What are the indications, contraindications (CI), and adverse reactions for midline catheters (midline cath)?

Midline Catheter: Indications, Contraindications, and Adverse Reactions

Indications

Midline catheters should be used when IV therapy duration is expected to exceed 6 days, particularly for peripherally compatible infusates, and when peripheral venous access is difficult or unavailable. 1

Primary Indications:

• Anticipated IV therapy duration >6 days with peripherally compatible solutions 1, 2
• Difficult peripheral venous access requiring repeated attempts 3, 4
• Antibiotic infusion requiring intermediate-term access (several weeks) 3, 5
• Frequent blood sampling needs over extended periods 6
• Alternative to short peripheral catheters to reduce phlebitis rates 1
• Alternative to central venous catheters when central access is not required, reducing infection and thrombosis risk 1

Specific Clinical Scenarios:

• Hospitalized patients with cancer requiring frequent phlebotomy or difficult access for ≤14 days 1
• Critically ill patients who are hemodynamically stable requiring peripherally compatible infusions for 6-14 days 1
• Patients with coagulopathies where central line insertion carries excessive bleeding risk 1
• Peripheral parenteral nutrition when central access is not feasible, though this requires careful thrombophlebitis surveillance 1

Contraindications

Absolute Contraindications:

• Vesicant or irritant chemotherapy administration - requires central access 1
• Hemodynamically unstable patients requiring vasopressors - central access preferred 1
• Solutions with osmolarity incompatible with peripheral administration 1, 7
• Solutions with pH <5 or >9 1, 7

Relative Contraindications:

• Expected therapy duration <6 days with peripherally compatible infusates - short peripheral catheter preferred 1
• Expected therapy duration >3 months - tunneled catheter or port preferred 1
• Lower extremity placement in adults - upper extremity strongly preferred 1, 8
• Patients requiring lifelong vascular access with frequent hospitalizations - more permanent devices preferred 1

Adverse Reactions and Complications

Major Complications (Rare):

• Catheter-related bloodstream infection (CRBSI): 0.8 per 1,000 catheter-days 1, 8
• Deep venous thrombosis: 0.9% incidence 3
• Catheter-related central venous thrombosis: 4.0% 9
• Acute hypersensitivity reactions: Reported with elastomeric hydrogel materials (Aquavene) 5

Minor Complications (Common):

The overall complication rate is approximately 23.5-38% 3, 9, including:

• Catheter occlusion: 2.6-17.0% 3, 9
• Bleeding at insertion site: 12.0% 9
• Infiltration/extravasation: 10.0% (most common cause of catheter failure) 9
• Catheter dislodgement: 3.0-8.7% 3, 9
• Catheter kinking: 7.0% 3
• Phlebitis: 0.3% (significantly lower than short peripheral catheters) 1, 9
• Hematoma: 0.3% 9

Catheter Failure Rate:

16% of midline catheters fail prior to completion of therapy 9, most commonly due to:

1. Infiltration/extravasation
2. Accidental removal
3. Catheter-related thrombosis
4. Occlusion 9

Key Management Principles

Insertion Technique to Minimize Complications:

• Use ultrasound guidance for visualization and optimal vein selection 1, 8
• Select upper extremity sites (basilic or brachial veins preferred) 1, 8
• Choose smallest catheter diameter - ideally ≤1/3 of vein diameter 1, 7, 8
• Use polyurethane or silicone catheters rather than Teflon 1, 7, 8
• Apply maximal sterile barrier precautions during insertion 1
• Secure adequately with transparent adhesive membranes or sutureless fixation devices 1, 8

Daily Monitoring Requirements:

• Evaluate insertion site daily by palpation through dressing for tenderness 1, 2
• Visual inspection if transparent dressing is used 1, 2
• Remove immediately if signs of phlebitis (warmth, tenderness, erythema, palpable venous cord), infection, or malfunction develop 1, 2, 8

Duration of Use:

• Median dwell time: 7-11 days 1, 2, 3
• Maximum documented safe use: Up to 49 days 1, 2
• Do NOT routinely replace to prevent infection - replace only for specific clinical indications 1, 2
• No predetermined maximum dwell time specified in CDC guidelines 2

Common Pitfalls to Avoid

• Do NOT apply arbitrary time limits for catheter removal based solely on duration 2
• Do NOT use for vesicant chemotherapy - this requires central access 1
• Do NOT place in hemodynamically unstable patients requiring urgent vasopressor access 1
• Do NOT use steel needles for medication administration that could cause tissue necrosis if extravasation occurs 1
• Do NOT routinely apply prophylactic topical antimicrobials to insertion site 2
• Avoid lower extremity placement in adults due to higher complication rates 1, 8