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Physician’s Weekly spoke with Lynn Hadaway, MEd, RN, CRNI, about the use of midline catheters for vesicant and irritant medication administration.

There is still not enough evidence to support the use of midline catheters in administering vesicant and irritant medications, according to a narrative review published in the Journal of Infusion Nursing.

The researchers reviewed published studies regarding complications and extravasation in midline catheters. All study designs were eligible for inclusion, and the review ultimately included 39.

Physician’s Weekly (PW) spoke with the study author, Lynn Hadaway, MEd, RN, CRNI, about the review’s findings.

PW: Why was it important to study this topic?

Lynn Hadaway, MEd, RN, CRNI: The work to identify all non-oncology vesicant medications discussed the increasing practices of infusing vesicant medications through a midline catheter and the associated risk. The Vesicant Task Force from the Infusion Nurses Society decided that a literature search on midline catheters needed to be done to broadly assess clinical outcomes with this questionable practice. Many physicians and facilities are allowing infusions of these vesicant medications based only on a single study or a study with many questions left unanswered.

What were the conclusions of your review?

An examination of the literature shows many problems, including:

1. Various definitions for infiltration and extravasation are being used, making interpretations of the outcome difficult.
2. The clinical signs and symptoms of infiltration or extravasation from a midline tip location are not well-defined. They may differ significantly from those seen with a short peripheral IV catheter. For instance, many studies listed “leaking” from the puncture site as a complication when this is a sign of a true complication, such as thrombosis or infiltration/extravasation.
3. Many studies do not report the medications infused by midline catheters, while others do not correlate outcomes with the specific medications. Dilution and rate of infusion of these vesicant and irritant medications also play a role in the outcome and should be included in the studies.
4. The term “midline catheter” is used in Europe to mean a very different tip location. Some American physicians are using this European tip location, which leads to much confusion about where the tip is located. Both tip locations labeled as “midlines” are restricted by guidelines and consensus papers to avoid these vesicants and irritants through both midline tip locations. We have very little information about the difference in outcomes between the definition of a midline catheter used in the USA and the European midline tip location. Is one location better than the other? The answer is unknown.

How can this be used to guide choices in the clinic?

We must dramatically reduce the heavy reliance on both midline tip locations for vesicant and irritant medications and choose a peripherally inserted central catheter (PICC) or some other appropriate type of central vascular access device. A major reason for this dramatic increase in inappropriate use of both midline tip locations in American hospitals is the financial penalty imposed by CMS on those facilities with the highest rates of infections, including central line-associated bloodstream infections (CLABSI). Any type of central venous catheter meeting the criteria for CLABSI must be reported to CDC and then to CMS. This data leads to serious financial penalties for some hospitals with high infection rates. Midline catheters, as defined by the Infusion Therapy Standards of Practice, mean that any midline-associated bloodstream infections do not have to be reported, so the practice is to severely restrict or prohibit the use of all central vascular access devices. However, if the tip location is used from the European definition, those tip locations would be reportable to the CDC as a CLABSI.

What additional research is needed in this area?

Each facility using any midline tip location must track the clinical outcomes of these catheters. Outcomes reported in a published study may not be what is seen in each facility.

Many but not all midline catheters have package labeling that leads most to believe this is a 30-day maximum dwell time for the catheter. Referring to the FDA definition of a short-term catheter, one intended for less than 30 days of use. Many interpret this language to mean that the midline catheter will perform well for this period. Studies report that the average dwell time is between 14 to 16 days. Also, studies indicate the loss of blood return, a major sign to assess catheter patency, is lost within 3 to 4 days. So, nursing staff have fewer tools for evaluating catheter and vein patency and an unknown set of signs and symptoms for infiltration/extravasation in a deep vein where the midline catheter is located. Think about the difference in time required to see erythema and edema surrounding a short 1 to 1.5-inch catheter in a superficial vein versus the length of time for those same signs to be seen on the skin surface from a 6-to-8-inch-long midline catheter located in a deep vein under muscle tissue.

What else do you think is important to emphasize?

Midline catheters lie in the peripheral veins of the upper extremity in adults. Vesicant medications by continuous infusion, such as vasopressors and high concentrations of electrolytes such as calcium chloride, have been the cause of severe tissue necrosis and even amputations. These devastating clinical outcomes are happening now and have life-altering effects on the patients. The appropriate use of a central vascular access device is based on many factors related to the patient, the therapy, and the venue of care.

All these factors must be considered when choosing the most appropriate vascular access for your patients. If the infusion lasts longer than 24 hours, patients with continuous vesicant infusions require a central vascular access device. There are documented methods that will reduce the risk for CLABSI, and using a midline catheter is not one of them.

The use of a midline catheter for intermittent vesicant medications also increases the risk for vein thrombosis due to its irritant properties and the potential for extravasation injury. This will require multiple midline catheters to complete the course of therapy, and the patient may not have enough venous sites to reach the end of therapy. One PICC could have reached the end of therapy with much less risk and discomfort for the patient, less cost to the facility, and better time and resource management for all clinical staff.

Midline catheters have a place in the world of vascular access; however, they cannot safely infuse vesicant and irritant medications.