Midline catheters offer an alternative to peripheral venous access, providing vascular access in a larger peripheral vein without entering central venous circulation.

They are available in various sizes and for various durations of treatment and are inserted peripherally via the antecubital fossa using ultrasound guidance with the tip terminating in the axillary vein. Benefits to the patient include less frequent re-siting of the catheter and a subsequent reduction in associate venous trauma.

This guideline will provide you with the practical procedure to provide the care of midline catheters.

Please be aware that this guideline does not make / deem you competent in using these devices.

Purpose of the guideline

This guideline has been developed to inform nursing, clinical support workers and medical staff of the correct, routine care and maintenance of midline catheters to promote positive patient outcomes.
Midline catheters should only be accessed by staff that have undertaken clinical teaching in midline care & maintenance and completed the midline competency framework by utilising a competent practitioner.

Scope of the guideline

This guideline should enable any competent registered nurse, clinical support worker or doctor to provide support and care to patients with a midline catheter within Ayrshire and Arran. This guideline should be used for advice on changing the dressing, flushing midlines; blood sampling and commencing / discontinuing an infusion. Staff should adhere to these guidelines to ensure best practice across Ayrshire and Arran.

Definition of terms

Antimicrobial chlorhexidine sponge disc dressing:

e.g. Biopatch.

Aseptic technique:

This is a sterile procedure performed to prevent contamination and risk of contracting infection.

Blood culture:

Blood sample taken and sent to the laboratory to detect any bacteria or other microorganisms. When obtaining blood cultures from a midline, cultures must be taken peripherally first and then from each lumen of the midline. Each sample should clearly state where the blood culture has been taken from.

Chlorhexidine 2% in 70% alcohol sponge applicator:

e.g. Chloroprep.

Chlorhexidine 2% in 70% alcohol wipe:

e.g. Clinell wipe (green).

Extravasation:

The infiltration of a drug into the surrounding tissue.

Lumen:

The cavity of tube within an organ.

Needle free device:

Vygon TKO should be used on all midlines.

Securement device:

GripLoks should be used to secure all midlines.

Sterile transparent semi-permeable dressing:

e.g. IV Tegaderm Advance or IV3000 dressing.

Midlines are non-tunnelled peripherally-inserted vascular access devices which are inserted through a peripheral vein in the arm. Midlines can be used for a longer period of time than conventional peripheral cannulas and should be considered when patients require intravenous therapy for more than five days². The tip of a Midline does not terminate centrally in the Superior Vena Cava and instead typically terminates before entering the axillary vein at the shoulder. Since the catheter tip is of a much shorter length, a follow-up chest x-ray is not required to confirm catheter placement, although this might be useful for difficult insertions. Midlines do not enter the central system and therefore have the same limitations as a peripheral cannula.

Vygon offers three types of midline catheter:

• Smartmidline is indicated for up to 29 days of treatment.
• Leaderflex is indicated for up to 29 days of treatment.
• Lifecath Midline™ comes in a range of sizes and can be used for the duration of treatment.

Indications

• Patients undergoing IV therapy (eg antibiotics) for more than five days. (IV therapy must be suitable for peripheral administration. If central administration is required (i.e. total parenteral nutrition (TPN)) then central venous catheter (CVC) or peripherally inserted central catheter (PICC) line should be considered).
• Patients who have poor venous access in the lower arm where using central access would be contraindicated or not in the best interests of the patient.

Contraindications

• Same limitations as a peripheral catheter for medication delivery.
• Mastectomy on same side.
• Arterio-venous fistula on insertion side.
• Parenteral nutrition.
• Vesicant medications.
• Systemic anti-cancer therapies.
• Solutions with pH<5 or >9.
• Solutions with osmolarity>500mOsm/l.

The midline must be kept clean and dry around the exit site.

• The dressing on midline catheters must be changed on a weekly basis, or when soiled or lifting.
• The exit site should only be swabbed if clinical signs of infection e.g. inflammation, pus are indicated.

Equipment required

• sterile dressing pack
• sterile swab for culture (only if signs of infection)
• two pairs of sterile gloves
• non sterile gloves
• plastic apron
• chlorhexidine 2% in 70% alcohol sponge applicator
• sterile transparent semi-permeable dressing approx. 10cmx12cm
• disposal bag
• alcohol based hand rub or alternative antiseptic hand hygiene product
• chlorhexidine gluconate BP 2% & isopropyl alcohol 70% wipes
• Vygon TKO needle free device (one per lumen) – Do not use needle free devices with extension sets e.g. vadsite octopus
• 0.9% sodium chloride (10mls per lumen) (10ml PosiFlush XS may be used – ensure the packaging stipulates XS as only these syringes are externally sterile)
• 10ml Luer-Lok syringes
• blunt needles
• antimicrobial chlorhexidine sponge disc dressing
• measuring tape
• Griplok.

Procedure for changing the dressing

1. Explain and discuss the procedure with the patient and ensure that the patient understands fully.
2. Clean and dry working surface. Perform hand hygiene as per the WHO 5 moments for hand hygiene (See section 1 – Standard Infection Control Precautions of the Control of Infection Manual)
3. Put on a plastic apron.
4. Open dressing pack onto clean area and open the necessary equipment onto the dressing pack aseptically.
5. Perform hand hygiene as per the WHO 5 moments for hand hygiene and apply non sterile gloves.
6. Remove old dressing from site and antimicrobial disc dressing and dispose of this as per infection control guidelines. Remember that midline catheters need to remain secure during removal of the dressing to prevent migration. Remove non sterile gloves.
7. Perform hand hygiene as per the WHO 5 moments for hand hygiene and apply sterile gloves.
8. A swab for bacteriology should be taken from the exit site if clinical signs of infection are present.
9. Clean the insertion site with chlorhexidine 2% in 70% alcohol sponge applicator using the appropriate technique for 30 seconds and allow to dry.
10.  Clean the line from insertion site downwards to the lumen with chlorhexidine gluconate BP 2% & isopropyl alcohol 70% wipe and allow to dry.
11. Position antimicrobial chlorhexidine sponge disc dressing (blue side upwards) around the midline at exit site. Place a Griplock to secure the midline. Apply sterile transparent semi-permeable dressing approximately over the exit site, touching only the corners, to minimize skin irritation and reduce the risk of the dressing peeling or becoming damaged.
12. Remove PPE and perform hand hygiene as per the WHO 5 moments for hand hygiene.
13. Dispose of all waste appropriately as per waste management guidelines.
14. Document procedure, including the length of the midline, any problems and action taken with review date in the CVAD care and maintenance bundle DRS 6104 and appropriate notes.

Trouble shooting

If there is any evidence of infection at the exit site or midline migration advise the patient to contact their medical or surgical team.

This procedure should be carried out prior to and following infusions/boluses and at regular intervals to ensure midline patency.

Strict aseptic technique must be used for all midline manipulations, appropriately cleaned trolleys must be used in the hospital.

The Vygon TKO needle free device at the end of each line should be changed weekly or when damaged, leaking or soiled followed by a port protector. Octopus extension sets must not be used on Midline Catheters.

No smaller than a 10ml syringe should be used for drug administration or flushing into the midline. This is to prevent excessive pressure being exerted on the lumen which might cause it to rupture.

Equipment required

• sterile dressing pack
• one pair of sterile gloves
• plastic apron
• disposal bag and sharps bin
• antiseptic hand hygiene product*
• chlorhexidine gluconate BP 2% & isopropyl alcohol 70% wipe
• Vygon TKO needle free device (one per lumen – only needs changed once per week at routine line care and maintenance). Do not use needle free devices with extension sets
• 0.9% sodium chloride (10mls per lumen). 10ml PosiFlush XS may be used – ensure the packaging stipulates XS as only these syringes are externally sterile
• 10ml Luer-Lok syringes (number depends on how many lumens and if blood sampling required)
• blunt needles.

Procedure for flushing the line

Procedure

1. Perform hand hygiene as per the WHO 5 moments for hand hygiene. Put on sterile gloves using an aseptic technique.
2. Draw up 0.9% sodium chloride solution for flushing using an aseptic non touch technique (10mls per lumen) or 10ml PosiFlush XS may be used – ensure the packaging stipulates XS as only these syringes are externally sterile.
3. Remove the old Vygon TKO needle free device using sterile swabs and clean the end of the lumen thoroughly with chlorhexidine gluconate BP 2% & isopropyl alcohol 70% wipe and allow to dry. Put on new Vygon TKO needle free devices securely. Do not use needle free devices with extension sets.
4. Attach a 10ml syringe, open clamp (if applicable) and withdraw 5-10ml stagnant blood, close clamp and discard stagnant blood appropriately. If infection is suspected this blood must be sent for blood culture as well as a separate peripheral blood culture sample (see section 8 of this guideline for blood culture procedure). If other laboratory blood samples are required they can be taken once initial 5-10mls of stagnant blood is removed.
5. (Open clamp if applicable) and flush with 10mls of 0.9% sodium chloride using a brisk push/pause action, closing the clamp on the last push to create positive pressure in the line.
6. Remove PPE and perform hand hygiene as per the WHO 5 moments for hand hygiene. Dispose of all waste appropriately as per waste management guidelines.
7. Document procedure any problems, action taken and review date in the care bundle DRS 6104 and appropriate notes.

An aseptic technique must be adhered to when taking blood samples. A trolley should be set up in the same way as to do the dressing change and flushing the midline with the required equipment.

Steps 1 to 8 for flushing the midline should be followed. Only step 3 should be omitted. Laboratory bloods should be taken at step 4 once the 5-10mls of stagnant blood has been removed and discarded (unless blood cultures required). The syringe with blood for blood sampling should be placed at the side of the sterile field.

Once the line care has been completed the syringe with the blood should gently agitated prior to transferring into the appropriate laboratory blood bottles over the sterile field at waist level. If blood is left to sit in the syringe for a few minutes the blood sediments therefore red cells drift down and plasma/platelets are left at the top. If the syringe is not gently agitated prior to transferring into the blood bottles there is a risk of either concentrated red cells (elevated haemoglobin and Haematocrit) or dilute plasma (reduced haemoglobin and Haematocrit)– so the full blood count result could be inaccurate.

Procedure for obtaining blood cultures from a midline catheter

An aseptic technique must be adhered to when taking blood cultures. Blood cultures require to be taken peripherally and then from each lumen of the midline. For the peripheral blood cultures follow G083: Obtaining Peripheral Blood cultures in adults (16 years and over).

It is important to emphasise that peripheral blood cultures must be taken prior to blood cultures from the midline.

The rationale for this is: If the midline blood cultures are taken first the midline will need to be flushed / locked and this will inoculate the organisms into the bloodstream. If the peripheral blood culture is then taken it will then contain more organisms than it should do, and this blunts the differential time to positivity that is recorded in the blood culture machine.

To diagnose a systemic midline infection, the midline blood culture and the peripheral blood culture should grow the same organism. The midline blood culture should become positive at least 2 hours faster (because of the biofilm inside the lumen) than the peripheral blood culture.

Take peripheral blood cultures first. For blood cultures from a midline, a trolley should be set up in the same way as to flush the midline.

Procedure

1. Prepare the equipment aseptically on a sterile trolley.
2. Check sample bottles and equipment are not faulty and within expiry dates (Do not place these on the top of the trolley as these are not sterile, place these on the lower shelf of the trolley).
3. Put on personal protective equipment (PPE) and perform hand hygiene as per the WHO5 moments for hand hygiene (See section 1 – Standard Infection Control Precautions of the Control of Infection Manual)
4. Apply sterile gloves.
5. Decontaminate the needle free device with chlorhexidine gluconate BP 2% & isopropyl alcohol 70% wipe and allow to dry.
6. Attach a Luer-Lok syringe and aspirate 20mls of blood (2 x 10ml Luer-Lok syringes), place the sample in the sterile container within the sterile pack ensuring it does not contaminate any other equipment.
7. Flush with 10mls of 0.9% sodium chloride using a brisk push/pause action, closing the clamp on the last push to create positive pressure in the line.
8. The tops of media bottles are clean but not sterile and should be wiped with 70% isopropyl alcohol swab and allowed to dry, a new blunt needle used to inoculate blood into bottles.
9. Approximately 5-10mls blood should be introduced into each bottle as results are dependent on the volume of blood cultured.
10. Dispose of all waste appropriately as per waste management guidelines.
11. Remove PPE and perform hand hygiene as per the WHO 5 moments for hand hygiene.
12. Document procedure any problems, action taken and review date in the care bundle DRS 6104 and appropriate notes.

Label the bottles correctly and complete microbiology form, stating the date and time of sample, sign and print name as instructed on the form. Label the site of the culture set (e.g. white lumen, red lumen or peripheral), as it is important in helping to distinguish pathogens from contaminants.

Do not remove bar code from bottles; these are for Laboratory use only.

An aseptic technique must be adhered to when commencing an infusion. A trolley should be set up in the same way as to do the dressing change and flushing the midline with the required equipment. The giving set must be primed using an aseptic technique on the dressing trolley and must not be run over a sink (This would significantly increase the risk of infection from sink organisms from splash back)

Do not prime giving sets prior to starting the procedure.

Equipment required

• sterile dressing pack
• one pair of sterile gloves
• plastic apron
• disposal bag and sharps bin
• antiseptic hand hygiene product
• chlorhexidine gluconate BP 2% & isopropyl alcohol 70% wipes
• 0.9% sodium chloride (10mls per lumen). 10ml PosiFlush XS may be used – ensure the packaging stipulates XS as only these syringes are externally sterile
• 10ml Luer-Lok syringes
• blunt needle
• sterile infusion giving set
• sterile prescribed infusion product for administration
• infusion pump to deliver the product – Infusion devices must always be used when delivering treatment or fluids via a midline to reduce the risk of midline occlusions.

Procedure for connecting an infusion to a midline

1. Perform hand hygiene as per the WHO 5 moments for hand hygiene. Put on sterile gloves using an aseptic technique.
2. Draw up 0.9% sodium chloride solution for flushing (10mls per lumen) or 10ml PosiFlush XS may be used – ensure the packaging stipulates XS as only these syringes are externally sterile.
3. Aseptically run through the sterile giving with 0.9% saline and place on the sterile field ready for connection.
4. Clean the needle free device thoroughly with chlorhexidine gluconate BP 2% & isopropyl alcohol 70% wipe for 30 seconds and allow to dry.
5. Attach a 10ml syringe, open clamp (if applicable) and withdraw 5-10ml stagnant blood, close clamp and discard stagnant blood appropriately.
6. Attach syringe with 10mls of 0.9% sodium chloride (open clamp if applicable) and flush using a brisk push/pause action, closing the clamp on the last push.
7. Aseptically attach the sterile giving set to the patient’s midline.
8. Load giving set into the infusion device and then open clamps on midline (if applicable) and clamp on the giving set. Start the infusion.
9. Dispose of all waste appropriately as per waste management guidelines.
10. Remove PPE and perform hand hygiene as per the WHO 5 moments for hand hygiene.
11. Document procedure including any problems, action taken and review date in the care bundle DRS 6104 and appropriate notes.

Following this all equipment should be appropriately disposed of, the contents of this trolley should never be kept to be used for disconnecting the infusion, no matter how short the infusion as this significantly increases the chance of infection.

When disconnecting an infusion pump a strict aseptic technique must be followed. A trolley should be set in a similar way to doing the dressing change and flushing the line with the required equipment.

Equipment required

• sterile dressing pack
• one pair of sterile gloves
• plastic apron
• disposal bag and appropriate disposal bin
• antiseptic hand hygiene product*chlorhexidine gluconate BP 2% & isopropyl alcohol 70% wipes
• 10ml Luer-Lok syringes
• blunt needle
• 0.9% sodium chloride (10mls per lumen). 10ml PosiFlush XS may be used – ensure the packaging stipulates XS as only these syringes are externally sterile.

If an infusion is running via one lumen only, then only the one lumen will need flushed with 0.9% sodium chloride.

Procedure

1. Perform hand hygiene as per the WHO 5 moments for hand hygiene. Put on sterile gloves using an aseptic technique.
2. Draw up 0.9% sodium chloride solution for flushing (10mls per lumen) or 10ml PosiFlush XS may be used – ensure the packaging stipulates XS as only these syringes are externally sterile.
3. Stop the infusion and close any clamps. Remove the infusion from the midline and dispose into appropriate bin according to the waste management for the type of product. Clean the end of the line thoroughly with chlorhexidine gluconate BP 2% & isopropyl alcohol 70% wipe for 30 seconds and allow to dry.
4. Attach syringe with 10mls of 0.9% sodium chloride (open clamp if applicable) and flush using a brisk push/pause action, closing the clamp on the last push to create positive pressure in the line.
5. Dispose of all waste appropriately as per waste management guidelines.
6. Remove PPE and perform hand hygiene as per the WHO 5 moments for hand hygiene.
7. Document procedure including any problems, action taken and review date in the DRS 6104 and appropriate notes.

Midline catheter removal should only be undertaken by clinicians who are competent to do so.

Equipment required

• cleaned trolley or tray
• sterile pack
• chlorhexidine 2% in 70% alcohol sponge applicator
• sterile gloves (nitrile or latex)
• small dressing pack

Rationale

To prepare for the procedure and ensure that aseptic non-touch technique (ANTT) is used throughout.

Procedure

1. Explain procedure to patient and reassure them that this is normally a simple uncomplicated procedure. Check patients NEWS.
2. Perform hand hygiene as per the WHO 5 moments for hand hygiene. See section 1 – Standard Infection Control Precautions of the Control of Infection Manual and prepare equipment.
3. Prepare the patient and gain consent.
4. Wash and dry hands and apply sterile gloves.
5. Make the patient comfortable with arm supported on a pillow and the insertion site below the level of the heart. This minimises the risk of air embolism.
6. Loosen the existing dressing.
7. Remove dressing, griplok and antimicrobial chlorhexidine sponge disc dressing. Clean the site with chlorhexidine 2% in 70% alcohol sponge applicator.
8. Hold a piece of gauze above the excision site to support the surrounding skin.
9. Apply traction on the Midline and gently pull the catheter in a steady and even manner moving the hand along the length of the Midline and pulling from the insertion point.
10. When the line is completely removed sterile gauze should be held over the insertion/ excision site point, apply gentle finger pressure until any bleeding stops.
11. Once any bleeding has stopped replace the gauze with further sterile dressing and then bandage the site; this will act as a pressure bandage and will minimise the risk of a haematoma formation.
12. Carry out and record NEWS.
13. Dispose of all waste management appropriately as per Waste Management Procedure.
14. Remove PPE and perform hand hygiene.
15. Document procedure, review date and any issues in the patients notes using the midline care plan.

Occlusions: Regular flushing with correct flush technique and the use of a suitable needle-free device (Bionector TKO) will help to prevent catheter occlusion.

Phlebitis: Monitor for signs of phlebitis at regular intervals.

Extravasation/infiltration: Measure arm circumference and report any increase, report early signs and instruct patient to report pain, swelling, leakage etc.

Infection: Use aseptic non-touch technique (ANTT), good care and maintenance and assessment, patient involvement (report pain, discomfort, redness, swelling)

Any patient demonstrating potential complications should be reviewed by a competent practitioner.

Professional accountability

All nurses and doctors are personally accountable for their actions and omissions and are professionally accountable for the patient assessment and treatment, including the care and maintenance of midline catheters.

Continuous professional development

As with any area of practice, every nurse and doctor is responsible for ensuring they maintain their knowledge and skill around their practice. All health professionals are expected to keep themselves up to date with current best practice in the management of midline catheters.

Line manager / professional lead

To ensure safe and effective practice, the line manager is responsible for working closely with the registered nurse or doctor caring for a patient with a midline catheter and ensuring adequate clinical support in relation to supervision.

Midline catheter care and maintenance

The person accepting responsibility for the care and maintenance of midline catheters must ensure that the documentation record of the care is accurate and clear.

Related documents

National Services Scotland. National infection prevention and control manual.

References

1. Loveday, H.P., Wilson, J.A., Pratt, R.J., Golsorkhi, M., Tingle, A., Bak, A., Browne, J., Prieto, J. & Wilcox, M. (2014) ‘Epic3: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England’, Journal of Hospital Infection, 86, pp. S1–S70.
2. Gorski L, Hadaway L, Hagle ME, McGoldrick M, Orr M, Doellman, D (2016) Infusion therapy standards of practice. Journal of Infusion Nursing. 2016;39(suppl 1):S1-S159.
3. Gilies, D et al. (2003) Central venous catheter dressings: a systematic review. Journal of Advanced Nursing. 44 (6) 623 – 632.
4. Royal College of Nursing (2016) standards for infusion therapy. RCN Intravenous Therapy Forum, London.
5. Gorski, et al (2016) Infusion Nurses Society. Policies and Practices for Infusion Therapy. Available at: http://ins.tizrapublisher.com/hha7v4/
6. Hadaway, L (2010) Technology of flushing vascular access devices. Journal of Infusion Nursing. 29(3 137 – 145).
7. Centers for Disease Control and Prevention (2011) Guidelines for the Prevention of Intravascular Catheter-Related Infections. http://tinyurl.com/4yg8bh9 [accessed March 2016]
8. Biopatch Literature.

Midline competency document

Midline cannula insertion and maintenance bundle