By Stan Deresinski, MD, FACP, FIDSA
Clinical Professor of Medicine, Stanford University
SYNOPSIS: Midline catheters are, at a minimum, at least as safe or safer than peripherally inserted central catheters for durations of at least 14 days, thus offering an effective alternative for venous access.
SOURCE: Swaminathan L, Flanders S, Horowitz J, et al. Safety and outcomes of midline catheters vs peripherally inserted central catheters for patients with short-term indications: A multicenter study. JAMA Intern Med 2022;182:50-58.
Swaminathan and colleagues examined data collected by the Hospital Medicine Safety Consortium from 48 hospitals in Michigan to compare the safety and outcomes associated with the use of midline catheters and of peripherally inserted central catheters (PICC). Inclusion in the analysis required documentation that the reason for use of the catheters was either difficult venous access or prescription of intravenous antibiotic therapy for ≤ 30 days.
During the three years of the study, 5,758 patients received PICCs and 5,105 received midline catheters. The median age of each cohort was 64.8 years. Fewer PICCs (63.2%) than midlines (84.9%) were single lumen devices, and 40.1% and 72.4%, respectively, were inserted because of difficult venous access. PICCs were replaced more often for short-duration (≤ 30 days) antibiotic administration. PICCs, with a median dwell time of 14 days, were in place for a longer duration than were midlines (six days).
On adjusted analysis, PICCs were associated with a greater risk of major complications — defined as a composite that included symptomatic upper extremity deep venous thrombosis (DVT) or pulmonary embolism (PE), or catheter-related bloodstream infection (BSI). The odds ratio for developing a major complication was 1.99 (95% confidence interval [CI], 1.61 to 2.47). Midline catheters were associated with a lower risk of device occlusion (2.1% vs. 7.0%; P < 0.001) and BSI (0.4% vs. 1.6%; P < 0.001). There was no significant difference in DVT or PE overall, but when dwell time was taken into account, there was a lower hazard of DVT events for PICCs (hazard ratio [HR], 0.53; 95% CI, 0.38 to 0.74), but no significant difference was seen when the analysis included only the first 10 days after placement of the device.
COMMENTARY
Midline catheters are vascular access devices placed into upper extremity veins whose tip terminates in the brachial, basilic, or cephalic veins at or near the axilla. In contrast, PICCs terminate in the superior vena cava or right atrium. The terminal point of the device is confirmed by imaging, ultrasound in the case of midlines, and, usually, radiography in the case of PICCs.
The choice between these modalities, as well as of short peripheral intravenous catheters, has been addressed previously. While the purpose of venous cannulation also must be considered, the Centers for Disease Control and Prevention has stated: “Use a midline catheter or peripherally inserted central catheter (PICC), instead of a short peripheral catheter, when the duration of IV therapy will likely exceed six days.”1 Similarly, an international panel concluded that, in addition to considering its purpose, the choice of catheter type depends on its planned duration of use and that “short peripheral catheters may be used for up to 5 days without replacement.”2 A recent study concluded that the use of midline catheters is safe for at least 14 days and that the evidence for use from 14-28 days is limited.3
Thus, midline catheters are, at a minimum, at least as safe as PICCs for durations of at least 14 days and possibly, in some cases, as long as 28 days. The lower cost and relative ease of insertion make midlines a suitable alternative in many patients. These include patients receiving outpatient parenteral antimicrobial therapy, an indication of particular interest to infectious disease specialists.
REFERENCES
- O’Grady NP, Alexander M, Burns LA, et al. Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. Centers for Disease Control and Prevention. https://www.cdc.gov/hai/pdfs/bsi-guidelines-2011.pdf
- Woller SC, Stevens SM, Evans RS. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) initiative: A summary and review of peripherally inserted central catheter and venous catheter appropriate use. J Hosp Med 2016;11:306-310.
- Seo H, Altshuler D, Dubrovskaya Y, et al. The safety of midline catheters for intravenous therapy at a large academic medical center. Ann Pharmacother 2020;54:232-238.
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Midline catheters are, at a minimum, at least as safe or safer than peripherally inserted central catheters for durations of at least 14 days, thus offering an effective alternative for venous access.
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