HWN Suggests

“The Adventure of the Sussex Vampire”

A brief forethought. This post we will stray from the usual whimsical rants regarding recent literature in Emergency Medicine. Instead we will focus on the far more practical topic of the insertion of the Midline catheter. Of note, I am overwhelmingly biased in favor of these devices and have taken such a fanciful liking to them I can't possible be an objective critic. With this in mind…

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 A Procedural Guide to Midline Catheter Insertion

8 or 12cm Arrow "red" line. The basilic and brachial are preferred over the cephalic vein as their higher flow ensures lower complication rates. Avoid the cephalic vein as flow rate is usually lower, and it gets narrower proximally.

Articles of Interest

Midline Catheters in Paediatrics – The Long and Short of it

Midline catheters (MCs) are peripheral intravenous lines that are longer (usually 6-20 cm) than routine peripheral IV cannulas. However, the tip of the catheter does not extend into a central vein. The final position of the tip should be in the axillary vein, ideally in the infraclavicular segment. MCs usually allow blood reflux. They are also sometimes called “short long line,” which is pretty much the definition mentioned above.

Midline Catheters: Enticing Alternative to Central Lines in Critically Ill Patients

Fewer central lines are being placed in emergency departments, given evidence that peripheral administration of vasoactive agents can be safe and increased use of ultrasound guidance in patients with difficult access. Yet peripheral intravenous (IV)-line failure is common. One option is the midline catheter, a long (10–25 cm) catheter that is inserted into a peripheral vein and extends just proximal to the axilla but does not enter the central circulation. Midline catheters are placed using the Seldinger technique, generally with ultrasound guidance, and sterile technique.

Midline IV Catheters

Midline catheters are really about having safe access that is unlikely to be dislodged. This is a great option when you have medications you want to give but not have extravasation occur (i.e. vasopressors, hypertonic saline, calcium chloride, etc.).

Midline IV Catheters: The Battle of AST vs MST

There are two main types of midline catheters: AST midlines and MST midlines. AST midlines are inserted using an “all-in-one” technique, while MST midlines are inserted using a two-step technique. Both MST and AST midline catheters share commonalities in their purpose and benefits. They are both minimally invasive techniques for venous access that offer a less invasive alternative to central venous catheters.

Midlines in the Emergency Department; a literature review

Previous studies have shown midline catheters inserted in upper arm veins have lower complication rates compared to central lines, and high rates of successful placement in critically ill ED patients.

The Case of the Sussex Vampire Continues…

Midline catheters have been proposed as a viable method of accessing deep vessels without introducing the mechanical and infectious complications associated with central venous access.

The efficacy of midline catheters—a prospective, randomized, active-controlled study

In patients requiring more than 5 days of IV therapy, a midline catheter strategy reduced the need for insertion of a CVC or four or more PVCs.

The Midline Catheter: A Clinical Review

The MC is a versatile venous access device with a low complication rate, long dwell time, and high rate of first-attempt placement. Its utilization in the ED in patients deemed to require prolonged hospitalization or to have difficult-to-access peripheral vasculature could reduce cost and risk to patients.

The Utility of Midline Intravenous Catheters in Critically Ill Emergency Department Patients

Midline catheters are an alternative to more invasive types of vascular access in patients in whom obtaining peripheral access has proven difficult. Little is known of the safety and utility of midline catheters when used more broadly in critically ill patients in the emergency department (ED). These are long peripheral catheter, ranging from 10 to 25 cm in length, typically placed with assistance of ultrasound and the Seldinger's technique.

The varying terminology surrounding Midline Catheters

Typically, the tips of these devices terminate in the peripheral veins and do not extend beyond the axilla. They can be inserted into the veins of the forearm: cephalic or basilic, or the veins of the mid upper arm: cephalic, basilic or brachial

The varying terminology surrounding Midline Catheters

To bridge the gap between PIVCs and central venous catheters such as peripherally inserted central caterers (PICC), midlines were introduced into practice in the 1980s. Subsequently, the midline catheter has continued to grow in popularity as a more appropriate alternative to the short PIVC or unnecessary central venous catheter placement

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WikEM

Length: 8-25 cm, inserted through upper arm veins, terminates at axilla. Shorter ones last better than ultrasound guided peripheral IVs. Longer ones can run pressors and has less complications than central lines. Because they terminate at axilla, are peripheral access, not a central venous catheter.