STRATEGY OR RISK: THE USE OF MIDLINE CATHETERS. Timothy R. Spencer BH, RN, APN, VA- BC

Transcription

1 STRATEGY OR RISK: THE USE OF MIDLINE CATHETERS Timothy R. Spencer BH, RN, APN, VA- BC

2 Learning Objectives: Recognize the appropriate clinical use of midline catheters. Review current practice and evidence regarding midline use. Identify appropriate strategies and use of technology to optimize midline catheter outcomes and prevent adverse events.

3 Question 1 Should midlines be used to replace CVADs in critically ill patients? 1. Yes 2. No

4 Question 2 Do you consider a midline to be less thrombotic than a PICC? 1. Yes 2. No

5 Introduction What is the state of current peripheral IV technology? standard PIV; ~2-5cm USGPIV/Extended dwell device; ~5cm Midline catheters; 8-20cm INS Guidelines Terminology: Anatomical insertion location, dwell times and tip position determines this. These are all peripheral devices. Infusion Therapy Standards of Practice (2016) Journal of Infusion Nursing JANUARY/FEBRUARY 2016 Volume 39 Number 1S

6 What does the CDC say? Selection of Catheters and Sites - Peripheral Catheters and Midline Catheters (2002 & 2011 versions) 1. In adults, use an upper-extremity site for catheter insertion. Replace a catheter inserted in a lower extremity site to an upper extremity site as soon as possible. Category II 2. In pediatric patients, the upper or lower extremities or the scalp (in neonates or young infants) can be used as the catheter insertion site [32, 33]. Category II 3. Select catheters on the basis of the intended purpose and duration of use, known infectious and non-infectious complications (e.g., phlebitis and infiltration), and experience of individual catheter operators [33 35]. Category IB 4. Avoid the use of steel needles for the administration of fluids and medication that might cause tissue necrosis if extravasation occurs [33, 34]. Category IA 5. Use a midline catheter or peripherally inserted central catheter (PICC), instead of a short peripheral catheter, when the duration of IV therapy will likely exceed six days. Category II CDC 2002 & 2011 Guidelines for the Prevention of Intravascular Catheter-Related Infections - HICPAC

7 INS Glossary definition Midline Catheter. A catheter inserted into the upper arm via the basilic, cephalic, or brachial vein, with the internal tip located level at or near the level of the axilla and distal to the shoulder. Infusion Therapy Standards of Practice (2016) Journal of Infusion Nursing JANUARY/FEBRUARY 2016 Volume 39 Number 1S

8 INS midline position statement Practice Criteria II. Short Peripheral and Midline Catheters H. Ensure appropriate midline catheter tip location: Adults and older children: at the level of the axilla and distal to the shoulder.24-26,32 (V) What defines the appropriate anatomical location for a midline?

9 Optimal midline tip location evidence Anderson (2004) quotes Hadaway (1990) The catheter is placed in the basilic, cephalic, or median cubital veins of the upper arm or antecubital area, with the tip residing in the cephalic or basilic vein in the upper portion of the arm.9 9. Hadaway LC. An overview of vascular access devices inserted via the antecubital area. Journal of Intravenous Nursing 1990;13(5): Dumont (2014) states the midline s tip terminates in the cephalic, brachial, or basilic vein distal to the shoulder (the tip doesn t enter the central vasculature), which flows into the distal axillary vein Dumont C, Getz O, Miller, S. Evaluation of midline vascular access: a descriptive study. Nursing ;44(10):60-66.

10 Axillary Anatomy Tip location by literature Distal axillary vein Image:

11 Axillary Line Image:

12 Question 3 What is the key factor you use to determine what type of VAD is placed? 1. Product name / type 2. Drugs/solution properties and duration of therapy 3. Physician s order 4. Patient assessment 5. Patient location (ICU, LTACH, home care, etc)

13 Question 4 Does your hospital currently track infectious complications of midline catheters? 1. Yes 2. No 3. Not sure

14 Question 5 Is the risk of infection less for midline catheters than PICCs? 1. Yes 2. No

15 WHAT DOES THE EVIDENCE TELL US?

16 Midline catheter-related infection Author Lawson Thiagarajan DiNucci Scoppettuolo Cummings Deutsh Sharp Caparas Pathak Moureau Leone Subjects database peds hospital ER CF SICU CF HAI Vent unit home infusion home infusion # devices d 31,130 1,097,715 mean dwell time (days) PICC MID BSI per cent PICC MID >1 0 BSI rate/1000 cd PICC MID Definition/ diagnosis BSI CDC no no no no no CDC no no no 1 suspected 2 catheter days

17 Purpose: to describe the incidence and outcomes of primary hospital acquired bloodstream infection (HABSI) secondary to Staphylococcus aureus that did and did not meet the NHSN definition for CLABSI Study design: retrospective cohort Setting: Cleveland Clinic Subjects: all consecutive patients diagnosed with SA HABSI from Cleveland Clinic Infection Prevention Registry

18 Results: Kovacs CS, et al. AJIC.2016;e-pub ahead of print. PMID 27158

19 Question 6 What are the clinical manifestations of midline associated upper extremity associated deep vein thrombosis (UE- DVT)? 1. Catheter occlusion / inability to draw blood 2. Leakage at the insertion site 3. Edema / swelling / pain 4. All of the above

20 WHAT DOES THE EVIDENCE TELL US?

21 Author Lawson Thiagarajan catheter-related thrombotic events Thrombosis PICC MID 0 0 Occlusion PICC MID 9 6 Phlebitis PICC MID Leaking PICC MID Infiltration PICC MID Pain PICC MID Diagnosis DVT/SVT Moureau no Leone no Cummings < 2 no piv Elia US Deutsh no 3 10 Sharp no Caparas DiNucci no no Scoppettuolo 0 major no 1 per 1000 cath days 2 occlusion + phlebitis 3 infiltration + dislodgement CDC no

22 catheter-failure rates Author Lawson Thiagarajan DiNucci Cummings Deutsh Sharp Caparas Pathak Moureau Leone Elia Subjects database CF SICU CF peds hospital HAI Vent unit home infusion home infusion high dependency unit BSI per cent PICC MID Therapy Completed PICC MID > Thrombotic Failure/adverse events (%) events (%) PICC MID PICC MID severe 5 9 > piv Unexplained removal (%) PICC MID

23 Question 7 What parameters determine if a solution is peripherally compatible? 1. Concentration (drug/volume) 2. ph / osmolarity / osmolality 3. Length of therapy 4. Hemodilution / vein size 5. All of the above

24 Question 8 What properties of IV drugs and solutions cause chemical phlebitis? Review of; ph titratable acidity osmolarity concentration/dilution

25 Solution stability/compatibility terminology (science) Based around ph (H + concentration of solution) Logarithmic increase for each 1 ph change = 10-fold increase in H + Osmolality and osmolarity Osmolality is defined as the number of mosm/kg of solvent. Osmolarity is defined as the number of mosm/l of solution. Intravenous fluid labeling has osmolarity, but not required for intravenous admixtures Titratable acidity increases the phlebitic potential a measure of the reservoir of H+ ion in the solution high titratable acidity irritates venous endothelial cells over a longer distance from the catheter tip common to parenteral nutrition molality

26 Histopathological changes Chemical irritation causes: Loss of venous endothelial cells Inflammatory cell infiltration Edema Thrombus formation Proximal and distal to the catheter tip

27 Standard 45. Phlebitis B. Recognize risk factors that can be addressed: 1. Chemical phlebitis may be related to infusates with dextrose >10% or high osmolarity (>900 mosm/l); certain medications (depending on dosage and length of infusion), such as potassium chloride; amiodarone, and some antibiotics; particulates in the infusate; too large a catheter for the vasculature with inadequate hemodilution; and skin antiseptic solution that is not fully dried and pulled into the vein during catheter insertion. Consider using a midline catheter or PICC for infusates listed above or identified as causing phlebitis, depending on length of infusion time and anticipated duration of therapy. Allow skin to dry after application of antiseptic. Infusion Therapy Standards of Practice (2016) Journal of Infusion Nursing JANUARY/FEBRUARY 2016 Volume 39 Number 1S

28 INS Standard 45. Phlebitis - comments ph removed from standards as a potential factor of chemical phlebitis Osmolarity risk increased to 900mOsm/L Irony of terminology and relationship Infusion Therapy Standards of Practice (2016) Journal of Infusion Nursing JANUARY/FEBRUARY 2016 Volume 39 Number 1S

29 What ph damages cells? ph s of 2.3 and 11 have been shown to kill cells on contact As the ph moderates, the cells survive for a longer time period Cell cultures at ph 4 survived for 10 minutes. Same for ph 9? ph is logarithmic, so ph 5 to 8 safer?

30 Commonly administered drugs Morphine Flucloxicillin 4.0 Dobutamine 2.5 Potassium 4.0 Vancoymycin 2.4 to 4.0 Promethazine 4.0 to 5.5 Tobramycin 3.0 Mannitol 4.5 Bactrim 10.0 Ampicillin 10.0 Phenytoin 10.0 to 12.0 Acyclovir 11.0

31 ph and phlebitis At its extremes, ph may have a larger role in the development of phlebitis. ph alone does not correlate well with the frequency of phlebitis. ph Phlebitis % Doxycycline Dopamine Dolasetron Amiodarone Milrinone Ondansetron Dobutamine Fluconazole Quina/Dalfo 5 40 Caspofungin Micafungin Ampicillin Pantoprazole Esomeprazole TMP/SMZ Ganciclovir Acyclovir 11 9 Phenytoin

32 Current IV Solutions SOLUTION ph RANGE OSMOLALIT VOLUME BUFFER Y 0.9% mOsm 1000ml Nil sodium chloride 5% glucose mOsm 500ml Nil (D5) 0.18% mOsm 1000ml Nil sodium chloride and 4% glucose Compound sodium lactate (Hartmann s mOsm 1000ml Lactate (29mmol/L)

33 ph as a cause of phlebitis Gorski LA, Hagle ME, Bierman S (2015) Authors concluded ph alone is not a predictor of phlebitis, the risk cannot be quantified. Does that mean that non-physiologic ph should not be considered among the factors that may cause phlebitis? The data are inconclusive, the recent analyses retrospective or look at therapy of less than 6 days. The focus seems to be on vancomycin, but it does not have the most extreme drug ph. Gorski LA, Hagle ME, Bierman S. (2105) Intermittently Delivered IV Medication and ph: Reevaluating the Evidence. J Inf Nurs. Jan-Feb;38(1):27-46

34 MAGIC compatible medications

35 MAGIC incompatible medications

36 The most recent publication (2015) on endothelial cell toxicity looks at vancomycin The results showed a significant increase in endothelial cell death from a vancomycin concentration of 2.5 mg/ml onwards Drouet M, et al (2015). Influence of vancomycin infusion methods on endothelial cell toxicity. Antimicrob Agents Chemother 59:

37 Modifying ph & Osmolality ph is still a primary cause of infusion phlebitis The drug ph profile determines the product formulation ph This ph results in optimum stability or solubility Optimum drug stability is usually found at the extremes of ph scale Manufacturers get as close to ph 7.35 as the pharmaceutical parameters permit.

38 Modifying ph & Osmolality The new standard adopts the ASPEN definition of osmolarity that can be tolerated for parenteral nutrition: 900 mosm/l, up from the previous 600 mosm/l Diluents can increase ph. A drug with a ph of 4.7 in NS has a ph of 4.9 in D5RL, a ph of 5.0 in D5, Plasmalyte 56, and a ph of 5.5 in Sodium Lactate. Most IV fluids ph is adjusted with hydrochloric acid Boullata JI, Gilbert K, Sacks G, et al. (2014) A.S.P.E.N. clinical guidelines: parenteral nutrition ordering, order review, compounding, labeling, and dispensing. JPEN

39 ph as a cause of phlebitis There are not enough data to implicate ph, osmolarity, or direct cellular toxicity as the sole cause of drug-induced phlebitis Isolated science has shown endothelial damage from these factors, but that s a clue, not proof Phlebitis is a convergence of factors such as gender, catheter insertion site, catheter materials, catheter tip location, vascular blood flow, drug infusion rate, frequency and duration of therapy, drug characteristics

40 Summary ph/osmo has a relationship to ALL peripheral devices this includes midline catheters Osmolality of drug solutions is not a primary concern ph will remain a potential cause of phlebitis in peripheral veins (at ph extremes) and is not the sole reason to change device selection. One might call it phlebitis One part of the full assessment process that should still be closely considered for each individual patients clinical situation.

41 THANK YOU