How can extravasation rates of midlines (peripherally inserted central catheters) be minimized?

Minimizing Extravasation Rates of Midlines

To minimize extravasation rates of midlines, healthcare providers should use ultrasound guidance for insertion, select the smallest appropriate catheter gauge, ensure proper tip positioning, and implement regular monitoring protocols. 1

Proper Insertion Techniques

• Use ultrasound guidance during midline insertion to visualize the vein and surrounding structures, which helps minimize damage to the vein wall and reduces the risk of extravasation 1
• Select an upper extremity site for midline catheter insertion in adults, as lower extremity sites have higher complication rates 1
• Choose a catheter with the smallest caliber compatible with the prescribed therapy to reduce vein trauma and thrombosis risk 1
• Ensure the catheter diameter is one-third or less of the vein diameter (as checked by ultrasound) to minimize risk of mechanical irritation and subsequent extravasation 1
• Use polyurethane or silicone catheters rather than Teflon cannulas, as they are less thrombogenic and cause less mechanical irritation to the vein wall 1

Optimal Catheter Positioning

• Position the catheter tip properly to prevent migration and dislocation, which can lead to extravasation 1
• Avoid the "pinch-off syndrome" which can lead to catheter damage and extravasation by using proper insertion techniques 1
• Secure the catheter adequately using transparent adhesive membranes and/or sutureless fixation devices to prevent movement that could lead to extravasation 1

Infusion Considerations

• Consider the osmolarity of the solution being infused through the midline, as high osmolarity solutions increase extravasation risk 1
• Use lipid-based solutions when appropriate, as fat emulsion may have a protective effect on the vein wall 1
• Maintain pH of infusates between 5 and 9 to minimize vein irritation and subsequent extravasation risk 1
• Use infusion pumps with appropriate pressure settings to help detect early resistance that might indicate extravasation 1

Monitoring and Assessment

• Evaluate the catheter insertion site daily by palpation through the dressing to detect tenderness and by visual inspection if a transparent dressing is used 1
• Remove the midline catheter immediately if the patient develops signs of phlebitis (warmth, tenderness, erythema, or palpable venous cord), infection, or a malfunctioning catheter 1
• Document thoroughly any incidents of extravasation, including patient information, date and time, type and amount of fluid extravasated, signs and symptoms, and management steps 2

Management of Extravasation

• Stop administration of IV fluids immediately upon first signs of extravasation 3
• Disconnect the IV tubing from the catheter but leave the catheter in place initially 3
• Attempt to aspirate any remaining drug from the catheter 3
• Administer any drug-specific antidote if applicable 3
• Apply appropriate thermal treatment: cold application for vasoconstriction to limit drug dispersion (15-20 minutes, every 4 hours, for 24-48 hours) 3
• Notify the physician of the extravasation event 3

Prevention Strategies

• Designate trained personnel for the insertion and maintenance of midline catheters 1
• Implement regular education programs for healthcare staff on extravasation prevention and management 3
• Maintain an extravasation kit with necessary supplies and antidotes 3
• Pay careful attention to patient reports of pain, burning, or discomfort at the insertion site, as these may be early indicators of extravasation 3

Special Considerations

• Midlines have been associated with lower rates of phlebitis than short peripheral catheters and with lower rates of infection than central venous catheters (BSI rate of 0.8 per 1,000 catheter-days) 1, 4
• The median dwell time for midlines is approximately 6 days, though they can remain in place for up to 49 days when properly maintained 1, 4
• Major complications with midlines are relatively rare (occlusion 2.2%, upper-extremity DVT 1.4%, and BSI 0.3%), but when they occur, they often lead to catheter removal 4

By implementing these evidence-based strategies, healthcare providers can significantly reduce the risk of extravasation with midline catheters while providing necessary intravenous therapy.