wanted to revisit this topic becasue---As a team we have reduced central line days and CLABSI but are beginning to notice a need for something else in some of our patients.
The standareds say we can only infuse nonvesicant nonirritant drugs (those with a pH greater than 5 or less than 9 and an osmolality lessthan 600). Yet we do this in peripheral veins for 3-4 days each time we start a peripheral cannula in smaller vessels of the forearms and hands. These sites are for shorter duration and assessment is easier for the staff nurse. I also realize that often these sites don't make it to more than 48 hours without complication. We are often awaiting culutres that will determine length of treatment parenterally versus PO and sometimes are blessed with a patient or two with pretty good peripheral access. What about the patient in this scenario that has poor to no access or the patient in the ED that needs a CT angio of the chest to rule out a PE? Would we or could we be looking at a patient that might benefit from a 3-4 inch length of catheter placed above antecubital for a 3-5 day length of stay to infuse irritant drugs? If the need is to be prolonged then action could be taken to place a PICC or other device as needed. We expect peripheral veins of the forearms to hold up to these therapies. Just looking for some discussion on this topic.... include the patient that is needing just 24-48h more of IVAB and has lost his last good IV site in your thinking.
Reducing the number of CVADs and CVAD line days has been the action taken, but I fear this has been at the expense of choosing the most appropirate VAD with the capability of reaching end of therapy with the minimum number of devices used. So my question is - Are you avoiding the use of CVADs when it is clinically appropriate for their use or are you removing a CVAD and inserting a PIV long before the therapy is complete? Neither of these are appropriate strategies for improving the overall patient safety. Infiltration and extravasation are the most frequent cause of infusion-related lawsuits. If a CVAD is indicated by the type and length of therapy or other patient-related factors, then a PIV or midline is putting the patient at risk for these serious complications. OK, so you have reduced the facility infection rate. But you now can end up in a nasty lawsuit with an infusion expert saying the correct catheter was not chosen.
The 3-4 inch catheter you are referring to would be a midline device and I firmly believe this type of catheter has been overlooked as an important alternative. It can NOT replace a CVAD. It can replace a PIV. Osmilarity and pH restrictions are the same for a PIV and midline. The concern has always been that the midline tip is deeper in tissue, making it more challenging to detect infiltration/extravasation. The amount of fluid escaping could be quite large before it is recognized. There are large nerves and arteries in very close proximity to the midline tip location that could be damaged from excessive tissue edema. Also there can be edema from thrombophlebitis in such large quantities that it produces complex regional pain syndrome. There is only one brand of midline cath that I know of with a labeled indication for power injection in radiology - the new one from Access Scientific. This product came to market under new FDA rules for obtaining the labeled indication of power injection. They had to do clinical trials before it received this indication. As for allowing this line to remain in place for infusion of vesicant, phlebotogenic medications - there is no evidence yet to support this practice. I would be concerned about severe thrombophlebitis from a chemical source that would then prohibit you have doing any exchange to place a PICC through the same vein. Finally, the patient may not have any viable peripheral veins that can be seen or palpated blindly. but that is where the use of infrared light devices comes in. US is designed to locate veins deeper than 1 cm. Infrared is best for located veins less than 1 cm deep. So US may not be helpful enough and this is where infrared light is best suited. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I would agree we have created a different set of problems because we are so concerned with reducing CLABSI and that has only been popularized since we no longer get reimbursed for that care.... there I said it...administrators are not concerned with the thrombophlebitis and extravasation because the increases that we are going to see have not hit their pocketbooks yet.
I also agree that patients sometimes get more different devices than they need. That said, we have had some who were 2 days from discharge that we have not wanted to take out the central line because of their peripheral access and then they have develpoed clincal signs of CLABSI and had to stay longer.
We still have that patient population with limited access that are admitted and cultures are pending. Here we go putting in 22g and 24g and infusing Vacnomycin or Rocephin and other drugs of that nature. We expect the periperhal vein with a lesser diameter than where the "midline" tip placement is to take that infusion and think our average staff nurse is going to be there to stop that infusion the minute it starts to hurt...or turn red.... etc and reality is most of the time it is pretty ugly by the time she gets there to assess. Theoretically the vessel diameter being larger where the midline tip lies would allow for more hemodilution and there should be less liklihood for chemical phlebitis on the shorter duration treatments. If the patient is found to need longer term access for greater than 3-5 days with this type of infusiion they could be converted to central line at that time.
Infrared technology is improving for the adult patient but I am still not sure the hand helds are all they are cracked up to be...I would want to trial them in sick poor venous access patients and all I have had the benefit of so far is the use on healthy adult subjects. It is an area for more investigation for sure.
Jose Delp RN BSN VA-BC
Hi Lynn,
Can you let me know where to look for studies that show a power PICC cut to Midline length say 20cm cannot be used for power injection?... I can't imagine why that would be. Normally a 56cm PICC rated at 5cc/sec cut to 20cm would yield a stronger catheter. Now there is nothing in the catheter literature that states that but I would think if you cut a catheter down then you would shorten the duration of the pressure against the wall therefore making the catheter in essence "stronger". What I'm thinking is you may get more of a whipping motion. But, can that be enough whipping to break through the venous wall?.....Interesting topic though if you have any literature on that I would love to read it.
Jack Diemer, RN BSN
Kennedy University Medical Center
[email protected]
No studies like this are available to my knowledge. The most important reason to not cut a PICC to a midline length is that you have seriously altered the product and are using it in an off-label manner. For a legal standpoint, this is not the safest thing for you or your employer. Within the past couple of years, FDA created new guidelines for what is required by a device manufacturer to obtain a labeled indication for power-injection. The only midline catheter currently sold with the labeled indication for power injection is the one from Access Scientifc. They were required to do more clinical testing of that product during power injection because this product came to market under the new guidelines. There has been laboratory work with animals showing serious catheter whipping with PICCs used for power injection, up to an including complete laceration of the SVC in swine. The same equivalent studies with the midline tip location are only available with the Access Scientific device. If there is a new product that I am overlooking, please let me know.
Cutting any catheter is a very serious issue that requires careful consideration. I have long been concerned about this practice simply because we have no clinical outcome data on this issue. A few years ago, there were some publications in the neonatal literature about this issue. Janet Pettit conducted a lab study and presented it at AVA, finding jagged edges and loose pieces associated with cutting a PICC. That is about the extend of information available to us. The produce manufactueres have instructions about trimming to a patient-specific length. These statements are based on internal testing on their product and for correct tip location as a PICC. There are no instructions from any manufacturer stating that you can alter any catheter for a different tip location. In the absence of such instructions and no clinical data to support the safety of this practice, I would not do it. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Hi Lynn,
I,m not sure what it is your having a problem with.....the off-label use of a cut Picc for power injection, or the whipping motion of the line in the upper arm?. This is an interseting topic because we use the Midline for power injections in patients that are impossible access. And believe me, there are quite a few in Jersey. So I'm very curious as to the practicality of NOT doing this. What happens to these patients?....
Jack
My concern is both the off-label use of a cut PICC for power injection. Lawyers will take you apart for that in a legal case. And the potential for whipping and vein damage. The problem is that we do not have clinical outcomes studies as evidence for the safety of this practice. If you use a midline catheter with the labeled indication for power injection, you at least eliminate one of these risks. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
So the INS would not classify the Power Wand as a midline....right? The 3in definition was dropped in the 2011 edition.
So the labels or classifications have changed but I don't understand why this new product is now safe for power injection. The catheter itself has been tested and rated for the Psi, but how does that change the fact that the tip is in a deeper vein of the upper arm and an infiltration of a large volume of contrast could be very problematic. (the catheter is intact but the vein blows out)
Midlines fell out of favor in our department due to the high dvt rates. How does this product differ? Still a 5FR catheter, right?
I am also very interested in a product that could bridge the gap between PIV and PICC.
Martha
The PowerWand was not even on the market when the INS Standards committee changed the defintion of a midline catheter to eliminate the reference to a specific catheter length. So we were not thinking about a specific product. Product definitions and characteristics usually come from FDA, AAMI, ISO, etc. We searched everywhere to find a defnition of a midline catheter that made any reference to a specific length and we could not find it. So that statement was eliminated as the tip location is what creates a midline device and not a specific length.
The PowerWand has been cleared for market under the new FDA guidance requirements for power injection. This involved testing the device for worst case scenarios such as exposure to chemicals such as antiseptic that could weaken the product. As you know, device coming to market under the 510 (K) process do not require any clinical studies before the product receives FDA clearance. Please note that the correct word for a device is "clearance" not "approval". Approval would imply that the device has met some level of clinical safety and efficacy and that is simply not the case for devices. For devices, the FDA is saying that these devices are substantially equivalent to another similar device already on the market. So there have been no published clinical studies using the PowerWand as a midline catheter. So yes, I guess you could say that the product will withstand the pressure but the vein may not. The only difference for the PowerWand is that it does have a labeled indication for power injection. Plus the PowerWand would have the accelerated seldinger technique, avoiding the use of multiple separate pieces for insertion. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Hi Lynn,
This is an interesting discussion. Since the 3" description for a midline has been eliminated, what are we to use as a guideline for charting what type of line we just placed? Legally speaking.
Thanks,
Monica Sorg
Monica J. Sorg, R.N.
The definition of a midline catheter has never been and is not now based on the catheter length. Like all catheters, it is based on the tip location. Measure from the intended insertion site to the level of the axillary crease. Put in that much catheter and chart that length. This is the midline tip location, always has been regardless of whether the midline being used is 3 inches or 6 or 8 inches. Tip location is the key. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Martha I'm looking into this as well. I was told that the Powerwand will be available in a 4f by May. There is also no reverse taper on the Powerwand. Do you happen to know if the powerwand or midlines have to be reported as a CRBSI?
If you are asking about reporting of any type of infection, that depends upon the language of the law in your state and the rules made to support that law. Many states use the CDC process through the NHSN. This process ONLY collects data on CLABSI, not CRBSI. Big difference. See 2011 CDC guidelines or more info on CDC website. Basically, CLABSI is a surveillance term used for data collection, only applies to central venous catheters with a strict definition of tip location and how to count line days, etc. CRBSI is a diagnostic term when trying to decide how to treat a real patient with a BSI. CLABSI is known to overestimate the actual rates.
So infections from a peripheral or midline catheter are not included in the CDC processes so would not be reported if your state laws make refereence to the CDC methods. However, CMS is a different story. CMS would not allow any payment for treatment of any type of infection (BSI, cellulitis, supporative thrombphlebitis) from any type of catheter regardless of type or tip location if that infection is acquired while a patient in your hospital. So you might not have to include peripheral and midlines infections in your reported rates, but you will not get paid for treating them. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
The real issue for all of us here is the technique of power injection. We know it does damage. It can happen through any length of catheter. We hope that when we place a catheter in a larger diameter vessel there will be less risk of intmal damage or infiltration into the tissue. IT would be nice to know is what the rate of occurrance of these complications is as well as the severity. Certainly we will be looking for a way to track this data if we choose to use an extended dwell peripheral for contrast etc. In reality though, without ultrasound of each arm after the catheter is removed it may not be valid data.
Jose Delp RN BSN VA-BC
The published rate of infiltration associated with power-injected contrast media with short peripheral catheters is now up to 0.9%. Does not sound like a lot and the reports state that most heal without any surgical intervention, however this is always a possibility when the volume is greater than 50 mLs, which is considered a large amount. Since the number of power injection began, this rate has increased 3-4 times. Also, I continue to receive lawsuits involving serious injury from contrast infiltration associated with power injection. I find the primary reason is that rad techs have not been taught how to properly assess the site before they use it. By a complete assessment I mean - OPAL - observe for anything visible, palpate for changes, aspirate for a blood return and manually flush the catheter, and listen to any and all patient complaints. A simple way to teach and remember site assessment - OPAL. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Well thanks for the clarification but that makes for an interesting quandary. There are hospitals, I'm sure, all across the country that are putting in Midlines that are "cut down" PICC lines. Not every manufacturer or every hospital budget allow for seperate specific purchases as in PICC trays and MIDLINE trays. I quess some do...and it's great ....but we all know that a 20cm Midline does not fit all so you will have to cut anyway.
In that case, you have alot of lines out there that are "whipping" around in upper arm veins. Yet I have never heard of any problems with damage or read any literature about this practice. However, if true we as Picc nurses need to look at that and come to some concensus.
With all due respect to our fine legal system, a lawyer will try to discredit Jesus if he had him on the stand. So we can't worry too too much about the lawyers. But I'm much more interested from a safety standpoint. As a practicioner, you can do the best you can with as much knowledge and skill as you can......that's all you really can do. If your touching patients everyday, you should be an expert in your field or at least working toward that.
I for one am not using PICCs cut down for injections in the manner Jack describes, but am insearch of a solution for those patietns we cannot get into for some of these injections. You are right. We need to look at what happens with these catheters in the upper arm that are more than an inch long during contrast injectinos. Better yet why can't we get a diagnosis with better technology in terms of testing. Every few months my CT division is uping the speed of what they need to deliver contrast for certain tests. They have asked for 6cc/sec speeds. Sometimes the drive to cover ourselves as clinicians in terms of possibly misdiagnosing puts our patients through a lot of misery.
Jose Delp RN BSN VA-BC
When radiology wants to increase rates of contrast injection under power, check the catheter manufacturer's instructions to see if the faster rate is included. Many may not be tested for these faster rates. I am curious to know what technology you are looking for for a better diagnosis of catheter problems. For infiltration/extravasation, several companies are working on this. A visible light device has been tested to detect 5 mL of fluid in the tissue, however work with this issue using infrared devices is ongoing and could be available soon. There is also one study with injection of indigo carmine through the catheter to detect infiltration but the authors listed numerous problems with this procedure. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Great topic...I want to add: Pressure injection testing for PICC's preformed by manufacturers is just that....testing a PICC (not a trimmed PICC in a midlien location) with the tip in the SVC (not the upper arm). So anything other than that would be an off-label use.
Cheryl Kelley RN BSN, VA-BC
Hi Lynn,
We will be starting, to insert Powerwand in our trust(NHS) I am aware that it passed the 510(k) for power injections. As it is considered "midline", does this means that this line still dependent on the type and nature of infusion? pH and Osmolality? I am aware that there still no evidence to support about administration of vancomycin with this particular type of lines will this product be treated as no difference from other midlines in the market?
Hi Lynn,
We will be starting, to insert Powerwand in our trust(NHS) I am aware that it passed the 510(k) for power injections. As it is considered "midline", does this means that this line still dependent on the type and nature of infusion? pH and Osmolality? I am aware that there still no evidence to support about administration of vancomycin with this particular type of lines will this product be treated as no difference from other midlines in the market?
In my opinion, yes any midline catheter falls under the same parameters as what is written in the INS standards - pH between 5 and 9 and osmolarity below 600. However I will tell you that the osmolarity of some of the contrast agents are above 600. If you choose to insert PowerWand and allow it to remain indwelling for other infusions, you really do need to track outcome data, at least in the beginning until you know what outcomes you are seeing. Midlines developed a bad impression due to inappropriate use and not knowing your own outcomes until something really bad happened. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I thought it would be helpful to let people know the osmolalities of the most common low osmo contrast solutions. These low osmo agents are all above 600 except for one, so unless your hospital buys Visipaque, everyone who power injects through this device will be going against INS standards. This is a similar situation where hospitals ask nurses to infuse PPN through a PIV even though the osmolality is well over 800 on many PPN formulas. When an adverse event happens those INS standards will be the first referenced material!!
Isovue 370..........Osmolality 796
Omnipaque 350...Osmolality 884
Oxilan 350..........Osmolality 695
Ultravist 370.......Osmolality 774
Visipaque 320.....Osmolality 290
Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness