Vascular Access in Children with Congenital Heart Defects Ranjit Aiyagari, MD,A David S

Vascular Access in Children With Congenital Heart Defects Ranjit Aiyagari, MD,a David S. Cooper, MD, MPH,b Jeffrey P. Jacobs, MDc WHY THE MICHIGAN APPROPRIATENESS Simultaneously accounting for all of these KEY RECOMMENDATIONS FROM GUIDE FOR INTRAVENOUS CATHETERS IN factors can result in an incomprehensible MINIMAGIC PEDIATRICS MATTERS FOR CARDIOLOGY morass. Through the Michigan AND CARDIAC SURGERY PRACTICE In neonates and infants who require Appropriateness Guide for Intravenous vascular access, it is critical to choose Vascular access in pediatric cardiac Catheters in pediatrics (miniMAGIC), we devices and insertion sites that patients is an inherently complex topic. have employed the use of an expert panel minimize the likelihood of long-term Many clinicians struggle to understand and the RAND Corporation and vessel damage, thrombosis, and the “plumbing,” let alone the implications University of California, Los Angeles occlusion. that particular cardiovascular anatomic appropriateness methodology (which is and physiologic derangements and our similar to the approach that was used in For children with complex congenital strategies of palliation have for children, the development of the Michigan heart disease, it is important to both for the present and the future. Each Appropriateness Guide for Intravenous understand the long-term trajectory of choice a clinician makes regarding where Catheters)1 in an attempt to distil the their palliation strategy (ie, functionally and how to place a vascular access multitude of patient-, catheter-, and univentricular physiology versus device (VAD), the length and diameter condition-related factors into biventricular circulation) as well as of the catheter, the surveillance and a reasonable and straightforward their stage of palliation if functionally maintenance practices for the catheter, framework. miniMAGIC2 provides univentricular. For example, such the duration the catheter is left a starting point for the multidisciplinary understanding is critical in deciding indwelling, the types of therapies discussions that necessarily precede the whether to place a peripherally administered through the catheter, the individualized decisions surrounding inserted central catheter in the arm or blood sampled through the catheter, and vascular access in the congenital cardiac the leg of an infant or whether to place thedecisiontoremovethecathetercan population. These recommendations do a femoral or jugular short-term central have major implications for a child’s not necessarily reflect policy of the venous access device (CVAD) in the future candidacy for additional American Academy of Pediatrics operating room before cardiac surgery. catheterization and surgery. (Table 1). In general, a strategy that preserves aDivision of Pediatric Cardiology, Department of Pediatrics, Medical School, University of Michigan, Ann Arbor, Michigan; bDepartment of Pediatrics, College of Medicine, University of Cincinnati and Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; and cSouthern Thoracic Surgical Association, Chicago, Illinois All authors drafted the manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work. DOI: https://doi.org/10.1542/peds.2019-3474N Address correspondence to Ranjit Aiyagari, MD, Division of Pediatric Cardiology, C.S. Mott Children’s Hospital, 1540 E Hospital Dr, Ann Arbor, MI 48109- 4204. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2020 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: Supported by grants from the Association for Vascular Access Foundation, Griffith University, and the University of Michigan. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose. The guidelines/recommendations in this article are not American Academy of Pediatrics policy, and publication herein does not imply endorsement. Downloaded from www.aappublications.org/news by guest on September 30, 2021 SUPPLEMENT ARTICLE PEDIATRICS Volume 145, number s3, June 2020:e20193474N the patency of upper extremity Today, with the availability and decision support (displaying the veins for patients with functionally extremely high quality of vascular relevant tables in the electronic health univentricular physiology undergoing ultrasound machines, we have record system as adjunctive staged palliation is paramount. a need to modernize and use them information to the ordering clinician intraprocedurally when it is and posting these protocols on the Patients undergoing biventricular feasible to do so. Internet so that they can be accessed repair generally have fewer risks at the bedside from mobile devices) to associated with upper extremity At many centers, special effort is bring the knowledge to the bedside. catheters, and the known issues of made to place a central umbilical fl thrombosis and infection inherent to venous catheter (under uoroscopic femoral VADs should be taken into guidance, if necessary) in the ACKNOWLEDGMENTS 3 account. In patients who require future neonate prenatally diagnosed with We thank Vineet Chopra, Amanda cardiac catheterization through femoral a functionally univentricular heart Ullman, and the entire miniMAGIC fi veins, these vessels should be within the rst 24 hours after birth panel, from whom we learned preserved when possible (eg, patients to postpone the use of femoral a tremendous amount during the with Tetralogy of Fallot with pulmonary CVADs and peripherally inserted process of creating and disseminating atresia and patients receiving cardiac central catheters in these patients. these guidelines. transplant who will need multiple We necessarily left many choices endomyocardial biopsies). in the table as uncertain. This ABBREVIATIONS Although data on many unusual routes underscores the importance of access (ie, intracardiac and of having multidisciplinary CVAD: central venous access transthoracic, umbilical, transhepatic, discussions between cardiologists, device and translumbar routes) are sparse, surgeons, nurses, anesthesiologists, miniMAGIC: Michigan these routes should be considered as radiologists, and other allied health Appropriateness options. In particular, the umbilical vein professionals when trying to balance Guide for Intravenous can provide a free CVAD route for risks and benefits for an individual Catheters in pediatrics neonates requiring several days of patient for whom there is no clear VAD: vascular access device central access without jeopardizing any correct answer for VAD selection. longer-term access sites, but care must Finally, recommendations do be taken to ensure such catheters not particularly help when REFERENCES remain central and to remove them they only exist in the electronic 1. Chopra V, Flanders SA, Saint S, promptly when they are no longer ether; we plan to employ et al; Michigan Appropriateness needed. Similarly, the use of both low-technology decision transthoracic intracardiac right atrial or Guide for Intravenous support (printing out the common atrial lines can help preserve Catheters (MAGIC) Panel. The Michigan relevant tables and mounting both upper and lower extremity veins. Appropriateness Guide for Intravenous them to our clipboards for easy Catheters (MAGIC): results from Vessel visualization with ultrasound viewing) and high-technology a multispecialty panel using the RAND/ should be employed whenever UCLA Appropriateness Method. Ann Intern Med. 2015;163(suppl 6):S1–S40 achievable to minimize vessel trauma TABLE 1 Key Points for Pediatric Cardiology and the number of access attempts. and Cardiac Surgery Practice 2. Ullman AJ, Bernstein SJ, Brown E, et al. Key Points The Michigan Appropriateness Guide for It is usually inappropriate to dedicate Intravenous Catheters in pediatrics: additional lumens of a central venous Understand the cardiac diagnosis and strategy miniMAGIC. Pediatrics. 2020;145(suppl 3): of palliation or treatment fully before line for blood sampling because of the e20193474I risks posed by additional lumens.4 deciding what VAD to place and where to place it 3. Aiyagari R, Song JY, Donohue JE, Totally implantable venous devices Choose devices and sites that minimize long- Yu S, Gaies MG. Central venous catheter- do not have much of a role in the term vessel damage associated complications in infants with Use intraprocedural vascular ultrasound congenital cardiac population. single ventricle: comparison of umbilical anytime it is feasible and femoral venous access routes. Minimize number of VAD lumens and do not Pediatr Crit Care Med. 2012;13(5):549–553 IMPLICATIONS FOR PRACTICE dedicate lumens for blood draws Do not forget about unusual or nonstandard 4. Bozaan D, Skicki D, Brancaccio A, et al. Many of us who trained in earlier routes of access Less lumens-less risk: a pilot intervention eras became accustomed to Avoid placing an upper extremity CVAD in to increase the use of single-lumen placing peripheral and central patients with functionally univentricular peripherally inserted central catheters. VADs using landmark techniques. physiology, especially in neonates and infants JHospMed. 2019;14(1):42–46 Downloaded from www.aappublications.org/news by guest on September 30, 2021 PEDIATRICS Volume 145, number s3, June 2020 S295 Vascular Access in Children With Congenital Heart Defects Ranjit Aiyagari,

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