Today on the podcast, we discuss Midlines. This is the first of two parts. In a week, I will interview Rory Spiegel on the topic, so send me your thoughts and questions in anticipation of that episode.
Our Article
What the Heck is a Midline?
a 8-25 cm catheter that is placed in the arm and doesn't extend past the shoulder
Why Ultrasound-Guided IVs Suck?
- They aren't long enough [30021833]
- Nearly 1/2 of them are dislodged in 24 hrs [Ann Emerg Med 1999;34(6):711]
- Another study demonstrating they do not last [AJEM 2010;28:1]
- Vessel Depth and Catheter Depth are the key to longevity [AJEM 2011 Fields et al.]
- Need 2.75 cm in the vessel for good reliability [https://doi.org/10.1016/j.annemergmed.2019.11.013]
- Midlines are better for avoidance of infections
Which Midlines Do We Use?
10 cm Midline
20 cm Midline
I take no money from any of these folks
Video of the Dual-Lumen Midline Placement
Other Lit
Send Me ?s below or on Twitter
Additional New Information
More on EMCrit
EMCrit 268 – Midlines Part 2-Explosion with Rory Spiegel
Additional Resources
You Need an EMCrit Membership to see this content. Login here if you already have one.
Loved this episode, in fact, we received training for Midlines few months ago. Yet to be stocked in the ED. They are awesome. For naming the new podcast idea in 2020, I thought of couple of names: 1: ( AB-Crit): word crit has resonated in the mind by the high end Critical care stuff, now adding AB which indicates basics. It also rhymes with the big name mashup (EMCrit) which is even better. 2: (AZ-Crit): same notion as above while AZ emphasizes learning or teaching the basics of a particular matter from A-Z, then the Crit part comes in the… Read more »
I enjoyed the discussion about mid lines. I have never even thought about the drawbacks of ultrasound-guided IVs. Do you think this skill could ever become available for paramedics who work in the Emergency Room to perform? Or even specially trained nurses?
At our facility, midline placement is primarily done by the PICC nurses (IR nurses). However, our PICC nurses don’t usually take call (overnight, weekends, etc.)
Our techs (emts and medics) place the majority of the US PIVs at my shop so I dont see why not.
Hey Scott, I work as one of the US IV champions in our hospital. We routinely place US IVs in the forearms/upper arms and run pressors (norepi + vaso sometimes) through them with very little extravasation issues. A lot of the problems that you’re describing with US IVs extravasation – could this be a technique issue? Or poor needle tip visualization on your ultrasound machines? In my experience, the needles should not routinely be backwalling the vessels. I do appreciate your point about the trigonometry, and once vessel depth gets to > 3 cm (like in a very obese patient),… Read more »
I’m impressed you’re finding success with depths down to 3cm. What length of catheter are you using? My hospital currently will only stock the 1.75 inch length. Perhaps because of this, I’ve experienced the problems Scott describes and now only cannulate vessels about 1cm below the surface (especially when using the upper arm). I’m not an expert (probably placed around 400), but there have been several upper arm lines that have extravasated that I would have bet my life on (single puncture, no backwall, threads easily, good blood return, etc); this has made me pretty wary as I’m realizing sometimes… Read more »
Hi Ben One thing to consider adding to your practice is once the IV is placed to confirm catheter length intra-lumen in longitudinal view. (I use traverse view and dynamic tip tacking to place) It should be >2/3 of the overall catheter (depending on your device and screen depth settings you can estimate this as a screen full of catheter intra-lumen). A recent study reported on dwell time and catheter longevity and >2/3 intralumen was the cut off for 100% success at 3 days. For 1.75″ catheters around 1cm deep is the spot where I would reach for a 2.5″… Read more »
Domhnall, thanks for your helpful reply. That’s a great article. Intuitively, I knew the importance of getting as much catheter in the vein as possible, but the goal of 2/3s is enlightening and probably explains many of the problems I’ve observed. I can’t imagine many folks are getting 2/3s the catheter within the lumen in any but the shallowest of vessels with 1.75 inch catheters. What you mention about the collapsability of the subq tissue in the upper arm has been a frustration in the past, and has led me to avoid that site in all but thin patients. It’s… Read more »
If required here’s the link to evidence supporting peripheral catheter length and dwell time. Our experience is if we see enough peripheral catheter intra-lumen (in longitudinal view) we have similar low complication rate as these authors. For cost consideration the 6cm catheter we are using for deeper access are between $2 and $8 each (depending on gauge). https://www.ncbi.nlm.nih.gov/pubmed/30021833/
I was under impression that manufacturers do not recommend to give pressors through midlines, is it correct?
The rationale is probably that if extravasation is to happen, one will be able to notice it only much later in the incident.
The guidelines for use from Bard, manufacturer of the powerglide, states it is not to be used for prolonged infusions of pressors or vesicants, at least as of 2 years ago when I last read them. Listening to the cast I was wondering how you got around that with implementing this process.
In my hospital, there are no IR fellows, so I used it as an opportunity to learn to do all procedures IR style. I spent full three months in the IR and I personally had cases of distal vein occlusion. You have a perfect stick, wire glides smoothly and then the catheter gets stuck at 10 or 15 cm. Then under fluoroscopy, we would see distal occlusion. If that would be more distal stick with a catheter tip stopping right before the occlusion, I would think it would be a disaster to give pressors. So I would stay away from… Read more »
The double lumen midline has been deemed acceptable for vasoactive agents. As for the extravasation -best practice supports frequent IV assessments especially when using vesicants. This is really has no higher risk than a CVAD.
Hey Scott, Loved this episode. I have been looking for a kit that functions exactly like the micropuncture kit (using seldinger and internal dilator). The kit you’re using looks great to replace US guided IV’s. Is there a similar device out there that is approved for central arterial access? I hate standard A-line kits. I often use a 4 french micropuncture kit for femoral or axillary A-lines but it’s off-lable with respect to dwell times. I just want to find a purpose made device that adopts the same approach as micropuncture for both venous and arterial access. Would definitely make… Read more »
there are a ton of them out there.
we use
Arrow AK-045 10-S
Great discussion. I absolutely love the idea of using midlines in the ED and replacing ultrasound guided IVs with them makes a lot of sense. I just wanted to comment on US guided IVs. At my hospital we had the issue of catheters being too short and failing, even with 1.75 in catheters. We switched to the 2.25” Bard Accucath which is an angiocath with a built in guidewire. Insertion is incredibly easy and I found success rates to be much higher (personally 100% success on >200 insertions). Primarily using basilic or cephalic veins. We also had low rates of… Read more »
We also use the accucath and I can’t see a need for anything longer. Extravs are almost exclusively contained to US IV lines started with a normal length catheters. The accucath is the nicest iv setup I have ever worked with.
I’ve found that switching to the forearm sites as skill level increases does the most to reduce extravs. The large easy veins of the upper arm are much more prone to extrav.
Did u even read the articles above because they site the exact opposite in regards to cath length.
Plus the larger vessels being more prone to extravasation doesnt make sense.
Scott, I have been using these for a couple years now. Buy in from ICU has been slow but growing for use with pressors (currently against recs). Two questions with regard to midlines. 1: when converting a PIV to midline… i only do this when i place the first catheter myself as I find that anything below elbow will kink. Also, the wire won’t pass through a 20 guage. how are you selecting appropriate PIVs to convert? 2: we use the arrow 15cm 5.5 fr kit (similar to medcomp and bard). I find that because the sheath is larger than… Read more »
midline wires happily pass through 20 G ivs, (as opposed to the .035 central line wires). Anything below the elbow is unsuitable regardless who put the iv in. antecub or higher is where we go.
the bard that we use are thicker in the proximal 5 cm to avoid this issue
I am an ED nurse at at inner city Level 1 Trauma center. Many of our patients present with difficult access secondary to myriad of issues (chronic disease, IVDU, and so on). This prompted the adoption of ultrasound IV for nurses who have completed a certain competency developed by Experienced Nurses in the ED and VAT teams on the floor as well as a certain number of successful lines observed by trainers and checked off. As a trainer and super user, I place USIV lines all day in my ED and have found through tracking, very little extravasation rates (roughly… Read more »
experience has little to do with it as the studies above have demonstrated. The problem is the length of the catheter and how much winds up in the vein. Unless you are only going for superficial vessels, your lines are probably failing at the 24 hour mark (again, as the studies demonstrate) With your expertise, I think the short midlines would be perfectly suited to your practice.
Do you avoid using in patients with CKD with creatinine clearance less than 45ml/min ( common presence in ED/ICU patients) for future vein preservation in case they need longterm dialysis…
Typically a pts CKD and creatinine clearance is not considered when placing midline. In the ED we use them for vasoactive agents which are usually emergent. If they need HD we will put in a HD catheter and then transition to a permanent alternative in the ICU.
a pt’s renal status (acute vs chronic) (fistula formation and plan of care) is always considered in vessel selection, in renal pt’s with EMERGENT needs, the appropriate device is a cvc. This is well documented and the standard of practice,
Do you use the same rationale for TPN as you do with pressers/inotropes (ok in 20cm lines and not 10cm)?
i would be very wary to administer TPN through anything but central line
Scott, Nice one. I love midlines for the same reasons you describe. Even in the literature the average lifespan of “long” angiocaths under ultrasound is only a day or two. Great if you want your learners to practice with them, annoying if you’re over it. Midlines usually last a good while and “fail” due to little clots or fibrin sheaths (usually they stop aspirating but still flush fine), not infiltration. I’ve recently been working on a series of procedural videos filmed from the user’s point-of-view (http://critcon.org/archives/870) and am hoping to do one for midline placement as well; hopefully that will… Read more »
on ours, last proximal 5cm are thicker than rest of line to avoid ooze.
Great podcast! I completely agree with the sentiment on US IVs. Too often the catheter length is not adequate. My hosp just switched to 2.25” US PIVs from 1.25” and we’ve seen better results.
Ideas for your new podcast format:
1. Dual Lumen
2. Biphasic
Hi Scott
Excellent episode – tonnes to think about here.
Specifically with regard to vasopressin: would you be happy to infuse vasopressin through a midline (the MedComp device) and is there any data on the safety of vasopressin through midlines per se?
Looking forward to the next part of this discussion.
Dean
In the course of our study, we put vasopressin through these lines with no negative events. Do with that what you will.
Hi Scott How do you make the decision on whether you go for a midline vs a traditional CVC? The MedComp has only 2 lumens. The CVCs I use have four lumens. In most of our critically ill patients, the need for additional lumens (for insulin, electrolyte replacement, vasoactive, etc) will often be the primary driver for CVC insertion, as well as the need for secure access. Do you find the two lumens of the MedComp sufficient for your critically ill patients? Do you find yourself sometimes placing a midline and then needing a CVC anyway? Thanks for this post.… Read more »
Been a huge shift in the USA to avoid central access in the ICUs as much as possible (probably driven more by pay-for-performance metrics than anything else). The upside of this is the realization that you can get by in many patients with just peripheral access in many of the ICU players. The dual lumen allows 2 ports for extrav-dangerous meds. If you need more than 2, they need a central line. But you don’t need one for insulin, most lytes, etc. My very loose rule is if a patient needs more than 1 pressor/inotrope, they generally get a central… Read more »
Re using bubble study to confirm placement: I learnt from a crit care cardiologist that you can use propofol as echo contrast. They use 1ml of 1% diluted up to 20ml.. I haven’t tried it yet