From everything that I have read about midline catheters, hemodilution seems to be a key component for successful outcomes. This idea then leads the inserter to place a midline in the upper arm, preferably in the basilic vein, related to better blood flow and increased vein-to-catheter ratio. However, others (manufacturers, some physicians and nurses) view midlines as one of the ways in which we can aid in vein preservation, therefore avoiding the upper arm when possible and choosing veins in the forearm for midline placement. Is there a definitive best practice? If not, what are the considerations/recommendations for midline placement in the forearm vs. the upper arm? What is everyone's current midline practice?
ALL VAD catheters are defined by the tip location and tip location alone. You can place a catheter in the forearm but that will never make it a midline, even if you use a catheter labeled as a midline product. For years, many used a PICC and placed it in the midcalvicular region but that was NOT a PICC. There are no standards or guidelines for placing these new devices labeled as a midline in the forearm. Now with that being said, the forearm could be a useful place for a 3 inch catheter when you need a longer catheter due to vein depth (bariatric patient, using deep veins vs superficial veins) but there is no data on the use of these new midlines in the forearm. The standard of care is to use the smallest catheter that will deliver the needed therapy.
All VADs should be changed based on clinical indications and not by the calendar or clock. But a midline tip location is now, has always been, and will remain (unless changed by well designed clinical studies) to be in the basilic, cephalic, or brachial vein of the upper part of the arm for adults, level with the axilla (not the same as the axillary vein), and not extending into the shoulder. This definition has stood since 1997 with the first position paper that addressed their use was released by the INS. 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
Thank you for the information--much appreciated!
Thank you for this information. We also have started discussion around this midline placement from the forarm. That it may be possibly safer to train a staff nurse to use ULT place the catheter in the forarm and it is 10cm length, so it ?? possible to have distal tip in axillary regiion??
Celia Brown
A midline catheter requires the same level of max barriers for insertino, the same knowledge and skill as a PICC insertion. So I have serious reservations about this being put in the hands of staff nurses. It is definitely not the same as any PIV. I do not thinek there is not a midline on the market that will be long enough to reach the midline tip location from the forearm insertion site. Insertion sites directly in the ACF are not good, greater complications. So a midline should be inserted above the ACF using US. For a forearm placement of one of the 3 inch midlines, once again, there is no evidence to support this but someone has to do it to collect the needed data. Sorry, not sure what ULT stands for. 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
One of the reasons we went to US guided insertions was to access the larger veins in the arm. By placing a midline in the lower arm and having it cross-over the ACF sounds like something you really don't want to do. First, anatomically, any IV the continues to be bent by arm movement is not good. I know they are flexible but I believe they were not designed to bend with the arm. Secondly, and more important, you really won't be able to reach the largest lumen diameter. How long would this catheter have to be to terminate in the upper axillary. I understand you may question the effectiveness of this...and you may even say "why not"?....but I think it's just one of those things that you should not do!
Jack Diemer