If I used a PICC catheter and trimmed it to make it a midline, is this considered an off label use? I have a pregnant patient who we are trying to avoid exposing to X-ray who needs one week of IV cefipime and the home health agency will not do peripheral infusions. We do not carry midline catheters.
Yes it is because you are severely altering the device from the way it was designed to be used. Many reasons and you will find lots of previous discusions about this. Just search the site, upper right corner. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
thanks, Lynn. That is what I thought!
Colleen M. Cavallo, RN, VA-BC
Lynn,
If we trim a picc to the proper length for placement, for example trim a 55cm picc to 42 cm so that you do not have excess extending out from the insertion site, then why is it wrong to trim it further to make a midline? I've never been able to find a good answer for that, would appreciate your input.
Thanks
BJ Sherman, RN
Trimming a PICC to a patient specific length has been questioned and has several studies to support the fact that there are jagged edges and small pieces left by this cut. Nonetheless, I do know it is an accepted practice, even though it is questionable. There is a huge difference when you alter a device so that the device will be used in a totally different manner. A PICC and a midline catheter are NOT interchangeable. A PICC cut to be a midline will still have the letters "PICC" stamped on the external segment. You could make all the notes, posters, signs, etc, but this is simply setting up a patient for a serious medication error. Let's say the original prescription was for 5% dextrose in 0.45% sodium chloride with 20 mEq KCl. Then the order changes to parenteral nutrition. Or there is an order for calcium chloride or some other vesicant. That trimmed down PICC is not acceptable for infusing these solutions, however the staff nurse sees the stamped "PICC" and proceeds. This is the type of error that would lead to thrombophlebitis, subcutaneous tissue destruction, need for surgical repair, and complex regional pain syndrome. It is not worth the risk to the patient, you, or your facility. From a legal standpoint, you have dramatically altered the product so that it is not being used according to the product labeling. You and your facility are assuming total legal responsibility for any and all complications. If there is a lawsuit due to some complication, the manufacturer is not involved because you altered the product. When you trim from 55 cm down to 42, your goal is still to have the PICC tip located at the cavoatrial junction. That is not true when to change it to a midline. There is simply far too much risk. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
There as several simple to place midline catheters available on the market today that are pressure rated and address the concerns stated below like trimming and marking. One such product is the M/29 Midterm from Flexciath. You can visit our website for further details or contact me for further information - I will be happy to provide information on our products and the competitive products mentrioned above. I have been in contact with Vitaline recently about this subject matter.
Chip Hanlon
412-915-6442
[email protected]
www.flexicath.com
I just looked at the website for Flexicath and see that it is recommended to be placed below the antecubital fossa. What we learned with piccs inserted in this area (before ultrasound insertion insertion in the upper arm) is that there is a huge problem with mechanical phlebitis and thrombosus due to pistoning with arm bending. A midline catheter is no less subject to this problem.
Darilyn Cole, RN CRNI VA-BC
Darilyn Cole, RN, CRNI, VA-BC
PICC Team Mercy General Hospital Sacramento, CA
there are others as well. you can also look into the powerwand.
http://the-wand.com/html/products-power-wand.html
Hope this helps. You can also look up the insertion video on youtube. They do place them above the AC.
Darilyn,
We don't recommend or advocate a placement above or below the A/C - this is a clinical decision made by the experts in the field. We simply offer a set of products that can support placement above or below the A/C which are pressure rated and ultrasound compatible. We have experience with both placements (above and bleow) and due to the very flexible, thin walled nature of the catheter design we have had no reported issues of phlebitis, thrombosis, or even alarming of pumps. I would welcome the opportunity to further discuss this with you offline - I respect Sarah and this forum and don't want to overstep the boundaries.
Chip Hanlon
412-915-6442
[email protected]
Not only is this off label use - only a pedantic issue but none the less. The larger issue is the cost- a PICC is two to three times the cost of a midline catheter.
S Gordon
I have been cutting PICC's to Midlines for 10 years and have never encountered a problem. Whether you trim a 58cm to a 40 or to a 20cm you'll still encounter the "jagged" edge risk. You just have to be aware and careful when cutting. My only suggestion would be to remember, Midlines in the past used to be a standard 20cm. That's when we were putting Midlines in the antecubital space. Now we use US so we have advanced the Midline just by moving up the arm. I have now modified my practice to make Midlines 15cm for that reason.
It's better practice to have a Midline tip terminate straight in the vessel rather then curved along the axillary arch.
Jack Diemer
I have had to deal several times with PICCs that have been trimmed to a midline in another facility. The most memorable was a woman who went home with this device and received outpatient therapy. Her wound did not heal and she got an order for Vancomycin. By this time, it wasn't easy to determine that this was not a PICC so she received several doses of Vanco in the PICC-cut to a mid-line. When I saw her at my hospital, her arm was enormously swollen and painful. She came to us because she felt she wasn't being treated appropriately and was getting worse. I determined that in fact this was not a PICC and she had a very large and long DVT in her arm. She had to be hospitalized for a week to receive treatment for this DVT. I know the nurse that put in the PICC-cut to a midline was not aware of this. She probably thought that everything was fine and had been doing this for many years. I was unable to find out this nurses name to let her know of this problem but was unable to.
There are much better ways than x-ray to determine PICC tip position. Both VasoNova and Bard's 3CG systems are available. CXR is not the gold standard anymore. Cutting a PICC to midline is not an acceptable or defensable solution.
Whether it's a line meant for use as a midline or not, it needs to be labelled beyond the nearly undreadable, and typically unnoticed, marking on the catheter itself. I've come accross incidents where a midline was not recognized as a midline despite it's "label" from the manufacturer. Conversely, Nurses don't recognize a PICC as a PICC because it says "PICC" on the catheter. I asked around today and only one Nurse was aware that our PICC's actually say "PICC" on them. Expecting that to be obvious to all practitioners is like expecting everyone to know what the fine print says at the bottom of their bank statements. We mark all midlines with a bright pink sticker that says "midline", this becomes the primary indicator of the type of line, this can be done with either a PICC or a midline.
As far as trimming goes, it was my understanding that so long as a trimming tool is used, the tip is equally (possible more) likely to be smooth. I believe this comes from an often quoted AVA paper.
"Off label" uses are extremely common in healthcare and by itself doesn't constitute a failure to meet the standard of care. The FDA labelling only dictates what the product can be marketed for, not what it can be used for. In terms of liability, there is a world of difference between using a product "off-label" and going against FDA labelling.
Just because you have never had a problem making a PICC a midline doesn't mean there never was one later. If you are working in a large facility there is no way you can know if the person that handle that line next was aware it was a "midline". If I were to see a PICC in someones arm I would think to myself, "it looks like a PICC, it must be a PICC." Just use a real midline! They are cheaper too! Read through the stories in this thread, especially what Lynn has to say.
As I mentioned previously midlines are also often mistaken for PICCs, they also look like PICCs. Whether a dedicated midline, or a PICC turned into a midline, it needs to be properly labelled as a midline beyond the labelling on the catheter itself which is rarely noticed.
Our midlines are more than twice the cost of our PICCs.
What I have done in our facilities is write policy that Midlines can only dwell for 7 days. This has been helpful in preventing those Vanco infusions for 2 weeks problem. The Midline is clearly marked with brightly colored stickers and the chart clearly states Midline. No discharges are OK'd with a Midline without consultation with the PICC team and the physician. So, d/c's are very rare.
Of course, anything CAN happen and even UNCOMMON situations do arise. Just saying, if you have inserted thousands of Midlines in several instituions over 10 years, if it were something to be really worried about, something would have popped up by now. Life as well as nursing is the law of probabilities...so always ask yourself..What's the probability that something WILL go wrong....otherwise you won't perform any procedures.
Jack