We recently had a situation with a patient with SVC syndrome. Before the initial diagnosis of SVC syndrome we were asked to place a PICC line. Our attempts were unsuccessful. The patient had a midline placed instead. This patient has been in and out of the hospital and on one admission the surgeon attempted to place a CVL into the SVC without success. A few weeks back the patient came in again and had a midline that was placed at another hospital. The midline had been almost 1 month so we left a note for the attending regarding IV access and the need for another device to be placed by a certain date. Now...this patient was a very difficult case. She had a mastectomy on one side and a recent pacer placement to the same side as mastectomy so only one arm to work with. We had questioned a portacath possibly being placed due to her extensive medical history to give her a more permanent access if this was an option or an area of the SVC could be accessed that did not have occlusion. It was ordered to be done and then cancelled a day later. I immediately tried to research articles on dwell times for midlines, complications, ect. I did find the article published by the CDC regarding midlines which had a study where a midline had been in for over 40 days. I also pulled from the Core Curriculum for Infusion Nursing (INS) book regarding midlines. I gathered all this information for the M.D. so that an informed decision could be made regarding IV access. This patient has been very sick on her multiple admissions...on a ventilator...has coded several times. I worried about the location of the tip of the midline and the dwell time of the catheter. This patient was discharged 2 days later with the midline still intact. Just this week she was readmitted to our hospital ...yes, with the same midline. This midline was placed the first part of December '08. I also might make mention that she had a brachial DVT with the very first midline that was placed for her and they placed her on Coumadin. Last admission they did a U/S of her arm and found no occlusions and patent veins to this arm. Very complicated history for this patient but I am very concerned regarding the dwell time of this catheter. Anyone...Lynn if you are reading please let me know your thoughts...any articles, ect. regarding this.
Thanks,
Beth
Wow, very complex issues for this patient. There are no firm guidelines on the dwell time for a midline catheter. The CDC guidelines states that the optimal dwell time is unknown for midlines and all CVCs including PICCs. Many years ago, an INS task force recommended that midlines be chosen when the therapy was needed for between 2 to 4 weeks. This is not the same as the max or optimal dwell time. CDC guidelines also now recommends that a midline or PICC be considered when the therapy will be needed for longer than 6 days, again not the optimal dwell time recommendation we would like. In fact, short peripheral caths are the only ones with this recommendation for a dwell time of 72-96 hours from CDC, 72 hours from INS. It sounds like this patient is doing ok with this midline but I think you should be looking toward the future needs as you are doing. I think it is obvious that there will be a need for vascular access in this patient for the foreseeable future. It is also obvious that this midline will not last forever and now is the time to insert a CVC. But that option is not available from the usual routes. So I would recommend you work with an interventional radiologist to get and implanted port or tunneled catheter inserted through the lumbar or hepatic veins so that the tip will be residing in the inferior vena cava. This would be the best option I can think of. Let us know the outcome.
Lynn Hadaway, M.Ed., RN, BC, CRNI
www.hadawayassociates.com
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