The earliest midlines were IntraCath® devices; they were introduced in the 1950s and intended most often for subclavian access. Rigid materials and indelicate cannulation methods limited the adoption and use of these early midlines.
In the 1980s MenloCare introduced the Landmark® midline catheter, made of a unique material—Aquavene®—that softened once in the bloodstream. Additionally, the cannulation method of the Landmark midline was cleverly designed to provide easy insertion while reducing vessel trauma. Two independent studies showed low bloodstream infection rates with the Landmark midline—0.3 percent and 0.3 per 1,000 catheter days.(33,34) Unfortunately, between 1992 and 1995, an acute hypersensitivity-like reaction became associated with the Landmark midline and attributed, rightly or wrongly, to its novel material and/or insertion technique.(35) Ultimately, the device was withdrawn from the market.
C.R. BARD now offers two different kinds of midlines: MST-introduced midlines, made of either silicone or polyurethane -- these midlines are not power-injectable; and AST-placed, power-injectable, polyurethane midlines, branded POWERGlide®.
BARD’s first type of midline (PerQCath®, silicone catheter) was studied over a six-year period at Evangelical Hospital and yielded “less than 1 percent” infection rate, a phlebitis rate that “averaged 2 percent to 7 percent,” and a completion of therapy rate of 86 percent.(19)
The recently-launched POWERGlide offers all-in-one construction (without a dilator) and built-in needlestick safety. The 3.1-inch catheter is made of polyurethane and inserted over a stainless steel guidewire that is shorter than the catheter itself. The catheter is 20 gauge with a flow rate of approximately 40 ml/minute. Whether the POWERGlide catheter can be used for drawing diagnostic blood draws during hospitalization is an unanswered question. In fact, at the present time, the POWERGlide is unsupported by published studies.
Owing to certain design features, the POWERGlide may find its primary utility in the shallower vessels of the forearm. One should note that current data relating to midlines arises from the tip of the catheter being in the upper arm, where blood flow is faster and vessel diameters are larger than in the forearm and hand. Forearm catheter tip placement of midlines—regardless of brand—is thus without an evidence base at the present time.
Presently, Arrow/Teleflex offers a polyurethane midline catheter (3, 4, and 5Fr), not power-injectable and inserted by means of the MST. The product does not include a passive needlestick safety introducer. One observational study of this device (4Fr, single lumen), used for Cystic Fibrosis patients, reported a “lower than 1.0 percent” bloodstream infection rate over a two-year period, and “lower than 2 percent” thrombosis rate. No other complications--such as leakage, phlebitis or infiltration—were addressed.(20) The POWERWAND® initiated the new era of midline design, insertion and use. It offers a unique AST delivery system, with passive needlestick safety and all-in-one (needle-dilator-guidewire-catheter) construction, and a 3.1 inch power-injectable 4Fr and 5Fr catheter made uniquely of ChronoFlex C.
Because the POWERWAND contains a dilator, its echogenic 22g and 21g needles are capable of introducing larger 4Fr and 5Fr catheters with high flow rates (130 ml/minute and 160 ml/minute, respectively). Additionally, the device includes a full-length Nitinol guidewire and passive needlestick safety.
The POWERWAND extended dwell catheter is made of Chronoflex C, a proprietary blend of polycarbonate and polyurethane, and is specially treated so as to be kink-resistant. Multiple centers have reported on the catheter’s 60 percent to 84 percent utility for blood sampling throughout the length of stay, resulting in a 98 ® patient satisfaction rating.(21,22,23) POWERWAND is, thus, one of the only midlines to demonstrate the possibility of a one-stick hospitalization, or at least, far fewer needlesticks than they otherwise would have to suffer. Moreover, the POWERWAND data demonstrate a 0.0 percent bloodstream infection rate with the lowest total complication rate and an equal or better completion of therapy rate (89.5 percent) as compared with any VAD yet studied. (21, 22, 23)
There are other brands of midlines. They are generally made of polyurethane or silicone, are inserted by means of the modified Seldinger technique, and generally are not CT power-injectable. (Note: The M/29 Midterm® catheter is the exception here; while also made of silicone, it is inserted through an over the needle, peelable sheath using an internal “stiffening” guidewire; it is pressure injectable.) The authors are unaware of peer-reviewed, published studies specific to these brands.
Inarguably, the best ways to reduce CLABSIs are to only place central lines where they are absolutely necessary, using ultrasound guidance; when a CVAD is necessary, insert under maximum barrier protection using impeccable sterile technique; and finally, remove central lines as promptly as good clinical care will allow.
There are now reliable, power-injectable midlines that allow for daily blood draws, high flow rates and reduced complications, including very low bloodstream infection rates. These midlines represent a new era of technological innovation and offer evidence-based alternatives to older, less serviceable devices. Use of these midlines will, at times, obviate the need for central venous access and, at other times, hasten the removal of CVCs.(22)
Given the economic pressures on all institutions to decrease CLABSIs (and increase patient satisfaction), and the mounting peer-reviewed, published evidence in favor of midlines, it is hard to imagine a CLABSI reduction program that does not give serious consideration to the expanding role of midline catheters.
Robert B. Dawson, MSA, BSN, RN, CRNI, CPUI, VA-BC, has been a registered nurse since 1996 and currently works as both a clinical consultant and vascular access nurse. He is a member of the Concord Hospital IV Team in Concord, NH.; is the founder and president of the New Hampshire Association for Vascular Access (NHAVA); and is the owner of PICC Academy. He is currently finishing a doctor of nursing practice (DNP) program at the Massachusetts General Hospital Institute of Health Professions, specializing in vascular access.
Nancy L. Moureau, BSN, RN, CRNI, CPUI, VA-BC, is an internationally recognized speaker on peripherally inserted central catheters and issues of vascular access practice. She began her nursing practice in 1981, has been certified in the intravenous specialty since 1987 and is currently part of the PICC/IV team at Greenville Memorial Hospital in Greenville, S.C. She serves as an educational consultant working with program development and speakers bureaus in conjunction with PICC Excellence.
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