The Midline Catheter: A Clinical Review

The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–7, 2016 Ó 2016 Elsevier Inc. All rights reserved. 0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2016.05.029

Clinical Review THE MIDLINE CATHETER: A CLINICAL REVIEW Daniel Z. Adams, MD,* Andrew Little, DO,† Charles Vinsant, MD,* and Sorabh Khandelwal, MD* *Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio and †Department of Emergency Medicine, Doctors Hospital, Columbus, Ohio Reprint Address: Daniel Z. Adams, MD, Department of Emergency Medicine, The Ohio State University Wexner Medical Center, 760 Prior Hall, 376 W. 10th Avenue, Columbus, OH 43210.

, Abstract—Background: Venous access in the emergency department (ED) is an often under-appreciated procedural skill given the frequency of its use. The patient’s clinical status, ongoing need for laboratory investigation, and intravenous therapeutics guide the size, type, and placement of the catheter. The availability of trained personnel and dedicated teams using ultrasound-guided insertion techniques in technically difficult situations may also impact the selection. Appropriate device selection is warranted on initial patient contact to minimize risk and cost. Objective: To compare venous access device indications and complications, highlighting the use of midline catheters as a potentially costeffective and safe approach for venous access in the ED. Discussion: Midline catheters (MC) offer a comparable rate of device-related bloodstream infection to standard peripheral intravenous catheters (PIV), but with a significantly lower rate than peripherally inserted central catheters (PICC) and central venous catheters (CVC) (PIV 0.2/1000, MC 0.5/1000, PICC 2.1–2.3/1000, CVC 2.4–2.7/1000 catheter days). The average dwell time of a MC is reported as 7.69– 16.4 days, which far exceeds PIVs (2.9–4.1 days) and is comparable to PICCs (7.3–16.6 days). Cost of insertion of a MC has been cited as comparable to three PIVs, and their use has been associated with significant cost savings when placed to avoid prolonged central venous access with CVCs or in patients with difficult-to-access peripheral veins. Placement of a MC includes modified Seldinger and accelerated, or all-in-one, Seldinger techniques with or without ultrasound guidance, with a high rate of first-attempt success. Conclusion: The MC is a versatile venous access device with a low complication rate, long dwell time, and high rate of firstattempt placement. Its utilization in the ED in patients

deemed to require prolonged hospitalization or to have difficult-to-access peripheral vasculature could reduce cost and risk to patients. Ó 2016 Elsevier Inc. All rights reserved. , Keywords—midline catheter; midline; venous access devices

INTRODUCTION Midline catheters (MC) are typically 8–20 cm in length and are placed peripherally into the antecubital fossa or upper arm, with the tip located at or below the axillary vein (1,2). As such, they are not considered to dwell in the central circulation, as are central venous catheters (CVC) or peripherally inserted central catheters (PICC). Their introduction dates back to the 1950s; however, hypersensitivity reactions to the catheter material in certain designs led to a decline in their manufacturing and use in the 1990s (1-5). After a redesign of materials and methods of insertion, they have again gained popularity as an alternative peripheral venous access device given the potential for a reduction in repeated venipuncture in patients with difficult peripheral venous access, minimal complications, and potential for prolonged use (3,5). MCs offered on the market are a diverse group of venous access devices that can be tailored to patient and clinician needs. They are typically composed of

RECEIVED: 14 March 2016; ACCEPTED: 6 May 2016 1

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polyurethane or silicone, have up to two lumens, and have a range of sizes available (3). Power-injectable devices exist (Table 1), allowing for use of iodinated contrast for contrast-enhanced radiographic studies, and many include a valve system to prevent backflow of blood, precluding the need for heparin flush to maintain patency. Placement of MCs depends on the brand and includes use of a modified Seldinger technique required for some, and others using an accelerated, or all-in-one, Seldinger method that helps eliminate the risk of contamination. The optimal insertion site is the nondominant arm 1– 1.5 inches above or below the antecubital fossa utilizing the basilic, cephalic, or brachial vein with the tip of the catheter at or proximal to the axillary line, precluding it from the central circulation. Radiography is not necessary to confirm placement. Some brands have adjustablelength 20-cm catheters that can be tailored to the patient. Other devices that are shorter in comparison, at 8–10 cm, require no adjustment. The use of MCs in the emergency department (ED) for patients with difficult venous access has been described, as has utilization of ultrasound guidance to help with placement (6,7). Reported benefits of MCs include fewer overall needle sticks in select patients, a low complication rate (i.e., infection and catheter-related thrombosis), and potential for cost-benefit for the hospital (1). A case report by Moureau et al. demonstrated the effectiveness of a program implementing MCs to reduce catheter-related complications and associated cost (8). In the study, they reported a decline in overall central-line-associated bloodstream infection (CLASBI) from 1.7/1000 catheter-days to 0.2/1000 catheter-days by utilizing MCs in place of central venous access devices when central access was not clearly indicated. This translated to a cost savings of $531,570 annually. With increased pressures on hospitals for improved patient satisfaction, cost reduction, and a reduction in catheter-related complications, early use of MCs in the ED for patients with difficult peripheral venous access or anticipated prolonged hospitalization might be beneficial on all fronts (6-8). DISCUSSION Indications The use of a MC is supported for patients requiring medium- to long-term intravenous therapy (3,9). It is thought that the placement of a MC near the axilla allows for further hemodilution of administered medications, possibly reducing the incidence of chemical phlebitis, infiltration, and patient discomfort with drug administration (10-12). Given a potential dwell time of up to 28 days, it would seem reasonable to pursue placement early in the course of

Table 1. Comparison of Commonly Available Midline Catheters Catheter MedcompÒ CT Midline NexusTM CT Midline PowerwandÒ PowerglideÒ

Size

Length (cm)

4–5 Fr 20 3–5 Fr 10–20 4–5 Fr 8 and 10 18–22 8 and 10 gauge

Power Injectable Lumens Yes Yes Yes Yes

1–2 1–2 1 1

Device-related information obtained from manufacturer Web sites. Information demonstrating indications, contraindications, and technique can be found at the following: www.medcompnet.com/CT/features.html. www.galtneedletech.com/product/nexus-ct-midline. www.accessscientific.com/the-powerwand. www.bardaccess.com/products/midline/powerglide.

hospitalization or at the time of contact in patients anticipated to require prolonged intravenous infusions and laboratory draws or difficult venous access requiring multiple attempts at peripheral intravenous catheter placement (3). Currently, the Centers for Disease Control (CDC) and others recommend consideration of MC placement when the duration of therapy is likely to exceed 6 days, which may be difficult to anticipate in the acute care setting (13,14). However, given that the average peripheral venous catheter reportedly lasts < 48 h and multiple attempts in difficult-to-access patients may be required, early selection for their use in patients deemed to require prolonged hospitalization might be a cost-effective approach (5-8,13). Compatible infusion solutions include those with an osmolarity < 600 mOsm, pH of 5–9, and blood products (1,5). As previously mentioned, some MCs are also power injectable and can tolerate high flow rates via an infusion pump for contrast-enhanced radiographic studies (Table 1) (3). Whereas some literature suggests that vesicant medication solutions cannot be administered through MCs, recent studies and anecdotal reports indicate otherwise, and placement of a central venous access device based solely on the pH of an intended therapy other than total parenteral nutrition is not supported in the literature (8,14). A recent study by Caparas et al. showed safety and efficacy of short-term (< 6 days) vancomycin administration via a MC vs. a PICC using the PowerwandÒ (15). Fewer complications were noted without incidence of phlebitis, thrombosis, or catheter-related infection. Ultrasound-guided placement of MCs has also been used to facilitate early central line removal in the surgical intensive care setting as a low-complication, cost-effective alternative for patients with difficult IV access (16). Device Comparisons Standard peripheral intravenous catheters (PIV) are the workhorse of venous access devices, with a reported

The Midline Catheter

200 million catheters placed annually in United States acute care hospitals (17). They are simple, inexpensive, and provide well-documented short-term results. Though evidence has mounted refuting the need for routine replacement, CDC guidelines still recommend close monitoring and removal every 72–96 h (13,18). Additionally, many hospitals have protocols in place for this practice. Common complications with their use include phlebitis, thrombophlebitis, infiltration, extravasation, and infection. With certain medications, infiltration or extravasation events may result in severe injuries. Such injuries range from simple burning/ stinging to tissue necrosis and ulceration, particularly in the case of vasopressor extravasation (19–22). Moreover, multiple attempts are often required in difficult-to-access patients, increasing patient exposure to repeated painful procedures and cost. The firstattempt failure rate has been reported to be as high as 26% in adults and 54% in children, with an average dwell time of 44 h, increasing the need for repeated venipuncture in patients with difficult-to-access veins or requiring prolonged (> 48 h) hospitalization (8,19,23). The use of ultrasound guidance has improved first-attempt success rates in multiple settings and patient satisfaction in the ED (24–26). Overall, PIVs are simple to insert and have a track record of reliability. However, it would seem prudent to ensure proper patient selection and reconsider their use in patients with difficult venous access or those deemed to require prolonged hospitalization without indications for central venous access given the availability of MCs (6-8). In comparison, the widely used CVC has the ability to provide long-term medication administration, administration of a wider range of therapeutics contraindicated via peripheral infusion (i.e., vesicants such as CaCl), laboratory testing, and hemodynamic monitoring. They also provide for rapid infusion rates and multiport access, depending on catheter type. However, their insertion is not without complications, including but not limited to local infection, thrombosis, CLASBI, pneumothorax, and lifethreatening bleeding. The overall complication rate has been reported as high as 15%, with mechanical complications such as failure to place the catheter (22%), arterial puncture (5%), catheter malposition (4%), pneumothorax (1%), subcutaneous hematoma (1%), hemothorax (< 1%), and cardiac arrest (< 1%) reported (27). The overall rate of CLASBI has been reported as 5.8% or 2.4–2.7/ 1000 catheter days, a rate similar to PICCs in the hospital setting. Recent evidence has also brought attention to whether central venous pressure monitoring in critically ill patients with sepsis provides benefit and may also lead us to consider alternatives when central venous access is not absolutely necessary (25,28–32). Furthermore, a recent study by Cardenas-Garcia et al. re-

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ports the safe administration of vasopressors via peripheral venous access in a single-center intensive care unit (ICU) (33). Further studies may one day allow us to forgo the placement and complication risk associated with this method of vascular access in some circumstances. PICCs provide central venous access with indications similar to CVCs but with greater dwell times for longterm infusion therapy. They do, however, share some of the complications associated with CVC placement. The rate of CLASBI has been reported to be comparable to CVCs in hospitalized patients (2.3 per 1000 catheterdays vs. 2.4 per 1000 catheter days respectively) (30). However, infection rate can vary depending on the (ICU versus non-ICU) in which they are placed (34). Moreover, selection of patients that would benefit from PICCs has been nonuniform. A review by Chopra et al. showed patient selection for PICC use was inappropriate in upwards of 43% of patients (35). In their review, they highlighted that MCs would be a more acceptable venous access device for use between 6 and 14 days and CVCs for use in critically ill patients for < 14 days compared to PICCs. Lastly, PICC placement is not without associated risks, such as thrombosis. The rate of asymptomatic deep vein thrombosis (DVT) associated with PICC use has been reported as 27.2%, with a symptomatic DVT rate ranging from 1–38.5% (32). Complications such as ventricular dysrhythmia and cardiac tamponade have also been reported, as has catheter displacement associated with power-injection of contrast media (36–38). Proper patient selection is important, as the rate of CLASBI is similar to CVCs in the hospital setting and complications such as catheter thrombosis are still present. In particular, this modality of venous access is not amenable to the ED setting, especially in the critically ill. Compared to standard PIVs, the MC functions as a longer catheter, with a reported dwell time up to 28 days. The rate of catheter-related bloodstream infection is reported between 0 and 0.2/1000 catheter days, compared to PIVs (0.5/1000 catheter days), PICCs (2.12.3/1000 catheter days), and CVCs (2.4-2.7/1000 catheter days) (26,31–33). MCs also have a lower rate of thrombosis (< 2%) in comparison to PICCs (1–38.5%) (8,15,32). Other complications encountered include infiltration, dislodgement, and thrombophlebitis, as would be anticipated for a peripheral venous catheter. The rate of thrombophlebitis, however, is much lower (< 11%) in comparison to PIVs (27–70%) (5,8). On average, the dwell time for a MC is 7.69–16.4 days in comparison to a PIV (2.9–4.1 days) and comparable to a PICC (7.3–16.6 days) (8,31,39). The standard cost of MC insertion is reported as similar to approximately three standard PIVs, or < $90 (7,15,16). The high firstattempt failure rate of PIVs (26% in adults, 54% in

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Table 2. Device Comparisons Device

PIV

MC

PICC

CVC

Catheter associated blood stream infection (per 1000 catheter days) Average inpatient dwell time (days) Cost of insertion (in hospital)† Failed first attempt (%) Procedure time (minutes) Rate of infiltration (%)

0.5

0.2

2.1–2.3

2.4–2.7

2.9–4.1* $9.67 12–26 2.5–13 23.9

7.69–16.4 $94.88 3.2 9.5 Unknown

7.3–16.6 $94.88 1.2 N/A N/A

N/A $124.96 14 2.3‡ N/A

PIV = peripheral intravenous catheter; MC = midline catheter; PICC = peripherally inserted central catheter; CVC = central venous catheter; CMS = Centers for Medicare & Medicaid Services; CPT = Current Procedural Terminology. * Dependent on hospital protocol (i.e., routine vs. clinically indicated removal). † Utilizing CMS CPT Codes 36410, 36569, 36556 – recommended CPT coding for the MC is the same as for PICC. ‡ Ultrasound-guided internal jugular vein CVC in the emergency department.

children) and average dwell time of 44 h potentially requiring repeated cannulation for venous access during a prolonged hospitalization will quickly account for a single well-placed MC at the time of hospital admission (8,19,23). Furthermore, a study by Moureau et al. demonstrated the cost-effectiveness of introducing a MC program in reducing the rate of CLASBI from central venous access via use of MCs in patients deemed to have difficult-to-access peripheral vasculature, defined as more than two unsuccessful PIV attempts (8). Their study showed a dramatic reduction in requests for PICC placement, a reduction in CLASBI from 1.7 to 0.2/1000 catheter days, and a projected overall cost savings of $531,570 annually in one of their hospitals where MCs were utilized. The overall success rate of placement was high (99.4%). They concluded that establishment of an effective MC program in patients with difficult-toaccess veins and as a measure to reduce use of central venous access devices has the potential for cost-savings through longer dwell times, lower rates of infection, lower rates of thrombosis, and improved patient satisfaction via a reduction in repeated cannulation. In particular, they highlight the possibility of the MC as filling a gap for vascular access in patients requiring treatment for longer than 48 h. Considering the large number of patients presenting to the ED with obesity and other factors that make venous access more difficult, the MC might be considered a first-line option in patients with difficult venous access and anticipated hospital admission for > 48 h (5-8). Though MCs have limitations to include the type of infusions that can be utilized, recent literature indicates that the scope may be expanding, as previously mentioned (15). Similarly, it might be proposed that because MCs are nearer the central circulation, the risk of extravasation might be lower in properly placed lines, and management of critically ill patients might be afforded through the placement of a MC alone. To date, there is sparse literature available to describe the incidence of infiltration or

extravasation, indicating an area of potential future research. With increased utilization of ultrasoundguided venous access, overall success rates in difficultto-access patients has increased (25,26). A study by Deutsch et al. showed that ultrasound-guided MCs provide a cost-effective venous access alternative to CVCs and can help facilitate early CVC removal in the surgical ICU (16). A recent study by Scoppettuolo et al. highlights the utility of ultrasound-guided MC insertion in the ED in patients with a clinical indication for peripheral venous access but difficult superficial veins, defined as the absence of a visible or palpable vein of the arms or failure of two or more PIV attempts (7). In their retrospective analysis of 76 patients receiving ultrasound-guided MCs using a Seldinger technique for insertion, they found no complications with a 100% placement rate (7). Without the need to monitor central venous pressure and sparse data indicating the absolute infiltration or extravasation rate, future studies might focus on management of critically ill patients in the ED with MCs. Table 2 provides a reference for comparison of the aforementioned venous access devices discussed, to include rate of catheter associated blood stream infection, average inpatient dwell time, cost of insertion with regards to Current Procedural Terminology codes, failed first-attempt rate, reported procedure time, and rate of infiltration (7,14,20,28,33-35,39-45). CONCLUSION With rejuvenated interest in utilization of MCs, consideration should be given to further studies aimed at clearly defining the indications, contraindications, and patient selection for their placement. Early adoption and utilization in the ED at initial patient presentation to the hospital might see a benefit to patient satisfaction through a reduction in invasive procedures and cost savings for the hospital (6,8). Similarly, risks associated with other catheter choices may be avoided, improving overall patient

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outcomes. Further studies are needed prior to clinical adoption of increased MC use, particularly in the ED, where experience with their use is lacking in the literature. REFERENCES 1. Alexandrou E, Ramjan L, Spencer T, et al. The use of midline catheters in the adult acute care setting – clinical implications and recommendations for practice. J Assoc Vasc Access 2011;16:35–41. 2. Cheung E, Baerlocher MO, Asch M, Myers A. Venous access: a practical review for 2009. Can Fam Physician 2009;55:494–6. 3. Griffiths V. Midline catheters: indications, complications and maintenance. Nurs Stand 2007;22:48–58. 4. Adverse reactions associated with midline catheters – United States, 1992–1995. From the Centers For Disease Control and Prevention. JAMA 1996;275:749–50. 5. Caballero C, Montealegre S, Cubero P. Medial venous catheter or midline (MVC). Rev Enferm 2014;37:36–41. 6. Mills CN, Liebmann O, Stone MB, Frazee BW. Ultrasonographically guided insertion of a 15-cm catheter into the deep brachial or basilica vein in patients with difficult intravenous access. Ann Emerg Med 2007;50:68–72. 7. Scoppettuolo G, Pittiruti M, Dolcetti L, et al. Ultrasound-guided ‘‘short’’ midline catheters for difficult venous access in the emergency department: a retrospective analysis. Int J Emerg Med 2016;9:3. 8. Moureau N, Sigl G, Hill M. How to establish an effective midline program: a case study of 2 hospitals. J Assoc Vasc Access 2015; 20:179–88. 9. Intravenous Nurses Society. Position paper: midline and midclavicular catheters. J Intraven Nurs 1997;20:175–8. 10. Hadaway L. Catheter connection: can midline catheters be used to infuse vesicant mediations? J Vasc Access Dev 2000;5:41. 11. Rosenthal K. Bridging the IV access gap with midline catheters. Med/Surg Insider 2008;2:4–5. 12. Anderson NR. Midline catheters: the middle ground of intravenous therapy administration. J Infus Nurs 2004;27:313–21. 13. Centers for Disease Control and Prevention (CDC). Background information – 2011 BSI guidelines – HICPAC 2016. Available at: http://www.cdc.gov/hicpac/BSI/04-bsi-background-info-2011.html. Accessed February 21, 2016. 14. Vallecoccia MS, De Pascale G, Taraschi C, et al. Closed vs open systems: when should short peripheral intravenous catheters be the first choice? J Hosp Infect 2015;89:72–3. 15. Caparas JV, Hu JP. Safe administration of vancomycin through a novel midline catheter: a randomized, prospective clinical trial. J Vasc Access 2014;15:251–6. 16. Deutsch GB, Sathyanarayana SA, Singh N, Nicastro J. Ultrasoundguided placement of midline catheters in the surgical intensive care unit: a cost-effective proposal for timely central line removal. J Surg Res 2014;191:1–5. 17. Bernatchez S. Care of peripheral venous catheter sites: advantages of transparent film dressings over tape and gauze. J Assoc Vasc Access 2014;19:256–61. 18. Webster J, Osborne S, Rickard C, Hall J. Clinically-indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database Syst Rev 2010;(3):CD007789. 19. Helm RE, Klausner JD, Klemperer JK, Flint LM, Huang E. Accepted but unacceptable: peripheral IV catheter failure. J Infus Nurs 2015;38:189–203. 20. Richard JD, Salomon L, Boyer A, et al. Central or peripheral catheters for initial venous access of ICU patients: a randomized controlled trial. Crit Care Med 2013;41:2108–15. 21. Loubani OM, Green RS. A systematic review of extravasation and local tissue injury from administration of vasopressors through peripheral intravenous catheters and central venous catheters. J Crit Care 2015;30:653. e9–17.

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ARTICLE SUMMARY 1. Why is this topic important? The goal of this article is to provide foundational knowledge about midline catheters and their potential use in the acute care setting, as well as communicate differences in our vascular access device selection. 2. What does this review attempt to show? The article provides indications, complications, and comparisons of various venous access devices, with attention to the midline catheter. 3. What are the key findings? Midline catheters provide a viable alternative to peripheral intravenous lines or central venous access devices in patients presenting with difficult-to-access veins, no clear indication for central venous access, and a likelihood of hospitalization for > 48 h. 4. How is patient care impacted? The insertion of midline catheters has the potential to reduce cost, patient exposure to procedures, and complications of venous access devices when used in appropriately selected patient population.