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PICC vs. Midline in Pregnant women


I work in a home infusion department where we place vascular accesses for patients to infuse at home. We have had several discussions and disagreements on whether a pregnant patient with a diagnosis of hyperemesis gravidum and an unknown length of therapy should have a PICC line placed rather than a midline. Part of our issue is that our pharmacy team relies heavily on the word of a previous nurse who did not always do things based on evidence, but rather based upon how she felt. The research is not consistant from what I find. However, based upon my own knowledge of Virchow's triad (hypercoagulability, hemodynamic changes, and endothelial injury/disfunction), I believe that should we place a midline, we run the risk of increasing our chances of encountering the components of Virchow's triad more often, hence, increasing the risk of thrombosis. Whereas, if we place a PICC line, we have the risk, but it may be lessened than a midline. Because of the disagreement between what the pharmacists want and what most of our nursing team wants, I always explain both procedures to the patient and allow them to make an informed decision on which they choose to have placed. When placing a PICC line, we use the tapered line, but we always leave at least 1cm out to avoid any issues at the hub due to movement. We always aim for a vein diameter of 30-35% to be conservative and safe. We always try to use the basilic over the cephalic. We always use a stabilizer and ensure that they agree to come see us weekly (or if they are with another company for maintenance, they agree to see them weekly) and to contact us for any issues or concerns. 

We have actually seen more thrombi with midlines than with PICC lines. They have been placed at other facilities so there is no way of knowing what the vein size was at the time of placement. And most have been in the cephalic vein. 

Is anyone aware of any research articles that address this? What is your take on this? What does your policy look like? I worry that if we were to only follow the pharmacist, who is not trained to place lines, we lose our ability to apply nursing judgement in each individual case and place the patient and ourselves at risk. 



The 2021 INS SOP, #22

The 2021 INS SOP, #22 Vascular Visualization now states that catheter to vein ration is measured prior to insertion to ensure a CVT of less than 45%. It goes on to state that research is focused on PICCs but this ratio should be applied to midlines as well since they are placed in the same vein. Cephalic is not always the smallest diameter but no way to know this unless it is measured. Pregnanacy is a hypercoaguable state. Evidence is trending toward midlines causing more risk of thrombus but I cannot recall a study about direct comparison of thrombus rates between midlines and PICCs. Bottom line is this CVR should be written in your policy and procedure for midlines and PICCs. Then everyone must comply which is going to mean audits of their work. 

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

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257


Office Phone 770-358-7861

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