Venous Access In Children Research Articles

The pediatric DAV-expert algorithm: A GAVeCeLT/GAVePed consensus for the choice of the most appropriate venous access device in children

In pediatric patients, the choice of the venous access device currently relies upon the operator’s experience and preference and on the local availability of specific resources and technologies. Though, considering the limited options for venous access in children if compared to adults, such clinical choice has a great critical relevance and should preferably be based on the best available evidence. Though some algorithms have been published over the last 5 years, none of them seems fully satisfactory and useful in clinical practice. Thus, the GAVePed—which is the pediatric interest group of the most important Italian group on venous access, GAVeCeLT—has developed a national consensus about the choice of the venous access device in children. After a systematic review of the available evidence, the panel of the consensus (which included Italian experts with documented competence in this area) has provided structured recommendations answering 10 key questions regarding the choice of venous access both in emergency and in elective situations, both in the hospitalized and in the non-hospitalized child. Only statements reaching a complete agreement were included in the final recommendations. All recommendations were also structured as a simple visual algorithm, so as to be easily translated into clinical practice.

Bedside placement of tunneled femorally inserted central catheters in pediatric patients on extracorporeal life support: A case series and discussion.

Pediatric patients requiring extracorporeal life support (ECLS) often need central venous access for extended periods of time. In this population, the placement of an upper extremity peripherally inserted central catheter (PICC) can be challenging due to the location and size of the venous ECLS cannula. Bedside placement of a tunneled femorally inserted central catheters (T-FICC) can be a viable alternative to a traditional PICC. In this case series we present five children who were on ECLS and had a T-FICC placed at the bedside. In this series of five patients we successfully placed T-FICCs while the patients were on ECLS. The T-FICCs dwelled from 15 to 182 days. There were no events of central line associated blood stream infections or deep vein thrombosis. There was only one unintentional line dislodgement noted. The use of T-FICCs placed at the bedside is a safe and reliable alternative for secure long-term venous access in children who are on ECLS.

Objective and subjective barriers to the effective pediatric iron deficiency anemia control: results of questionnaire assessment of pediatricians and parents

Background. Iron deficiency anemia (IDA) remains a pressing pediatric issue to date. Despite the availability of clinical guidelines and other publications that highlight the objective causes for the lack of effectiveness of treatment and prevention of IDA in children, the subjective reasons are unrenowned.Objective. The aim of the study is to evaluate health beliefs of pediatricians and parents on the problem of anemia in children to investigation into the objective and subjective causes for inadequate control of iron deficiency conditions in childhood.Materials and methods. In September 2022, single-step parallel survey of pediatricians and parents on the problem of IDA in children was conducted by random sampling technique using original questionnaires. The questions were formulated on five topics and related to a common understanding of the term “anemia”; priority reference sources; availability of diagnosis of IDA in medical institutions (MI); the position of pediatricians and parents on the treatment and prevention of IDA in children. Based on the results, the main subjective and objective barriers to the control of IDA in children are identified. The χ2 method was used for the comparative evaluation of the responses. The differences were considered significant at statistical significance of p < 0.05.Results. Pediatricians (n = 81) and parents (n = 363) from 23 members of the Russian Federation took the survey. Among the objective barriers to the IDA control in children, the low availability of serum ferritin in MI, difficulties of venous access in children, a shortage of a range of iron preparations for children on Russian market were revealed. The subjective barriers were the skepticism of pediatricians and parents about the necessity for conservative prevention of IDA; poor knowledge of the criteria for diagnosis IDA and completion of IDA therapy by pediatricians; insufficient independence and selectivity of pediatricians when prescribing iron preparations; orientation of the majority of parents (93.7%) to the opinion of doctors, along with the actual rarity of full-fledged conversations with a pediatrician (16.3%).Conclusion. The main limitation of this study was the random sample method inclusion of respondents due to the impossibility of conducting a full-fledged population study. Elimination of the revealed subjective and objective factors can contribute to improving the detection of IDA in children, early appointment and higher effectiveness of treatment, reducing the frequency of disease recurrences, as well as increasing the confidence of parents in pediatricians.

Central venous access in children: Placement trends over the last decade

PurposeTo evaluate central venous access placement trends for radiology and non-radiology services over the last decade. Materials and methodsChildren who had central venous access procedures included in a large administrative database of 49 pediatric institutions in the United States between 2010 and 2020 were included. Patient demographics and patient specific factors were compared between groups. The percentage of procedures performed by interventional radiology (IR) and non-radiology services were compared over time and by region. ResultsA total of 483,181 vascular access encounters were recorded (45.3% female; median age 2 years (IQR 0–11 years)). Approximately one quarter of vascular access encounters were IR-led, with a slight increase of 3.8% between 2010 and 2020. Children who underwent IR-placed vascular access were older (median age of 4 years compared to 1 year in non-radiology encounters). Interventional radiology-placed access was greatest in the Midwest (33.5%) with a decrease of 5.9% over the study period; in the other three regions, IR-performed encounters increased. Patient comorbidities more prevalent in the IR encounters were technology dependence (42.4% of all radiology encounters), gastrointestinal (34.9%), respiratory (20.8%), and transplant (8.1%), while those which were more prevalent in the non-radiology encounters were nephrology/urology (21.4% of all non-radiology encounters), prematurity/neonatal (17.3%), and malignancy (17.3%). ConclusionsInterventional radiology-provided vascular access services have slightly increased over the last decade without significant service-line transfer to other specialties. Underlying comorbidities in IR-led vascular access encounters vary across institutions based on referral patterns, possibly reflecting the adoption of ultrasound guidance by other pediatric subspecialties.

Ultrasound-guided placement of long peripheral cannula in children with cystic fibrosis.

BackgroundThe natural history of cystic fibrosis (CF) lung disease is a chronic deterioration of lung function with intermittent episodes of pulmonary infectious exacerbations (PExs). Reliable venous access is a milestone of effective management of such exacerbations, managed both in hospital and outpatient chronic therapy. The aim of our study was to analyze the feasibility of ultrasound‐guided positioning of long peripheral catheters (LPC) as reliable midterm venous access in children affected by CF.MethodsIn this single‐center prospective study, over a 60‐month period, we included paediatric CF subjects admitted with PExs and undergoing intravenous antibiotic treatment. LPCs were inserted in all participants by paediatric anaesthesiologists with ultrasound guide technique. Prospective data were collected assessing catheter positioning procedure and complications.ResultsA total of 122 LPC insertions were performed in 55 CF children. Participants had a median age of 6.75 years (interquatile range: 3.7−13.5) at the time of catheter insertion. Implantation was successful on the first attempt in 86% of cases; 2 (1%) major insertion‐related complications were reported. Eighty‐eight percent of catheters were electively removed at the end of antibiotic therapy without any complication. Seven percent of the catheters were removed electively for occlusion and 2% for local dislodgment.ConclusionsThe results of the present study suggest that ultrasound‐guided positioning of LPCs are safe alternative means of peripheral venous access in children with chronic diseases such as CF.

Comparison Between Open and Ultrasonography Guided Venous Access Ports in Children with Malignancy

Background: Long-term central venous access is used in children for various reasons specially for delivering chemotherapy. Since vessels in children have smaller diameters, they are more prone to injury and complications such as thrombosis. Different methods are used for implantation of port-a-cath in children. We aimed to compare the complications of insertion of central venous access ports between two methods of open and ultrasound (US) guided. Methods: All children who were referred to pediatric surgery department of a children hospital from April 2018 to March 2020 for implantation of port-a-cath were included. Right jugular vein was the target vein and patients were randomly divided between two methods of insertion of open lateral neck exploration and ultrasound real-time guided percutaneous insertion and the reservoir was fixed in subpectoral fascia pouch. All open cases in which jugular vein was ligated proximally were excluded. Patients were followed up for early and late complications two days and one week later by the surgical team, then monthly by a trained nurse and were referred to the surgeon if any complication or malfunction had occurred for at least 6 months. Results: We included 76 patients (21 girls and 55 boys) less than 18 years of age: 24 patients with ultrasound guided method (1-13 years, median 3 years) and 52 patients with open exploration method (4 months-17 years, median 6 years). We observed no statistically significant difference between two groups with respect to sex, underlying disease, and complications. Most patients had hematological malignancies including ALL (52.9%), AML (19.1%) and the rest had solid organ malignancies. Early complications were observed in 2 (3.8%) in the open and 1 (4.2%) in the US- guided group (P=1). Late complications were observed in 9 (17.3%) patients in the open group and 1 (4.2%) in the US guided group. Infection was observed in 9.6% and malfunction in 5.8% of the open group leading to earlier removal of the catheter. There was not any complication indicative of infection in the US-guided group. Conclusion: US-guided method can be suggested for routine use as a safe method of insertion of port venous access in children.

Randomized, Controlled Clinical Study on the Use of Noninvasive (Near-Infrared Light) Technology Compared with the Conventional Technique for Peripheral Venous Access Puncture in Pediatrics

Highlights Abstract Background: Obtaining peripheral venous access, especially in children, is usually a challenging procedure for nursing professionals. In pediatric patients this is because of the small caliber of the vessels, deep localization in the tissue, and multiple previous attempts of venipuncture. This experiment compared the success in obtaining venous access in pediatric patients with the use of near-infrared light and with the conventional technique. Method: True experiment, developed in a large private general hospital and a public general hospital under the same management. The study included children aged 0 to 6 y (including newborns and pediatric patients up to 5 y, 11 mo and 29 d) under clinical or surgical treatment, undergoing peripheral venous puncture both for laboratory test collection and for infusion of medications and solutions. A total of 144 punctures were analyzed, 51.4% with the conventional technique and 48.6% using the device with near-infrared light. Results: The success for the conventional technique was 89.2%, and 97.1% on the technique with near-infrared light, P = 0.098, with no evidence of significant differences. Conclusion: The success rate for obtaining peripheral venous access in children was similar in the study groups. This study expands the knowledge about the success in the peripheral venous puncture by considering that this is not exclusively related to the use of supportive technologies.

WITHDRAWN: Response to the Letter to the Editor: Concerning the Article “Open vs ultrasound guided tunnelled central venous access in children: A randomised controlled study”

WITHDRAWN: Response to the Letter to the Editor: Concerning the Article “Open vs ultrasound guided tunnelled central venous access in children: A randomised controlled study”

Central Venous Access in Children: Technique and Complications

Children with complex diseases often need central venous catheter, not only for intraoperative use, but also for parenteral nutrition, multiple blood draw due to lab examination and to administer drugs that cannot be given via peripheral lines. Whereas the landmark driven vascular access was teached for years, nowadays the routine use of ultrasound based techniques can be called the gold standard. This article highlights standard locations for central venous access like cannulation of the internal jugular vein as well as novel alternatives such as the cannulation of the brachiocephalic vein. The correct insertion depth of central lines is essential to avoid serious complications. Several different formulas are available and can be used. Independent of the used formula, you have to make sure that complications due to incorrect depth of central venous line are a topic of the past. Finally, important tips and tricks to avoid failure and serious complications are discussed.

Management of Central Venous Access in Children With Intestinal Failure: A Position Paper From the NASPGHAN Intestinal Rehabilitation Special Interest Group.

Intestinal failure requires the placement and maintenance of a long-term central venous catheter for the provision of fluids and/or nutrients. Complications associated with this access contribute to significant morbidity and mortality, while the loss of access is an increasingly common reason for intestinal transplant referral. As more emphasis has been placed on the prevention of central line-associated bloodstream infections and new technologies have developed, care for central lines has improved; however, because care has evolved independently in local centers, care of central venous access varies significantly in this vulnerable population. The present position paper from the Intestinal Failure Special Interest Group of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) reviews current evidence and provides recommendations for central line management in children with intestinal failure.

Open Versus Ultrasound Guided Tunneled Central Venous Access in children: A Randomized Controlled Study

BackgroundThe purpose of this study was to compare open insertion to ultrasound guided percutaneous insertion of central access catheters performed in a tertiary pediatric hospital in terms of its safety and complication rates. MethodsThis was an ethics approved prospective randomized trial of children under 16 y of age. Procedure was performed by surgeons with varying experience with percutaneous and open insertion. Primary outcome studied was complications-immediate and late. Secondary outcomes were time taken to complete procedure, conversion rates, duration of line use. ResultsA total of 108 patients were analyzed. Sixty-four were male. Right internal jugular vein was accessed in 97. Eighty-one lines were double lumen, 23 implantable access devices, and the rest were single lumen catheters. More than one needle puncture was needed in 22% of the cases but there were no conversions in the ultrasound group. Twelve patients needed more than one insertion to achieve optimal position of the tip. Eleven patients had immediate and late complications. Percutaneous lines lasted 45 d longer though this was not statistically significant. Operating time was 20.6% shorter with percutaneous access. Post-removal measurement of vein size by ultrasound demonstrated significant decrease in size in the open group. ConclusionsUltrasound guided percutaneous insertion was safe. The study also demonstrated a decrease in operating times, preservation of vein size, and no increase in complication rates in the US group when performed by operators of varying expertise.

Difficult Peripheral Venous Access in Children: An International Survey and Critical Appraisal of Assessment Tools and Escalation Pathways.

Peripheral venous cannulation is considered a routine procedure, yet 50% of first attempt insertions fail, necessitating repeat insertion attempts. Identification of children with difficult intravenous access (DIVA) can help promote prompt escalation to an appropriately skilled clinician. To describe current international practice regarding the identification and management of children with DIVA, and to systematically review clinical tools and clinical pathways for children with DIVA. A cross-sectional, international survey; followed by a systematic review and critical appraisal of clinical pathways using the Appraisal of Guidelines for Research Evaluation (AGREE) II checklist. A total of 148 clinicians from eight countries completed the survey. The majority were nurses (n = 92; 62%), practicing as vascular access specialists (n = 27; 18%). Twenty-three respondents (16%) reported using a DIVA tool, of which the DIVA Score was most common (n = 5; 22%). Five clinical pathways were identified from the survey and review. Based on the AGREE II domains, pathways generally scored well for scope and purpose, and for clarity of presentation areas. Information on the rigor of development and editorial independence was infrequently detailed. Based on AGREE II findings, one pathway was recommended for clinical practice, and four were recommended for use with modification. Resources for the identification and escalation of children with DIVA are not standardized or consistently used. Further work is needed to streamline processes for DIVA identification and escalation to the appropriate clinician, with technology-assisted insertion capability. This will enhance patient experiences and reduce harm from multiple insertion attempts. Multiple failed insertion attempts come at great cost to the child, family, and healthcare service. Early identification and management of the child with DIVA can ensure prompt escalation and management, improving the patient and family experience.

Effect of Adding a Pediatric Vascular Access Team Component to a Pediatric Peripheral Vascular Access Algorithm

Intravenous (IV) placement outcomes in pediatric patients need to be improved. The purpose of the study was to examine if a pediatric peripheral vascular access algorithm with a pediatric vascular access team (PPVAA-VAT) improved IV placement outcomes compared with Pediatric Peripheral Vascular Access Algorithm (PPVAA)-alone use. This study was a prospective, comparative, two-group design of hospitalized children. Multivariable logistic regression models were used to evaluate differences between cohort outcomes. The PPVAA-alone IV attempts (n = 302) were followed by PPVAA-VAT attempts (n = 294). First attempt and overall IV success were higher in the PPVAA-VAT group after adjusting for confounding patient characteristics (p<.001 and p = .002, respectively). The IV attempts and staff required per encounter decreased in the PPVAA-VAT vs. PPVAA-alone group. The PPVAA-VAT group had greater first attempt and overall IV success, and was more likely to have fewer attempts and staff involved in IV access encounters.

P089 Early life risk factors for predicting difficult central venous access in children with cystic fibrosis

P089 Early life risk factors for predicting difficult central venous access in children with cystic fibrosis

Evidence-Based Strategies and Recommendations for Preservation of Central Venous Access in Children.

Children with chronic illness often require prolonged or repeated venous access. They remain at high risk for venous catheter-related complications (high-risk patients), which largely derive from elective decisions during catheter insertion and continuing care. These complications result in progressive loss of the venous capital (patent and compliant venous pathways) necessary for delivery of life-preserving therapies. A nonstandardized, episodic, isolated approach to venous care in these high-need, high-cost patients is too often the norm, imposing a disproportionate burden on affected persons and escalating costs. This state-of-the-art review identifies known failure points in the current systems of venous care, details the elements of an individualized plan of care, and emphasizes a patient-centered, multidisciplinary, collaborative, and evidence-based approach to care in these vulnerable populations. These guidelines are intended to enable every practitioner in every practice to deliver better care and better outcomes to these patients through awareness of critical issues, anticipatory attention to meaningful components of care, and appropriate consultation or referral when necessary.

Cateter Central de Inserção Periférica em Oncologia Pediátrica: um Estudo Retrospectivo

Introdução: A obtenção de um acesso venoso em crianças e adolescentes com câncer é um desafio para os enfermeiros. O cateter central de inserção periférica (PICC) tem sido utilizado como uma alternativa para obtenção de um acesso venoso duradouro, confiável e seguro na Oncologia Pediátrica. Objetivos: Identificar o perfil das crianças e adolescentes com indicação do uso de PICC, elencar os motivos de remoção e o tempo de permanência do cateter durante o tratamento oncológico. Método: Estudo quantitativo, descritivo e retrospectivo, que utilizou como técnica de pesquisa a análise documental, por meio de prontuários e registros institucionais. A amostra foi constituída por 51 prontuários nos quais constam registros de cateteres inseridos no período de 2012 a 2016. Resultados: Pacientes do sexo masculino corresponderam a 66,6% dos registros, sendo a faixa etária prevalente entre 4 e 9 anos (30,7%). Os diagnósticos mais frequentes foram de leucemias (41%) e linfomas (25,6%), com tempo de diagnóstico no momento da inserção do PICC menor que um mês (51,9%). Os motivos de remoção do PICC foram o término do tratamento (45%), infecções (17,6%), tração do acidental (15,6%), obstrução (11,7%) óbito do paciente (5,8%) e ruptura do cateter (3,9%). O tempo médio de permanência foi de 145 dias. Conclusão: Os dados apontam que a maior parte das remoções do PICC foi por motivos eletivos; ou seja, decorrentes do término da terapêutica intravenosa, além de uma alta taxa de permanência do cateter. O PICC mostrou ser uma importante opção para terapia intravenosa em Oncologia Pediátrica.

Ultrasound guidance improves safety and efficiency of central line placements

BackgroundUse of ultrasound-guidance for central venous access in adults is the standard of care. There is, however, less clarity in the role of routine ultrasound use in obtaining venous access in children. We sought to evaluate safety and efficiency of the placement of central lines utilizing an ultrasound-guided approach compared to the traditional, landmark approach in pediatric patients. Study designA single-institution retrospective chart review, using CPT codes, was performed for all tunneled central venous catheters in children between 2005 and 2017 by the same pediatric surgery group. During the study period, a practice change occurred from exclusively landmark-based line placement to ultrasound-guided line placement. Groups were divided into three phases: a traditional/landmark era (Phase 1), transitional period (Phase 2), and the ultrasound era (Phase 3). The primary outcomes analyzed were postoperative chest tube insertions and operative time. ResultsA total of 2010 tunneled central lines were included for analysis: Phase 1 (N = 930), Phase 2 (N = 313) and Phase 3 (N = 767). Venous access for chemotherapy was the most common indication (29%). Phase 1 had a chest tube placement rate of 9.7/1000 procedures, while Phase 2 had a rate of 6.4/1000 procedures, and Phase 3 had no chest tube insertions (p = 0.009). Phase 1 had longer OR times compared to Phase 2 (57 vs. 49, p = 0.0026) and Phase 3 (57 vs. 46 min, p < 0.001). ConclusionsThis study represents the largest analysis of ultrasound-guided access for children. A complete practice transition to the ultrasound-guided approach was feasible within a two-year period. The ultrasound-guided approach had a shorter operative time and less chest tube insertions than the traditional, landmark technique in children.Level III evidence.

Arteriovenous shunts as venous access in children with haemophilia.

Venous access is essential in patients with haemophilia for administration of factor concentrates. Peripheral venipuncture may be challenging, particularly in young children or during immune tolerance induction (ITI). Central venous access devices (CVADs) carry a significant risk for complications. An alternative for venous access is peripheral arteriovenous shunts (AVSs), but there is sparse documentation in the literature. The aim of this study was to document our experience with AVS over 12years in 27 boys with severe haemophilia. For AVS creation, a subcutaneous vein is connected end-to-side with an artery at the wrist (Cimino) or at the forearm (Gracz shunt). Factor concentrates were substituted as for intermediate size surgery. To prevent shunt occlusion, heparin (5units/kg/h) was given during the first 3days. Indications for AVS creation were prophylaxis start (n=20) and ITI (n=7). Age at shunt insertion was median 1.5years (minimum 8months; maximum 11.7years). Shunt maturation was achieved within a median of 3weeks after surgery (1.5weeks; 18weeks). Age when home treatment was established was median 2.1years (9months; 11.7years). Four patients required AVS revisions due to stenosis, but 26 of 27 patients (96%) achieved good long-term shunt function. There were few other complications. Arteriovenous shunts provide a good alternative to CVAD and carry a lower risk of complications. AVSs allow earlier start of prophylaxis and home therapy with an improved quality of life for patients and families.

How useful is ultrasound guidance for internal jugular venous access in children?

The aim of this study was to determine whether US reduces number of puncture attempts, procedure time, and complication rate during IJV access in children. A prospective study was performed in children (age ≤18years) admitted to our institution, from September 2013 to July 2014, with indications for central venous access. Patients meeting the inclusion criteria were randomized to the US-guided or control groups. The same physician performed all IJV cannulations in both groups. The end-points for comparison were: length of time to venous access, number of attempts, and rate of complications. Fifty-one patients were included: 23 in the US-guided group and 28 in the control group. There were no between-group differences in weight, age, or sex. In the US-guided group, the number of punctures needed to achieve IJV access (median [interquartile range], 3 [2-5] vs. 1 [1, 2]; P<0.001), time to achievement of venous access, and complication rate (39% vs. 4.3%, P<0.009) were significantly lower. US guidance is a useful adjunct to central venous access in children, facilitating the procedure, decreasing time to cannulation, and increasing safety. Prospective randomized study. 1.

Central venous access in children: indications, devices, and risks.

Central venous catheters (CVCs) have a prominent role in the diagnostic and therapy of neonates and children. Herein, we describe the multiple indications for CVC use and the different devices available for central venous access. Given the prevalent use of CVCs, healthcare systems are focused on reducing complications from their use, particularly central line-associated bloodstream infections (CLABSIs). The most up-to-date information available sheds light on best practices and future areas of investigation. Large systematic reviews of randomized trials suggest that ultrasound guidance for placement of CVCs in children is safer than using blind technique, at least for internal jugular vein access. Appropriate catheter tip placement is associated with decreased complications. Furthermore, the prophylactic use of ethanol lock between cycles of parenteral nutrition administration has reduced the rates of CLABSI. A recent randomized trial in pediatric CVCs showed a benefit with antibiotic-coated CVCs. Based on the available evidence, multiple techniques for CVC placement are still valid, including the landmark technique based on practitioner experience, but ultrasound guidance has been shown to decrease complications from line placement. Adherence to CVC care protocols is essential in reducing infectious complications.