Our team is collecting data to identify criteria for placement of midlines? MDs' are requesting them now as there are new products out such as the Powerwand (among others). At our staff meeting the other day an interesting question came up and I wanted some input. These are open tipped catheters and most are 18ga. Are they safe to send home in place based on air embolus risk? One of our vascular access nurses thought that this risk would be less than a PICC line as the tip location of a midline is not central so therefore, the pressure fluctuations would be less. Another nurse felt that these are much shorter than a PICC, most large gauged, and thus higher risk for air embolus. What are your thoughts and is there evidence to support either way. Also, which products are you using? Do you like it? Why?
There is no available outcome data yet so that these risk can be quantified and evaluated. You seemed to be concerned that these are "open-ended" catheters. Most all CVADs including PICCs are open ended, are used in alternative settings constantly. By open-ended, I assume you are referring to a CVAD with some type of integral valve either in the internal end or external hub. Those with the valve on the internal end do have published case reports of air embolism due to thrombus/fibrin preventing complete closure of the valve. So regardless of whether there is or is not an integral valve in a CVAD or midline catheter, all nurses must use appropriate precautions to prevent air from entering the system. See INS Standard #50 Air Embolism. 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
Lynn,
Our IV Team does not (with some exceptions) send patients home with the BARD double or triple lumen power PICCs as they are open ended with only a clamp. There is no valve externally. Some of the outpatient caregivers in our community do not use the end caps they stock correctly, whether it be positive, negative or neutral pressure or understand how to use the clamp according to which cap is used. This can result in blood back flow and occlusions. As inpatients, we flush these lumens twice a day and have positive pressure end caps. The outpatient caregivers see this as an issue with regards to having to flush them more and that sometimes is not feasible for outpatients. This becomes an issue with (for example), a cancer patient that is admitted to our ICU with neutropenia and sepsis or another oncologic emergency. The intensivist orders a triple lumen power picc and upon discharge the oncologist wants a single lumen groshong or power solo for outpatient chemo and/or antibiotics. The lines we generally send with a patient on discharge are either the 4fr single lumen solo power picc (external valve), the 4fr single lumen groshong (internal valve), or the 5fr double lumen groshong (internal valve). We have sent an occasional Hospice patient with an open ended non valved multi lumen picc line for comfort care. Recognizing that all nurses must recognize that an internal or an external valve on a catheter can indeed fail, we generally feel that keeping those with neither option for inpatient use only. Since we are now looking at the midlines for limited patient populations we wondered if anyone is sending patients home with these lines and if the risk of air embolus would be the same if the cap were to fall off as it would be for an open tipped non valved line with central tip location. Hope that clears up my question. Thanks! :)