Midlines

iluvivt, BSN, RN · Jun 25, 2012

When I first starting placing Midlines a long time ago when we first used the Landmark catheter the only way to access the vein was via a traditional palpation method. So from the veins in the ACF or slighty above you needed aprrox 20 cm to get to the upper arm below the shoulder. Now with the widespread use of Ultrasound many infusion specialist are using US to access the desired veins well above the ACF and I can understand why INS changed their wording a bit. The wording allows for an US accessed midlines as well as for a traditional palpation method. No matter where you access it you still want to get it just below the shoulder. That may be 20 cm inserted or it may just be 10 cm . I still will on occasion place a Midline for a home care patient and do not have access to US. I tend to avoid placing midlines for hospitalized patients since the prescribed IV therapies are changed frequently and noone seems to follow our policy and will just administer anything through it. As far as using the cepahlic vein for regular PIVs..yes we still do as long as it is not a Dialysis patient. You are most likely going to be using a short PIV (1 inch to 1 1/4th inch ) so you should not thread it past the shoulder. On occasion I will use a 1 3/4th inch introcan in this vein but I select my access point carefully so it does NOT extend past the shoulder. Is that what you needed clarification on?

Asystole RN · Jun 25, 2012

From the INS definition any catheter placed that has it's tip terminate in one of the great proximal veins is to be considered a midline. So would you consider that PIV placed in the cephalic a midline? If so, are you following the standard of practice of placing the catheter aseptically under maximal barrier precautions?

I am writing a P&P and while doing some research I came across this issue. From what I have deduced, the great veins of the proximal arms are off limits for PIVs unless one inserts a midline, and does everything that goes along with a midline.

My hospital has a vascular access team and so restricts the placement of PICCs, midlines, and US guided PIVs to that team. The floor nurses routinely access the cephalic and sometimes the basilic for routine infusions. The change in definition from the INS would indicate that floor nurses are not to access these veins anymore.

iluvivt, BSN, RN · Jun 27, 2012

It is only a midline if an actual midline catheter is used and if the tip resides in the upper arm at the level of the axilla and below the shoulder joint. You can still use the upper arm veins for regular length PIVS (3/4th inch -1 3/4th inch) for regular IV therapies and it is NOT considered a midline nor do you need to use maximal barrier precautions to place them. These veins will often be used to place large gauge catheters for a power injection in CT scan. I use the upper arm cephalic vein all the time for PIVs. I have really good luck with patients that pull everything out..they tend to leave this this site alone because it is not in their way where I work they let everyone stick so often when I get to the patient their veins have had a lot of abuse so I often use this vein because others with less experience usually can't hit it and b/c of its location and the sites tend to last awhile. You never want to modify a PICC to function as a midline either.