The staff nurses have been drawing labs from Bards new Midlines with the doctors order. After 1-2 days we are no longer able to obtain a blood return. What do you do when the midlines will not give back a blood return. What should be done we sometimes try alteplase but it does not work. And we are using alteplase off label, it is for CVAD but the doctors always order it for midline when there is no blood return. How safe is it to draw labs from Midlines? And should we continue to to draw labs? The FDA approves this practice with the Bard midlines does the INS or AVA support this practice. Should the midline be replaced after 2 days when no longer able to obtain blood return? Thank you.
The fact that instillation of alteplase is not solving this problem says that the problem is not inside the catheter lumen. This indicates it is a vein thrombus or fibrin problem obstructing the catheter tip and instillation of alteplase will not correct this problem. There is no studies to my knowledge of the use of midlines for drawing blood samples. Your statement about FDA "approving this practice" is not quite the case. FDA does not "approve" any product as this word implies that there has been some level of performance for the device. FDA clears devices for the market, which means that the specific device has been judged to be substantially equivalent to a similar device. So the first midline device included blood draws and all other brands use that same language. No studies are required by the FDA. So I would avoid using midlines for blood drawing. I would not infuse without a blood return based on both the statements from INS and ONS. 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, you are a very valuable asset. The manufactures should consult with you prior to releasing statements on VAD that contradict SOP. Because when the sales reps promote that routine labs can be successfully drawn from Midlines hospitals and PICC nurses that are not knowledable will support this practice and put the patient at risk for long term complications.
Never accept anything stated by a sales rep. unless you see it in writing from the manufacturer. Although all VAD instructions include drawing blood, the issue is very controversial now. Many infection preventionists are prohibiting this procedure as it increases hub manipulation and also the possiblity of contamination and infection. Manufacturer's instructions for use is one source for information but you also must be in compliance with other documents such as Infusion Nursing Standards of Practice and CDC Guidelines among others. 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
Blood drawing from midlines should be treated in the same manner as it is with peripheral catheters. In actuality this catheter from Bard is structured along it's length exactly like an IV cathter. Kinking and crimp memory play greatly into the blood draw capability of this device. (At least that has been our experience.) We do use them for blood drawing. Education for the staff nurses includes no greater than 5 cc syringes for aspiration and slow gentle pull back. We flush with 20 cc NSS as if it were a central line. In some patients we have had good blood return for up to 14 days after insertion. We are at this time ultrasounding the arm of the patient on removal of the device and also the axillary region. This area of care needs much research. There is little to go on with regards to outcomes that is anywhere near recent. Our average length of stay is relatively short at 5-7 days in this acute care setting but 4 patients have gone home with the device in place to complete 14 days of non-irritant therapy. IF I am smart enough to remember I will post our experiences later this year.
Jose Delp RN BSN VA-BC
If a physician wrote an order for me to do something off label I would put my critical thinking skills to work. Off label has no intimidation factor in my practice if it is reasonable, prudent, and I like the extra safety of knowing it is fairly common practice. Your scenario of CathFlo through a midline is troubling for a few reasons. We give this drug when we suspect a fibrin buildup in the catheter from either poor flushing or the bodies attempt to deal with a foreign body like a central line. The alteplase dissolves the fibrin and all is well. In the midline scenario I am much more concerned about lack of blood return due to vessel thrombosis narrowing the space that the catheter tip dwells in and thus limiting blood return. This is the start of a thrombotic injury process. Maybe an irritating PRN med or a borderline ph infusion, or the tip position in relation to vessel structure has caused this "irritation". In a PIV most likely the device no longer functions and it is D/Ced. In the midline your MD orders the CathFlo, it is given and perhaps the device functions properly for a bit....which also allows the irritation that caused the thrombotic process to continue and this further injures the vein wall. Tough to assess this area because of where the tip lies in the axilla. If that pt. develops an UEDVT and PE resulting in death where is the exposure for you as a nurse? If the family decided to investigate through legal channels the nurse that gave that off label cath flo, I would not want to be the MD that ordered it or the nurse that gave it.
Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness