Journal of Parenteral and Enteral
Volume 00 Number 0
xxx 2019 1–24
C2019 American Society for
Parenteral and Enteral Nutrition
Evidence-Based Strategies and Recommendations
for Preservation of Central Venous Access in Children
Kevin M. Baskin, MD1; Leonard A. Mermel, DO, ScM2;
Theodore F. Saad, MD3; Janna M. Journeycake, MD4; Carrie M. Schaefer, MD5;
Biren P. Modi, MD, MPH6; John I. Vrazas, MD7; Beth Gore, PhD8;
Barbie B. Drews, RN, CPNP9; Darcy Doellman, RN, BSN, CRNI10;
Samuel A. Kocoshis, MD11; Kareem M. Abu-Elmagd, MD, PhD12;
Richard B. Towbin, MD13; and Venous Access: National Guideline and Registry
Development (VANGUARD) Initiative Affected Persons Advisory Panel1
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 identies 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.*(JPEN J Parenter Enteral Nutr. 2019;00:1–24)
central venous access complications; coordination of care; guidelines; pediatrics; shared decision-making; venous access
From the 1VANGUARD, Venous Access (VANGUARD) Task Force, Society of Interventional Radiology (SIR), Pittsburgh, Pennsylvania, USA;
2Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA; 3Nephrology Associates of Delaware, Newark, Delaware,
USA; 4Jimmy Everest Center for Cancer and Blood Disorders in Children, University of Oklahoma, Oklahoma City, Oklahoma, USA; 5Pediatric
Interventional Radiology, Phoenix Children’s Hospital, Phoenix, Arizona, USA; 6Center for Advanced Intestinal Rehabilitation, Children’s
Hospital of Boston, Harvard Medical School, Boston, Massachusetts, USA; 7Royal Children’s Hospital, Melbourne, Victoria, Australia;
8Association for Vascular Access, Herriman, Utah, USA; 9Children’s Medical Center of Dallas, Dallas, Texas, USA; 10Vascular Access Team,
Children’s Hospital of Cincinnati Medical Center, Cincinnati, Ohio, USA; 11Pediatric Nutrition and Intestinal Care Center, Children’s Hospital
of Cincinnati Medical Center, University of Cincinnati, Cincinnati, Ohio, USA; 12Cleveland Clinics Foundation Hospitals and Clinics, Case
Western Reserve University, Cleveland, Ohio, USA; and the 13Department of Radiology, Phoenix Children’s Hospital, Phoenix, Arizona, USA.
A complete list of nonauthor contributors appears in Appendix 1.
∗These recommendations have been endorsed by the Board of Directors of the American Society for Parenteral and Enteral Nutrition.
Financial disclosure: None declared. No funding was secured for this study.
Conict of interest: None declared.
Disclaimer: These standards do not constitute medical or other professional advice and should not be taken as such. To the extent that the
information published herein may be used to assist in the care of patients, this is the result of the sole professional judgment of the attending
healthcare professional whose judgment is the primary component of quality medical care. The information presented in these standards is not a
substitute for the exercise of such judgment by the healthcare professional. Circumstances in clinical settings and patient indications may require
actions different from those recommended in this document and in those cases, the judgment of the treating professional should prevail.
Received for publication January 25, 2019; accepted for publication March 19, 2019.
This article originally appeared online on xxxx 0, 2019.
Kevin M. Baskin, MD, 138 Chapel Harbor Drive, Pittsburgh, PA 15238.
2Journal of Parenteral and Enteral Nutrition 00(0)
Children are particularly vulnerable to complications
of chronic disease, and symptoms of severe acute
complications can often be missed in these patients.1,2
Central venous catheter (CVC)-related complications can
be life-threatening, with an estimated 12.5%–25% mortality
associated with catheter-related bloodstream infections
(CRBSIs).3,4 Catheter-related complications also add tens
of billions of dollars to healthcare costs in the United States
annually,5chiey attributable to chronic (prolonged or
repeated) venous access. Additional systemic complications,
interruption of life-preserving therapies, and increased fre-
quency of thrombosis and endocarditis are associated with
bloodstream infections in certain high-risk populations.6,7
Because conventional venous access routes are frequently
impaired, establishing and maintaining high-quality venous
access in high-risk children can be very challenging.8
In 2016, the VANGUARD (Venous Access: National
Guideline and Registry Development) multistakeholder
symposium prioritized anticipatory planning for chronic
venous access, including individualized review of venous
access history, to preserve central venous pathways (venous
capital) and reduce complications in pediatric patients who
require chronic central venous access, and thereby save lives
and reduce the frequency and duration of hospitalization
and associated healthcare costs.5A multidisciplinary panel
of subject matter experts was invited to meet this charge
and, based on available evidence and expert consensus,
develop recommendations regarding common CVC failure
points and critical components of care that anticipate the
potential need for lifetime access (Table 1). The purpose of
these guidelines is to help the clinical community improve
the quality of CVC-related care and the quality of life for
patients who require chronic central venous access.
An in-depth Medline (PubMed) search of the relevant
medical literature was performed. Peer-reviewed articles
were critically reviewed with regard to study methodol-
ogy, results, and conclusions. To fulll the Institute of
Medicine standards for guideline development, a subset of 5
panel members used a modied Grading of Recommenda-
tions Assessment, Development, and Evaluation (GRADE)
process to evaluate the quality of evidence for and the
strength of each recommendation, similar to the classica-
tion systems used by specialty practice societies such as the
American College of Cardiology and the American Heart
The strength of each recommendation reects the au-
thors’ judgments about the relative strengths and weak-
nesses of study data, including the risks and benets iden-
tied by the evidence and a synthesis of conicting nd-
ings among multiple studies. The Good Practice Statement
(GPS) was used for recommendations without published
evidence or consensus.10 GPS recommendations were de-
veloped from indirect literature and the experience of the
expert panel and may address social, legal, and ethical
questions and implementation issues not appropriate to
more formal evidence grading. Details of the classication
hierarchy are included with the recommendations. Where
evidence was weak and expert opinions were conicting or
contradictory, a modied Delphi technique was utilized to
facilitate effective decision-making.11 Perspectives of an ad-
visory panel of affected persons (patients, parents, families,
caregivers, and support organizations) were incorporated
into the document (Appendix A1).
Failure Points and Essential Components
Widely advocated practices to reduce catheter-related com-
plications in the acute care environment include insertion
and maintenance bundles and removal of catheters that are
no longer required.12-16 For patients who require chronic
venous access for life-preserving therapy, the situation is
more complex, the opportunities for device failure and
adverse events more varied, the accumulation of venous
injuries more insidious, and the need for collaborative,
evidence-driven care more pivotal. Compartmentalized and
discontinuous clinical reasoning too often results in avoid-
able adverse outcomes with potentially devastating results.
The following sections encourage collaborative manage-
ment reasoning17 through critical practices and precautions
that facilitate optimal preservation of venous health and
patency in high-risk chronic venous access patients.
Diagnostic Venous Imaging and Evaluation
Venous compromise is prevalent in patients requiring
chronic access. At least 40%–50% of intestinal failure and
renal failure patients have obstruction of at least 1 major
venous pathway.18,19 Vascular imaging studies should an-
swer clinical questions and characterize the location, nature,
and extent of abnormalities, directed by experts in vascular
imaging and interventions. Imaging must be timely, problem
centered, and task oriented for identication of relevant
issues and therapeutic planning, to assess and document
venous patency and outcomes of device or pathway salvage
Venous injury can be cumulative, progressing from dis-
organized thrombus and perivascular edema through suba-
cute thrombus or stenosis to mature clot or vein wall brosis.
However, even a single injury can lead to irreversible ob-
struction. Early recognition and aggressive intervention are
necessary to preserve venous capital at risk.20 Initial venous
injuries, often subtle and occult, inuence the success of
Baskin et al 3
Table 1. Recommendations for Preservation of Central Venous Access in High-Risk Patients.
Grade Class Strength Recommendations
Venous imaging and evaluation
1.1.1 C I Strong In high-risk patients, venous imaging and evaluation should include review of all available and
relevant prior vascular imaging studies.
Diagnostic contrast venography
1.2.1 B I Strong DIV should be used as the primary initial modality to survey the venous system for patency,
obstruction, or abnormalities of the major venous pathways.
1.2.2 GPS Strong Baseline DIV should ideally be performed before the patient’s rst venous access device is
removed regardless of the reason for removal and should include each pathway in which an
access device has been inserted.
1.2.3 GPS Strong If prior history cannot be conrmed, then an initial survey of all major venous pathways should
Diagnostic venous ultrasound
1.3.1 C IIa Strong Venous ultrasound should be used as a secondary diagnostic modality to follow targeted lesions
and evaluate specic clinical questions as part of a comprehensive plan to routinely survey the
state of the patient’s venous capital.
1.3.2 B I Strong Venous ultrasound examination and its documentation should adhere to appropriate standards.
Venous access planning
2.1.1 C IIa Strong Prospective venous access planning should begin at the time the high-risk patient is rst diagnosed
with an indication for chronic access.
2.1.2 C IIa Strong The prospective venous access plan should govern every elective venous event; no elective
vein-related intervention should be undertaken outside the scope of this plan.
2.1.3 C IIb Strong If an experienced multidisciplinary venous access team (see 6.1.1) does not exist within the
treating institution, consultation with or referral to such a center should be considered.
2.1.4 C I Strong For high-risk patients with a history of difcult access or venous access–related complications,
liaison with or transfer to a pediatric tertiary care facility with expertise treating high-risk
patients should be obtained as early after diagnosis as practicable.
Elective access conditions
3.1.1 C IIa Strong Venous access should be performed under the supervision of an experienced practitioner,
preferably an expert in venous access and related salvage procedures in high-risk children.
3.1.2 A I Strong Only individuals appropriately educated to protect the integrity of the device and access site and
to prevent access-related complications should provide continuing care of venous access devices.
3.1.3 A I Strong Elective venous access in high-risk patients should always be performed in a sterile environment
with sterile technique, appropriate apparel, and other sterile barriers.
3.1.4 B I Strong If temporary venous access (ie, a nontunneled, noncuffed central catheter or a catheter, including
a midline catheter, that does not terminate near the cavoatrial junction) must be acquired for a
central venous indication due to exigent clinical circumstances, it should be accompanied by a
plan for removal or elective access in an appropriate theater as soon as possible thereafter.
3.1.5 A I Strong For venous access, real-time ultrasound guidance for percutaneous venipuncture is preferred to
the cut-down or landmark techniques.
3.1.6 A I Strong Guide wire positioning and catheter delivery and positioning during CVC insertion should be
performed with real-time uoroscopic control.
3.2.1 B I Strong Conventional access sites from most to least preferred include neck veins (eg, internal or external
jugular), arm veins (eg, brachial or basilic), femoral vein, and subclavian vein.
3.2.2 C IIa Strong Use of upper extremity veins for access should be avoided in patients with potential future need
Catheter tip position
3.3.1 B I Strong A long-term catheter tip should be positioned in the proximal cava near the cavoatrial junction.
3.3.2 B I Strong The tip(s) of a long-term hemodialysis catheter should be positioned within the right atrium.
3.3.3 C IIa Strong A temporary catheter tip should be positioned in the lower SVC from above the diaphragm, or
above the iliac conuence from below.
3.3.4 C IIa Strong A CVC should not be used until the catheter tip position has been veried with medical imaging.
3.3.5 B IIa Strong If a catheter is malpositioned, it should be promptly repositioned or replaced.
3.3.6 GPS Strong In a growing child, catheter tip location should be veried at least every 12 months.
3.4.1 C I Strong Peripherally inserted or tunneled, cuffed central catheters are preferred to temporary or uncuffed
3.4.2 B I Strong Subcutaneous indwelling venous ports should be reserved for chronic intermittent therapy in
patients immunocompetent at the time of insertion.
3.4.3 C I Strong In all cases, the smallest catheter diameter and the fewest lumens required to deliver anticipated
therapy safely are recommended.
3.4.4 B I Strong Antimicrobial-impregnated catheters should be considered for CVC insertion in all high-risk
4Journal of Parenteral and Enteral Nutrition 00(0)
Table 1. (continued)
Grade Class Strength Recommendations
3.4.5 B IIb Weak Antimicrobial lock therapy should be considered for CVC care in all high-risk patients.
Documentation of suspected catheter-related infection
4.1.1 C I Strong For all high-risk patients with a venous catheter in place with signs and symptoms that suggest a
bloodstream infection, diagnosis of a catheter-related infection should follow a rigorous
4.1.2 C I Strong The associated elements that lead to support for or rejection of a diagnosis of catheter-related
infection in each case should be clearly documented in the medical record.
4.1.3 A I Strong Diagnosis should ideally be supported by central and peripheral culture, or culture from the
dialysis bloodline, of an organism known to cause catheter infections with a differential latency
to positivity, or by purulent discharge related to the exit site, subcutaneous tract, or port pocket,
or by catheter tip culture, which grows the same microorganism as the peripheral or bloodline
4.1.4 B IIa Weak For suspected CRBSI, blood cultures should be obtained from each catheter lumen if possible.
4.1.5 A I Strong If the catheter is removed under suspicion of infection, a roll-plate culture of the catheter tip
should be obtained.
4.2.1 C I Strong In a high-risk patient, a functioning noninfected and appropriately positioned chronic venous
access device should be removed only at the end of therapy.
4.2.2 B I Strong In the event of a CVC-related infection that cannot be successfully treated with the catheter in
situ, including Staphylococcus aureus, Gram-negative enterococcus, and catheter-associated
fungemia, the catheter should be removed.
4.2.3 A I Strong When the patient is symptomatic of sepsis, including cardiovascular instability or end organ
failure, particularly with positive blood cultures, and another focus cannot be identied, the
catheter should be removed.
Catheter-related thrombosis and venous obstruction
5.1.1 B I Strong If there are signs or symptoms of deep venous obstruction, or a known history of obstruction or
previous difcult access, proactive investigation should be instituted prior to attempting new
5.1.2 C I Strong Diagnosis of venous obstruction or injury should be documented in the EHR, using standard
nomenclature, including the nature and extent of involvement and the outcome of any related
5.1.3 GPS Weak If central venous obstruction is diagnosed, it should be preemptively treated.
5.1.4 C IIa Strong In the event of central venous obstruction, every reasonable attempt should be made to reestablish
patency for the purpose of venous access across an injured vein before accessing an uninjured
5.1.5 C IIa Strong Insertion of a venous stent should be avoided except as a last option to permit transplantation,
alleviate risk to a vital organ, relieve intractable pain, or reduce functional impairment from
venous hypertension and related inammation and secondary lymphedema.
5.1.6 C IIb Weak Consideration should be given to prophylactic anticoagulation in patients with chronic need for
central venous access.
5.1.7 B IIa Strong Alternate routes should be considered only if conventional venous pathways cannot be accessed
or recanalized for access.
5.2.1 C IIb Weak Vascular specialists with training and experience in difcult access and vessel and catheter salvage
should perform treatment of venous obstruction, catheter salvage and venous recanalization
procedures, stent insertion, and access via unconventional pathways.
Collaborative care and information management
6.1.1 C IIa Strong Each institution routinely caring for high-risk patients who require chronic central venous access
should identify a CVAT.
6.1.2 C IIa Strong Ideally, the CVAT should supervise continuing venous access device care and maintenance,
guideline and policy development, and resolution of difcult or contentious issues regarding the
maintenance of venous health and successful venous access in children at high risk for
6.1.3 C I Strong To preserve venous capital and minimize risks of catheter-related dysfunction, it is strongly
recommended that the CVAT develop and maintain a long-term plan for preservation of venous
access for each high-risk patient.
6.1.4 C IIa Strong The unied plan developed by the CVAT should be maintained as part of continuing care
6.1.5 GPS Strong Patient and device selection, device insertion, continuing catheter care, device and venous pathway
salvage, treatment of related complications, and device removal should be considered in
accordance with the existing CVAT preservation plan or in consultation with the CVAT
responsible for maintaining and updating that plan.
Baskin et al 5
Table 1. (continued)
Grade Class Strength Recommendations
6.1.6 GPS Strong The CVAT should work to achieve full engagement of affected persons (patients, parents, families,
caregivers, and support organizations) in the planning and process of care to ensure that
patient-important outcomes are prioritized.
6.1.7 C I Strong The patient-healthcare relationship should include bidirectional communication and shared
decision-making, support for patient self-management, and appropriate use of eHealth
technology as a complement to care.
Electronic medical record
6.2.1 GPS Strong Development of a unied set of interoperable CDE specic for the venous access domain is
6.2.2 GPS Strong A continuous electronic summary of all venous access events should be part of continuing care
documentation, easily accessible to and transferable by the patient.
6.2.3 GPS Strong The venous access event record should be reviewed prior to any new venous intervention.
6.2.4 C I Strong Active patient-reported outcomes and other patient-generated health data should be integrated
with clinical data to develop real-world evidence reective of data and issues important to the
CDE, common data elements; CRBSI, catheter-related bloodstream infection; CVAT, Collaborative Venous Access Team; CVC, central venous
catheter; DIV, diagnostic infusion venography; EHR, electronic health record; SVC, superior vena cava.
A: Recommendation based on evidence from multiple randomized trials or meta-analyses.
B: Recommendation based on evidence from a single randomized trial or nonrandomized studies.
C: Recommendation based on expert opinion, case studies, or standards of care.
GPS: Good Practice Statement.
•Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective.
•Class II: Conditions for which there is conicting evidence and/or a divergence of opinion about the usefulness/efcacy of a procedure or
•Class IIa: Weight of evidence/opinion is in favor of usefulness/efcacy.
•Class IIb: Usefulness/efcacy is less well established by evidence/opinion.
•Class III: Conditions for which there is evidence or general agreement that the procedure/treatment is not useful/effective and in some cases may
For each recommendation, an overall rating was provided:
S: Strongly recommended.
W: Weakly recommended.
subsequent efforts to maintain or restore venous patency.
A baseline study of the major central veins should ideally
be obtained at or before the time the high-risk patient’s rst
CVC is removed.
Although venous ultrasound (US) is strongly recom-
mended in some guidelines,21 it is neither a survey modal-
ity nor adequate for diagnosis, especially in a high-risk
population.22 However, it is very useful as a secondary
modality to follow targeted lesions and evaluate specic
clinical questions. The use of diagnostic venous US should
adhere to established guidelines.23-25
Conventional diagnostic infusion venography (DIV)
demonstrates ow dynamics and is highly sensitive and
specic with a high negative predictive value,22 but must
be directed to each vascular territory of interest. DIV is
considered the reference standard to evaluate the patency
of conventional central venous pathways and to document
the nature and extent of anatomic abnormality or central
Computed tomography (CT) and magnetic resonance
(MR) venography have technical limitations but offer useful
information regarding venous obstruction.30 Superparam-
agnetic iron oxide–based contrast agents may help avoid
gadolinium-based MR contrast complications, such as in
patients with renal failure.31 The venous information con-
tained in CT and MR studies, especially in delayed-phase
imaging, should be reviewed and incorporated into the
documented venous history.32,33 Volumetric reconstruction
may help delineate location and extent of obstruction and
involvement of collateral pathways.34 Intravascular ultra-
sound can also provide high-quality cross-sectional imaging
of focal venous segments and may add critical information
regarding pathophysiology (eg, compression, wall thicken-
ing, or perivenous brosis) and the response to therapeutic
interventions (eg, recoil following venoplasty).35,36
Venous Access Planning
According to the VANGUARD Affected Persons Advisory
Panel, affected persons perceive that central venous access is
often treated as an incidental series of episodic events until
something catastrophic happens. Although extraordinary
measures can manage life-threatening complications and re-
canalize obstructed pathways, they are not always successful
6Journal of Parenteral and Enteral Nutrition 00(0)
and can incur disproportionate clinical and economic costs.8
The anticipatory planning and preventive measures repre-
sented within these recommendations should be initiated
at the time a patient is rst diagnosed with a condition
likely to require chronic venous access of an indeterminate
period (from months to a lifetime).37 Once initiated, such
individualized planning should govern every elective venous
access–related event, over time and across venues.
Elective Access Conditions
A multidisciplinary approach to venous access care in
patients with chronic venous access is advised. For patients
whose underlying diagnosis predicts long-term reliance on
central venous access or whose venous history is already
marked by difcult access or signicant central obstruc-
tion, elective venous access procedures should ideally be
performed at a center with advanced expertise.8,38
Imaging is critically important during the primary ve-
nous cannulation and catheter insertion procedure to reduce
injuries that threaten venous patency and to ensure suitable
location of the catheter tip. US with high-quality near-eld
imaging and penetration and the training and experience to
use it effectively reduces the number of punctures necessary
to gain access and helps to avoid injury to related vital
structures. Real-time cross-sectional imaging also facilitates
adaptation to local anatomic variations and identication
of undiagnosed irregularities such as thrombophlebitis or
venospasm.39,40 Real-time US is the modality of choice for
venous access guidance.41-43
Preferred sites of access include the deep veins of the
neck and chest (eg, internal jugular or brachiocephalic
veins) or the deep veins of the arm and shoulder (brachial,
proximal basilic, and axillary),44-46 although patient-specic
factors may affect selection. Other conventional routes,
including femoral,47 subclavian, and cephalic veins, are
associated with higher rates of mechanical and infectious
complications. The subclavian route in particular should
be avoided, especially for elective insertion of hemodiaysis
Alternative routes are available. Transmediastinal access
to the brachiocephalic veins or distal superior vena cava can
be achieved with coronal retroclavicular US with good long-
term stability.38,49 Translumbar and transhepatic inferior
vena cava access are more technically difcult. Transhep-
atic access is associated with greater mechanical instabil-
ity, higher short-term and long-term complication rates,
and risk of infection.50-53 Hemizygosorazygoscollaterals
are feasible54 albeit rarely used. Transthoracic transatrial
access51,55 is sometimes performed at the time of cardiac
surgery. More invasive alternatives such as creation of an
arteriovenous (AV) access56 and use of arterial access57 have
been described, but experience in children is too limited to
make a recommendation.
To date, no published studies evaluate the risk prole
of catheter tip position against an anatomically validated
reference standard. It is common empiric practice to intend
CVC tip position near the cavoatrial junction58 or in the case
of hemodialysis catheters, within the right atrium.59 Un-
ambiguous methods for accurately describing catheter tip
position relative to anatomic structures that are visible on
a plain radiograph have been published60,61 and integrated
into quality improvement guidelines.62
High-quality uoroscopy is essential for control of cen-
tral venous guide wire and catheter positioning.44 Alter-
native tracking technologies for tip positioning (eg, elec-
trocardiographic and electromagnetic) are promising but
have not yet been objectively validated.63 Transthoracic
echocardiography has been suggested to determine catheter
tip position, but randomized, controlled trials (RCT) have
not been published and expertise with the technique and
equipment is not widely available.64,65 The frequency of
unsuccessful and complicated insertions without imaging
(eg, at the bedside) remains unacceptably high and should
not be routinely attempted in high-risk patients.66,67 Collab-
oration between vascular access nurses and interventional
radiologists may offer improved outcomes compared with
Emergent and urgent devices (ie, “temporary catheters”)
placed without maximum sterile barrier precautions, or
catheters with tips positioned at a distance from the cavoa-
trial junction, should be removed as soon as possible after
stabilization of the patient.69-75 A malpositioned catheter
(that was not too short initially) should be promptly eval-
uated with imaging and either repositioned or replaced to
avoid adverse outcomes.76,77
For elective central venous access, device selection should
be governed by specic indications documented prospec-
tively as part of the assessment/insertion process, including
the expected duration and endpoint of therapy and the
intended route and tip position (Appendix A2). Affected
persons should be considered shared decision makers in the
selection process, especially when issues such as preference,
comfort, and body image do not compromise safety and
preservation of venous pathways. The smallest lumen num-
ber and diameter should be used that accomplish the clinical
objectives safely and effectively.78-80 Vesicants, including
high osmolal, extreme pH, and many chemotherapeutic
agents, should be administered centrally.81,82 Chronic con-
tinuous or frequent infusions should employ a tunneled,
cuffed catheter through veins of the neck, chest, or groin.
There have been no RCTs evaluating midline catheters as
an alternative to CVCs or evaluating their use in high-risk
pediatric patients, and current evidence does not support
such use.83,84 Peripherally inserted central catheters are
an acceptable alternative. However, arm veins should be
avoided in patients with potential future need of hemodial-
ysis (chronic kidney disease higher than grade G2A2 or
Baskin et al 7
Table 2. Reported Central Venous Catheter Infection Rates in
Pediatric Patient Populations.
Pediatric Patient Population
Infections per 1000 Catheter
General population 0.2–0.9
Intensive care units 1–5
Hematology-oncology units 1–4
Hemodialysis patients 2
Intestinal failure patients 1–11
Neonatal intensive care units 11–29
Burn units 30
G3a85) because of the cumulative risk of thrombosis and
loss of potential AV stula sites.26,86 For chronic intermit-
tent access, an indwelling venous port may be placed in
the veins of the chest, extremity, or groin. Ports should be
used with caution in patients who are immunocompromised
at the time of insertion.87 For example, in patients with
intestinal failure, ports may be relatively contraindicated
prior to intestinal adaptation.88 The port septum should
be distant from contaminated sites. Chronic hemodialysis
catheters are ideally tunneled, cuffed devices that should
deliver adequate dialysis blood ow to achieve target dose
(Kt/V at least 1.2) while arterial and venous pressures
remain within acceptable parameters.89
Antibiotic-impregnated catheters have shown signi-
cant reduction in catheter-related infections in high-risk
children90 and have demonstrated superiority to con-
ventional and heparin-bonded catheters in a large pe-
diatric RCT91 without increasing resistance to bacterial
pathogens.92 They may be especially valuable for chil-
dren in the intensive care unit91 and those with intestinal
overgrowth,93 those with active infection at the time of
insertion,4,90 immunocompromised patients, those with a
history of multiple catheter-related infections, or those with
deep venous obstruction of VANGUARD Class II or higher
either above or below the diaphragm (Appendix 4).
Evidence for prophylactic use of antimicrobial lock
solutions has been encouraging in small samples.74,94-98
Meta-analysis suggests they reduce infection risk and can
be additive to other therapies,99,100 although support for
ethanol lock therapy was equivocal in a recent double-blind,
placebo-controlled RCT.101 Similarly, evidence regarding
heparin-bonded catheters in children remains too weak for
a recommendation at this time.102
The reported frequency of venous catheter–related infec-
tions is unacceptably high and still may signicantly un-
derestimate the true rate. Infection rates seem signicantly
higher in populations that require chronic access (Table 2),
although the quality of most currently available data is
low, representing retrospective review of small numbers
of patients with great variability in methodology.103,104 To
know the actual rate of catheter-related infection in high-
risk populations, one must know how many catheters are
placed in high-risk patients; dwell time; number of culture-
positive bloodstream infections, exudates, or catheter tips
(if explanted); and whether there is an alternate source of
Reliable meta-analysis of catheter-related infections is
not currently available. The majority of published studies
report infection rates using the surveillance denition of
central line–associated bloodstream infections, which may
signicantly overestimate the true CRBSI rate.105 Con-
versely, the inuence of penalties for reporting healthcare-
associated infections and the associated reluctance to obtain
blood cultures (as well as the historic aversion to peripheral
venous sampling in children) may account for signicant
underreporting of catheter infections.5,106,107 Both strate-
gies increase uncertainty and may result in presumptive
treatment of catheter-related infection without adequate
conrmation, leading to unnecessary catheter removal and
other potentially harmful treatment. To better ensure ap-
propriate recognition of catheter-related infections and
to prevent inappropriate treatment and device removal,
all high-risk patients with a chronic venous catheter and
signs or symptoms that suggest sepsis should be rigorously
evaluated for a venous catheter–related infection,12 ideally
including differential time to positivity74,108,109 from each
catheter lumen if possible,110,111 and roll-plate culture of
the catheter tip if it is removed.4A consensus strategy for
such evaluation is provided in Infectious Disease Society
of America (IDSA) guidelines (in press). It is essential
that studies of catheter-related infection express results in
events per 1000 catheter days. Because CRBSI signicantly
increases risk of mortality, especially in transplant and
immunocompromised patients, it is also important that
sepsis and mortality be included as key outcome measures
Removing the source is fundamental in the treatment of
infection. This creates a difcult conict because of the need
for critical catheter-dependent therapies such as parenteral
nutrition and hemodialysis, the risk of loss of venous path-
ways, and the increased vulnerability of malnourished, im-
munocompromised patients to risks of catheter reinsertion
and delays in therapy. It is especially problematic because
proof of CRBSI has traditionally included catheter removal
and culture of the tip if another source cannot be identied
and because a large proportion of catheters removed for
suspicion of infection lack microbiologic conrmation.4,113
Ideally, a functioning CVC in a high-risk patient should
be removed at the end of therapy and not before. Quanti-
tative and semiquantitative analysis has allowed more ac-
curate in situ diagnosis of CRBSI.114 Nevertheless, when a
patient is in septic shock due to suspected or proven CRBSI
8Journal of Parenteral and Enteral Nutrition 00(0)
(fever with circulatory compromise or collapse), or remains
symptomatic of sepsis115-117 for >48 hours after initiation of
broad-spectrum therapy, or has a complicated infection (eg,
purulent discharge from the port pocket or subcutaneous
tract, septic thrombosis, endocarditis, osteomyelitis), it is
imperative to remove the catheter.4If the catheter is to
be removed in the setting of septic shock, other vascular
access should rst be established.118 If alternative access is
difcult, the catheter may be exchanged for an antibiotic-
Catheter-Related Thrombosis and Venous
Infectious and thrombotic complications of CVCs are
interrelated.119 Since thrombus serves as a nidus of infec-
tion, there is a higher catheter-related sepsis rate in the
presence of thrombosis.120 Thrombosis and stenosis occur
in children with a history of chronic central venous access
with an incidence of 26%–75% in prospective and cross-
sectional studies.22,37,121 Compromise of central veins leads
to increased hospital admissions for venous access–related
complications and contributes to high morbidity and cost
of care.26,122-124 Thrombosis risk is signicantly increased
in patients who have had multiple CVCs, in patients with
temporary and midline catheters, and in patients with
cardiovascular implanted electronic devices.125-127 Inherited
or acquired thrombophilia should be considered in any child
who develops deep vein thrombosis (DVT).128,129
The true incidence of DVT and stenosis in patients who
require chronic access is unknown because most studies
are limited to symptomatic patients130 and reporting has
been largely nonstandardized.131 However, asymptomatic
thrombosis has clearly been demonstrated in children with
CVCs37,132,133 with serious consequences including loss of
venous access, infection, pulmonary embolic disease, and
post-thrombotic syndrome.134 For these reasons, at the time
of CVC removal in a high-risk patient, especially with a
history of prior venous compromise, venography should be
performed to document patency and to treat compromising
lesions before access is lost. This opportunity for vessel and
catheter salvage may be invaluable to facilitate preservation
of venous capital.
A variety of methods to salvage CVC complications and
to recanalize obstructed pathways have been reported.135-138
For patients with obstructive thrombus in whom thrombec-
tomy or systemic thrombolysis fails or is unsuitable, balloon
or aspiration thrombectomy or catheter-directed pharma-
comechanical thrombolysis have demonstrated effectiveness
in children.139,140 For recanalization of mature thrombus
or nonthrombotic obstruction, less invasive methods (eg,
softer guide wires and dilators, noncompliant angioplasty
balloons) should be attempted before more aggressive tech-
niques and devices (eg, sharp recanalization, cutting bal-
loons, stent insertion) are employed, although risk-benet
analysis and the experience of the procedural team will ulti-
mately govern these decisions. Without long-term outcomes
data for venous stents in children, they should be used with
caution and restraint.141-143
Although evidence for high morbidity and mortality
in children with venous catheter–related DVT is
compelling,8,144,145 until recently, data favoring anticoagu-
lation for CVC-related thrombi and infection prophylaxis
have been relatively weak.146 Evidence regarding the
effectiveness of a shorter duration of therapy and selective
use is evolving.147-149
Standard nomenclature and relationships for veins
commonly involved in venous access are illustrated in Ap-
pendix A3, Figure A1.150 Following the lead of the Interna-
tional Small Bowel Transplant Symposium,18 a comprehen-
sive VANGUARD classication system for supradiaphrag-
matic (Appendix 4, Figures A2-A6) and infradiaphragmatic
(Appendix A4, Figures A7-A11) venous obstruction is illus-
trated. This system is equally useful for documenting the lo-
cation, extent, and nature of venous lesions, including fresh
thrombus, wall thickening/brosis, stenosis, perivascular
brosis, external compression, extravasation/perforation,
and persistent stenotic elastic recoil. A similar framework
can be used to document the location, extent, and nature
of venous salvage procedures and other interventions, such
as adherent catheter retrieval, catheter tip repositioning,
recanalization, venoplasty, and stent insertion. As data
accumulate on the relationship between patterns of venous
injury, obstruction, and other critical endpoints, disease-
specic analysis may prove increasingly useful.131,151
Collaborative Care and Information
Healthcare institutions that routinely care for high-risk
CVC patients should have designated multidisciplinary
Collaborative Venous Access Teams (CVATs).152 Although
the components of care addressed by such a team should
be universal, personnel will vary from site to site but
should ideally consider patient and caregiver representa-
tives; vascular access, infusion, intestinal care, and apheresis
nurses; interventional radiologists; hepatologists; surgeons;
nephrologists; gastroenterologists; infectious disease physi-
cians; intensivists; hematologists; pharmacists; and home
health planning experts. Unfortunately, with the current
focus on indiscriminate reduction of cost, the tendency has
been to disband such teams rather than to form, strengthen,
and value them.153,154
The existence of a multidisciplinary team does not ensure
improved outcomes.155 To be effective, the CVAT should
supervise continuing CVC care and maintenance, guideline
and policy development, and resolution of difcult or con-
tentious access-related issues. CVAT leadership should have
Baskin et al 9
signicant experience with advanced access and salvage
techniques, understand the challenges inherent in treatment
of high-risk populations, and be current with the evidence
base that guides relevant best practices. To preserve venous
capital and minimize risks of catheter-related dysfunction,
the team should develop and maintain individualized long-
term plans for preservation of venous access.156,157 Con-
tinuing care of CVCs in high-risk populations should be
performed by healthcare providers with appropriate educa-
tion and experience, including currency with principles of
exit-site management including antimicrobial-impregnated
dressings and passive disinfection caps, catheter access
technique and protocols, and locking solutions or other cap-
devices to reduce infection risk.12,21,74,158-161
Persons affected by chronic diseases experience signi-
cant disruption in their lives due to morbidity and mortality
from CVC complications; frequent hospitalizations; loss
of time at work, home and school; and other related
costs of care. Healthcare providers often misunderstand
quality of life issues for these patients, especially emotional
disruption, perceptions of pain and discomfort, and impact
on family.162,163 The CVAT should pursue full engagement
of affected persons in the planning and process of care
to ensure that patient-important outcomes are prioritized
and that patient values guide all clinical decisions.164 The
patient-healthcare relationship should include bidirectional
communication and shared decision-making, support for
patient self-management, appropriate use of eHealth tech-
nology as a complement to care, education on safety and
access preservation, and respect for the experiences and
concerns of affected persons.165
Through the 21st Century Cures Act, the U.S. Congress
emphasized the need for interoperability, that is, the ability
for health information access, use, and exchange by au-
thorized persons “without special effort.”166 The concepts
embodied in this law are timely and germane to the complex
coordination-of-care needs of high-risk patients. Develop-
ment of unied and unambiguous electronic vocabulary
specications is essential.5It is imperative that such a unied
venous access vocabulary become the community standard,
including electronic health record, registry, and other health
information technology vendors; payers; publishers; and
government and private agencies. It should also be used
in structured reporting of catheter insertions and other
venous access–related events.167 Each documented event
should become part of a continuous summary of venous
events available to the patient and to health providers across
time and venue. The summary record and multidisciplinary
plan of care should be reviewed prior to any new venous
Inputs from affected persons should be integrated with
clinical data to develop a body of real-world experience,
accessible to the patient, to improve communication and
shared decision-making. Data could also be linked through
the patient’s Unique Device Identier168 to permit coordi-
nation with national outcome tracking networks like the
National Health Safety Network and other big data sources
to inform guidelines, standards, reimbursement, and policy
development. The needs for a robust and interoperable
central venous access registry and for large-scale prospective
research have been identied as national multistakeholder
More than half of Americans have a chronic medical
condition, and more than three-quarters of each health-
care dollar is spent on their care.169 High-risk pediatric
patients are by denition disproportionately vulnerable.
Reliance on central venous access and the impact of re-
lated complications are particularly concentrated in this
population. This paper provides recommendations that can
help stakeholders improve care and quality of life for these
patients. The authors recognize that the quality of evidence
underlying these issues is generally weak, although the need
for consistent guidance and improved communication is
highly compelling. These recommendations should serve
as a foundation for the carefully constructed investigations
needed to provide high-quality evidence that can guide their
use and modication over time.
The authors would like to thank Ms. Stephanie Pitts for her
review of the manuscript.
Statement of Authorship
K. M. Baskin contributed to the conception and design of
the research and drafted the manuscript; K. M. Baskin, T.
tributed to the acquisition and analysis of the data. All authors
contributed to the interpretation of the data, critically revised
the manuscript, agree to be fully accountable for ensuring the
integrity and accuracy of the work, and read and approved the
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The following members of the Venous Access: National
Guideline and Registry Development (VANGUARD) Ini-
tiative and the VANGUARD Affected Persons Advi-
sory Panel are nonauthor contributors: Swapna Kakani,
Emily Hoopes, Aly Becker, Kristin Huibregste, Ansley
McCormick, Alaina McCormick, and Sarah Palya.
A2. Essential Data Elements of a Venous
Access Record for Children at High Risk
of Venous Catheter Complication
1. Diagnostic category: underlying disease, patient
acuity, comorbid illness, American Society of
2. Any contraindicating or complicating factors
c. Fever, sepsis, known infection, immunode-
ciency, nutrition status
d. Venous stenosis
e. Acute thrombosis
f. Local skin infection
g. Evidence of intestinal overgrowth
3. Referring service and provider; inpatient or
4. Indication(s) for venous access placement
or replacement; intended function (eg,
parenteral nutrition, blood products, antibiotic
administration, uid and electrolyte therapy,
dialysis, plasmapheresis/apheresis, phlebotomy,
chelation, simultaneous delivery of incompatible
5. Anticipated duration of and endpoint for venous
6. Intended route and catheter tip position
Baskin et al 15
7. Provider responsible for access (interventionalist,
surgeon, nurse, etc)
8. Procedure location (interventional suite, operating
room, bedside, etc)
9. Preprocedural or periprocedural interventions (eg,
antibiotics; blood products; thrombolytic, antico-
agulant or antiplatelet agents; imaging)
10. Initial access
a. Entry side and site (eg, basilic vein, internal
jugular vein, femoral vein)
b. Method (eg, visual landmarks, uoroscopic
venography, ultrasound, cut-down)
c. Route (eg, percutaneous, transmediastinal,
paraspinal (eg, translumbar), transhepatic,
d. Device (eg, angiocatheter, single wall needle,
e. Number and location of unsuccessful and suc-
f. Complications (eg, arterial puncture, pneu-
g. Reason for deferral, discontinuation, or failure,
if insertion not completed
11. Access device and position
a. Catheter manufacturer, description, lumen
number and diameter, nal internal length,
composition, coating or impregnation, etc.
(documentation of unique device identier
b. Implanted, tunneled, or direct?
c. Cuffed or uncuffed?
d. Tip position (for method, see Baskin et al60 )and
catheter functional status
e. Method of catheter xation, wound closure, and
f. Preventive therapy (eg, alcohol or antibiotic
lock, heparinization, vitamin K antagonists, tis-
sue plasminogen activator (tPA))
g. Procedure time, radiation exposure (eg,
uoroscopy time or estimated radiation
h. Procedural complications (eg, venospasm, ex-
travasation) and management
i. Adjunctive therapies required (eg, papaverine,
nitroglycerine, hot packs)
12. Complications, including
a. Catheter-related infection (include dates)
i Type (phlebitis; catheter-related sepsis; bac-
teremia; colonization; exit site, tunnel, or
pocket infection, etc)
ii Suspected (basis) or proven (method and
iii Management (eg, antibiotics, catheter re-
moval, repeat cultures)
iv Result of catheter tip and blood cultures
b. Catheter dysfunction (include dates)
i Type (eg, phlegmasia, extravasation or in-
ltration, fracture, fragment embolization,
brin sheath formation, tip thrombus, etc)
c. Vein injury or obstruction (eg, stenosis,
thrombosis, brosis, or occlusion) (include
i Method of diagnosis or documentation
ii Location and extent
iii Related complications (eg, superior vena
cava syndrome, post-thrombotic syndrome)
d. Dislodgment, migration, or malposition (in-
i Method of diagnosis or documentation
ii Site of malposition
e. Other catheter-related complications
13. Catheter and venous pathway salvage procedures
a. In situ antibiotic therapy
b. In situ lock therapy (eg, ethanol, antibiotic,
c. tPA catheter thrombolysis
d. Hydrochloric acid clearance
e. Over-the-wire exchange
f. Endovenous repositioning
g. Blunt recanalization
h. Sharp recanalization
j. Stent or stent-graft insertion
14. Complications (include dates and additional de-
a. Major (early [within 30 days of insertion] or late)
i Admission to hospital for therapy
ii Unplanned increase in level of care
iii Prolonged hospitalization
iv Permanent adverse sequelae
i No sequelae
ii Nominal therapy
iii Short hospital stay (for observation)
c. Procedurally related (within 24 hours of inser-
15. Removal or replacement (reason and date; end-
16 Journal of Parenteral and Enteral Nutrition 00(0)
Figure A1. (a) Central venous anatomy. (b) Upper extremity venous anatomy. (c) Lower extremity venous anatomy.
Modied from Baskin, with permission. Baskin KM.
Venous Access and Related Procedures. Temple M, Marshal-
lack F, eds. Philadelphia, PA: Springer; 2014.
A3. Venous Anatomy
The central veins are illustrated in Figure A1A. Variant
anatomy, communicating, and collateral veins are not rep-
resented. The common supercial (blue) and deep (green)
veins of the extremities are illustrated in the right upper ex-
tremity in Figure A1B and the right lower extremity in Fig-
ure A1C. These are mirrored on the left. The numerous
short perforating branches that pierce the supercial muscle
fascia to join the supercial and deep systems are not shown.
The supercial veins of the extremities form extensive and
highly redundant networks, often duplicated or even trip-
licated, the visualizable components of which are variably
expressed. The great (GSV) and small (SSV) saphenous
venous trunks run within sheaths of dense perivascular
connective tissue. Common branches of the supercial veins
of the lower extremity may include anterior and posterior
accessory saphenous veins that parallel the GSV and SSV,
with their conuence near the saphenofemoral junction in
the thigh and near the saphenopopliteal junction in the
posterior calf. Other anterior and posterior tributary veins,
sometimes only visualized when pathologically dilated, may
join the saphenous veins at variable locations along their
length and take their name from their position and drainage
(eg, right posterior thigh tributary of the GSV, left anterior
distal leg tributary of the SSV). Communicating veins may
also join the GSV and SSV, the largest of which is the
postero-medial communicating vein of the thigh, known as
the vein of Giacomini.
Baskin et al 17
Figure A1. Continued.
Figure A2. (a and b) SDO Class I venous obstruction: hemodynamically signicant deep venous obstruction AND at least 1
preserved (uninvolved) conventional systemic venous pathway from each side.
18 Journal of Parenteral and Enteral Nutrition 00(0)
Figure A3. (a and b) SDO Class II venous obstruction: hemodynamically signicant deep venous obstruction involving both
pathways from 1 side, with preservation of contralateral thoracic pathways.
Figure A4. (a and b) SDO Class III venous obstruction: hemodynamically signicant deep venous obstruction involving both
pathways from 1 side, with preservation of at least 1 conventional thoracic pathway.
Baskin et al 19
Figure A5. (a and b) SDO Class IV venous obstruction: hemodynamically signicant deep venous obstruction with no patent
conventional thoracic pathways, with preservation of antegrade ow from the azygos to the right atrium.
Figure A6. (a and b) SDO Class V venous obstruction: hemodynamically signicant deep venous obstruction with no patent
conventional thoracic pathways AND retrograde or static ow through the azygos (all blood returns to the right atrium from
below the diaphragm).
20 Journal of Parenteral and Enteral Nutrition 00(0)
Figure A7. (a) IDO Class IA: Unilateral hemodynamically signicant venous obstruction below the femoral vein without
contralateral involvement. (b) IDO Class IB: Bilateral hemodynamically signicant venous obstruction below the femoral veins.
Baskin et al 21
Figure A8. (a) IDO Class IIA: Unilateral hemodynamically signicant obstruction between the popliteal vein and the inguinal
ligament with patent contralateral ow proximal to the popliteal vein. (b) IDO Class IIB: Bilateral hemodynamically signicant
obstruction between the popliteal veins and the inguinal ligaments.
22 Journal of Parenteral and Enteral Nutrition 00(0)
Figure A9. (a) IDO Class IIIA: Unilateral hemodynamically signicant iliofemoral obstruction with patent ow proximal to the
contralateral common femoral vein. (b) IDO Class IIIB: Bilateral hemodynamically signicant iliofemoral obstruction with
infrarenal inferior vena cava reconstitution.
Baskin et al 23
Figure A10. (a) IDO Class IVA: Hemodynamically signicant infrarenal obstruction with venous return via renal capsular,
portomesenteric, hepatic, and azygos/hemizygos collaterals. (b) IDO Class IVB: Hemodynamically signicant suprarenal inferior
vena cava obstruction with venous return via portomesenteric, hepatic, and azygos/hemizygos collaterals.
24 Journal of Parenteral and Enteral Nutrition 00(0)
A4. VANGUARD Classication of Venous
The obstruction of systemic central venous segments
can be classied by the extent of involvement. Supra-
diaphragmatic venous obstruction (SDO; Figures A2–A6)
is reported separately from infra-diaphragmatic venous
obstruction (IDO; Figures A7–A11).
Figure A11. IDO Class V: Hemodynamically signicant
suprahepatic inferior vena cava obstruction with all venous
return to the right atrium from above the diaphragm.