Safety and efficacy of vasopressor administration through midline catheters
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.
References (18)
- et al.
The midline catheter: a clinical review
J Emerg Med
(2016) - et al.
Clinical and economic burden of bloodstream infections in critical care patients with central venous catheters
J Crit Care
(2016) - et al.
Ultrasound-guided brachial and basilic vein cannulation in emergency department patients with difficult intravenous access
Ann Emerg Med
(1999) - et al.
Early goal-directed therapy (EGDT) for severe sepsis/septic shock: which components of treatment are more difficult to implement in a community-based emergency department?
J Emerg Med
(2012) - et al.
Complications from administration of vasopressors through peripheral venous catheters: an observational study
J Emerg Med
(2018) - et al.
How to establish an effective midline program: a case study of 2 hospitals
J Assoc Vasc Access
(2015) - et al.
Comparison of complications in midlines versus central venous catheters: are midlines safer than central venous lines?
Am J Infect Control
(2018) - et al.
The use of midline catheters in the adult acute care setting—clinical implications and recommendations for practice
J Assoc Vasc Access
(2011) Midline catheters: the middle ground of intravenous therapy administration
J Infus Nurs
(2004)
Cited by (22)
Midline Catheters Are the Optimal Vascular Access Device For Managing Septic Shock in the Emergency Department
2024, Annals of Emergency MedicineUltrasonography and procedures in intensive care medicine
2023, Medicina IntensivaAdverse effects related with norepinephrine through short peripheral venous access: Scoping review
2023, Enfermeria IntensivaMidline catheter tip position and catheter-related complications in antimicrobial therapy: A multi-center randomized controlled trial
2023, International Journal of Nursing StudiesThe midline venous catheter in critically ill COVID-19 patients
2022, Medicina IntensivaComparison between modified Allen's test and Barbeau test for the assessment of hands’ collateral circulation before arterial puncture among critically ill patients
2021, International Journal of Africa Nursing Sciences