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Peripheral vascular access as exclusive access mode in pediatric intensive care unit
Sonya Hayes Armstrong1, Shantaveer Gangu2, Alina Nico West2
1Pediatric Intensive Care Unit, Le Bonheur Children's Hospital, Memphis, TN, United States.
Insights
Extended dwell catheters offer longer use than peripheral intravascular catheters (PIVCs) in pediatric intensive care units (PICUs). Factors like vancomycin and blood transfusions reduce PIVC dwell time, making extended catheters a better option for prolonged treatment.
Area of Science:
- Pediatric Critical Care Medicine
- Vascular Access Devices
- Catheter Dwell Time
Background:
- Vascular access in pediatric critical care is crucial, with choices between central and peripheral lines based on treatment duration, medication properties, and monitoring needs.
- Peripheral intravascular catheters (PIVCs) are increasingly utilized, with extended dwell or midline catheters emerging as alternatives, yet lacking placement guidelines.
Purpose of the Study:
- To estimate the dwell time of PIVCs in pediatric intensive care unit (PICU) patients.
- To identify specific parameters influencing PIVC dwell time.
- To develop recommendations for transitioning to extended dwell or midline catheters as alternatives to standard PIVCs.
Main Methods:
- A retrospective study analyzed 484 patients (0-18 years) admitted to the PICU for over 24 hours, receiving only peripheral vascular access between 2019 and 2021.
- Data collected included patient demographics, clinical parameters, insertion attempts, and dwell times for PIVCs and extended dwell/midline catheters.
Main Results:
- The mean PIVC dwell time was 50.1 hours, with an average of 1.6 insertion attempts.
- Patients requiring three or more PIVC insertions had a significantly higher odds ratio (5.2) for receiving an extended dwell or midline catheter.
- Factors associated with increased dwell time included female gender, first-attempt insertion, 24G catheter use, left-sided insertion, less agitation, and less edema. Vancomycin infusion and blood transfusions were associated with decreased dwell time.
Conclusions:
- Extended dwell catheters demonstrate longer dwell times compared to PIVCs in the PICU setting.
- Consideration of treatment length, edema, patient restlessness, vancomycin use, and blood transfusions is essential when deciding on catheter type.
- Extended dwell catheters may be preferable even for treatments projected to be less than 6 days, especially when factors reduce PIVC dwell time and increase painful insertions.
Introduction:
The type of vascular access (central or peripheral) in pediatric critical care depends on several factors, including the duration of treatment, the properties of the medication (osmolarity or vesicant), and the need for central pressure monitoring. The utilization of peripheral intravascular catheters (PIVCs) has shown a notable increase in the number of patients being treated. Extended dwell or midline catheters are another peripheral access option in addition to PIVCs. However, there are currently no established guidelines on their placement.
Objectives:
The aim of this study is to estimate the duration of dwell time for PIVCs, analyze the specific parameters affecting it, and develop recommendations for switching to extended dwell and midline catheter placement as an alternative to peripheral access.
Methods:
The study enrolled patients aged 0-18 years admitted to the pediatric intensive care unit (PICU) for over 24 h and managed with peripheral access only over 2 years (2019-2021).
Measurements And Main Results:
A total of 484 patients met the specified criteria. Patients who had peripheral access exhibited a lower PRISM score and a shorter length of stay in the PICU, with mean values of 18 (SD: 8.5) and 9.5 (SD: 6.4) days, respectively, compared with patients who had central access with mean values of 8.9 (SD: 5.9) and 5.7 (SD: 3.6) days, respectively. The PIVC dwell time was found to be 50.1 h (SD: 65.3) and required an average of 1.6 insertion attempts. Patients with three or more insertions exhibited an increased odds ratio of 5.2 (95% CI: 3.1-8.5) for receiving an extended dwell or midline insertion. Increased dwell time was associated with female gender, 59.5 h (P < 0.001), first attempt insertion, 53.5 h (P < 0.001), use of 24 Ga bore, 56.3 h (P = 0.04), left-sided insertions, 54.9 (P = 0.07), less agitation, 54.8 h (P = 0.02), and less edema, 61.6 (P < 0.001). Decreased dwell time was associated with the use of vancomycin infusion at 24.2 h (P < 0.001) and blood transfusions at 29.3 h (P < 0.001).
Conclusions:
Extended catheters last longer than PIVCs in PICU patients. Extended catheter placement requires consideration of the length of treatment, as well as the overall body edema, the level of the patient's restlessness, and the need for vancomycin infusion or blood transfusions, as these factors reduce PIVC dwell time and expose the patients to painful insertions. For such cases, an extended dwell catheter may be a better option, even if the projected treatment time is less than 6 days.
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