Having a problem with MD's ordering Midlines for patients getting 3 - 4 wks of iv antibiotics -- where the drug falls in the ph 5-9 and the osmolarity 270-300 range but the drug itseilf has properties that cause thrombophlebitis per the 2011 Intravenous Medications Guide. Is there an INS Standard that limits use of Midlines to 2 wks or less? Are there any studies that suggest that a longer use of Midlines than 2 wks can lead to increased thromobophlebitis? Need some evidence to support this as the MD's think it is IV Therapy "preference" and not science based. We don't place that many midlines because of issues in the past d/t leaking and phlebitis.
See page S37 of INS standard #32 Vascular Access Device Selection, Practice Criteria II. Midline Catheters. The pH and osmolarity parameters for infusion through a midline are the same as for infusion through a short peirpheral catheter. There is no recommendation for the length of dwell for any catheter including a midline. There are studies that have shown appropriate midline dwell times out to 4 weeks and beyond. pH and osmolarity are the most essential factors that increase risk. Midline tip location offers a larger vein diameter and therefore more hemodilution of the drug by the blood. You did not state which drugs you are actually referring to but I suspect you are asking about routine ABX such as a cephalosporin or aminoglycoside. All of these should be acceptable through a midline catheter. Osmolarity can be adjusted based on the type and volume of fluid used to dilute the medication. pH is not adjustable and is not altered by dilution. Also, I would want to know what fluids and medications were being infused through the midlines you used in the past. Did staff strictly adhere to the pH and osmolarity parameters? Was peripheral parenteral nutrition ever infused through these midlines? Were vesicant meds infused through these midlines? Please indicate the specific meds you are asking about and I am certain that others on this forum can tell you about their experiences with these drugs through a midline. I would not choose a midline for vancomycin or nafcillin (both vesicants) but I would infuse Rocephin or Tobramycin through a midline, as examples. 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
Getting orders for zosyn (piperacillin-tazobactam) and imipenum for up to 4 wks via midline? Some sources cite zosyn as a vesciant and imipenum as an irritant. Both antibiotics are described in 2011 Intravenous Medications 27th edition by Gahart and Nazareno as "may cause thrombophlebitis" under Monitoring section in drug description. It seems a PICC would be safer in these circumstances. What is the cut off for midline vs PICC - 2wks of these drugs only via a midline or PICC only? Has any study been done to look at sclerosis or thrombophlebitis in the axillary/subclavian veins after using a midline for a month with irritant antibiotics?
First of all, midline tip location is absolutely not in the axillary or subclavian vein. You are describing a midclavicular tip location and that is never acceptable for any type of infusion, ever. Midline tip location is in the upper part of the arm, level with the axilla in either the basilic (preferred), cephalic, or one of the paired brachial veins. Gahart's does not have this statement, "Determine absolute patency of the vein. Extravasation will cause necrosis." This statement would indicate the drug is a vesicant and should not be infused through a peripheral or midline catheter. A warning about thrombophlebitis is based on short peripheral infusion. Studies on midline catheters are very few and rather old by now. So I would expect to see any evidence to provide a specific answer. Recommendations to use a large vein would include the use of midline tip location, in my opinion. So I woiuld use a midline for these drugs. 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
Let me clarify - midline tip location is of course within the arm. I was just thinking that the medication pathway is going through the axillary/subclavian veins after it exits the midline therefore these veins that are in close proximity would be seeing the effect of any irritant infusion. It concerns me that we may not know if we are causing sub-clinical thrombophlebitis/sclerosis of veins in these areas from midlines with irritant medications that go for 4 wks at a time.
Maybe not due to the diameter of the vein lumen and the fact that the catheter tip is not located in the curvature of the axillo-subclavian vein The fact is that the largest majoirty of all VADs have clinically silent thrombosis. We usually do not see inflammation associated with drugs in larger veins beyond the midline tip location. I think you are confusing chemical irritation and mechanical irritation. Vein diameter and blood flow dilute the meds. Tip location can produce mechanical irritation. The bottom line is that there is no evidence-based answer to your questions because the studies on this issue with midlines has not been done. I also think that the complications are going to be more prevalent at the catheter tip and not beyond. 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
Ryder, Marcia A
Surgical Oncology Clinics of North America1995 July
Volume No Pages 4 3 395-427What I have implemented is the 7 day rule. We all know , and the literature states, that Midlines can dwell for 2-4 weeks. So, theorically, a med with a ph of 5-9 can safely be infused through that line for 2-4 weeks. However, the reality is that is in a hospital situation, we can't guarantee that every nurse follows the rules all the time. Even if it's in the chart and the tails of the line are clearly marked "Midline" things happen.
So in order to safe guard against any mistakes, I set the rule at 7 days....if the patient needs longer than 7 days we are re-consulted and the PICC team makes the call for what line goes beyond that. It works for us and I hope no nurse has to defend herself in a court because she gave something like Vanco for 3 weeks through a Midline.
Jack Diemer
Just infusing vancomycin through a midline for 3 weeks would not cause a nurse to be named in a lawsuit. There would also have to be damages resulting from that 3 weeks of infusion. This would be foreseeable, or this drug infused through this site is a known risk. If there is no problem or negative outcome that resulted in damages, there is no basis for a lawsuit. 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
That goes without saying. Vanco through a Midline for 6 weeks with no harm, would not be a problem. But we all know Vanco has a ph 2.9 and since the Midline is deep into the upper arm veins you may not see that phlebitis for a while. Next you have a patient being incised to drain the infection deep in her upper arm. No defending that Lynn . Even if you gave it for only 2 weeks. You never know when your infusing battery acid ( my pet name for Vanco) just how long it would take. And believe me I have seen the result of a misguided infusion through a Midline and the subsequent surgery that followed. Not pretty!
When in doubt the 7 day rule probably won't land you in court...not impossible though, but not likely.
Jack
Your 7 day rule would provide a more indepth assessment of vascular access needs, something that primary care staff nurses do not have the knowledge and skill to do. You are correct about vancomycin. The pH will always be below 4 and it is a vesicant. Infection may not always be your problem and extravasation could involve tissue damage, necrotic ulceration, nerve injury, etc, etc. My only point was that using a midline for 2-4 weeks of vancomycin infusion is not the fact that would lead to a lawsuit. Many generalist nurses do not understand that fact. There must be damages along with practice that is below the standard of care. 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