Mid-lines

[Jabbed]

We're discussing having residents place mid-lines rather than US-PIVs and possibly CVLs in certain selected ED patients.

Pros:

• Longer life than PIVs
• Reduced CLABSI
• Double lumen access

Cons:

• More time intensive, although could probably be done <10 minutes with practice
• Fewer CVL opportunities for learners
• Potentially ruins dialysis access

Would like to hear thoughts from people who have or are doing this routinely.

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[Rekt]

Why?

Also, you shouldn't run vasopressors through a midline (for long periods of time), so I'm not sure why it would decrease CVLs unless you're routinely doing CVLs for poor peripheral access. The catheter length of a midline would also reduce infusion times. If you need quick access just for poor vasculature, just do a rapid IJ. If you're being asked to do a USPIV, then your first target should be brachial veins anyway as everything distal is already ruined by the prior attempts and you can easily dump an 18g in. A brachial USPIV should take maybe two minutes if you have your ancillary staff gather all the supplies in the room.

 

[clibby]

It is only a reduced CLBSI risk compared to CVLs, not PIVs. I'm not sure a scenario where I can't get an U/S PIV and I can get a mid-line. Just make sure your department has the long PIV catheters (1.75"+) and they will last. If the patient needs a line for rapid resuscitation, then why aren't you either doing an IO or a blind CVL (or Cordis)? If you have time, do an U/S PIV or CVL if they need pressers. If you need it for pressers, then a mid-line doesn't help you. If you only need it for poor access, see my first comment. There are also dual lumen PIVs made by arrow if that is an issue, but I'm not sure the need in the ED; if you need to infuse meds that quickly, you need at least two actual lines in different veins in case one blows.

The value of a mid-line is for prolonged IV meds in the hospital and frequent blood draws if the nurses aren't allowed to pull from a PIV. They also like mid-lines over CVLs for CLABSI metrics. These are floor issues and should not take up the time of a resident who should be seeing other patients.

 

[Groove]

We're discussing having residents place mid-lines rather than US-PIVs and possibly CVLs in certain selected ED patients.

Pros:

• Longer life than PIVs
• Reduced CLABSI
• Double lumen access

Cons:

• More time intensive, although could probably be done <10 minutes with practice
• Fewer CVL opportunities for learners
• Potentially ruins dialysis access

Would like to hear thoughts from people who have or are doing this routinely.

Not a fan. It’s just not reflective of the real life opportunities that they will have in the majority of community shops as well as academic jobs (I’ve never worked in a place where midlines were readily accessible in the ED). They also take too long. For a non CVL line, better to just do an US guided PIV or throw in an EZ IJ. In fact, I can throw in a subclavian CVL in half the time it would take me to do a midline. Also, if I were an academic attending I’d probably encourage more CVLs because I think that is reflective of classical EM procedural training and I don’t think I would want to rob my residents of the experience. When they graduate, they would literally be the only doc in their particular group doing midlines. I don’t think residents can ever do too many CVLs. There’s always something new to practice. US guided subclavian, landmark subclavian, US guided axillary, supraclavicular line with landmark, supraclavicular US guided, etc.. I’d much rather them practice any of those vs waste time fiddling with a midline of all things.

In those morbidly obese difficult sticks that don’t need central access, I typically throw in an EZ IJ and consult the PICC team for when they hit the floor upstairs.

 

[Jabbed]

I agree with IO/CVL/EZ-IJ for unstable patients and US-PIV for stable patients. The envisioned situation where it may have an advantage would be the difficult access stable patient who is going to the floor/step-down. I personally would not let a stable patient leave the ED with an EZ-IJ, and I have mixed feelings about putting a short PIV in the proximal basilic and ruining the only viable PICC/mid-line site. I agree that it is an upstairs problem, but I do feel that I am setting up both the inpatient team and the patient for failure in these situations. I have sometimes placed a long 20 gauge angiocatheter that we use for our femoral arterial lines in these patients.

Weingart et al were popularizing the idea of mid-lines for patients on single vasopressors with additional access. I have not had any experience with that, although my inclination with most ICU patients is to err on the side of placing a CVL.

 

[alpinism]

Yeah I can't really see a situation when you'd be needing to place an emergent midline.

Place an US PIV or CVC in the ED and then let the inpatient team decide after they're admitted.

If its an issue with the catheters being too short ask your leadership to buy some of the long catheters.

 

[Porfirio]

One of the best parts of not being a resident anymore is the ability to say, “I don’t know how to do US guided PIV.” (Total lie)

It always amazes me how the impossible to stick patient suddenly has an IV placed by a nurse.

 

[Tenk]

There is no way in hell you can place a sterile midline in less than ten minutes from the moment you say: I need access.

 

[Lexdiamondz]

If the midline is for a floor bound patient, why cant they just get PIVs and have a midline placed...on the floor?

 

[Arch Guillotti]

Yeah I can't really see a situation when you'd be needing to place an emergent midline.

Morbidly obese anti coagulated patient with no access (who needs it) that can't lay flat.

 

[The Knife & Gun Club]

We're discussing having residents place mid-lines rather than US-PIVs and possibly CVLs in certain selected ED patients.

Pros:

• Longer life than PIVs
• Reduced CLABSI
• Double lumen access

Cons:

• More time intensive, although could probably be done <10 minutes with practice
• Fewer CVL opportunities for learners
• Potentially ruins dialysis access

Would like to hear thoughts from people who have or are doing this routinely.

We recently got these “micro-puncture kits” which have been great. It’s ultra-echogenic 21g needle, an ultra-echogenic mini wire, and a 8cm 14g catheter.

You can do it as fast as an USPIV, but the needles way easier to see and you can pass the wire several inches into the vein to be sure you’re in. 14g cath is long enough not to pull but not too long so infusion times are solid.

it’s like a mid-mid-line!

 

[SpacemanSpifff]

We recently got these “micro-puncture kits” which have been great. It’s ultra-echogenic 21g needle, an ultra-echogenic mini wire, and a 8cm 14g catheter.

You can do it as fast as an USPIV, but the needles way easier to see and you can pass the wire several inches into the vein to be sure you’re in. 14g cath is long enough not to pull but not too long so infusion times are solid.

it’s like a mid-mid-line!

What is the product you're using?

 

[Jabbed]

We recently got these “micro-puncture kits” which have been great. It’s ultra-echogenic 21g needle, an ultra-echogenic mini wire, and a 8cm 14g catheter.

You can do it as fast as an USPIV, but the needles way easier to see and you can pass the wire several inches into the vein to be sure you’re in. 14g cath is long enough not to pull but not too long so infusion times are solid.

it’s like a mid-mid-line!

Interesting. Most of the failure rates with PIVs seem to be due to intravascular catheter length. 2.75 cm seems to be the magic number for 100% patency at 3 days.

Are you placing these proximal or distal to the AC?

Do you have the product ID?

 

[Arch Guillotti]

Interesting. Most of the failure rates with PIVs seem to be due to intravascular catheter length. 2.75 cm seems to be the magic number for 100% patency at 3 days.

Are you placing these proximal or distal to the AC?

Do you have the product ID?

Probably something like this:

Hail the mighty micropuncture

Please meet my friend and colleague, the micropuncture kit: Oh, you haven’t been introduced? Allow me the honor. The kit and how it works These setups usually include three items: A small-bor…

critcon.org

I have placed many in the AC or right above. Don’t usually go below AC.

 

[alpinism]

Morbidly obese anti coagulated patient with no access (who needs it) that can't lay flat.

Yeah but you could also just place an US PIV using one of the specialty made long IV catheters.

That's pretty much our typical CHF with SCAPE on CPAP and no IV access. Instead of going through all the trouble of placing a sterile midline
we'll just grab the US machine and place a long catheter in one of the deep upper extremity veins. Its much faster and often times we'll be finished before the nurses have even put them on the monitor and gotten a full set of vital signs.

 

[Fox800]

We did midlines for a bit in residency. They took just as long as a central line because they wanted us to place them with sterile gloves, towels, sterile US probe, etc. They didn't save any time, and take MUCH longer than a long peripheral IV placed under US in the upper arm.

 

[thegenius]

We did midlines for a bit in residency. They took just as long as a central line because they wanted us to place them with sterile gloves, towels, sterile US probe, etc. They didn't save any time, and take MUCH longer than a long peripheral IV placed under US in the upper arm.

Exactly...that's why I'm not particularly excited about midline catheters if all of the setup is the same as a central line (at least for the ED)

What the ED needs is an ultrasound guided easy IV that doesn't require the same setup as a central line (full sterilization, etc.). It has to be quick and safe. Or something a nurse can do.

 

[The Knife & Gun Club]

What is the product you're using?

Interesting. Most of the failure rates with PIVs seem to be due to intravascular catheter length. 2.75 cm seems to be the magic number for 100% patency at 3 days.

Are you placing these proximal or distal to the AC?

Do you have the product ID?

Its this one - Angiodynamica micro-introducer kit. We use the 10cm cath.

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I wasn’t involved in the decision to stock these so have no idea how they stack up compared to other similar systems.

But I hear they’re pretty cheap, which makes the barrier to entry lower I guess?