Strategy or Risk: The Use of Midline Catheters

2 Course Description - Abbreviated

Objectives:

• Recognize the appropriate clinical use of midline catheters

• Review current practice and evidence regarding midline use

• Review policy structure to ensure inclusion of critical elements

• Identify appropriate strategies and use of technology to optimize

midline catheter outcomes

3

Introduction1

What is the state of current peripheral IV technology?

• Standard PIV; ~2 - 5cm

• USGPIV/Extended dwell device; ~5cm

• Midline catheters; 8 - 20cm

Infusion Therapy Standards Terminology:

• Peripheral. Pertaining to or situated at or near the periphery; situated away

from a center or central structure.

Anatomical insertion location, dwell times and tip position determines

this.

4

What does the CDC say?2

CDC – 2002 & 2011 Guidelines for the Prevention of Intravascular Catheter-Related Infections - HICPAC

Selection of Catheters and Sites - Peripheral Catheters and Midline Catheters (2002 & 2011 versions)

1. In adults, use an upper-extremity site for catheter insertion. Replace a catheter inserted in a lower extremity site to an upper extremity site as soon as possible. Category II

2. In pediatric patients, the upper or lower extremities or the scalp (in neonates or young infants) can be used as the catheter insertion site [32, 33]. Category II

3. Select catheters on the basis of the intended purpose and duration of use, known infectious and non-infectious complications (e.g., phlebitis and infiltration), and experience of individual catheter operators [33–35]. Category IB

4. Avoid the use of steel needles for the administration of fluids and medication that might cause tissue necrosis if extravasation occurs [33, 34]. Category IA

5. Use a midline catheter or peripherally inserted central catheter (PICC), instead of a short peripheral catheter, when the duration of IV therapy will likely exceed six days. Category II

5

INS Glossary definition1

Infusion Therapy Standards of Practice (2016) Journal of Infusion Nursing JANUARY/FEBRUARY 2016 Volume 39 • Number 1S

6

INS Midline Position Statement1

Practice Criteria

II. Short Peripheral and Midline Catheters

H. Ensure appropriate midline catheter tip location:

• Adults and older children: at the level of the axilla and distal to the

shoulder. 24-26,32 (V)

What defines the appropriate anatomical location for a midline?

7

INS Midline Position Statement1

• Avoid the use of a midline catheter when the patient has;

• a history of thrombosis,

• hypercoagulability,

• decreased venous flow to the extremities,

• or end-stage renal disease requiring vein preservation.1,16-17 (IV)

Infusion Therapy Standards of Practice (2016) Journal of Infusion Nursing JANUARY/FEBRUARY 2016 Volume 39 • Number 1S, S52

8

Optimal Midline Tip Location Evidence4-6

Anderson (2004) quotes Hadaway (1990) “The catheter is placed in the

basilic, cephalic, or median cubital veins of the upper arm or antecubital

area, with the tip residing in the cephalic or basilic vein in the upper

portion of the arm”.9

Dumont (2014) states “the midline’s tip terminates in the cephalic,

brachial, or basilic vein distal to the shoulder (the tip doesn’t enter the

central vasculature), which flows into the distal axillary vein”.26

9

Axillary Anatomy4-6

Tip locations

discussed by

literature

Distal axillary vein

Image: https://en.wikipedia.org/wiki/Axillary_vein#/media/File:Gray576.png

10

Axillary Line

11

Question

Does your hospital currently track infectious complications of midline

catheters?

1. Yes

2. No

3. Not sure

12

What Does the Evidence Tell Us About Infection?

13

Does PIV attempts influence infection?8

14

Kovacs et al, 2016

15

Kovacs et al, 2016

• Clear evidence exists in the literature that PIVs and midline catheters are linked to

nosocomial bacteremia

• Potential explanations –

• emergency placement of peripheral device

• longer dwell times

• decreased vigilance to care and monitoring of peripheral IV locations

• Furthermore, competing demands exist daily at the bedside, and questionable IV

cannulation sites may be extended in efforts to improve patient experience by

decreasing episodes of repeated venipuncture9

16

Midline Catheter-Related Infection16

Midline catheter-related infection

Author Subjects # devices mean dwell time

(days) BSI % BSI rate (/1000

days) Definition/diagnosis BSI

PICC MID PICC MID PICC MID

Lawson database 5459 3 1 CDC

Thiagarajan peds 587 16.6 11.4 2.3 1 no

DiNucci hospital 406 1.5 0 no

Scoppettuolo ER 76 0 no

Cummings CF 42 >1 no

Deutsch SICU 31 0 no

Sharp CF 328 14 22 0.4 CDC

Caparas HAI 58 6.3 5.8 2.6 0 no

Pathak Vent Unit 6006 (days) 3.2 0 no

Moureau Home Infusion 31130 0.11 0.09 no

Leone Home Infusion 1,097,715 0.124 0.002 no

17

Question

What are the clinical manifestations of midline associated upper

extremity associated deep vein thrombosis (UE-DVT)?

1. Catheter occlusion / inability to draw blood

2. Leakage at the insertion site

3. Edema / swelling / pain

4. All of the above

18

More questions… about data!

• Where does your patient/catheter go after you place it?

• Who is accessing the device?

• Who is following the pathway of the catheter?

• Who is collecting data, beside insertion related data?

19

What Does the Evidence Tell Us About Thrombosis?

20

Catheter-Related Thrombotic Events16 Catheter-related thrombotic events

Author Thrombosis Occlusion Phlebitis Leaking Infiltration Pain Diagnosis

PICC MID PICC MID PICC MID PICC MID PICC MID PICC MID DVT/SVT

Lawson 9 6 2 10 0 3 CDC

Thiagarajan 0 0 3.5 9 3 6 1 2 1 3 no

DiNucci 4.5 no

Scoppettuolo 0 major no

Cummings <2 no

Elia piv 12.5 20.9 (2)2.5 11.4 (3)42.5 2.3 US

Deutsch (1)29.9 34.6 3 10 no

Sharp 0 5.9 6.7 15.8 0 3.9 67 35.3 39.9 17.6 no

Caparas 0 0 0 0 0 3.3 0 10 no

Moureau 0.88 0.009 0.29 0.01 0.006 0.002 no

Leone <2 no (1 )per 1000 cath days (2) occlusion + phlebitis (3) infiltration + dislodgement

21

Catheter Failure Rates16 Catheter failure rates

Author Subjects BSI % Thrombotic

events (%) Failure/adverse

events (%) Unexplained

removal (%)

Therapy

Completed

(%)

PICC MID PICC MID PICC MID PICC MID PICC MID

Lawson database 3 1

Thiagarajan peds 2.3 1 8.5 21 15.8 21 73 68

DiNucci hospital 1.5 0 13 5.8 19.5

Cummings CF >1 >2 severre 5 9

Deutsch SICU 0 13 3

Sharp CF 2 0.4 13 55 (1)11 14 2.89 (1)6.9

Caparas HAI 3.6 0 3.3 17.9 19.9

Pathak Vent Unit 3.2 0

Moureau Home Infusion 0.11 0.99

Leone Home Infusion 0.124 0.002 0.67 0.06

Elia HDU piv 57.6 34.3 45 14

22

Midline catheter types

23

Histopathological Changes

• Chemical irritation causes:

− Loss of venous endothelial cells

− Inflammatory cell infiltration

− Edema

− Thrombus formation

− Proximal and distal to the catheter tip

24

INS Standard 45. – summary1

B. Recognize phlebitis risk factors that can be addressed:

1. Infusates with dextrose >10%

2. High osmolarity (>900 mOsm/L);

3. Certain medications (depending on dosage and length of infusion), such as

potassium chloride; amiodarone, and some antibiotics; particulates in the infusate;

4. Too large a catheter for the vasculature with inadequate hemodilution;

5. Skin antiseptic solution that is not fully dried and pulled into the vein during catheter

insertion.

Infusion Therapy Standards of Practice (2016) Journal of Infusion Nursing JANUARY/FEBRUARY 2016 Volume 39 • Number 1S

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INS Standard 45. Phlebitis1

• pH removed from standards as a potential factor of chemical phlebitis

• Osmolarity risk increased to ≥ 900mOsm/L

• Is still in INS SOP Glossary - irony of terminology and relationship

Infusion Therapy Standards of Practice (2016) Journal of Infusion Nursing JANUARY/FEBRUARY 2016 Volume 39 • Number 1S

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What pH damages cells?10

• pH’s of 2.3 and 11 have been shown to kill cells on contact

• As the pH moderates, the cells survive for a longer time period

• Cell cultures at pH 4 survived for 10 minutes. Same for pH 9?

• pH is logarithmic, so pH 5 to 8 safer?

27

Commonly administered drugs

Dobutamine

2.5

Morphine

2.5 – 7.0

Potassium

4.0

Flucloxicillin

4.0

Ampicillin

10.0

Bactrim

10.0

Vancoymycin

2.4 to 4.0

Promethazine

4.0 to 5.5

Phenytoin

10.0 to 12.0 Acyclovir

11.0

Tobramycin

3.0 Mannitol

4.5

28

MAGIC – Peripheral Compatible Medications11

29

MAGIC – Peripheral Incompatible Medications11

30

pH as a cause of phlebitis?13

Gorski LA, Hagle ME, Bierman S (2015)

• Authors concluded pH alone is not a predictor of phlebitis, the risk cannot be

quantified.

• Does that mean that non-physiologic pH should not be considered among the

factors that may cause phlebitis? The data is inconclusive, the recent analyses

retrospective or look at therapy of less than 6 days.

• The focus seems to be on vancomycin, but it does not have the most extreme drug

pH.

31

Influence of vancomycin infusion methods on

endothelial cell toxicity (Drouet 2015)

• Conclusion showed a significant increase in endothelial cell death from a vancomycin

concentration of 2.5 mg/ml onwards

Drouet M, et al (2015). Influence of vancomycin infusion methods on endothelial cell toxicity. Antimicrob Agents Chemother 59:930 –934

32

pH and Phlebitis14 pH Phlebitis%

Doxycycline 2.5 10

Dopamine 3.3 18

Dolasetron 3.5 1

Amiodarone 3-4 8-55

Milrinone 3-4 8

Ondansetron 3-4 4

Dobutamine 2.5-5 11

Fluconazole 4-8 5

Quina/Dalfo 5 40

Caspofungin 5-7 18

Micafungin 5-7 19

Ampicillin 8-10 3

Pantoprazole 9-10 2-4

Esomeprazole 9-10 2-4

TMP/SMZ 10 10

Ganciclovir 11 20

Acyclovir 11 9

Phenytoin 10-12 50

• At its extremes, pH may have a larger

role in the development of phlebitis

• pH alone does not correlate well with

the frequency of phlebitis

33

pH as a Cause of Phlebitis14

• There is not enough data to implicate pH, osmolarity, or direct cellular

toxicity as the sole cause of drug-induced phlebitis

• Isolated science has shown endothelial damage from these factors,

but that’s a clue, not proof

• Phlebitis is a convergence of factors such as; gender, catheter insertion

site, catheter materials, catheter tip location, vascular blood flow, drug

infusion rate, frequency and duration of therapy, drug characteristics

34

2016 INS Vesicant Taskforce15

• The scope of work was limited to creating an evidence-based list of

non-cytotoxic vesicant medications/solutions and developing an

extravasation checklist that outlines risk reduction strategies

including early recognition of signs and symptoms of extravasation.

35

2016 New INS Vesicant Taskforce15

NONCYTOTOXIC VESICANT MEDICATIONS and SOLUTIONS

36

Policy Review

• Education

• Patient type

• Use of technology

• Pharmaceutical considerations

• Clinically indicated dwell

• Blood draw

• Flushing techniques

• Pressure injection

• Documentation

37

Summary

• pH/Osmo has a relationship to all peripheral devices – this includes

midline catheters

• pH will still remain a potential cause of phlebitis in peripheral veins (at

pH extremes) and is not the sole reason to change device selection

• A full vessel and device assessment process should be considered

for each individual patients clinical situation

• Policy must be current and evidence based

38

Any Questions?

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Teleflex, the Teleflex logo, [List here in alphabetical order any other Teleflex trademarks found displayed in the document]

are trademarks or registered trademarks of Teleflex Incorporated or its affiliates, in the U.S. and/or other countries.

© 20XX Teleflex Incorporated. All rights reserved. MC-XXXXXX

39

References 1. Infusion Therapy Standards of Practice (2016) Journal of Infusion Nursing JANUARY/FEBRUARY 2016 Volume 39 • Number 1S

2. O'grady, N. P., Alexander, M., Burns, L. A., Dellinger, E. P., Garland, J., Heard, S. O., ... & Raad, I. I. (2011). Guidelines for the prevention of intravascular catheter-related infections. Clinical infectious

diseases, 52(9), e162-e193.

3. O'grady, N. P., Alexander, M., Dellinger, E. P., Gerberding, J. L., Heard, S. O., Maki, D. G., ... & Raad, I. I. (2002). Guidelines for the prevention of intravascular catheter–related infections. Clinical

infectious diseases, 35(11), 1281-1307.

4. Anderson NR (2004) Midline Catheters The Middle Ground of Intravenous Therapy Administration Journal of Infusion Nursing Vol. 27, No. 5, September/October 2004

5. Dumont C, Getz O, Miller, S. Evaluation of midline vascular access: a descriptive study. Nursing 2014. 2014;44(10):60-66.

6. Hadaway LC. An overview of vascular access devices inserted via the antecubital area. Journal of Intravenous Nursing 1990;13(5):297-306.

7. Lawson, T (1998) Infusion of IV medications and fluids via PICC and midline catheters - Influences of tip position on the success of infusion Journal of Vascular Devices, Summer 1998 pp.11-17

8. Kovacs, C. S., Fatica, C., Butler, R., Gordon, S. M., & Fraser, T. G. (2016). Hospital-acquired Staphylococcus aureus primary bloodstream infection: A comparison of events that do and do not meet the

central line–associated bloodstream infection definition. American journal of infection control, 44(11), 1252-1255.

9. Rickard CM, Webster J, Wallis MC, Marsh N, McGrail MR, French V, et al. Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled equivalence trial.

Lancet 2012;380:1066-74.

10. Stranz, M (2008) Understanding pH and Osmolarity: Presented at 2008 INS Scientific Meeting, Phoenix, Arizona, USA.

11. Chopra, V., Flanders, S. A., Saint, S., Woller, S. C., O'grady, N. P., Safdar, N., ... & Pittiruti, M. (2015). The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a

Multispecialty Panel Using the RAND/UCLA Appropriateness Method - Michigan Appropriateness Guide for Intravenous Catheters (MAGIC). Annals of internal medicine, 163(6_Supplement), S1-S40.

12. Gorski, L. A., Hagle, M. E., & Bierman, S. (2015). Intermittently delivered IV medication and pH: reevaluating the evidence. Journal of Infusion Nursing, 38(1), 27-46.

13. Drouet, M., Chai, F., Barthélémy, C., Lebuffe, G., Debaene, B., Décaudin, B., & Odou, P. (2015). Influence of vancomycin infusion methods on endothelial cell toxicity. Antimicrobial agents and

chemotherapy, 59(2), 930-934.

14. Schaps, F and Stranz, M - CVAD Standards of Care for Pharmacists and Nurses, Presented at National Home Infusion Association National Conference, Mar 21-24, 2016, New Orleans LA, USA.

15. Gorski, L. A., Stranz, M., Cook, L. S., Joseph, J. M., Kokotis, K., Sabatino-Holmes, P., & Van Gosen, L. (2017). Development of an Evidence-Based List of Noncytotoxic Vesicant Medications and

Solutions. Journal of Infusion Nursing, 40(1), 26-40.

16. Ryder, M, Presented at the Association for Vascular Access Conference 2016

40

Thank You

[Placeholder for additional 3rd party trademark owner]

Teleflex, the Teleflex logo, [List here in alphabetical order any other Teleflex trademarks found displayed in the document]

are trademarks or registered trademarks of Teleflex Incorporated or its affiliates, in the U.S. and/or other countries.

© 20XX Teleflex Incorporated. All rights reserved. MC-XXXXXX