Q – According to the PICC excellence Midline Manual, midlines are useful for blood draws and therapies that last up to 29 days. I was wondering what steps we would need to take should the therapy last longer than 29 days. We have a patient who is requiring 6 weeks of antibiotic therapy, and I placed a midline 1 week ago. From the information I gathered, the catheter should be in long enough prior to the completion of the therapy, but if it doesn’t I couldn’t find the right resources that would tell me what to do next or if the midline is still good to use past the 29 days of therapy.
A – This is a very good question. While we may say midlines are rated up to 29 days, this is really an FDA category rather than a clinical application. What I mean by that is that a midline can remain in place as long as needed and fall under the peripheral clinically indicated dwell time. Based on a large randomized controlled trial, the INS Standards and the CDC Guidelines all peripheral catheters, including midlines, can remain in place as long as there are no complications and is still being used for therapy. Evaluation of all vascular access devices for medical necessity with prompt removal when no longer being used is an assessment criteria we all need to apply to patients with catheters. There is research supporting midline dwell longer than 29 days.
According to the 2011 CDC Guidelines (see attached) it states: “Replace midline catheters only when there is a specific indication. Category II”
The new INS 2021 Standards state:
45. VASCULAR ACCESS DEVICE REMOVAL Standard
45.1 The clinical need for each VAD is assessed daily for acute inpatient settings and during regular assessment visits in other settings, such as the home, outpatient facility, or skilled nursing facility.
45.2 VADs are removed when clinically indicated (eg, unresolved complication, discontinuation of infusion therapy, or when no longer necessary for the plan of care).
45.3 VADs are not removed based solely on length of dwell time, because there is no known optimal dwell time.
I. Short and Long PIVCs and Midline Catheters
A. Remove if no longer included in the plan of care or if not used for 24 hours or more.1-4 (I)
B. Remove PIVCs and midline catheters in pediatric and adult patients when clinically indicated, based on findings from site assessment and/or clinical signs and symptoms of systemic complications (refer to Standard 46, Phlebitis; Standard 47, Infiltration and Extravasation; Standard 48, Nerve Injury; Standard 50, Infection)
I hope this information is helpful to you!
Nancy Moureau, PhD, RN, CRNI, CPUI, VA-BC
CEO – PICC Excellence, Inc. Hartwell, GA USA