Central Vascular Access Devices: From Orders to Insertion

Central vascular access devices (CVAD) are essential to providing reliable access for infusions, medications, and blood sampling in pediatric patients.¹ Common types of pediatric CVADs include PICCs, implanted ports, and tunneled and nontunneled catheters.² Other specialized devices, such as hemodialysis or apheresis catheters, are used for specific therapies and may be cuffed or noncuffed depending on the intended duration of use.^2,3

Selecting the most appropriate device is critical to supporting the patient’s treatment plan. However, CVAD device selection is a complex process involving multiple disciplines and requiring careful consideration of numerous factors, including:

• Patient’s size, anatomy, underlying condition, and developmental level.²
• Duration of therapy
• Type of therapy (e.g. vesicants, PN, chemotherapy)
• Frequency of access
• Multiple or failed PIV attempts
• Need for blood sampling
• Patient body habitus
• Number of lumens required
• Need for a power-injectable CVAD
• Preference of the patient or caregiver
• Previously used access sites
• Anticipated future access site needs

Improper device selection may increase the risk of complications, delay essential therapies, and contribute to higher health care costs._⁴ Certain factors increase risks, such as thrombosis, more than three previous tunneled CVADs, history of congenital heart disease, difficult access, or documented abnormal anatomy by preprocedure imaging.⁵

Risk of harm

Inserting an inappropriate CVAD can lead to serious consequences, including vessel scarring, thrombosis, CLABSI, treatment delays, and the need for additional procedures to place the correct device.⁶ In neonates with gastroschisis, a lower extremity PICC carries an increased risk of infiltration and phlebitis during silo-reduction and within the first five days after abdominal closure.⁷ These complications have significant implications for both patients and hospitals, including increased risk of harm, prolonged hospital stays, and erosion of trust between their providers and the hospital.⁶

Pediatric considerations

A thorough evaluation should be completed prior to CVAD insertion and should include a review of the patient’s electronic medical record (EMR) along with an interview with the patient or caregiver.⁵ This evaluation should address prior CVAD history, including failed insertion attempts, anatomical abnormalities, and previous complications.⁵

There are several contraindications to CVAD insertion⁸:

• Local skin infection or non-intact skin over the planned insertion site
• Bloodstream infection (generally recommended for cultures to be negative for 36-48 hours prior to a CVAD insertion)
• Thrombosis of the vessel
• Uncorrected coagulopathy
• Obstruction of the vein by a tumor or mass
• Abnormal vessels
• Patients with a low absolute neutrophil count (ANC)

Special considerations

Children who may require future hemodialysis should have their upper extremity and subclavian veins preserved to maintain potential sites for arteriovenous fistula formation.³ If long-term access is required for this population, a single-lumen, tunneled, cuffed, silicone catheter should be inserted in the right internal jugular vein.³

Recommended actions

Vessel preservation is a priority in pediatric patients, especially in those with chronic conditions such as intestinal failure, which may require a lifetime of CVADs for therapy.⁹ Selecting the most appropriate CVAD and utilizing a standardized pathway helps prevent harm and supports safe, consistent care.^5,9 The following actions can help mitigate risks of harm related to CVADs.

• Standardize the evaluation process for patients who require a CVAD.5 Inconsistent evaluation of the patient prior to CVAD placement can result in missed risk factors, failed insertion attempts, or the need to cancel the procedure.⁵
  • Establish a multidisciplinary team of key stakeholders that includes providers, nurses, vascular access specialists, infection preventionists, pharmacists, and IT support.5.⁹
  • Educate providers on the standardized CVAD evaluation process and the pediatric vascular access device pathway to improve engagement and awareness.⁵
  • Select the appropriate device in collaboration with the interdisciplinary care team, ensuring a shared, patient-centered approach.⁴
  • Proactively reassess CVAD necessity and changing clinical needs of the patient. If a patient has a nontunneled CVAD, reassess the patient’s vascular access needs after 14 days of therapy.²
  • Use the smallest catheter size appropriate for therapy and minimize the number of lumens to reduce the risk of infection.^1,2
  • Use ultrasound to determine vessel measurements and appropriate catheter gauge. Small French-sized PICCs (1 Fr, 1.2 Fr, 1.4 Fr and up to 1.9 Fr) are designed for the neonatal population to accommodate small vessel sizes.
  • Consider the use of ultrasound guidance.⁶
• Collaborate with the IT department to develop a standardized consultation and procedure note.⁵
  • Use standard terminology to document the type of CVAD (e.g., tunneled CVAD, implanted port) and number of lumens.^2,5
  • Distinguish between the brand names of CVADs (Broviac, PowerPICC).⁵
  • Implement a standardized computerized provider order (CPOE) and order sets for CVAD insertion.5 Ensure that key factors such as indication, anticipated duration, patient condition, and vessel preservation are considered before device selection.^1,2,5
• Use a detailed standard consent form for each type of CVAD available for placement.⁵
• Consider having the ordering provider or proceduralist obtain the CVAD kit to verify the correct type of CVAD is used.
• Confirm readiness and details of the CVAD insertion by conducting a pre-procedure verification process, marking the procedure site, and performing a timeout as outlined in the Universal Protocol.^5,10
  • Verify the number of lumens and type of CVAD to be inserted during the timeout.
• Collaborate with supply chain to standardize CVADs across the organization, focusing on narrowing selections and ensuring adequate supply.⁵
• Confirm catheter tip position following the procedure and prior to potentially damaging medication administration.¹¹
• Incorporate quality improvement initiatives and systematic data collection for monitoring CVAD metrics related to CVAD selections.^2,5

Target audiences

Clinical Leaders, Infection Prevention, Legal/Risk Management, Medical Leaders, Nursing Leaders, Organizational Leaders, Patient Safety, Quality Improvement, Radiology, Surgical Leaders, Supply Chain Management/Value Analysis, IT Department

What can I do with this Risk Review?

• Forward to the recommended target audiences for evaluation.
• Include in your daily safety brief.
• Create loop-closing process for evaluating risks and strategies implemented to decrease risk of repeat harm.
• Let us know what is working and what additional information you need.

Resources

The Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics: miniMAGIC

References

1. Pittiruti M, Crocoli A, Zanaboni C, et al. The pediatric DAV-expert algorithm: A GAVeCeLT/GAVePed consensus for the choice of the most appropriate venous access device in children. J Vasc Access. 2025 May;26(3):715-725. doi: 10.1177/11297298241256999. Epub 2024 Jun 10. PMID: 38856094.
2. Nickel B, Gorski L, Kleidon T, et al. Infusion Therapy Standards of Practice, 9th Edition. J Infus Nurs. 47(1S): pS1-S285, January/February 2024. | doi: 10.1097/NAN.0000000000000532.
3. Raina R, Mittal A, Sethi SK, Chakraborty R. Challenges of vascular access in the pediatric population. Adv Chronic Kidney Dis. 2020 May;27(3):268-275. doi: 10.1053/j.ackd.2020.02.005. PMID: 32891312.
4. Moureau NL. Vessel Health and Preservation: The Right Approach for Vascular Access. Springer Nature; 2024.
5. Wagner ML, Doellman D, Forlenza KN, et al. Standardizing Preoperative Evaluation for Pediatric Central Venous Access: A Care Algorithm to Improve Safety. J Infus Nurs. 2020 Sep/Oct;43(5):262-274. doi: 10.1097/NAN.0000000000000386. PMID: 32881813.
6. Paterson RS, Chopra V, Brown E, Kleidon TM, Cooke M, Rickard CM, Bernstein SJ, Ullman AJ. Selection and insertion of vascular access devices in pediatrics: A systematic review. Pediatrics. 2020 Jun;145(Suppl 3):S243-S268. doi: 10.1542/peds.2019-3474H. PMID: 32482738.
7. Ma M, Garingo A, Jensen AR, Bliss D, Friedlich P. Complication risks associated with lower versus upper extremity peripherally inserted central venous catheters in neonates with gastroschisis. J Pediatr Surg. 2015 Apr;50(4):556-8. doi: 10.1016/j.jpedsurg.2014.08.026. Epub 2014 Dec 17. PMID: 25840062.
8. Putigna F, Kim ES. Central venous access in the pediatric patient treatment & management. Updated Feb 01, 2024. Accessed emedician.medscape.com/article/940865-treatment
9. Nunn JL, Takashima MD, Wray-Jones EM, Soosay Raj TA, Hanna DMT, Ullman AJ. Central venous access device adverse events in pediatric patients with cancer: a systematic review and meta-analysis. Supp Care Cancer. 2024 Sep 16;32(10):662. doi: 10.1007/s00520-024-08853-0. PMID: 39283363; PMCID: PMC11405478.
10. Speak Up Poster (2018). The Joint Commission. (The Universal Protocol). Retrieved from https://cvquality.acc.org/docs/default-source/pci-bleeding-risk-checklist/universal-protocol-from-the-joint-commission.pdf
11. Sharon, S. (n.d.). Emergency and elective venous access in children. UpToDate.