemia; ANZICS, Australian and New Zealand Intensive Care Society; ARC, Australian Resuscitation Council; BCV, brachiocephalic vein; CF, Cystic Fibrosis; CNS, Central Nervous System; ECMO, Extracorproeal membrane oxygenation; IJV, internal jugular vein; IQR, interquartile range; IVNNZ, Intravenous Nursing New Zealand Incorporated Society; LM, Landmark; miniMAGIC, Michigan Appropriateness Guide for Intravascular Catheters in Pediatrics; mo, months old; NZRC, New Zealand Resuscitation Council; SCV, subclavian vein; TIVD, totally implantable venous device; VTE, venous thromboembolism; —, not applicable.

a

Low strength of evidence: observational study (with comparator) and other (eg, clinical review or pilot study).

b

High strength of evidence: CPG, systematic review.

c

Moderate strength of evidence: RCT.

d

Same sample.

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