Forum topic

We just started placing them within the last couple weeks.  We did not trial them, just brought them in as an alternative VAD.  We went with the BARD Power Glide because BARD is the preferred company for our system.  Yes, we have a separate policy for midlines, as well as a protocol for midlines that covers the PICC nurse's placement of the line. Our policy states that it is the PICC nurse who makes the determination of the appropriateness of a midline after they complete a full assessment of the patient, meds, diagnosis etc.  Our team does a lot of difficult PIV placements using ultrasound so they do the same assessment for PIVS and can consider a midline if appropriate instead of a PIV.  They then would discuss this option with the provider.

We have only placed 6 midlines thus far - no problems as of yet with meds changing.  We've struggled with finding a list of what can and can't go through a midline - there are so many factors to take into consideration, but based on BARD's information, we have 6 that we are absolutely forbidding to be given via a midline:  TPN, Dopamine, vancomycin, phenergen, Postassium greater than 20 meg and continuous chemotherapy.  Our system has IV Adminstration Guidelines that idenitfy extravasation risk so we will avoid those medications as well.  Lynn Hadaway led a good video conference yesterday about Midlines and Vancomycin - we found that helpful as well.

 Wendy I sent you an email.  Let me know if it helps!

Hi Joann,

Midlines have been around a long time. I'm sure Lynn remembers the J&J product in the 90's. Some hospitals use Midlines extensivly some hospitals don't use them at all. Midline catheters are just another tool in our kit for vascular access. IMHO I hate the peripheral IV. I have seen more damage and tissue destruction from a simple peripheral IV then I will see EVER from a Midline. I wish they would abolish them or at the least limit their use. Midline will become the "go to" catheter in the future. The is a study that shows the low incidence if infection with Midlines. I mean rediculously low!...Nancy Moreau recently published a study showing even Vanco can go through a Midline for 7 days without incident. To me, I think it's common sense. Everything we do as nurses brings a risk. But as critical thinkers we weigh the risks vs benefits. And believe me , the Midline has alot of benefits. But again, you'll find nurses that hate them. You'll get plenty of nursing opinion on why should not use them. But the one thing you won't hear is why everyone is so afraid of them. It amazes me the amount of excuses for NOT using a Midline, extravasation, phelbitis, ...etc. Basically, the same things for a peripheral, and we use them all the time. Not only that all those horrible things happen with peripherals EVERY DAY. Yet I see no outcry for the dangers of peripherals. I'm sure right now there are thousands of patients across this country that are lying in their hospital bed with an infiltrated , red, painful area caused by a peripheral. But it's the most widely used device.

So, get your Midline program up and running. You'll save alot of tissue damage I promise you.

Jack Diemer, RN BSN, VA-BC

My manager just put me as leed to trial Midlines. We will using Bard product, but not sure which yet. We will trial a certain population, again not idenified. We will, when approved, will have a Mid Line policy and some sort of algorithm to determine if Mid Line is appropriate. It will remain in the VAT to make final decision though.

I will be checking in to see what kind of response come through.

Debra R. Long Beach Memorial, LB, CA

I apologize I left an important detail out. I created our policy for use of the Midline catheter. I capped it's dwell time at 7 days. The rerason is I didn't want anything that shouldn't go through a Midline for an extended period , to in fact, be given for an extended period. (Vanco).

The common rule for Midline usage is no meds with a ph <5 or >9 or an osmolarity above 500. So can you give Vanco for 3 days through a Midline...yes. Can you give Vanco for 7 days? Well, I think you probably can based on Nancy's study and common sense. There is NOTHING innately wrong with the Midline..NO. The problem is the nurses surveillance of these lines....for the most part we don't do any. That's why everyone is afraid. So if you just say don't use them....you don't have to worry!

But to say it's not a good line?.....it's the best line in your bag!!

 According to the literature on the Vancomycin, it is a vesicant because it can caused blisters when it extravasates. And midlines literature documents extravasation. I would agree the risk is small but it does exist. Also the midline tip location is deeper in the tissue than a PIV causing more fluid to escape before it would be recognized. And midlines are not known folr producing an easy blood return. I am a strong supporter of midline use - I worked on the first midline catheter that introduced the concept to the market in 1989. I firmly believe they have a significant place in clinical practice but I am concerned about certain types of meds that can cause complications and give a bad impression of what a midline can do. That is what happened 10-15 years ago. Also, the study being referenced was done by Jona Caparas and not Nancy Moureau. Lynn

Lynn,

Your right I just read that study. However, I do remember seeing something that Nancy was involved in and documented on. It may have been something she was referencing but I remember thinking "wow, this will cause alot of controversy"...Anyway, I do understand the risks associated with a Midline, fortunately, I have not had any problems in the 11 years I have been placing them. However, I have heard of some bad outcomes on occasion. My biggest problem is that our own nurses, are what holds the expansion of Midline use. I recently worked for 2 months at a DC hospital with a good reputation but did not use Midlines. The nurses on the PICC team said they do NOT want to use them because of the concerns you had. But, they will put in tons of peripheral IV's that will end up infiltrating, damaging veins, and not to mention multiple sticks before getting a good vein. C'mon you can't possible think that this practice is our only recourse for difficult access.

Jack

 Nancy wrote an editorial in the issue where the study was published. 

I firmly believe that ALL VADs have a place in clinical practice. I think that the issue with midlines is that some have thought they could replace CVADs but that is simply not true. When many began using them for unacceptable types of therapy, they got a bad reputation which shut down their use and stop the research. So we do not truly have a good understanding of what is and what is not appropriate for infusion through a midline. They can and have replaced the multiple sticks required for many patients when PIVs are used exclusively. I do believe that vancomycin is a vesicant and there could be problems through ALL types of VADs including CVADs. 

I also firmly believe that PIVs are an acceptable type of VAD. The problem is that nurses and others have not been taught the correct information about site selection, catheter size selection, catheter stabilization, joint stabilization, etc. This is not taught in nursing school and most hospitals do not teach it to new nurses. So they have to rely upon the "whisper down the lane" approach, where one preceptor teaches something that is not correct and it gets passed on to others who put their own spin on it. So the basic priniciples and evidence are ignored. 

Lynn

Jack, 

  I am not getting why you are saying it is even ok for giving Vanco in a midline for 3 days?   Am I missing something here?  I do not see any specification on giving drugs for short periods of time or longer periods of time, just the specifics on what is and is not indicated according to PH. 

Did you also say you only keep a midline in for 7 days?   Isnt it designed for up to 29 days??  

I have not read or seen any of the latest talk about this issue from Lynn, or Nancy so maybe there is the answer.

Thanks for your feedback, Gina

 29 days is NOT a maximum dwell time, although the marketing information would makde you think that. FDA guidance to the manufacturers states the each catheter must be classified as short term (30 days or less) and long term (greater than 30 days). This is not required to be supported by any clinical evidnece when the 510(k) applicaiton is made to the FDA. This is the source of the 29 days and it only indicates the FDA classification and NOT a dwell time in any way. Lynn

 Lynn,  I understand what you are saying.  But, it appears that from Jacks statement.  They are placing midlines but only allowing them to stay in 7 days.  They are also giving Vanco via these lines for 3 days or so but, not 7 .....?? 

I am not clear on the decison making in that? 

thanks, Gina

Hi Joanne,

To respond directly to your questions, based on INS Standards and AVA position statements, and my years of experience:

The key to being successful with implementing midlines is to educate, educate and reeducate the hospital staff (inclding MDs) as to what Midlines are, and how they are used appropritely.  This education has to occur on a regular basis as a reminder and to all new employees.  It also has to occur to the patient, family and staff caring for the patient at the time of placement.   This clears up misunderstandings and helps to prevent mishaps.

Yes, you will need to write a separate policy for the use and care of midlines or make it a separate section of your Peripheral IV policy   Do not make it a section of your Central line policy, this creates more confusion. 

It will require a through assessement of the patent's needs, and then you will still have those patients who need access changed to central because of medication plan changes.

The determination for type of line should fall to the vascular access experts.  There should be an "access consult" generated, then a discussion with the MD for the appropriate order.   Even if there is an order for some other device, but the VA expert decides a better option for the patient based on the assessment, the discussion should be with the MD and a more appropriate order placed.

An order is not a absoute, and no one orders a surgeon to operate in a certain fashion, their clinical knowledge is respected.  Same should be for the VA expert.

It would be hard to trial midlines on a certain population, because it may be rare that you need them. 

You should trial whatever midline products are available to you on contract, and pick the one that suits your team best. 

Good luck!  I have always been an advocate of midline use in all settings. 

Nice answer Chris, you put it more eloquently then I did.