the michigan appropriateness guide for …...the majority of all hospitalized children require...

The Michigan Appropriateness Guidefor Intravenous Catheters inPediatrics: miniMAGICAmanda J. Ullman, RN, PhD,a,b,c Steven J. Bernstein, MD, MPH,d,e Erin Brown, PhD,a,f Ranjit Aiyagari, MD, FACC,g

Darcy Doellman, MSN, RN, CRNI, VA-BC,g E. Vincent S. Faustino, MD, MHS,h,i Beth Gore, PhD,j

Jeffrey P. Jacobs, MD, FACS, FACC, FCCP,k Julie Jaffray, MD,l Tricia Kleidon, RN, MNursPrac,a,c

Prashant V. Mahajan, MD, MPH, MBA,m Craig A. McBride, FRACS,a,c,f Kayce Morton, DO,n Stephanie Pitts, MSN, RN, CPN, VA-BC,o,p

Elizabeth Prentice, MBBS, FANZCA,q Douglas C. Rivard, DO,r,s Erin Shaughnessy, MD, MSHCM,t Marc Stranz, PharmD,u

Joshua Wolf, MBBS, PhD, FRACP,v,w David S. Cooper, MD, MPH,x Marie Cooke, RN, PhD,a,b Claire M. Rickard, RN, PhD,a,b

Vineet Chopra, MD, MScd,y

abstractOBJECTIVES: Vascular access device decision-making for pediatric patients remains a complex, highly variable process. To date,evidence-based criteria to inform these choices do not exist. The objective of the Michigan Appropriateness Guide for IntravenousCatheters in pediatrics (miniMAGIC) was to provide guidance on device selection, device characteristics, and insertion techniquefor clinicians, balancing and contextualizing evidence with current practice through a multidisciplinary panel of experts.

METHODS: The RAND Corporation and University of California, Los Angeles Appropriateness Method was used todevelop miniMAGIC, which included the following sequential phases: definition of scope and key terms, informationsynthesis and literature review, expert multidisciplinary panel selection and engagement, case scenario development,and appropriateness ratings by an expert panel via 2 rounds.

RESULTS: The appropriateness of the selection, characteristics, and insertion technique of intravenous catheters commonlyused in pediatric health care across age populations (neonates, infants, children, and adolescents), settings, diagnoses, clinicalindications, insertion locations, and vessel visualization devices and techniques was defined. Core concepts including vesselpreservation, insertion and postinsertion harmminimization (eg, infection, thrombosis), undisrupted treatment provision, andinclusion of patient preferences were emphasized.

CONCLUSIONS: In this study, we provide evidence-based criteria for intravenous catheter selection (from umbilicalcatheters to totally implanted venous devices) in pediatric patients across a range of clinical indications. miniMAGICalso highlights core vascular access practices in need of collaborative research and innovation.

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

WHAT’S KNOWN ON THIS SUBJECT: Vascular accessdevice decision-making in pediatric patients remainsa complex, highly variable process. To date, evidence-based criteria to inform these choices do not exist.Consequently, over- and underuse of available devicesis common, frequently resulting in harm to patients.

WHAT THIS STUDY ADDS: In this study, we provideevidence-based criteria for intravenous catheterselection (from umbilical catheters to totallyimplanted venous devices) in pediatric patients acrossa range of clinical indications.

To cite: Ullman AJ, Bernstein SJ, Brown E, et al. The MichiganAppropriateness Guide for Intravenous Catheters in Pediatrics:miniMAGIC. Pediatrics. 2020;145(s3):e20193474I

aAlliance for Vascular Access Teaching and Research, Menzies Health Institute Queensland and bSchool of Nursingand Midwifery, Griffith University, Nathan, Queensland, Australia; cQueensland Children’s Hospital, South Brisbane,Queensland, Australia; dPatient Safety Enhancement Program and Center for Clinical Management Research, USDepartment of Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan; eDivisions of GeneralMedicine and yDivision of Hospital Medicine, Department of Internal Medicine, gDivision of Pediatric Cardiology,Department of Pediatrics, and mDepartment of Emergency Medicine and Pediatrics, Medical School, University ofMichigan, Ann Arbor, Michigan; fChild Health Research Centre, The University of Queensland, Brisbane,Queensland, Australia; hCincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; iSection of PediatricCritical Care Medicine, Department of Pediatrics, School of Medicine, Yale University, New Haven, Connecticut;jAssociation for Vascular Access, Herriman, Utah; kSouthern Thoracic Surgical Association, Chicago, Illinois; lKeckSchool of Medicine, University of Southern California and Children’s Hospital Los Angeles, Los Angeles, California;nSchool of Medicine, University of Missouri, Columbia, Missouri; oSt Joseph’s Children’s Hospital, Tampa, Florida;pB. Braun Medical, Bethlehem, Pennsylvania; qDepartment of Anaesthesia and Pain Management, Royal Children’sHospital, Victoria, Australia; rChildren’s Mercy Hospital, Kansas City, Missouri; sSchool of Medicine, University ofMissouri–Kansas City, Kansas City, Missouri; tCollege of Medicine, University of Arizona and Phoenix Children’sHospital, Phoenix, Arizona; uStranz Crossley Inc, Philadelphia, Pennsylvania; vDepartment of Infectious Diseases, StJude Children’s Research Hospital, Memphis, Tennessee; wDepartment of Pediatrics, The University of TennesseeHealth Science Center, Memphis, Tennessee; xDepartment of Pediatrics, College of Medicine, University ofCincinnati and Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; and

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The majority of all hospitalizedchildren require placement ofa vascular access device (VAD) toreceive medications for life-savingtherapies and to facilitate bloodtests.1 In addition, many children whoare chronically ill are VAD dependentfor much of their lives. These devicesare required across a continuum ofage and acute, subacute, and homecare settings.2 Although vital fortreatment, VADs have well recognizedinsertion morbidity risks (eg,pneumothorax), are costly,3 and canlead to lethal complications such asthrombosis and bloodstreaminfection.4 Even minor VAD-associated adverse events, such asocclusion or dislodgement, can havesignificant negative sequelae and leadto delays in treatment during acuteand chronic illness.2,5

When clinicians select a VAD,a number of characteristics are usedto determine which device may beoptimal for their patient. Forexample, anticipated duration andfrequency of use, complication risk,previous vascular access history,infusate characteristics, vesselhealth, course and size, and operatoravailability and skill are factorsweighed when making VADdecisions.4 However, this process ishighly variable and often defaults toinstitutional culture and practice(the way things are done, rather thanthe way they should be done).6

Despite the fact that VADs havevarying adverse event profiles andtreatment capabilities, an evidence-driven standardized process doesnot exist for the selection of the mostappropriate VAD in pediatrics. Thisuncoordinated approach to VADdecision-making can result ininappropriate device selection. Forexample, peripheral VADs may beinappropriately chosen for complexlong-term therapy,7 and peripherallyinserted central catheters (PICCs)may be unnecessarily used forshort-term peripherally compatibletherapies.6 These device-selection

decisions potentiate patient harmand inefficient treatment outcomes,adding to health care costs.

In 2015, Chopra et al8 developed theMichigan Appropriateness Guide forIntravenous Catheters (MAGIC) to aidappropriate VAD decision-making forhospitalized adults. Since publication,MAGIC has been implemented inmany hospitals worldwide butparticularly in the United States, withevidence suggesting significantreductions in inappropriate VAD use,patient harm, and costs.9–11 Similarevidence-based VAD appropriatenesscriteria have not been developed forpediatrics. Therefore, we sought todevelop the MichiganAppropriateness Guide forIntravenous Catheters in pediatrics(miniMAGIC), a pediatric-focusedversion of its adult counterpart, usingthe RAND Corporation and Universityof California, Los Angeles (RAND/UCLA) Appropriateness Method12 toaddress this knowledge gap.

METHODS

Design

miniMAGIC was developed inaccordance with the RAND/UCLAAppropriateness Method.12 A detailedprotocol is available.13 The studyreceived ethics approval from GriffithUniversity (2018/207) and wasdeemed exempt from review by theUniversity of Michigan InstitutionalReview Board (HUMM00144945).

In the RAND/UCLA methoda procedure is consideredappropriate when the expected healthbenefits exceed the expected negativeconsequences (eg, mortality,morbidity, anxiety, and pain) bya sufficiently wide margin such thatthe procedure is worth doing,exclusive of cost.12 The methodbalances the best available evidencewith expert judgement to forma statement regarding theappropriateness of individualprocedures.12 Within miniMAGIC, we

sought to develop appropriatenesscriteria for the selection and insertionof VADs for specific populations andindications within pediatrics,regardless of cost.

Following the RAND/UCLAAppropriateness Method, sequentialphases were performed to meet thisaim. These phases included thefollowing:

1. definition of scope and key terms;

2. information synthesis andliterature review;

3. expert panel selection andengagement;

4. case scenario development; and

5. appropriateness ratings by anexpert panel via 2 rounds.

Definition of Scope and Key Terms

miniMAGIC defined theappropriateness of VADs commonlyused across pediatric health systems(hospitalized and ambulatory care),including management frommaternity hospitals or equivalentdischarge, until 18 years of age.14 Theobjective of miniMAGIC was to provideguidance on important clinicalquestions (ie, device selection, devicecharacteristics, and insertiontechnique) for clinicians primarilymaking decisions regarding VADsin pediatrics (eg, vascular accessteams, interventional radiology,anesthesiologists, infectious disease,surgery, and nephrology),contextualizing evidence-based datawith current practice with theassistance of a multidisciplinarypanel of experts.

Comprehensive definitions of keyterms are provided here.13 Theseinclude VAD and infusion cathetertypes (intraosseous [IO] catheter;peripheral intravenous catheter[PIVC]; midline catheter; umbilicalcatheter; nontunneled centralvenous access device [CVAD]; PICC;tunneled, cuffed CVAD; and totallyimplanted venous device),8,15,16

insertion locations, population

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categories (age [neonates, infants,children, and adolescents]),17

setting and diagnosis (generalhospitalized patients, congenitalcardiac disease, critically ill,oncology and hematology, andlong-term VAD-dependentconditions),8,18–21 clinicalindications (peripherally compatibleand nonperipherally compatibletherapy, difficult vascular access,and blood sampling),8,15,22 andvessel visualization devices andtechniques (near infrared light,ultrasound, electrocardiogram tipguidance, fluoroscopy, surgicalcutdown, and catheter-to-vesselratio).15,19,23

Information Synthesis and LiteratureReview

As recommended by the RAND/UCLAAppropriateness Method,12 weconducted a synthesis of theliterature to summarize the evidenceregarding pediatric VAD selection,insertion practice, and risk ofcomplications. The methods andresults of the literature review areavailable in this supplement.24 Thefinal 133 studies and guidelinesincluded were of variable quality, withmany that were focused on deviceperformance in specialty populations(eg, hematology and oncology andcritical care) and on singleinterventions (eg, vessel visualizationtechnology and device insertionlocation). Important gaps in thepediatric literature were observed,especially surrounding neonataldevice selection (outside of the NICU),catheter-to-vein ratio, and long-termvascular access–dependent conditions.To bridge these gaps, additionalstudies from populations outsideof pediatrics (eg, NICU and adults)were included to informappropriateness discussions. Beforethe appropriateness ratings, theliterature review was provided tothe expert panel. Findings from thereview were also used during thein-person ratings process to informdiscussions.

Expert Panel Selection andEngagement

Fourteen clinicians and researchers,representing pediatric health caredisciplines typically responsible fordecisions about VAD choice, wereinvited to serve on the panel. Fulldetails on panel members areavailable.13 To ensure rigor andinclusion of the patient’s voice(especially when the evidence wasunclear), we included nonvotingpanelists who joined for the meetingand discussions but did not rate orvote on individual scenarios. Thesepanelists included a patientrepresentative and 3 facilitators(including a methodologist).

Case Scenario Development

The clinical scenarios for miniMAGICwere based on the original MAGICdocument8 but were restructured andrewritten to align with the results ofthe systematic review and panelistexpert opinion. We included areas ofcontroversy or ambiguity even ifthere was limited evidence availablebecause we recognized that cliniciansmay need guidance when makingthese decisions. With this framework,the clinical scenarios were dividedinto the following: (1) deviceselection (across VAD types), (2)device characteristics (includinglumen number, size, and insertionlocation), and (3) insertion technique(attempts and image guidance).Device selection was furthercategorized into chapters for ageand specific clinical populations.

Appropriateness Ratings by ExpertPanel

As per the RAND/UCLAAppropriateness Method, 2 rounds ofappropriateness rating of the clinicalscenarios were completed. The first-round rating was done independentlyand performed via paper copy.Individual panelist results werereturned electronically (eg, scannedand sent via e-mail) and centrallyinputted to create a master ratings

document incorporating all panelistresponses. The second-round ratingoccurred after all panelists traveled toAnn Arbor, Michigan, and participatedin a group discussion that includeda review of all panelist ratings.12

Appropriateness for each clinicalscenario was rated on a scale of 1 to 9,in which 1 indicates “harm outweighsbenefit” (highly inappropriate), and 9signifies “benefit outweighs harm”(highly appropriate). As previouslydescribed, the panelists were providedthe literature review and instructed torate each clinical scenario using theirbest clinical judgement and theevidence in the literature review.13

As recommended by the RAND/UCLAmethod, indications were classifiedinto 3 levels of appropriateness:

1. appropriate: panel median score of7 to 9, without disagreement;

2. uncertain: panel median score of 4to 6 or with disagreementregardless of median; and

3. inappropriate: panel median scoreof 1 to 3, without disagreement.

Disagreement existed if $5 panelistsrated in each extreme (1–3 and7–9).12

RESULTS

A total of 1234 clinical scenarios werecreated for review by the panelists. Inthe first round, panelists rated 424scenarios as appropriate (34.4%), 492as inappropriate (39.9%), and 266 asuncertain (21.6%). The panel disagreedon 52 clinical scenarios (4.2%). Duringthe second-round discussion, thepanelists removed 481 scenariosbecause they were consideredduplicative (eg, similarity inrecommendations for children andadolescents led to a revised category ofchildren and adolescents aged1–18 years old rather than 2 distinctpopulations), leaving 753 scenarios toreview. In the second round, the panelrated 284 scenarios as appropriate(37.7%), 314 as inappropriate (41.7%),and 137 as uncertain (18.2%) and

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disagreed on 18 clinical scenarios(2.4%). Thus, discussions andclarifications in round 2 reduced theproportion of clinical scenarios rated asuncertain and those with disagreement.

The Appropriateness of VADSelection in Specific Populations

Pediatrics encompassesa heterogeneous population withdiverse conditions and includespatients across a range of ages. Thevenous network matures significantlythroughout the first year of life afterterm delivery.25 The developing veinstructure has a smaller luminaldiameter, requiring clinicians to usesmaller catheters for both peripheraland central devices, impactingcatheter insertion and function.26 Toensure accuracy, device selection wasdivided into the following age-basedcategories: neonates, infants, andchildren and adolescents, andassociated specific clinical contexts(eg, critical illness, cardiac surgery).

The Appropriateness of VADSelection in Hospitalized PediatricPatients

Neonates (Birth to 30 Days)

Within this population, the panelconsidered term neonates who, in thefirst 30 days of life, are admitted toa pediatric or mixed pediatric-adultfacility. Infection and newly diagnosedcongenital abnormalities, includingcardiac conditions, are a commonsource of early hospital admission forthis population. Reliable access to thevascular system is thus necessary fordiagnosis and treatment.

For approximately the first week oflife, the umbilical vein is a viablemeans of venous access. The paneldetermined that selection of anumbilical catheter should beinfluenced by the infusatecharacteristics, therapy duration, andthe age of the neonate. The panelrated use of the umbilical catheter asappropriate up to 2 days after birthfor peripherally compatible infusatesfor a therapy duration of #14 days.

Inserting an umbilical catheter$5 days after birth (no matterthe therapy duration) was ratedas inappropriate. There wasdisagreement regarding theappropriateness of umbilicalcatheters for a longer therapyduration ($15 days) because it wasunclear whether the umbilicalvascular system and catheter wouldremain patent for the predictedclinical need.16,27

The panel rated umbilical catheters asappropriate for administeringnonperipherally compatible infusates(with placement occurring up to5 days after birth). Central tippositioning of umbilical catheters isfrequently problematic, with thecatheter tip often moving duringtreatment, which is related to a smalltarget of safe positioning (due topatient size) and difficultsecurement.4,27,28 The panel thereforeendorsed frequent assessment ofumbilical catheter tip positioning tosafely administer nonperipherallycompatible infusates. The panel ratedit as appropriate to transition toalternative vascular access, froma functioning umbilical catheter,from 8 days after umbilical catheterplacement but rated transitionbefore 5 to 7 days after placementas uncertain rather than appropriate.

The miniMAGIC recommendations forappropriate device selection forhospitalized term neonates, acrossclinical indications and therapydurations, are summarized in Fig 1.PIVCs and midline catheters wererated appropriate for #7 days ofperipherally compatible therapy;however, the panel rated them asuncertain or inappropriate for moreprolonged therapies because ofconcerns regarding the devicereliability. In agreement with theNational Association for NeonatalNurses, PICCs were rated asappropriate for nonperipherallycompatible therapies andperipherally compatible therapies of$8 days of therapy.16 Tunneled,

cuffed CVADs were rated asappropriate for administration ofinfusates when therapy was projectedto last $31 days. The paneldeliberated extensively on theselection of an appropriate device forfrequent blood draws (more thanonce per day) because of the risk ofcatheter occlusion. Ultimately, midlinecatheters were rated as appropriatefor short durations (#7 days), andPICCs .3F catheter, or #20 gauge,were rated as appropriate for$8 days of therapy. Tunneled,cuffed CVADs were rated appropriatefor all long-term therapies ($31days). Totally implanted venousdevices were rated as inappropriatefor all clinical scenarios forhospitalized neonates, regardless oftherapy duration, reflectingdifficulty in implanting thesedevices below the skin and rapidgrowth impacting tip position inneonates.

Infants (31 Days to 1 year)

Infants require hospitalization fora range of conditions, withrespiratory conditions, such asbronchiolitis, being highly prevalent.miniMAGIC recommendations forthe selection of VAD for hospitalizedinfants are presented in Fig 2.

For hospitalized infants, PIVCs wererated as appropriate for #14 days oftherapy; however, robust evidencewith which to rate the appropriateuse of midline catheters in thispopulation was lacking. Panelistsreported successful use of thesedevices at some individual hospitalsbut stressed the necessity for high-quality insertion and maintenancepractices to promote safety. Thus,ratings for midline catheters forperipherally compatible infusateslasting #7 days were uncertain.

As with hospitalized neonates, PICCswere rated as appropriate foradministering nonperipherallycompatible infusates, with nontunneledCVADs rated as appropriate fora therapy duration of #14 days. The


panelists again deliberated extensivelyregarding the appropriateness ofdevice selection for frequent blooddraws (more than once per day). Thepanel rated the appropriateness ofPIVCs and midline catheters for#7 days as uncertain and rated PICCsas appropriate for $8 days if .3Fcatheter, or #20 gauge. The paneldiscussed the risk/benefit ratio ofVADs for this indication, includinginfection, thrombosis, and repeatedprocedures.4 Longer-term devices,including tunneled, cuffed CVADs andtotally implanted venous devices, wererated as appropriate for $31 days ofnonperipherally compatible therapybut as uncertain for other indications.

Children (.1–12 Years) andAdolescents (.12–,18 Years)

Although hospitalized children andadolescents representa heterogeneous group, overall, thepanelists determined that physiologicdifferences between children andadolescents do not make a clinically

meaningful difference when it comesto VAD appropriateness. Thus, thesesections were combined when ratingswere performed. As displayed inFig 3, consistent with the adultliterature (including MAGIC), midlinecatheters and PIVCs were rated asappropriate for peripherallycompatible infusates for #14days.8,11 Consequently, PICCs wererated as appropriate for usewhen $15 days of peripherallycompatible therapy is planned.PICCs remained appropriate for alldurations when nonperipherallycompatible infusates are planned.Nontunneled CVADs were rated asappropriate by the panel fornonperipherally compatible therapiesof up to 14 days’ duration and asuncertain in appropriateness forfrequent blood draws of between 8and 30 days’ duration. Tunneled,cuffed CVADs and totally implantedvenous devices were rated asappropriate for most indicationsof $31 days.

The Appropriateness of VADSelection in Special PediatricPopulations

Malignant Hematologic and OncologicalConditions

Compared with general hospitalizedpediatric patients, patients withmalignant hematologic andoncological conditions are atincreased risk of infection andthrombotic complications andadverse sequelae from treatmentdisruption.4,5,29 In addition,treatments and supportive therapiesare complex and diverse and oftenrequire cycles of peripherally andnonperipherally compatible infusates,frequent blood draws, andmanagement across home and healthcare settings. In agreement withinternational guidelines,30 the panelrated tunneled, cuffed CVADs asappropriate across this indication,with totally implanted venous devicesalso rated appropriate for patients$10 kg. The panel rated theappropriateness of PICCs (all ages

FIGURE 1miniMAGIC recommendations for appropriate device selection for hospitalized term neonates. a Less than or equal to 2 days after birth. b All neonatalages. c Less than or equal to 5 days after birth. NTCVAD, nontunneled central venous access device; TcCVAD, tunneled, cuffed central venous access device;TIVD, totally implanted venous device.


and weights) and totally implanted

venous devices (for patients ,10 kg)as uncertain, citing concerns

regarding procedural andpostinsertion complications such as

infection and thrombosis.30

The panel rated it appropriate toplace a PICC to commence urgent,

nonperipherally compatible therapyfor cancer and replace this with

a definitive device. However, theappropriateness of routinely using

this approach was rated as uncertain.When comparing the appropriatenessof PICCs versus tunneled, cuffed

CVADs, the panel rated itinappropriate to insert a PICC rather

than a tunneled, cuffed CVAD for all

FIGURE 2miniMAGIC recommendations for appropriate device selection for hospitalized infants. a Disagreement. G, gauge; NTCVAD, nontunneled central venousaccess device; TcCVAD, tunneled, cuffed central venous access device; TIVD, totally implanted venous device.

FIGURE 3miniMAGIC recommendations for appropriate device selection for hospitalized children and adolescents. For boxes with 2 colors, the left is for children(.1–12 years), and the right is for adolescents (.12–,18 years). a Disagreement. NTCVAD, nontunneled central venous access device; TcCVAD, tunneled,cuffed central venous access device; TIVD, totally implanted venous device.


aged populations undergoing bonemarrow transplant or other treatmentof cancer. Similarly, the panel ratedinsertion of a PICC, rather thana totally implanted venous device, forchildren and adolescents receivingtreatment of active cancer asinappropriate. The panel rated thesame comparison as appropriate forneonates and as uncertain for infants.

Patients With Critical Illness

For pediatric patients with criticalillness, miniMAGIC panelistsrecommended VAD selection onthe basis of illness severity (ie,physiologically unstable versusstable) rather than setting of care (ie,ICU versus emergency department)or other patient or clinicalcharacteristics. Ratings for patientswith critical illness were consistentwith existing guidelines31 withrespect to timeliness and importanceof early venous access. Displayed inFig 4, recommendations fora pediatric patient who is stablebut critically ill varied on thebasis of infusate characteristicsand monitoring requirements.Nontunneled CVADs were rated asappropriate for up to 14 days ofnonperipherally compatible therapyand for hemodynamic monitoring.Consistent with previousrecommendations, PICCs were ratedas appropriate for $8 days ofperipherally compatible therapiesand for all durations ofnonperipherally compatibletherapies. Despite minimal data,midline catheters were rated by thepanel as appropriate for all durationsof peripherally compatible therapies.For pediatric patients who are stablebut critically ill requiring peripherallycompatible therapy for #14 days,panelists preferred PIVCs over IOcatheters. Panelists disagreed on theappropriateness of IO catheter use formanaging pediatric patients withouthemodynamic compromise withoutreliable vascular access for #7 days.

Also displayed in Fig 4 (and inagreement with the AmericanHeart Association Guidelines forCardiopulmonary Resuscitation andEmergency Cardiovascular Care),31

for an unstable pediatric patient,speed of access was first priority. Forscenarios with hemodynamiccompromise, panelists rated itinappropriate to attempt for PIVCaccess for $120 seconds or $2attempts, instead recommending anIO device to gain intravenous (IV)access, citing how rapidly this can beinserted by clinicians with varyinglevels of training.31

Congenital Cardiac Conditions

For pediatric patients with congenitalcardiac conditions, inappropriate VADselection can directly impact bothshort- and long-term survival.Damage (thrombotic or stenotic) tokey vessels can prevent or complicatefuture life-saving procedures,including catheterizationinterventions, palliation of patientswith a functionally univentricularheart, and cardiac transplant.32

Because the implications of vascularaccess and route of access are highlyrelevant in decision-making, clinicalscenarios for this population weredivided into underlying cardiacphysiology: univentricular versusbiventricular circulation. Across allscenarios there were 2 commonrecommendations. First, the panelrated totally implanted venousdevices as inappropriate regardless ofindication because of concernsregarding irreparable vessel damage.Second, the panel rated umbilicalcatheters as an appropriate accessoption for neonates because these donot typically result in significantvessel compromise for futureprocedures.32

Congenital cardiac procedures areprimarily performed in highlyspecialized pediatric facilities.miniMAGIC does not includerecommendations surrounding theselection of transthoracic intracardiac

lines or other specialty cardiacdevices (eg, extracorporealmembrane oxygenation catheters).However, the panel recognized thatplacement of transthoracicintracardiac lines can minimize theneed for other types of VADs andthereby minimize the risks associatedwith percutaneous devices.33

For patients with univentricularphysiology, miniMAGICrecommendations were based on thepatient’s stage of cardiac repair (stage1, 2 or 3)17 and duration of therapy(Fig 5). Lower-extremity PICCs,umbilical catheters, and femoralCVADs (tunneled, uncuffed andnontunneled) were rated by the panelas appropriate for patientsundergoing stage 1 and 2 repair topreserve upper-extremity veinpatency for stage 2 and 3 palliation.32

To facilitate preservation of upper-extremity veins, a slightly variedCVAD insertion technique wasincluded: the tunneled, noncuffedCVAD placed in the femoral vein.34

After stage 3 repair, appropriatenesswas similar to recommendations forpatients with critical illness. Forpatients with highly complex,functionally univentricularphysiology at any stage of repair, thepanel discussed the potentialnecessity to consider alternatives andrecommended that such cases havecoordinated, interdisciplinary deviceplanning and consideration ofspecialist devices (eg, transhepaticCVAD).

For congenital cardiac conditionswith biventricular circulation,miniMAGIC recommendations werebased on patient age and duration oftherapy. Appropriateness ratingswere similar to those of pediatricpatients who are stable but criticallyill, owing to similar physiology andassociated risk. The panel ratedjugular-placed, nontunneled CVADsand upper extremity–placed PICCs asappropriate. Nontunneled CVADsplaced in femoral and subclavianveins were rated as uncertain by the


FIGURE 4miniMAGIC recommendations for pediatric patients who are critically ill. A, stable, critically ill patient. B, unstable, critically ill patient. a Disagreement.NTCVAD, nontunneled central venous access device; TcCVAD, tunneled, cuffed central venous access device; TIVD, totally implanted venous device.


panel, reflecting the insertion-relatedcomplications associated withsubclavian placement (which vary onthe basis of operator experience andthe use of ultrasound) and infectionand thrombotic risk associated withfemoral placement.32 Additionally,femoral vessel preservation was citedas being important for patients withconditions likely to require futuretranscatheter interventions (eg,patients with tetralogy of Fallot orpulmonary atresia and patientsreceiving a cardiac transplant whowill need multiple myocardialbiopsies).

Long-Term Vascular Access Dependent

With evolution in medical therapies,long-term (.2 months) and verylong-term (.1 year) vascular accessdependency in pediatrics isincreasingly common.2 Thisprolonged reliance on VADs includespediatric patients receiving treatmentof nonmalignant hematologic (eg,sickle cell), respiratory (eg, cysticfibrosis), gastrointestinal, metabolic,and immunologic conditions.Navigating VAD insertion decisionsfor children with chronic illness isvital but complex. To this end, ournonvoting patient representative wasinstrumental in providing context forthese ratings. With her input andinsight, the panel agreed that definingthe appropriateness of basicprinciples to enable vesselpreservation and complicationprevention in chronic conditions wasnecessary. The panel stronglyrecommended that clinicians partnerwith the child and family orcaregivers when selecting devices toensure that their immediate andevolving clinical and lifestyle needsare met.

In contrast to MAGIC, the panel didnot believe that frequency ofhospitalization should be used asa proxy for illness severity or asa defining criterion in pediatric VADselection. This distinction was madebecause acute hospitalization was

considered an unreliable proxy ofdisease in pediatric populations withchronic conditions, in whom anemphasis is placed on avoidinghospitalization.8 Instead, in each ofthe clinical scenarios, it wasrecognized that children with long-term vascular access dependencyspend time receiving treatmentacross home and health care facilities.In the scenarios, it was alsoconsidered that most childrendependent on long-term vascularaccess are likely to have difficultvascular access, related to previousvessel damage and proceduralfear.2

The criteria influencing the selectionof VADs for this heterogenouspopulation were focused on infusatecharacteristics (peripheral versusnonperipheral compatibility,including parenteral nutrition [PN]),continuous or intermittent therapies,and treatment duration. Specificrecommendations are provided forchildren requiring long-term PN, andin accordance with the EuropeanSociety for Parenteral and EnteralNutrition, the panel rated use oftunneled, cuffed CVADs for all agegroups as appropriate. However, theappropriateness of totally implantedvenous devices for children andadolescents was rated as uncertain,and there was disagreementregarding the appropriateness ofPICCs.35

Recommendations for non-PNinfusates are displayed in Fig 6. Forcontinuous infusates, appropriatenessmirrored PN recommendations,including tunneled, cuffed CVADs forall populations. The panel also rateduse of PICCs in infants and childrenand use of totally implanted venousdevices for children and adolescentsas appropriate for this indication. Forintermittent access, panelists ratedPICCs and totally implanted venousdevices in neonates and infants asuncertain, but they rated the use oftunneled, cuffed CVADs for allpopulations and the use of totally

implanted venous devices in childrenand adolescents as appropriate.Peripheral devices, including PIVCsand midline catheters, were rated asbeing inappropriate across all long-term, complex therapies.

For children and adolescentsrequiring regular, peripherallycompatible intermittent treatments(eg, steroids and antibiotics) for shortdurations (,7 days), the panel ratedPIVCs and totally implanted venousdevices as appropriate. The panelrated the use of midline catheters andPICCs as uncertain, owing largely toa lack of credible evidence supportingthis practice. Although some panelistshad substantial experience in usingmidline catheters for this purposeand reported few untoward events,the lack of evidence to support thispractice and the potential risk ofcomplications limitedrecommendations. When consideringmedium-duration (8–14 days)treatment, PICCs; tunneled, cuffedCVADs; and totally implanted venousdevices were rated as appropriate.

Difficult Venous Access

Difficult venous access is caused bya variety of factors in pediatrics,including physiology, pathology, VADdamage, and clinician proceduralskill.36 Appropriateness criteria fordifficult venous access are focused onthe number of insertion attempts,intramuscular (IM) therapysubstitution, and escalation of VADtypes. Each of these criteriaprovided a pathway to minimizevessel damage and patient distresswithout impacting treatmentprovision.

In agreement with the InfusionNurses Society guidelines, the panelrated $3 attempts at PIVC insertionby a single clinician asinappropriate.15 In parallel, thepanel rated 0 to 2 attempts by oneindividual as appropriate butrecommended early escalation toa more experienced PIVC inserter


for children with difficult venousaccess.

It is not uncommon in pediatrics fora child to need an additional day of IVtreatment only to lose reliable IVaccess. In such situations, the panelrated it appropriate to substitute anantibiotic that may be delivered viaalternative routes (eg, IM ceftriaxone)with a non-IV injection on the finalday of therapy when advancedinsertion staff are not available orafter $2 insertion attempts areunsuccessful. The panel rated thisapproach as uncertain with 0 to 1attempts but also indicated that itwas reasonable to attempt to inserta PIVC for completion of IVtherapy. Underlying the panel’srecommendation was theunderstanding (1) that the efficacy ofIV and IM administration for theantibiotic in question is similar and(2) that IM injections can be painful,and often multiple doses arerequired, thus making it less ideal.37

When transitioning from IV to IMtreatment, consultation with aninfectious diseases specialist wasrecommended. Additionally, the paneladvised considering oral antibiotictherapy in all such situations,including before IV therapy iscommenced.38

The panel rated placement of a PICCas appropriate for a child who doesnot need central access or access forextended periods but who, despiteappropriate escalation with skilledinserters and technology (eg,ultrasound), has required $2 PIVCinsertion attempts. For thisindication, the panel balanced therisk associated with delays totreatment and distressing repeatedPIVC insertion procedures withdevice complications andsequelae.

The Appropriateness of DeviceCharacteristics

The appropriateness of devicecharacteristics, such as size and

FIGURE 5miniMAGIC recommendations for congenital cardiac conditions in pediatric patients. A, Functionallyuniventricular physiology. B, Biventricular circulation. a Disagreement. Fem, femoral; Jug, jugular;Low, lower body; NTCVAD, nontunneled central venous access device; Sub; subclavian; TcCVAD,tunneled, cuffed central venous access device; TIVD, totally implanted venous device; TncCVAD,tunneled, noncuffed central venous access device; Up, upper body.


number of lumens, risk ofcomplications, device performance,and successful completion ofintended therapy, was also rated.The panel considered thesecharacteristics broadly, across allindications rather than for specificpopulations or clinical factors drivingtreatment.

Catheter-to-Vein Ratio

Although thrombosis risk is generallyconsidered to be lower in pediatricsthan in adults, the size of the vesselshould be considered carefully whenchoosing the size of a catheter.16 Inagreement with the Infusion NursesSociety guidelines and adultliterature, the panel rated a catheter-to-vein ratio of #45% as appropriatefor PIVCs and PICCs. The panel rateda catheter-to-vein ratio of 50% asuncertain and a ratio of $60% asinappropriate.15,23 For nontunneledCVADs, tunneled CVADs, and totallyimplanted venous devices, the panel’scatheter-to-vessel ratio ofappropriateness ratings were moreconservative, with #40%appropriate, 45% to 50% uncertain,

and $60% inappropriate. Althoughthe panel recognized the lack ofpediatric-specific literature in thisarea of practice, these ratings werean instance in which findingsfrom the adult literature were feltto be applicable to pediatricpatients. The panel did recommendthis a priority for future inquiry.

Device Lumens

In agreement with MAGIC8 andmultiple national and internationalguidelines,15,30,39 the panel ratedit appropriate to routinely placea single-lumen device, unlessthere were specific reasonsfor a multilumen device (eg,incompatible infusions that could notbe separated in time).8,30 Within thisdomain, the panel also rated itinappropriate to place a multilumendevice with dedicated lumens forblood transfusions and sampling.However, the appropriateness ofdedicating lumens for lipidemulsions and PN was rated asuncertain. This rating reflected a lackof evidence regarding risks andbenefits with respect to infectious

complications from PN and lipidemulsions versus risks and benefitswith respect to a multilumen device.Therefore, the panel recommendedcollaboration with a pharmacist and/or VAD insertion clinician to ensuredevice characteristic suitability(ie, lumen number and size) asappropriate.

The Appropriateness of the InsertionProcedure

Insertion Locations

The locations into which VADs areinserted directly impact the successof the procedure and risk ofcomplications.15,39–41 Vesselssuitable for VAD insertion ina neonate may become difficultand/or inappropriate to access(eg, scalp vessels) or lead to anincreased risk of complications(eg, lower-body PICCs ina mobilizing patient) later in life.Devices inserted into areas offlexion are associated with anincreased risk of postinsertioncomplications, including infiltration,phlebitis, and thrombosis.42

Recommendations for theappropriateness of VAD insertionvessels and sites are described inFig 7.

Vessel Visualization

Vessel visualization technologies,such as ultrasound, near infraredlight, and fluoroscopy, are used withincreasing frequency in pediatricclinical practice.43 High-qualityevidence is available to support theuse of vessel visualization techniquesduring the insertion of severaldevices, including PIVCs, PICCs, andnontunneled CVADs, to promoteinsertion success and preventinsertion and postinsertioncomplications.43–46 In agreementwith previous guidelines,15,43

panelists rated it appropriate toinsert all devices by using ultrasoundguidance. Similarly, panelists ratedplacement of PIVCs in patients withdifficult venous access and placement

FIGURE 6miniMAGIC recommendations for pediatric patients with non–PN-related long-term VAD dependency.a Disagreement. NTCVAD, nontunneled central venous access device; TcCVAD, tunneled, cuffed centralvenous access device; TIVD, totally implanted venous device.


of nonemergent central deviceswithout image guidance asinappropriate. The appropriateness ofnear infrared light to guide PIVC andmidline catheter insertion was ratedas uncertain because of limitedevidence. Similarly,electrocardiographically guidedinsertion of PICCs across populationswas rated as uncertain because(unlike in the adult population) theevidence in pediatrics for a benefit ofthis technology is limited. Evaluationof the venous anatomy usingultrasound before placement of allcentral devices, and placement ofVADs in neonates and pediatricpatients with long-term vascularaccess–dependent conditions, wasrated as appropriate by the panel.

DISCUSSION

Appropriate VAD selection andinsertion influences a child’s clinicalmanagement and outcome, reducingpain, complications, length of stay, and

costs and increasing overall safety andtreatment success.4,5,36 Following theRAND/UCLA AppropriatenessMethod,12 the miniMAGICrecommendations from a panel ofinterdisciplinary clinicians provideguidance to improve everyday VADselection and insertion decisions. Themethod balances contemporaryliterature with the pragmatic clinicalexperience of the expert panelists,ensuring the recommendations arerealistic and reliable.

miniMAGIC is the first time thebreadth of pediatric VAD selectionand insertion practices have beenthoroughly evaluated and critiqued.miniMAGIC also includesrecommendations encompassing thebroad and unique populations withinpediatrics. Findings from this workstand to improve decisions forclinically challenging patients acrossa broad range of VADs. Because manyrecommendations were grounded inevidence aimed at reducing harm,

these appropriateness criteria shouldalso help reduce complicationsrelated to poor device-selectiondecisions. Evidence of inappropriateuse of VADs and consequential harmin pediatrics and other populations isrising,47,48 including inappropriatePICC use for short-duration,peripherally compatible therapy.6

miniMAGIC fills this evidence-practicegap and offers a pragmatic and novelway to reduce patient harm.

As is common in pediatric health care,many aspects of VAD practice had notbeen evaluated rigorously, so thepanel recommendations werenecessarily conservative.Consequently, important differencesbetween miniMAGIC and MAGIC (forhospitalized adults) were observed.These included uncertainty regardingthe role of midline catheters, theinappropriateness of totallyimplanted devices in neonates, andthe appropriateness of PICCs insubspecialty populations. Scenariosclassified as uncertain and withdisagreement reveal opportunity forresearch and innovation. For example,midline catheter use; device selectionfor blood sampling; the use of PICCsin malignant hematology, oncology,and PN; totally implanted venousdevices for children and adolescentsrequiring long-term PN; and insertionlocations for PIVCs and nontunneledCVAD are areas in dire need of moreevidence. Because these gaps spanmany health disciplines, collaborativeand interdisciplinary research thatincludes intensivists, infectiousdisease physicians, hospitalists,nurses, oncologists, surgeons,anesthesiologists, interventionalradiologists and cardiologists, andpharmacists is necessary. To improvepediatric health outcomes and healthcare services, funding for theseresearch questions from foundations,national institutes, and investedstakeholders is needed.

miniMAGIC aims to broadly supportthe current diverse clinician inserterworkforce but does not diminish the

FIGURE 7Summary of miniMAGIC recommendations for the appropriate VAD insertion vessel and/or site inpediatric patients. aDisagreement.


need for vascular access experts,especially for complex cases. In thiscontext, processes andrecommendations to improve VADselection for patients with long-termand very long-term VAD dependency,including those with congenitalcardiac conditions relying on intactvessels for procedures, are especiallyimportant. A siloed approach withouta dedicated expert can result in poordecisions regarding device selection,placement, and management withoutconsideration of long-term vesselhealth and preservation.49

Coordination, communication, andplanning across disciplines within theart and science of vascular access isnecessary to ensure that vesseldamage does not occur and that thepatient’s and family’s health goals areconsidered.

The implementation of miniMAGICinto practice will require furthercollaboration and innovation. Likeits adult counterpart, the studyteam plans to develop a mobilehealth application to operationalizethe panel recommendations for useat point of care. Following theRAND/UCLA AppropriatenessMethod,12 miniMAGIC should alsobe used to evaluate historical,current, and planned VAD selectionand insertion decisions in pediatrichealth care. The recommendationscan first be used to motivatepractice change and then be used asa benchmark, with retrospectiveand prospective audits to monitoradoption. With implementation,health care institutions canexamine and celebratecorresponding improvements inpatient and health servicesoutcomes, such as reductions incentral line–associated bloodstream

infections, thrombosis,readmissions, and length ofstay.

Our study has limitations. First, therecommendations largely rely onthe quality of the evidence on whichthey have been generated. Manyaspects of pediatric vascular accesshave poor-quality evidence, whichmeans the recommendations wereoften reliant on clinical practiceguidelines and the expert opinion ofthe panel. However, therecommendations of miniMAGIC arenot permanent. As new evidence isgenerated, miniMAGICrecommendations should berevised. Second, the panel memberswere from the United States andAustralia. Health services in othercountries can be vastly different,including practitioner training andresource availability. As withMAGIC, we strongly recommendlocal contextualization of therecommendations before wideimplementation. Finally, not allsubspecialty populations wereconsidered when creatingminiMAGIC. This limitation is mostevident for children with long-termvascular access–dependentconditions. For this population wehave provided appropriatenesscriteria for practice principles;however, coordinated casemanagement and patient- andfamily-centered care are vital.

CONCLUSIONS

Coordinated, appropriate VADselection and insertion decisions canchange a child’s life. miniMAGICprovides robust appropriatenesscriteria for VADs in commonlyoccurring, sometimes complex,

pediatric clinical indications.Interdisciplinary clinicians witha range of expertise and training canuse this resource to reduce VAD-associated harm and accompanyinghealth care resources and to improvetreatment. miniMAGIC has also drawnattention to priority areas forresearch, innovation, and patientsafety across pediatric disciplines.The findings stand to challengeand improve current pediatricvascular access practice andoutcomes.

ACKNOWLEDGMENTS

We acknowledge the considerablework by the support staff, includingSuzanne Winter, Rita Nemeth, andRebecca Paterson.

ABBREVIATIONS

CVAD: central venous accessdevice

IM: intramuscularIO: intraosseousIV: intravenousMAGIC: Michigan Appropriateness

Guide for IntravenousCatheters

miniMAGIC: MichiganAppropriatenessGuide for IntravenousCatheters in pediatrics

PICC: peripherally inserted centralcatheter

PIVC: peripheral intravenouscatheter

PN: parenteral nutritionRAND/UCLA: RAND Corporation

and University ofCalifornia, LosAngeles

VAD: vascular access device

Drs Ullman and Chopra conceptualized and designed the study, drafted the initial manuscript, reviewed the data, and reviewed and revised the manuscript;

Dr Bernstein assisted with designing the study and with protocol development and reviewed and revised the manuscript; Dr Brown, designed the data collection

instruments, collected data, conducted the initial analyses, and reviewed and revised the manuscript; Dr Aiyagari provided expertise for vascular access devices in

pediatric cardiology patients and reviewed and revised the final manuscript; Drs Cooper and Mahajan provided expertise for vascular access devices in critically ill


neonatal and pediatric patients and reviewed and revised the final manuscript; Ms Doellman provided expertise for vascular access devices in the neonatal and

pediatric patient and reviewed and revised the final manuscript; Dr Gore provided patient and caregiver perspective and reviewed and revised the final manuscript;

Dr Jacobs provided expertise for vascular access devices in pediatric cardiac surgery patients and reviewed and revised the final manuscript; Dr Jaffray provided

expertise for vascular access devices in pediatric hematology, oncology, and bone marrow transplant patients and reviewed and revised the final manuscript; Ms

Kleidon assisted in drafting case scenarios and funding applications, in protocol development, and in revision of the final manuscript; Mr McBride provided content

expertise in pediatric surgery and surgically inserted devices, assistance in drafting case scenarios, and reviewed and revised the final manuscript; Drs Morton

and Shaughnessy provided expertise in pediatric hospital medicine and reviewed and revised the manuscript; Ms Pitts supported the protocol development and

review, case scenario review, and panel recruitment and reviewed and revised the final manuscript; Ms Prentice provided content expertise in pediatric surgery

and surgically inserted devices and reviewed and revised the final manuscript; Dr Stranz provided content expertise in pediatric pharmacology and reviewed and

revised the final manuscript; Dr Wolf provided expertise in pediatric infectious diseases and pediatric hematology and oncology and reviewed and revised the

manuscript; Dr Rivard provided expertise in pediatric interventional radiology and image-guided insertion of vascular access devices in the neonatal and pediatric

patient and reviewed and revised the final manuscript; Drs Rickard and Cooke assisted with funding applications, protocol development, and revision of the final

manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

DOI: https://doi.org/10.1542/peds.2019-3474I

Address correspondence to Amanda J. Ullman, RN, PhD, School of Nursing and Midwifery and Menzies Health Institute Queensland, Griffith University, 140 Kessels

Rd, Nathan, QLD 4111, Australia. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2020 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: Dr Ullman reports fellowships and grants from the National Health and Medical Research Council; employment by Griffith University;

grants from the Children’s Hospital Foundation, the Royal Brisbane and Women’s Hospital Foundation, the Emergency Medicine Foundation, and the Australian

College of Critical Care Nursing; and investigator-initiated research grants and speaker fees provided to Griffith University from 3M Medical, AngioDynamics, Becton

Dickinson, and Cardinal Health (unrelated to the current project). Dr Bernstein reports grants from the Agency for Healthcare Research and Quality and the US

Department of Veterans Affairs. Dr Brown reports employment by Griffith University. Dr Doellman reports honoraria from Genentech and Lineus Medical and

consulting with Teleflex Medical. Dr Faustino reports grants from the National Institutes of Health. Ms Kleidon reports grants from the National Health and Medical

Research Council; employment by Griffith University; grants from the Children’s Hospital Foundation, the Emergency Medicine Foundation, and the Association for

Vascular Access Foundation; and investigator-initiated research grants and speaker fees provided to Griffith University from 3M Medical, AngioDynamics, Baxter,

BD-Bard, and Medical Specialties Australiasia (unrelated to the current project). Dr Gore reports honoraria for invited talks in patient safety and patient advocacy.

Dr Mahajan reports grants from the National Institutes of Health, Agency for Healthcare Research and Quality, Maternal and Child Health Bureau of the Health

Resources and Services Administration, Oculus, and Microsoft. Mr McBride reports travel and accommodation expenses from medical device companies (Roche,

Smith & Nephew) unrelated to this project, a research grant from ABIGO Medical AB (also unrelated to this project), and employment by Queensland Health. Dr

Cooke reports employment by Griffith University; grants from Griffith University, Children’s Hospital Foundation, Royal Brisbane and Women’s Hospital Foundation,

Cancer Council Queensland, and Australasian College for Infection Prevention and Control; and investigator-initiated research grants and speaker fees provided to

Griffith University by vascular access product manufacturers (Baxter, Becton Dickinson, Entrotech Life Sciences) unrelated to this project. Dr Rickard reports

a fellowship from Queensland Health; employment by Griffith University; and grants from the National Health and Medical Research Council, Griffith University,

Children’s Hospital Foundation, Princess Alexandra Hospital Foundation, Royal Brisbane and Women’s Hospital Foundation, American Society for Parenteral and

Enteral Nutrition (Rhoads) Foundation, Cancer Council Queensland, Australasian College for Infection Prevention and Control, Association for Vascular Access

Foundation, Australian College of Nursing, Australian College of Critical Care Nurses, and Emergency Medicine Foundation; and investigator-initiated research

grants and speaker fees provided to Griffith University by vascular access product manufacturers (3M, AngioDynamics, Baxter, B. Braun Medical, BD-Bard,

Medtronic, ResQDevices, and Smiths Medical) unrelated to this project. Dr Chopra reports grants from the National Institutes of Health, Agency for Healthcare

Research and Quality, Centers for Disease Control and Prevention, American Hospital Association, Blue Cross/Blue Shield Foundation, and Blue/Cross Blue Shield of

Michigan; book royalties from Oxford University Press for The Saint-Chopra Guide to Inpatient Medicine and from Wolters Kluwer Inc for contributing chapters in

UpToDate; and honoraria for invited external talks as a visiting professor; the other 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: Dr Ullman reports investigator-initiated research grants and speaker fees provided to Griffith University from vascular access

product manufacturers (3M Medical, AngioDynamics, Becton Dickinson, Cardinal Health) unrelated to the current project. Dr Bernstein reports grants from the

Agency for Healthcare Research and Quality and the US Department of Veterans Affairs. Dr Doellman reports honoraria from Genentech and Lineus Medical and

consulting with Teleflex Medical unrelated to this project. Dr Gore reports honoraria for invited talks in patient safety and patient advocacy. Ms Kleidon reports

investigator-initiated research grants and speaker fees provided to Griffith University from 3M Medical, AngioDynamics, Baxter, BD-Bard, Centurion, Cook Medical,

Medical Specialties Australia, and Vygon (unrelated to the current project). Dr Wolf reports participation in research sponsored by Astellas Inc, Cempra

Pharmaceuticals Inc, and Merck Inc and in-kind research support from Karius Inc and Carefusion Inc. Ms Pitts reports employment by B. Braun Medical and

St Joseph’s Children’s Hospital, Tampa, Florida, previous employment and stockholder status with AngioDynamics, and board membership of Navi Medical

Technologies. Dr Cooke reports investigator-initiated research grants and speaker fees provided to Griffith University by vascular access product manufacturers

(Baxter, Becton Dickinson, Entrotech Life Sciences) unrelated to this project. Dr Rickard reports investigator-initiated research grants and speaker fees provided to

Griffith University from vascular access product manufacturers (3M, AngioDynamics, Baxter, B. Braun Medical, BD-Bard; Medtronic, ResQDevices, Smiths Medical)

unrelated to this project. Dr Chopra reports grants from the Agency for Healthcare Research and Quality and American Hospital Association, book royalties from

Oxford University Press for The Saint-Chopra Guide to Inpatient Medicine, and honoraria for invited external talks as a visiting professor; the other authors have


https://doi.org/10.1542/peds.2019-3474I

mailto:[email protected]

indicated they have no potential conflicts of interest to disclose.

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DOI: 10.1542/peds.2019-3474I2020;145;S269Pediatrics

David S. Cooper, Marie Cooke, Claire M. Rickard and Vineet ChopraElizabeth Prentice, Douglas C. Rivard, Erin Shaughnessy, Marc Stranz, Joshua Wolf,

Kleidon, Prashant V. Mahajan, Craig A. McBride, Kayce Morton, Stephanie Pitts,Doellman, E. Vincent S. Faustino, Beth Gore, Jeffrey P. Jacobs, Julie Jaffray, Tricia

Amanda J. Ullman, Steven J. Bernstein, Erin Brown, Ranjit Aiyagari, DarcyminiMAGIC

The Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics:

ServicesUpdated Information &

http://pediatrics.aappublications.org/content/145/Supplement_3/S269including high resolution figures, can be found at:

References

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DOI: 10.1542/peds.2019-3474I2020;145;S269Pediatrics

David S. Cooper, Marie Cooke, Claire M. Rickard and Vineet ChopraElizabeth Prentice, Douglas C. Rivard, Erin Shaughnessy, Marc Stranz, Joshua Wolf,

Kleidon, Prashant V. Mahajan, Craig A. McBride, Kayce Morton, Stephanie Pitts,Doellman, E. Vincent S. Faustino, Beth Gore, Jeffrey P. Jacobs, Julie Jaffray, Tricia

Amanda J. Ullman, Steven J. Bernstein, Erin Brown, Ranjit Aiyagari, DarcyminiMAGIC

The Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics:

http://pediatrics.aappublications.org/content/145/Supplement_3/S269located on the World Wide Web at:

The online version of this article, along with updated information and services, is

by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397. the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2020has been published continuously since 1948. Pediatrics is owned, published, and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it

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the michigan appropriateness guide for …...the majority of all hospitalized children require...

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