Most hospitalized infants and children require a vascular access device (VAD). These devices, although essential, come with risks. The pediatric-focused version of the Michigan Appropriateness Guide for Intravenous Catheters in pediatrics (miniMAGIC) provides guidance for pediatric hospitalists selecting the most appropriate VAD for specific clinical situations on the basis of what is currently known as well as the experience of experts regarding risks and benefits of various options.1 

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

A common decision point for many hospitalists is whether to place a peripherally inserted central catheter (PICC) in a hospitalized infant or child for a defined duration of peripherally compatible therapy, such as antibiotics. Increasingly, evidence shows that many children with infections who were previously treated with prolonged intravenous antibiotics may be safely and effectively transitioned to oral antibiotics early in a treatment course, thus eliminating the need for prolonged vascular access.24  These studies also highlight risks of PICCs, with the rate of complications, including thrombus, dislodgement, and infection, being as high as 15%.3  However, there remain clinical situations when a prolonged course of intravenous therapy may be necessary.

In general, for hospitalized infants, children, and adolescents, the miniMAGIC panel rated PICC placement as appropriate for peripherally compatible therapy of >14 days’ duration, which aligns with miniMAGIC recommendations for adults (Table 1). The panel was uncertain about PICC placement for peripherally compatible therapy of 8 to 14 days’ duration; however, for therapy <8 days, PICC use was rated as inappropriate. Other options for shorter durations of therapy include peripheral intravenous catheters (PIVCs) and midline catheters. The panel, mindful of the challenges in obtaining and maintaining PIVCs in neonates, opted to include peripherally compatible therapy of >7 days’ duration as an appropriate indication for PICC placement in that population (Table 1).

TABLE 1

Key Points for Pediatric Hospital Medicine

PICC placement for peripherally compatible therapies is generally appropriate for treatment duration >14 d; for neonates, >7 d is appropriate. 
Single-lumen PICCs are adequate for most cases unless multiple noncompatible infusions that cannot be separated in time are necessary. 
A midline catheter is an option for peripherally compatible infusates, but more research is warranted. 
In cases of difficult venous access, escalation to more skilled inserters should be done promptly and after no more than 2 PIVC attempts. 
PICC placement may be considered in children with difficult venous access regardless of treatment duration. 
PICC placement for peripherally compatible therapies is generally appropriate for treatment duration >14 d; for neonates, >7 d is appropriate. 
Single-lumen PICCs are adequate for most cases unless multiple noncompatible infusions that cannot be separated in time are necessary. 
A midline catheter is an option for peripherally compatible infusates, but more research is warranted. 
In cases of difficult venous access, escalation to more skilled inserters should be done promptly and after no more than 2 PIVC attempts. 
PICC placement may be considered in children with difficult venous access regardless of treatment duration. 

When opting to place a PICC, hospitalists have an opportunity to select the number of lumens (Table 1). The miniMAGIC panel rated routine use of a single-lumen device as appropriate unless specific indications for a multiple-lumen device (ie, incompatible infusions) exist. The panel rated it inappropriate to dedicate the lumen(s) for blood transfusion and blood sampling. The indication of dedicating a lumen for lipid and parenteral nutrition was rated as uncertain given the balance of risks of infectious complications from lipids and parenteral nutrition versus those associated with a multilumen device.

The midline catheter is another option for peripherally compatible therapy. Like PICCs, midline catheters are inserted in peripheral veins but end in the proximal portion of the extremity, with the catheter tip located at or near the level of the axilla and distal to the shoulder. In children, midlines are usually placed in the upper arm via the basilic, cephalic, or brachial vein; in neonates, they may be inserted into a scalp vein and threaded into the jugular vein. In adults, midline catheters demonstrate longer durability than PIVCs. Although several pediatric centers have anecdotally reported success with multiple age groups, including infants, a robust body of published evidence evaluating safety and efficacy of midlines in children is missing.

Recommendations around difficult venous access are also relevant to pediatric hospitalists. The panel made a strong statement about limiting the number of PIVC insertion attempts per provider to 2; the panel also rated 0 or 1 attempts before moving to escalation as appropriate. For infants and children with difficult access, this guidance emphasizes the importance of escalating PIVC placement to the best-equipped inserter, both to preserve potential insertion sites and reduce patient distress. The panel also recommended that for children with difficult access, when there are repeated (ie, ≥2) failed PIVC attempts despite escalation to skilled inserters, placement of a PICC is appropriate regardless of need for central access or extended therapy. This guidance may assist the hospitalist in determining if the placement of a PICC for predicted shorter-duration of therapy than the general guidance is warranted.

Recommendations that are particularly relevant to those inserting VADs include guidance on the appropriate insertion site, catheter-to-vessel size, and use of imaging. In agreement with other guidelines, the panel encouraged the use of ultrasound technology to aid the placement of VADs.1  Other vessel visualization technologies do not have evidence supporting routine use in pediatrics. The panel specifically supports ultrasound for PIVC placement in patients with difficult venous access. We note that proper training in ultrasound technology is essential to beneficial use.5 

At some pediatric centers, PICCs are routinely inserted for much shorter durations of therapy than those that are recommended in this guideline. miniMAGIC provides a framework for engaging our partners and collaborating specialists in discussing appropriate indications of PICCs versus PIVCs. When we do use PICCs, our default practice will be to request single-lumen devices unless there is a compelling reason to request multiple lumens.

Dr Shaughnessy participated in the miniMAGIC panel, conceptualized and drafted the initial manuscript, and reviewed and revised the manuscript; Dr Morton participated in the miniMAGIC panel, conceptualized the manuscript, and critically revised the manuscript; Dr Shah conceptualized the manuscript and critically revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

     
  • miniMAGIC

    Michigan Appropriateness Guide for Intravenous Catheters

  •  
  • PICC

    peripherally inserted central catheter

  •  
  • PIVC

    peripheral intravenous catheter

  •  
  • VAD

    vascular access device

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Competing Interests

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

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