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georgeb
Midline for use with intermittent home infusion pump

We have a physician who would like to have a midline placed in a patient who needs 10 -14 days of intermittent IV meropenum.  The patient would be going home with an electronic infusion device that delivers medication at the every 8 hour interval and in between doses will run at a KVO of 1ml per hour.  I am looking for information that either supports or does not support this practice of home ambulatory infusion pumps ( CADD)  with midline catheters. 

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Midlines and CADD

I would not use the intermittent feature of the CADD pump with a peripheral IV catheter. That includes MIDLINES.  I would insist on having a central catheter in place namely because of the fact that when you have a peripheral IV catheter, or in this case a long peripheral (a Midline) & one cannot palpate or see the vessels in the shoulder.  Therefore, monitoring these vessels for s/s of infiltration becomes quite difficult and usually by the time it is detected, the pt may have a serious problem.  In the SVC, the odds of this medication causing a infiltrate are much lower due to its size and much greater blood flow. 

I think this is even more problematic in a home care situation where there is NOT a nurse monitoring the arm on a frequent basis. Insist on a PICC, or place a midline and teach the pt &/or family to administer the q 8hr drug. 

Hope this helps.

lynncrni
 I have not found this theory

 I have not found this theory supported by published evidence. In the early days of midlines, drugs like vancomycin (a weak vesicant) were infused through a midline catheter withOUT documentation of severe extravasation and tissue damage. Of course it can happen but it is not in the literature from these studies in the early to middle 1990's. You would need to look at the osmolarity of the solution being prepared by your pharmacy. Osmolarity differs by the type of diluent and the quantity. An ambulatory pump may require a dedicated fluid container and thus a higher concentration and greater osmolarity. I would defer to nurses who do home infusion, but I am fairly certain an ambulatory pump is frequently used to infuse antibiotics thrugh both short peripheral and midline catheters. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

[email protected]
Midlines

Interesting that this showed up today. Just received a referral on a patient that is going to need 2 weeks of nafcillin q 4 hrs. and he has a midline. Med will be on an ambulatory infusion pump and my concern is nafcillin being given through a midline. My opinion is he needs a PICC but MD is of course resistant. Our facility is beginning to use midlines more often now and this is my main concern. They are ordering and placing midlines in patients that need PICCs. Unnecessary expense and discomfort for patients.

lynncrni
 The physician needs the

 The physician needs the knowledge you have about nafcillin being a vesicant. Back up what you say with evidence from publications like case reports in medical literature and the INS SOP. I know there are old case reports demonstrating tissue damage with extravasation. This information on nafcillin with recently updated bibliography can be found in our online course, Infiltration and extravasation from VADs. Learn more at www.hadawayassociates.com. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

[email protected]
Nafcillin

I am curious Lyn, as my information tells me that a 1-3gm dose of Nafcillin in 100mls of NS has a pH of 6-8.5 and an osmo of approx 380.
A 2 gm frozen in D5W 50mls has a pH of 6-7.2 and a osmo of 276-324. Neither appears to have vesicant properties. What say you?

lynncrni
 pH and osmolarity are only 2

 pH and osmolarity are only 2 factors that causes a medication to produce tissue damage and be categorized as a vesicant. There are many other factors. The drug itself could destroy cellular DNA. The excipients in the drugs could be the cause. Many drugs can cause phlebitis or be vesicants and still have pH and osmolarity close to a normal range. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

[email protected]
Yes..

I realize that at times the dyes, or preservatives etc, can be problematic for the vessel's integrity. But, do you have a concise list of what IV medications are problematic, or which ones may have excipients that can destroy the vessel? How would one know which ones will have that potential, as we do not truly know all of the additives that may be used to make up the final product, especially when it is compounded at the manufacturing facility?

lynncrni
 There is no such list that

 There is no such list that anyone has ever created. An INS committee is working on it, but they have been at it for more than a year and are still not finished. This is an excessively time consuming task. Any nurse giving any medication must know this information which comes from the manufacturer. It is found in the package insert. Drug books like Intravenous Medications, by far the best one available, will not always include the details of excipients but they do include statements such as "Determine absolutely patency of the vein as extravasation will cause tissue necrosis." So there is no reason for a nurse NOT to have this information readily available. All nurses giving any medication by any route must know what that med is capable of doing, adverse reactions, etc. This is nursing 101. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

JackDCD
Midline with pump

My 2 cents.....There is nothing wrong with giving meropenum through a Midline q8 for 10-14 days. Your concern should be the fact that you have a short catheter connected to a CADD pump. They are not that light in weight and I could see a accidental dislodge happening of the line. But if the patient is careful and stability of the line can be assured, then what would be the objection?. A Midline is appropriate access for this medication. Again every scenario is different and you would have to assess the home enviroment but as far as the medication and the Midline ..it's fine. I have no idea what tie below, back and forth, is accomplishing.??

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Jack,

Any time you have a midline catheter, and you are infusing a medication, the vessel track is not seen, much less palpated, and because it buries deep in the tissue, by the time the symptoms are apparent, the problem could be great. And yes, the pump could be problematic for the ML should the pump be dropped accidentally. And.. Meropenem was not the drug in question.

JackDCD
Midlines

PT,

The original post was asking about Meropenum. And as far as your comment on Midlines. Thank you , However, I am very familiar with the use of Midline catheters. You sound as if you read the talking points on the "dangers" of Midlines. OK, I'll bite...Midlines can cause a deep irritation that can fester deep below the surface and by the time it's noticable , BAM , you have a problem. I was at the seminar 9 years ago given by Bard. I too, saw that slide. But if you as a clinician are that worried about those types of issues, then Midlines should be outlawed. Because according to all manufactures, Midlines can be used for 2-4 weeks. That's medication going through for 2-4 WEEKS!!!. The original post said 10-14 days. So my suggestion to you one clinician to another...if you truly feel that strongly about Midlines. I wouldn't use them. Stick to PICC lines or the always dependable, never irritaing, short peripheral IV. Or, you could do more research and insert more Midlines observing outcomes and come to you own conclusions.

Jack

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Jack,

You are correct, the OP was about Meropenem, but my comment, as well as Lyn's were about Nafcillin. Talking points would be applicable for those needing to recite information in which they need to be familar with; that however, was not what I was doing. I have been placing Midlines since 1990, and have seen the outcomes, both pro and con, so my concern is NOT merely a "talking point", but rather real life observations. And yes, I will opt for PICC placement more often that not.

JackDCD
Midlines

Well, your right...If you have been inserting Midlines since 1990 then you certainly know about them. My only point is there are risk/benefits with every form of access. The damage caused by peripheral IV's outnumber PICC's, Midlines, ports combined. The difference is we don't count that as real "damage". Not to mention, in one study on peripheral damage, the adverse effects are grossly under reported. And as a clinician with 26 years of practice I know that to be true. So, every line has it's bad points. What's worse than sepsis from a PICC line?. But we use lines because we have to. Our practice should be based on what we think is the BEST alternative. Not without risks...just best alternative.

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