Elsevier

Journal of Critical Care

Volume 61, February 2021, Pages 1-4
Journal of Critical Care

Safety and efficacy of vasopressor administration through midline catheters

https://doi.org/10.1016/j.jcrc.2020.09.024Get rights and content

Highlights

  • Midline catheters are a safe means of delivering vasopressors to patients in the ICU.

  • Midlines have long dwell times and a low rate of infectious complications.

  • In our study population, there were no complications related to ineffective drug delivery or limb endangerment

Abstract

Context

Vasopressors are commonly administered through Central Venous Catheters (CVCs) as it is considered unsafe to administer them via peripheral IVs, mainly due to the concern of local tissue injury. Unlike peripheral IVs, midline catheters provide a wider lumen with the catheter tip ending in a large peripheral vein. The use of vasopressors through midline catheters has not yet been evaluated.

Objective

The primary objective of this study is to determine the safety and efficacy of long term administration of vasopressors through a midline catheter.

Design

This is a retrospective study between 2016 and 2019 looking at the outcomes of midline catheters.

Setting

45 bed Tertiary level ICU in a 600-bed teaching hospital.

Patients

A total of 248 patients received vasopressors via midline catheters.

Results

The average midline dwell time was 14.7 ± 12.8 days and the average duration of continuous vasopressor infusion was 7.8 ± 9.3 days. Vasopressors used with their average dose (AD) were norepinephrine (n = 165, 16.8 CE ± 10.7 μg/min), epinephrine (n = 56, 9.1 CE ± 6.0 μg/min), vasopressin (n = 123, 0.05 CE ± 0.02 units/min), phenylephrine (n = 158, 91.4 CE ± 64.7 μg/min) and Angiotensin II (50 CE ± 27.6 ng/kg/min). Early Complication rate was 3.6% due to Bloodstream infection (n = 6), drug extravasation (n = 1), thrombophlebitis (n = 1) and arterial puncture (n = 1). Late Complication rate was 0.8% (n = 2) due to midline-associated DVTs. There were no complications related to ineffective drug delivery or limb endangerment.

Conclusions

Many medical centers are attempting to limit the use of central venous catheters (CVCs) to avoid central line-associated bloodstream infections (CLABSIs). This study demonstrates that midline catheters are a safe alternative to CVCs, for the safe and efficacious administration of vasopressors for prolonged periods of time.

Introduction

The use of vasopressors is a common intervention in the care of the hemodynamically unstable, critically ill patient. Most institutions require that these medications be administered through a central venous catheter (CVC), primarily out of concern that extravasation of peripheral intravenous access can lead to local tissue injury due to the vasoconstrictive effects of these medications [1]. An estimated 5 million central venous catheters are inserted annually for the administration of vasopressors [2]. Patients with CVCs are at risk of mechanical, infection-related, and thromboembolic complications.

There is a growing body of evidence suggesting that short term administration of vasopressors through Peripheral Intravenous catheters (PIV) is feasible and offers an alternative to the placement of CVCs [1]. A review of prior literature on the peripheral infusion of vasopressors suggests that >85% of the complications were noted with peripheral infusion catheters distal to the antecubital fossa in the upper extremity and most notably when vasopressors were administered in the hands or feet [3]. This could be secondary to small gauge PIVs that are inserted at these sites or because of the susceptibility of these fragile veins to burst and infiltrate during the infusion of vasopressors [4]. Unlike PIVs, Midline Catheters (MC) are longer catheters terminating in larger peripheral veins and possess wider bore lumens, and have been reported to have much lower phlebitis rates [5]. They have a dwell time of 2–4 weeks allowing for longer duration infusions, with a lower risk of decannulation and extravasation compared to traditional PIVs [6].

Another major driver to use midlines has been to reduce the incidence of Central Line Associated Bloodstream Infections (CLABSIs). CLABSIs account for one-third of hospital acquired condition (HAC)-relateddeaths associated with an expenditure of $37,000–$39,000 per episode [7]. This has led to a growing emphasis on early removal of central lines and replacement with peripheral lines. Midline catheters (MC) are considered peripheral venous catheters as they are inserted near the antecubital area, with their tip terminating at or below the axillary vein. Various studies have reported a BSI rate of 0%–0.9% in patients with MCs, which is similar to the rate of BSIs from PIVs [9].

There is limited data evaluating the safety of vasopressor administration via midline catheters and the potential catheter-related complications associated with MC use such as DVTs, thrombophlebitis, and the risk of extravasation and local tissue injury [6]. The purpose of our study was to evaluate the safety of MC insertion, and the incidence of adverse effects of continuous administration of vasopressors through these MCs for patients admitted to the intensive care unit.

Section snippets

Study design and setting

A retrospective study was conducted at the George Washington University Hospital Intensive care unit, a 48 bed mixed critical care unit including medical, surgical, trauma, and neurosurgical patients. The hospital's electronic health record, Citrix (Cerner Corp, Kansas, MO), was used to collect data for the study. The study was approved by the Institutional Review Board of George Washington University.

Inclusion and exclusion criteria

Individuals were eligible if they met the following criteria: age 18 years or older; admission

Results

A total of 248 patients received vasopressors via midline catheters during the specified time period, with a relatively equal distribution of men and women. Table 1 shows the baseline demographics of the study population. The median age and body mass index were 66 and 28.3 respectively. Median SAPS II Score and SOFA score on admission were 38 and 8 respectively. Among the admission categories, Medical Intensive Care patients were the most common, accounting for 46.8% of admits, followed by

Discussion

Since their introduction in 1950 [10], MCs have undergone significant technological improvements. The modern catheters are most frequently polyurethane or silicone-based, measure between 20 and 25 cm in length, and consist of single or dual lumens [8]. In our study, the use of MCs was shown to be effective for uninterrupted and relatively long-term (7.8 ± 9.3 days) infusion of vasopressors.

Our study population included a wide spectrum of critically ill patients with varied indications for

Conclusion

In view of long dwell times, low rates of infection and improved patient satisfaction via a reduction in repeated cannulation [17], midline catheters can serve as a bridge between peripheral IVs and CVCs, especially in patients who are difficult to obtain venous access. Midline catheter insertion can be used as an early weaning strategy to reduce the number of CVC days and to avoid CLABSIs for patients with prolonged vasopressor requirements.

Declaration of Competing Interest

There are no financial conflicts of interest to disclose.

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