Our study is based on data collected by reviewing all modes of vascular access used for 168 consecutive patients admitted to ER-PICU during a 6-month period from May to October 2020.

In our study, most access devices were indicated for administration of medication and fluids’ infusions (99.7%) and 18% for transfusion of the blood or blood product which is consistent with others who studied access’ indications as Alexandrou et al. [8] whose indications of vascular access were 95% for medications and fluids and 5% for blood products and Abdelaziz et al. [9] who found 92.1% for medications and fluids and 7.9% for blood products’ transfusion.

Elective accesses represented 85.3% while 14.7% of accesses were urgently inserted. Closely similar results were observed in other literature, where 91% were elective in Alexandrou et al. [8], while 59.4% were elective as per another study [10]. Our results showed that peripheral lines were mostly chosen for emergency vascular access (P < 0.001).

The different definition for an “emergency/elective” access in each was found to be the main cause of the difference between the results, as per our methodology “All lines that had been inserted in the ED”. Notably, all lines inserted in the ED were peripheral lines.

No consistency was found between the literature, and our results obtained in this study regarding distributions of VAD type and site. External jugular vein was significantly more often the access of choice for peripheral access (47%) in ER-PICU, while its usage in most similar studies was very limited or even nonexistent; in Melyon et al.’s study of 458 peripheral lines’ [10], Alexandrou et al. [8]’s and Rickard et al. [11]’s all favored superficial limb veins, while external jugular vein was rarely used; most probably for the approach being more invasive thus increased risk of relatively major complications as pneumothorax compared to limb veins [12].

Our results regarding duration of peripheral and central access device use are consistent with the most recent recommendations by the American Academy of Pediatrics (AAP) recommending use of non-tunneled central venous catheters for durations less than 14 days Naik et al. (3) which was also later supported by the series of miniMagic studies in Ullman et al. [13] and US’s Center of Disease Control (CDC)’s guidelines recommending changing peripheral lines every 3 days to prevent increased risk of complications [14]. Other types of access were neither used nor available.

In our study, the incidence of VAD complications among all inserted devices (n = 333) was 30.9%, the reasons for catheter removal were 51.1% completion of treatment, and 30.9% were removed due to complications, 15.3% to prevent infection, and 2.7% as they were found expendable, mostly replacing peripheral access with central access.

Regarding reasons for removal, a significant variation was noted depending on the type of vascular access used (P < 0.001); 35.2% of peripheral lines were removed due to complications while only 22.8% of CVC were removed upon causing complications, which is consistent with the complication rates as it was found that peripheral lines cause more but less life-threatening/serious complications.

Peripheral line complications were found at 35.2%. The most common complications recorded were extravasation (41.6%), hematoma (36.4%), and catheter occlusion (20.8%).

According to previous literature, peripheral lines studied by Alexandrou et al. [8] showed a 12% incidence of complications, 25% by Malyon et al. [10], and 51.9% by Abdelaziz et al. [9], and Hathaway and Magee [15] reported 30.1% incidence of complications.

Regarding peripheral line-specific complications and reason for removal, in Malyon et al. [10]’s study, they were removed due to device failure, and infiltration represented 14.3%, accidental dislodgement 5%, blockage 2.6%, and phlebitis 1.5% with a total of 24.8% of catheters removed due to complications while 75.2% were removed due to completion of treatment, which is consistent with Foster et al. [16]’s study earlier that concluded 74.6% of 370 catheters were removed uncomplicated when they were no longer required.

The incidence of CVC-related complications was 22.8%, and the most common complications were occlusion (46.2%), bloodstream infection (42.3%), and local infection (15.4%).

The rate of complications associated with vascular access in our ICU was found high. Choices of access were found limited to peripheral lines and non-tunneled central venous catheters, relevant choices of access modalities were underutilized, and guidance of U/S was not used as the staff lacked the training needed. Vascular access-related decisions were broad and lacked basis. And there were no specific guidelines or protocols to assist the staff choosing the optimal access for patients based on their specific needs such as anticipated duration of access, infusate characters, and decision was instead left solely to the pediatrician or nurses on duty.

The prevalence of specific complications was consistent with other studies, except for CRBSI whose incidence is higher in our ICU, and the prevalence of pneumothorax which was not observed in our study varied in the literature from 1% as in Howthan and Mersal’s study [15] up to 41.3% in a study by Magee [17].

The incidence of CRBSI in our ICU was 9.05 per 1000 catheter days, which is consistent with studies conducted in developing countries but relatively high compared to developed countries. Howthan et al. (2021)’s study resulted in 3.2 per 1000 catheter days [17].

The reported incidence of CRBSI varies from country to country and even from hospital to hospital. A meta-analysis conducted at The Johns Hopkins Hospital revealed that bloodstream infections (BSIs) were the third leading cause of hospital-acquired infections.

Preventive measures must be planned and implemented in a systematic manner in order to reduce the rate of CRBSI and, as a result, improve healthcare quality. Knowledge of evidence-based interventions may help to reduce infection risks, and research into CRBSI epidemiology and pathogenesis is critical for improving pediatric healthcare quality [18].

Different reasons for admission were found; the most common are postoperative (19%) and pneumonia (14.3%). In Abdelaziz et al. (2017)’s study, most common admission causes were respiratory diseases (24.5%), infections (15.3%), and hematological diseases (18.3%) [9]. In our study period, patients admitted with pneumonia and chest-related conditions were relatively lower as the COVID-19 pandemic impacted the type and quality of the studied group, and COVID-19 patients were referred to specialized isolation hospitals directly from the emergency department (ED).

Our mortality rate is considerably higher than mortality rates in other developing countries as in Siddiqui et al. [19]’s study of 1919 patients admitted to a private-sector PICU located in Pakistan which only 248 died (12.9%). And our mortality was even higher when compared to developed countries’ PICUs such as in Burns et al. [20]’s study conducted in 5 US teaching hospitals that included 9516 pediatric patients of which only 227 died with an overall mortality of 2.39%.

The relatively high mortality rate may be explained by the difference in the severity of diseases in admitted patients as our hospital is a tertiary center and is a destination for referral of the most complicated conditions, also the relatively lower resources, socioeconomic, and educational status of our patients’ families contributes greatly to the outcome.

The median length of the ICU stay was 6 days which is consistent with Abdelaziz et al. [9] who also found the exact same median duration of the ICU stay (6 days), whereas longer stay was found in other studies as per Lin et al. (2017), the average length of stay was 12 days [21].

The COVID-19 pandemic impacted the type and quality of the studied group, and the suspected COVID-19 patients were referred to specialized isolation hospitals directly from the emergency department.

The choices of access were found limited to peripheral lines and non-tunneled central venous catheters.