CVC Pre-Op Evaluation and Line Selection Guideline

Guideline · Aug 2019 · 2 min read

In brief

Clinical guideline for preoperative evaluation and appropriate central venous catheter selection in pediatric patients requiring vascular access.

Written by the GCMD Library team from the guideline.

Line Selection by Therapy Type and Duration

Red medication infusions require tunneled CVCs for durations exceeding 2 months, while shorter durations may utilize PICCs or non-tunneled lines. Yellow/green medications follow similar duration-based algorithms with age considerations for patients under 2 years. Peripheral IV remains an option when appropriate, with midline catheters suitable for therapies under 14 days.

Apheresis Catheter Selection

Temporary apheresis procedures under 2 weeks utilize percutaneous double-lumen catheters, while prolonged apheresis requires tunneled double-lumen lines. Port-based apheresis systems are reserved for special circumstances including body habitus concerns and needle phobia.

Single vs Double Lumen Decision Algorithm

Double lumen catheters are indicated for specific infusion aids requiring dual access, simultaneous administration of incompatible medications, or frequent blood product transfusions. Single lumen lines are appropriate when these special circumstances do not apply.

Inpatient CVC Evaluation and Risk Stratification

Patients requiring access for 14 days or more with red infusates undergo systematic risk assessment using high, intermediate, and low risk criteria. High risk factors include 3 or more prior tunneled lines, venous thrombosis history, abnormal vascular anatomy, or congenital heart disease, while intermediate risk includes hematocrit under 30%, platelets under 50k, or BMI over 35.

Renal Failure Patient Pathway

Patients with renal failure or ESRD follow a specialized guideline separate from standard CVC algorithms. The pathway includes urgency assessment with timeframes under 12 hours, 12-48 hours, or greater than 48 hours for scheduling purposes.

High Risk Pre-operative Evaluation

High risk patients require great vessel ultrasound within 30 days, with abnormal findings prompting MRV and multidisciplinary review with interventional radiology and surgery. Abnormal vascular anatomy necessitates collaborative planning to confirm appropriate CVC type and placement approach.

Intermediate Risk Pre-operative Assessment

Intermediate risk patients undergo laboratory and skin assessment with pre-operative correction of abnormalities when feasible. Uncorrectable abnormalities require surgical discussion prior to scheduling, while skin issues necessitate wound care team involvement for perioperative management.

Low Risk and Anatomic Variant Pathways

Low risk patients proceed directly to CVC type confirmation and scheduling after standard evaluation. Patients with abnormal body habitus or elevated BMI undergo great vessel ultrasound, with normal studies proceeding to ultrasound-guided placement after surgical and requesting team confirmation.

Statements in this guideline

For red medication infusions, a PICC or non-tunneled CVC is appropriate if therapy duration is 15 days or less.
RecommendationLine Selection Guide for Appropriate CVC Type
For red medication infusions lasting more than 15 days but 2 months or less, a tunneled CVC is appropriate.
RecommendationLine Selection Guide for Appropriate CVC Type
For red medication infusions lasting more than 2 months, a tunneled CVC is appropriate.
RecommendationLine Selection Guide for Appropriate CVC Type
For continuous infusion or access one or more times per day with yellow or green medications, a PICC or non-tunneled CVC is appropriate if therapy duration is 2 months or less.
RecommendationLine Selection Guide for Appropriate CVC Type
For continuous infusion or access one or more times per day with yellow or green medications lasting more than 2 months, a tunneled CVC is appropriate if the patient is 2 years of age or older.
RecommendationLine Selection Guide for Appropriate CVC Type
For continuous infusion or access one or more times per day with yellow or green medications lasting more than 2 months in patients younger than 2 years, a tunneled CVC is appropriate.
RecommendationLine Selection Guide for Appropriate CVC Type
For intermittent infusion of yellow or green medications lasting more than 2 months, a port CVC is appropriate unless special circumstances exist.
RecommendationLine Selection Guide for Appropriate CVC Type
Special circumstances for port selection include body habitus such as obesity and needle phobia.
EstablishedLine Selection Guide for Appropriate CVC Type
For temporary pheresis lasting 2 weeks or less, a percutaneous pheresis-capable CVC with double lumen is appropriate.
RecommendationLine Selection Guide for Appropriate CVC Type
For prolonged pheresis lasting more than 2 weeks, a tunneled pheresis double lumen catheter is appropriate unless special circumstances require a port pheresis catheter.
RecommendationLine Selection Guide for Appropriate CVC Type
A midline catheter is appropriate for therapy lasting 14 days or less when PIV is not an option.
RecommendationLine Selection Guide for Appropriate CVC Type
A double lumen catheter is indicated when specific infusion aids require double lumen, such as Cyclosporin, Methotrexate, or Leucovorin.
RecommendationSelection Guide for Single vs. Double Lumen
A double lumen catheter is indicated when multiple incompatible medications are given simultaneously.
RecommendationSelection Guide for Single vs. Double Lumen
A double lumen catheter is indicated when multiple or frequent blood draws are anticipated.
RecommendationSelection Guide for Single vs. Double Lumen
A double lumen catheter is indicated when frequent infusion of blood products is anticipated.
RecommendationSelection Guide for Single vs. Double Lumen
High risk criteria for CVC placement include 3 or more prior tunneled lines, history of venous thrombosis, documented abnormal vascular anatomy, history of congenital heart disease or cardiac surgery, and history of difficult access.
EstablishedCare Algorithm for Evaluation of CVCs for Inpatients
Intermediate risk criteria for CVC placement include hematocrit 30% or less, platelet count 50,000 or less, abnormal skin condition, BMI greater than 35, and abnormal body habitus or anatomy.
EstablishedCare Algorithm for Evaluation of CVCs for Inpatients
For high risk patients, obtain great vessel ultrasound if not done within the past 30 days.
RecommendationCare Algorithm for Pre-op Evaluation
For high risk patients with abnormal great vessel ultrasound, obtain MRV and review with interventional radiology and surgery.
RecommendationCare Algorithm for Pre-op Evaluation
For intermediate risk patients, confirm CVC type and obtain labs; if labs are abnormal and able to correct, develop a plan with the primary team for pre-operative correction.
RecommendationCare Algorithm for Pre-op Evaluation
For intermediate risk patients with abnormal skin, develop a plan with the primary team and wound care team as necessary for perioperative management.
RecommendationCare Algorithm for Pre-op Evaluation
For intermediate risk patients with abnormal body habitus or elevated BMI, obtain great vessel ultrasound if not already done.
RecommendationCare Algorithm for Pre-op Evaluation
For low risk patients, confirm CVC type, discuss the case with the surgeon, and confirm the schedule.
RecommendationCare Algorithm for Pre-op Evaluation
Patients with renal failure or end-stage renal disease should be managed according to the Renal Guideline once it is finalized.
RecommendationCare Algorithm for Evaluation of CVCs for Inpatients

Full text

Line Selection Guide for Appropriate CVC Type Type of therapy PICC/Non-tunneled YesRed medication Frequency oftherapy Duration oftherapy Continuous infusion(or access ≥1 a day) Duration oftherapy≤ 2months > 2months 15 days ≤ infusion≤ 2 months > 2 months Tunneled CVC Patient’sage≥2yo Tunneled CVC<2yoIntermittent Tunneled CVC Yellow or green Duration oftherapyPheresis Percutaneous pheresiscapable CVC (double lumen) Temporary(≤ 2 weeks) Prolonged(> 2 weeks) A A START PIV is an optionConsult VAT teamYes No Midline catheter ≤ 14 days Tunneled pheresis(double lumen)Unique therapy requiring Port Special circumstanceYes NoPort CVC No Port pheresisYes Special circumstances:•Body habitance(e.g. obesity)•Needle phobia v. 2017 .929 Standard Notes•Type “ipstandard” into text box that reads “Insert SmartText”.•Choose appropriate note (tunneled CVC vs mediport)Updated 1/2019

Selection Guide for Single vs. Double LumenV 2017 929 START Special needsDouble lumenYes NoSingle lumen Special circumstances:-Specific infusion aids requiring double lumen (e.g. Cyclosporin, Methotrexate, Leucovorin)-Multiple, incompatible medications are given simultaneously-Multiple/frequent blood drawn is anticipated-Frequent infusion of blood productis anticipated

Patient needs CVC placement Care Algorithm forEvaluation of CVCs for Inpatientsv. 2017 .424 PIVor see PICC guideline for NeonatesNo Yes Follow Renal Guideline Yes Review line selection guide as neededAssess risk level(by surgery/VAT) High risk criteria HYes to any IYes to any L No to all No to all High risk placement Intermediate risk placement Low risk placement No High risk criteria:-≥3 prior tunneled lines-History of venous thrombosis-Documented abnormal vascular anatomy-History of congenital hearth disease or cardiac surgery-History of difficult accessIntermediate risk criteria:-HCT≤ 30%-Plt≤ 50k-Abnormal skin condition-BMI>35-Abnormal body habitus/anatomy Access ≥ 14 days or Red infusate Intermediateriskcriteria Patient:Renal failure or ESRD Obtain tentative schedule Confirm urgency:•<12 hours•12-48 hours•>48 hours * We are expected to utilize Renal Guideline for renal failure or ESRD patients once it is developed. Renal Guideline*is finalized No Yes

Care Algorithm forPre-op Evaluation H Obtain great vessel u/s Discuss w/ surgeon, review with IR as needed and confirm scheduleYes No Yes Obtain MRV NoNormal (w/i last 30 days) Review with IR and surgery Confirm schedule Abnormal LConfirm CVC typeDiscuss case with surgeonConfirm schedule Greatvessel u/s done in the past 30 days IConfirm CVC type LabsDevelop plan w/primary team for pre-op correctionAble to correctNo Discuss w/ surgeon and confirm schedule Yes Abnormal Skin Normal Normal Develop plan w/primary team and wound care team as necessary for periopmanagement Abnormal Review with oncall surgeon, consider discussion with IRConfirm scheduleYes L Abnormal body habitus / elevated BMINo Confirm CVC type Normal u/s Normal MRV Line placement w/ u/s. Confirm plan w/surgery and requesting team v. 2017 .424

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