vascular access infection prevention
Choosing the Best Catheter With Lowest Risk
Initiation of infusion therapy is performed using the most appropriate type of vascular access device , peripheral or central , and intended to accommodate the patients vascular access needs with the least invasive , fewest number of lumens , and lowest risk device selected .
common question among healthcare workers is
A which intravenous ( IV ) device is the best for the patient . Choosing the best catheter to deliver medical treatment involves consideration for multiple factors including risk .
As one of the most common invasive procedures , the insertion of peripheral catheters , while at the low end of risk for infection , still carries a degree of risk for injury . Peripheral catheters fail at a rate of 50 percent or higher , not often remaining patent for longer than 48 hours . As more and more patient veins are used venous depletion occurs making it more difficult to establish any vascular access . Patients with difficult access and many insertion attempts are becoming more common resulting in challenges with establishing a reliable form of vascular access . These types of patients require consideration for the insertion of a catheter that will last beyond 48 hours .
Enter midline catheters and peripherally inserted central catheters ( PICCs ) as an alternative to short peripheral catheter high failure rates . This discussion will focus on the “ what and why ” of device selection , primarily for midline catheters and PICCs . Refer to the Dashboard Table on page 40 for more detail on appropriateness of all types of vascular access devices ( Moureau and Chopra 2016 ).
According to the Infusion Nurses Society ( INS ) Standards of Practice , vascular access planning is a major consideration for patient safety in the delivery of IV infusions ( Gorski 2021 ). Initiation of infusion therapy is performed using the most appropriate type of vascular access device , peripheral or central , and intended to accommodate the patients vascular access needs with the least invasive , fewest number of lumens , and lowest risk device selected . Vessel health and preservation practices are a priority to minimize vessel depletion and injury .
Short peripheral catheters , ultrasound guided , and midline catheters are all types of peripheral catheters inserted into the veins of the forearm or upper arm . Short peripheral catheters are considered appropriate for four days or less , where a longer ultrasound guided peripheral catheter can be used for longer periods of time and removed when clinically indicated .
The Centers for Disease Control and Prevention ( CDC ), in its 2011 guidelines , state that midline catheters should be considered instead of peripheral catheters when the expected duration of IV treatment exceeds six days ( O ’ Grady 2011 ), which is consistent with INS expected treatment range for midline catheters of five to 14 days .
Since the publication of the Michigan Appropriateness Guidelines for Intravascular Catheters ( MAGIC ) in 2015 , clinicians have been encouraged to avoid central venous access devices , such as PICCs , in favor of peripheral options that include midline catheters ( Chopra 2015 ). According to MAGIC , midline catheters are most appropriate for use up to 14 days , and potentially up to 30 days . Catheter selection based on estimated duration of treatment is helpful but other factors such as availability of a trained inserter , choice of location , ease of insertion , comfort for the patient , and risk of infection all must be considered with the selection process .
What and Why of Midlines
Midline catheter popularity is increasing due to ease of insertion , longer dwell time than short peripheral catheters and lack of reporting requirements for infection . These midline catheters are generally 8-25 cm in length , inserted with ultrasound guidance and a sterile procedure , much like PICCs . The distinction of midlines versus short peripheral or PICCs is that the insertion is performed most often in the upper arm with a midline catheter not extending beyond the shoulder or into the chest . Limitations on the use of midline catheters include a focus on peripherally compatible medications and solutions , although some recent studies are considering the use of midlines for administration of vasopressors , known to be vesicant in nature ( Prasanna 2021 ). Midline catheter risk of infection is similar to short peripheral catheters and less than a PICC with an infection rate of 0-0.9 / 1,000 catheter days , making them a very attractive choice for vascular access ( Swaminathan 2022 ). Midline catheters do have complications resulting in catheter failure from occlusion , dislodgment , and thrombosis but the longer softer catheter generally achieves much better dwell times than short peripheral or even ultrasound guided longer peripheral catheters .
So , when is it best to use midline catheters ?
Midline catheters are a good option for patients with isotonic and non-irritating medications infusions who need more reliable access but do not require central venous access . Midline catheters , as a peripheral option , are replaced only when there is a clinical indication such as a complication or dysfunction . Those patients who require a longer plan of treatment , irritating or higher osmotic infusions are best accommodated with a PICC or another central catheter .
www . healthcarehygienemagazine . com • march 2022
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