Midlines and Nephrology Sign off

[cslagle1989]

Hello everyone, i am a newer nurse (Passed boards last September) and i work on a med-surg floor. We have alot of patients who get midlines and i was wondering why do we need nephrology to sign off on that patient getting a midline, along with the attending, before they get it? I understand the difference between a midline and a regular peripheral iv, but i think i am just overthinking this. Thanks!

[Hoosier_RN, MSN]

Are the patients nephrology patients? If so, it's because they will be used for dialysis treatments. There is a whole list of protocols that must be considered for those as well. For anyone who isn't a nephrology patient, I wouldn't know a reason

[popopopo]

Please ask someone on your floor. I'm curious of this! Also, we're definitely talking midlines right, not central lines?

[Hoosier_RN, MSN]

21 minutes ago, popopopo said:

Please ask someone on your floor. I'm curious of this! Also, we're definitely talking midlines right, not central lines?

I assumed central line. Midline, no idea why

[marienm, RN, CCRN]

The PICC nurses at my hospital place midlines as well. I've always been told they don't want to risk damaging the vessels on a patient who might, in the future, need a hemodialysis fistula placed in that arm. They simply won't do it...we can't even have nephrology sign off on it. These patients get CVCs (placed by an M.D. or PA or maybe an APRN) or PICCs in the IJ placed in the interventional radiology suite.

The conservative approach probably comes down to money and liability.

[Hoosier_RN, MSN]

11 hours ago, marienm, RN, CCRN said:

The PICC nurses at my hospital place midlines as well. I've always been told they don't want to risk damaging the vessels on a patient who might, in the future, need a hemodialysis fistula placed in that arm. They simply won't do it...we can't even have nephrology sign off on it. These patients get CVCs (placed by an M.D. or PA or maybe an APRN) or PICCs in the IJ placed in the interventional radiology suite.

The conservative approach probably comes down to money and liability.

Thanks, I'd never even thought of that. Midlines are popular in my area in the LTC community. Other settings, not so much

[MunoRN, RN]

I've never encountered the practice of requiring a nephrology sign of or just not placing midlines in patients who are not already established to likely have HD in their future. Even then, we only save the non-dominant arm for future fistula placement.

Whether it's a midline or a PICC or a PIV doesn't really apply since the issue is with the puncture through the peripheral vein, not how long the line extends beyond the puncture.

Bottom line though is that if the patient needs access to avoid harm or death then that's what needs to happen, there's not much point in saving veins for a future fistula in a dead patient.

[marienm, RN, CCRN]

9 hours ago, MunoRN said:

Bottom line though is that if the patient needs access to avoid harm or death then that's what needs to happen, there's not much point in saving veins for a future fistula in a dead patient.

If it's that urgent, the primary medical team (MD, PA, APRN) places a CVC. If it can wait until daytime, the interventional radiologist can place a PICC. I think the choice at my institution not to have the PICC RNs do it on these patients is driven by liability concerns more than anything else.

[Jkir]

My guess is because many medications need to be diluted beyond their normal concentration to be infused through a midline. For instance, Vancomycin can be infused at a concentration of 5mg/ml. For a midline, it must be 4mg/ml resulting in the patient getting more fluid over the course of treatment, often even a few liters more!  The diluting of many drugs for a midline is to prevent extravasation injury, but I always wonder about all the extra fluid jand special mixing of these meds just to be able to use a midline.