We are currently using Midlines for intermittent Vancomycin infusisons that are of a time frame of 2 weeks or less .
We did a little study/data collection to see how well tolerated it would be, because we knew we had seen phlebitis show up frequently with midlines and Vanco . Leadership cited articles regarding use of Midlines for Vanco. Of course their goal was to reduce the utilization of Central LInes in an attempt to reduce the risk of CLABSI. In these articles they all mention the concentration of Vanco of 4mg/ml as the maximum dose. In our data collection we noted that our pharmacy ( HCA division wide ) has several doses of Vanco that ends with a concentration of 5mg/ml. Without surprise we noted that over 50% of pts who received that concentration developed phlebitis.
I meet with pharmacy to see if they can dilute those particular doses more to bring the concentration down to 4mg/ml. I bring our data and the studies regarding the use of Midlines with Vanco and the concentration recommended and they say that no one else is doing that . That i need to do more data collection to see that Vanco is the cause of the phlebitis. i need to see what other facilities are doing.....
I was not pleased with that response. I explained that it is a known fact that Vanco has the potential to be an irritant to veins and cause phlebitis. That is why in the past we used PICC lines. But.......in an attempt to reduce useage of PICCs and reduce risk of clabsi people are doing studies to see if and how it can be given safely in a Midline.
So.......what are you all doing??
Do you have a maximum concentration of Vanco given peripherally?
Are you using midlines for Vanco therapy? any specific criteria for that ?
Anyone have any further studies or information that could help me? I dont understand why it is so difficult to change the dilution of a drug.
thanks, Gina Ward RN, VA-BC
Yes Gina, sounds like we are doing about the same thing, we often use Midlines to help cut down the number of Central lines & we place Midlines for about 2 weeks or less of IV therapy. (Including Vancomycin) If the plan for therapy is longer than 2 weeks we would recommend a PICC line be used instead.
I spoke with our pharmacy here about the concentration of Vancomycin, it turns out they buy the bags of vancomycin pre-made (I work at a level II regional trauma center). This might be one reason your pharmacy is saying no, they may only be thinking of cost related to making & mixing their own concentrations. One of our doses that are pre-made was 2000mg/500ml which equals out to 4mg/ml but everything else that is pre-made calculated to 5mg/ml or higher.
My pharmacist did hesitantly say they "might" be able to make a more diluted concentration if needed.
Can you share those articles that you mentioned or point me to them, the ones your leadership used?
Also, your study/data collection & the results from your facility phlebitis study that you did, (if you don't mind). We do see phlebitis here with the use of Midlines but have not had any extravasation event with the use of a Midline. (At least not that I am aware off)
I am getting quetions from senior leadership abou the use of Midlines for IV Vesicant therapy & would appreciate any research, articles, or insight from everytone that would support the use of Midlines with IV Vesicant therapy.
Are there any studies either published or int eh works that show a Midline is effective to use with IV Vesicants longer than 72 hrs. that any one is aware off?
Has anyone seen serious extravasation with a Midline?
any thing would be helpful thank you
[email protected]
Timothy McCrory, RN, BSN, CCRN, VA-BC
Absolutely NO to vesicant infusion through a midline. Vancomycin is a weak vesicant and is safely infused for a few days through a midline at 4 mg/mL, according to the studies. INS SOP says no continuous vesicants through a midline. NO studies support that practice. Reason is tissue depth of the tip location and the difficulty in seeing external signs. The phlebitis you are seeing is probably thrombophlebitis indicated by absense of a blood return and any leaking from the site. A midline is NOT a substitute for a CVAD, ever.
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 agree totally.
Lynn, I signed up and took your Midline course on your education website. I have not been able to access it and I think we spoke in the past that you were re doing the website and I would be able to access it again soon. Has that taken place? How could I gain access to my course? Thanks, Gina
Gina Ward R.N., VA-BC
My online CE courses were moved to another learning managemennt system. I was only able to get one course - Chest Radiograph Assessment - revised and on the new site before the pandemic began. On top of that, the work was growing on the INS Standards. A message was sent out to everyone who bought the Chest Radiograph course in 2019 and they will have access to the course now. Other courses will be updated and placed on the new system and again, anyone who purchased that course in 2019 will be sent a message when the new course is available. This has been a crazy year and I will get those updated soon. Thanks 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
Thank you both for your input.
Todd
We practice just as Lynn mentioned. No continuous vessicants via a peripheral or a midline. Now, we will always get the pt in ICU who just came from the ER who has Levo or Dopamine or Cardene or something going in the peripheral but as soon as they get to ICU the nurse is calling us and we are placing a PICC line or.......sometimes the ER dr placed a Central line.
There is just way too much risk with these drugs that are known vessicants. Another big big issue is that it by the time the nurse identifies an infiltration in a Midline it is usually a very large infiltrate. ( due to the location, especially is you select the basilic vein ) Ususally they are just doing a quick glance assessment instead of lifting up the arm and looking at the entire arm. We even stress to our patients to speak up if they feel any burning, pain or even tightness in the skin whenever we place a midline.
Gina Ward R.N., VA-BC
Is there a protocol re vanco and midlines? We tried to find one on the INS standards and cant find one.
You will not find protocols, or policies or procedures in the INS Standards. Standards are the basis for you and your facility to establish protocols, policies, procedures. What are you wanting a protocol to tell you?
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
Does anyone know the answer to this question. If a midline doesnt give blood return after 3 days and pt getting vanco should it be pulled and a PICC placed if vanco is continued. Or can it be exchanged for a picc?
A midline should never be used for vancomycin longer than a few days. No blood return means there is probably thrombosis developing at the tip and I would not exchange for a PICC. PICC should have been chosen originally. You can assess patency with US by flushing and scanning with each dose if the US machine is available to staff with US skills. You can assess for all other s/s of all complications. If patient complains of ANYTHING, the midline would come out and a new PICC placed in a different vein.
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