Safety and efficacy of vasopressor administration through midline catheters

Intravascular Catheter-Related Bloodstream Infections: Contemporary Issues Related to a Persistent Problem

Hospital-acquired infections, including central line associated bloodstream infections (CLABSI), are an ongoing source of cost, morbidity, and mortality worldwide. This article presents a summary of the impact of the recent SARS-CoV-2 pandemic on CLABSI incidence, an overview of current standard-of-care practices for reduction of CLABSI, and a look toward future changes in bacteremia metrics and challenges in prevention.

Comparison of complication types in patients receiving vesicant intravenous antimicrobials or vasopressors via midlines and peripherally inserted central catheters

We assessed adverse events in hospitalized patients receiving selected vesicant antibiotics or vasopressors administered through midline catheters or peripherally inserted central catheters (PICC). The rates of catheter-related bloodstream infections, thrombosis, and overall events were similar across the two groups, while occlusion was higher in the PICC group.

Development of an Evidence-Based List of Non-Antineoplastic Vesicants: 2024 Update

Infiltration of a vesicant, called extravasation, can result in severe patient injuries. Recognition of vesicants and their relative risk of injury is essential to extravasation prevention, early recognition, and appropriate treatment. In this article, the Vesicant Task Force (VTF) updates the previously published Infusion Nurses Society (INS) vesicant list from 2017. The 2024 INS list diverges from earlier vesicant lists, such as the 2017 VTF list, by adopting a risk stratification approach based upon documented patient outcomes, in contrast to the reliance on expert consensus or only surrogate risk indicators, such as pH and osmolarity. The methodology used to create the updated list is explained, and the criteria for high- and moderate-risk vesicants and cautionary vesicants are defined.

Vascular access device selection: Optimizing patient outcomes - Part 1

ABSTRACT

A systematic evaluation of vascular access device (VAD) selection incorporates patient, device, and infusate characteristics to ensure optimal device placement. This article explores VAD selection from the perspective of vessel health and preservation and describes VAD selection options and indications, VAD-related complications, and strategies to reduce those complications.

Midline catheters for blood gas and acid/base monitoring in critical patients: A prospective observational study

BACKGROUND

Arterial lines and central venous catheter (CVC) allow to monitor patients' acid-base status and gas exchange. Their placement and maintenance may however be burdened by severe complications. Midline Catheters (MC) are peripheral venous accesses that are less invasive and easier to insert compared to CVC and arterial lines.

METHODS

A prospective observational study was performed including stabilized critical patients with clinical indication to midline positioning before intensive care unit (ICU) discharge. The primary aim was to assess if venous sampling from MCs can be a reliable alternative to CVC for pH and CO2 monitoring. The secondary aim was to evaluate the correlation between samplings from MC, CVC and arterial line with regards to pH, carbon dioxide tension (pCO2), lactates and electrolytes. Three samples from CVC, arterial line and MC were collected simultaneously. Agreement and correlation of the studied parameters between different sampling sites were explored.

RESULTS

40 patients were included in the analysis. A good agreement for pH and pCO2 was recorded between MC and CVC: mean differences were 0.001 (95% CI -0.006 to 0.007) and 0.7 (-0.1 to 1.5), percentage error 0.4% and 11.2%, respectively. Correlation between MC and both central venous and arterial samples for pH, pCO2, lactates and electrolytes was found to be moderate-to-strong (Pearson's R coefficient range 0.59-0.99, p < 0.001 for all these parameters).

CONCLUSIONS

In stabilized critical patients, midline catheters represent a reliable alternative to CVC and arterial lines to monitor acid-base disturbances, CO2 levels and electrolytes. The present findings add to the known advantages of MC, which might be considered a first-line vascular access for non-critical or stabilized patients who do not require infusion of vesicant or irritant drugs.

Infiltration and Extravasation Risk with Midline Catheters: A Narrative Literature Review

Midline catheters have recently gained popularity in clinical use, with a common reason being the reduction of central venous catheter use and central line-associated bloodstream infections. At the same time, the number of nononcology vesicant medications has increased, and midline catheters are frequently being used for infusions of vesicant medications. The Infusion Nurses Society (INS) Vesicant Task Force identified midline catheter use as a possible risk factor for extravasation and concluded that a thorough literature review was necessary. This review highlights the variations in catheter terminology and tip locations, the frequency of infiltration and extravasation in published studies, and case reports of infiltration and extravasation from midline catheters. It also examines the many clinical issues requiring evidence-based decision-making for the most appropriate type of vascular access devices. After more than 30 years of clinical practice with midline catheters and what appears to be a significant number of studies, evidence is still insufficient to answer questions about infusion of vesicant and irritant medications through midline catheters. Given the absence of consensus on tip location, inadequate evidence of clinical outcomes, and importance of patient safety, the continuous infusion of vesicants, all parenteral nutrition formulas, and infusates with extremes in pH and osmolarity should be avoided through midline catheters.

Midline Catheters as an Alternative for Central Venous Catheters in Venous Oxygen Saturation Monitoring: A Single Center Experience

BACKGROUND

Central venous oxygen saturation (ScvO2) obtained from a central venous catheter (CVC) is often used to approximate oxygen delivery in critically ill patients. Despite their importance in administering medications and monitoring oxygen delivery, the use of CVCs can be associated with significant complications. Midline catheters are inserted via a peripheral vein above the antecubital fossa and provide a safe alternative to CVCs. This study aimed to determine the equivalence of ScvO2 and midline catheter oxygen saturation (SmO2) in critically ill patients.

METHODS

This was a single-center observational study of critically ill adult patients who had concurrently placed CVCs (internal jugular and subclavian) and midline catheters as part of standard ICU care. Venous oxygen saturation and lactate levels were measured from both catheters using the Abbott point-of-care i-STAT analyzer. Demographic and ICU admission data were collected. Continuous variables were compared using the paired t-test. Pearson's correlation was used to evaluate the linear correlation between ScvO2 and SmO2. The systematic error (bias) was calculated using Bland-Altman analysis. Receiver operating characteristic curves were constructed to evaluate the sensitivities and specificities for different values of SmO2 to predict ScvO2.

RESULTS

Forty-eight patients (n = 48) were enrolled in the study. The mean ScvO2 and SmO2 were 65.5% +/- 11.2% and 62.7% +/- 17.6% respectively (p = 0.1197). In the Bland-Altman analysis, the mean bias between ScvO2 and SmO2 was 2.8% +/- 12.3% with 95% limits of agreement of -21.3% to 26.9%. More than 60% of the ScvO2 and SmO2 values diverged by ≥ 5%.

CONCLUSIONS

The difference between the mean SmO2 and ScvO2 was not statistically significant and the mean bias between SmO2 and ScvO2 is low. Despite this, the substantially large standard deviation and limits of agreement preclude the use of SmO2 as a direct surrogate of ScvO2.

Safety and efficacy of peripheral metaraminol infusion in patients with neurological conditions: a single-center retrospective observational study

Introduction

Metaraminol is a sympathomimetic amine vasopressor that can be administrated through a peripheral venous access. However, limited evidence restricts its application in critically ill patients. This study aimed to investigate the safety and efficacy of peripheral metaraminol infusion in patients with neurological conditions.

Methods

Patients who received peripheral metaraminol infusion between May 2019 and April 2022 were recruited. Data on baseline characteristics, clinical parameters, and infusion-related complications were retrospectively collected and analyzed.

Results

273 patients who received metaraminol were enrolled. Of these, 35 (12.8%) patients required central venous catheter insertion due to inability in achieving hemodynamic stability following peripheral metaraminol monotherapy. In 29,574.2 hours of vasopressor infusion, metaraminol infusion resulted achievement of the target blood pressure 73.4% of the time. Meanwhile, adverse events occurred in 5 patients and resolved after local tissue treatment.

Discussion

Metaraminol could provide hemodynamic support and avoid complications associated with a central venous catheter and delay in vasopressor administration. Through careful and close monitoring, peripheral metaraminol infusion is safe and feasible for patients with neurological conditions. Future large-scale, prospective, multicenter studies are needed to evaluate the safety and efficacy of metaraminol infusion through a peripheral intravenous catheter.

Ultrasonography and procedures in intensive care medicine

The use of point-of-care ultrasonography (POCUS) is not limited to the diagnosis and/or monitoring of critically ill patients. Further, ultrasound guidance is of paramount relevance to aid in successfully and safely performing several procedures in the intensive care unit (ICU). In this article, we review the role of POCUS as a procedural guidance in the ICU. Core procedures include, but are not limited to, vascular cannulation, pericardiocentesis, thoracentesis, paracentesis, aspiration of soft-tissue collections/arthrocentesis and lumbar puncture. With time, the procedures performed by intensivists may extend beyond the core competencies depicted in this review. Ultrasound guidance should be part of the intensivist's competencies, for which appropriate training should be achieved.

Adverse effects related with norepinephrine through short peripheral venous access: Scoping review

Peripheral administration of norepinephrine is restricted due to the association of extravasation with tissue necrosis.

METHOD

Scoping review with the objective of describing the adverse effects related to the administration of norepinephrine through short peripheral venous access and the characteristics of drug administration in patients hospitalized in ICU, surgery, and emergency services.

RESULTS

12 studies with heterogeneous characteristics by size and type of population were included. The proportion of complications associated with peripheral norepinephrine administration was less than 12% in observational studies and it was less than 2% in those that used doses less than 0.13μg/kg/min, and concentrations less than 22.3μg/mL. The main associated complication was extravasation and there were no cases of tissue necrosis at the venipuncture site, some extravasation cases were treated with phentolamine, terbutaline or topical nitroglycerin. The drug administration time ranged between 1 and 528hours with a weighted mean of 2.78h.

CONCLUSION

The main adverse effect was extravasation, no additional complications occurred, phentolamine and terbutaline seem to be useful, and its availability is a necessity. It is essential for the nursing staff to carry out a close assessment and comprehensive care in patients receiving norepinephrine by peripheral route.

The Association of Vasopressor Administration through a Midline Catheter with Catheter-related Complications

Rationale: Little is known about the safety of infusing vasopressors through a midline catheter. Objectives: To evaluate safety outcomes after vasopressor administration through a midline. Methods: We conducted a cohort study of adults admitted to 39 hospitals in Michigan (December 2017-March 2022) who received vasopressors while either a midline or peripherally inserted central catheter (PICC) was in place. Patients receiving vasopressors through a midline were compared with those receiving vasopressors through a PICC and, separately, to those with midlines in place but who received vasopressors through a different catheter. We used descriptive statistics to characterize and compare cohort characteristics. Multivariable mixed effects logistic regression models were fit to determine the association between vasopressor administration through a midline with outcomes, primarily catheter-related complications (bloodstream infection, superficial thrombophlebitis, exit site infection, or catheter occlusion). Results: Our cohort included 287 patients with midlines through which vasopressors were administered, 1,660 with PICCs through which vasopressors were administered, and 884 patients with midlines who received vasopressors through a separate catheter. Age (median [interquartile range]: 68.7 [58.6-75.7], 66.6 [57.1-75.0], and 67.6 [58.7-75.8] yr) and gender (percentage female: 50.5%, 47.3%, and 43.8%) were similar in all groups. The frequency of catheter-related complications was lower in patients with midlines used for vasopressors than PICCs used for vasopressors (5.2% vs. 13.4%; P < 0.001) but similar to midlines with vasopressor administration through a different device (5.2% vs. 6.3%; P = 0.49). After adjustment, administration of vasopressors through a midline was not associated with catheter-related complications compared with PICCs with vasopressors (adjusted odds ratios [aOR], 0.65 [95% confidence interval, 0.31-1.33]; P = 0.23) or midlines with vasopressors elsewhere (aOR, 0.85 [0.46-1.58]; P = 0.59). Midlines used for vasopressors were associated with greater risk of systemic thromboembolism (vs. PICCs with vasopressors: aOR, 2.69 [1.31-5.49]; P = 0.008; vs. midlines with vasopressors elsewhere: aOR, 2.42 [1.29-4.54]; P = 0.008) but not thromboses restricted to the ipsilateral upper extremity (vs. PICCs with vasopressors: aOR, 2.35 [0.83-6.63]; P = 0.10; model did not converge for vs. midlines with vasopressors elsewhere). Conclusions: We found no significant association of vasopressor administration through a midline with catheter-related complications. However, we identified increased odds of systemic (but not ipsilateral upper extremity) venous thromboembolism warranting further evaluation.

CHARACTERISTICS AND PREDICTORS OF PATIENTS WITH SEPSIS WHO ARE CANDIDATES FOR MINIMALLY INVASIVE APPROACH OUTSIDE OF INTENSIVE CARE UNIT

ABSTRACT

Objective: To identify and describe characteristics of patients with sepsis who could be treated with minimally invasive sepsis (MIS) approach without intensive care unit (ICU) admission and to develop a prediction model to select candidates for MIS approach. Methods: A secondary analysis of the electronic database of patients with sepsis at Mayo Clinic, Rochester, MN. Candidates for the MIS approach were adults with septic shock and less than 48 hours of ICU stay, who did not require advanced respiratory support and were alive at hospital discharge. Comparison group consisted of septic shock patients with an ICU stay of more than 48 hours without advanced respiratory support at the time of ICU admission. Results: Of 1795 medical ICU admissions, 106 patients (6%) met MIS approach criteria. Predictive variables (age >65 years, oxygen flow >4 L/min, temperature <37°C, creatinine >1.6 mg/dL, lactate >3 mmol/L, white blood cells >15 × 10 9 /L, heart rate >100 beats/min, and respiration rate >25 breaths/min) selected through logistic regression were translated into an 8-point score. Model discrimination yielded the area under the receiver operating characteristic curve of 79% and was well fitted (Hosmer-Lemeshow P = 0.94) and calibrated. The MIS score cutoff of 3 resulted in a model odds ratio of 0.15 (95% confidence interval, 0.08-0.28) and a negative predictive value of 91% (95% confidence interval, 88.69-92.92). Conclusions: This study identifies a subset of low-risk septic shock patients who can potentially be managed outside the ICU. Once validated in an independent, prospective sample our prediction model can be used to identify candidates for MIS approach.

Reducing Central Line Utilization by Peripherally Infusing Vasopressors

BACKGROUND

Central line-associated bloodstream infection is a preventable contributor to excess death and excess cost in the health care system. Vasopressor infusion is one of the primary reasons for central line placement. In the medical intensive care unit (MICU) at an academic medical center, there was no standard practice for peripheral versus central infusion of vasopressors.

OBJECTIVE

The objective of this quality improvement project was to implement an evidence-based, nurse-driven protocol to guide the peripheral infusion of vasopressors. The goal was to reduce central line utilization by 10%.

METHODS

Education on the protocol was provided to the MICU nurses, MICU residents, and crisis nurses, followed by a 16-week implementation period. Nursing staff were also surveyed preimplementation and postimplementation of the protocol.

RESULTS

Central line utilization was reduced by 37.9%, and there were no central line-associated bloodstream infections recorded during project implementation. Most of the nursing staff indicated that use of the protocol increased their confidence in administering vasopressors without a central line. No significant extravasation events occurred.

DISCUSSION

Although a causal link between implementation of this protocol and reduction of central line utilization cannot be established, the reduction is clinically meaningful given the known risks of central lines. Increased nursing staff confidence also provides support for continued use of the protocol.

CONCLUSION

A nurse-driven protocol to guide the peripheral infusion of vasopressors can be effectively implemented into nursing practice.

Midline Catheter Tip Position and Catheter-Related Complications in Antimicrobial Therapy: A Multi-Center Randomized Controlled Trial

BACKGROUND

The use of midline catheters (MCs) in intravenous therapy has increased over the last few years; however, scientific evidence is scarce. The recommendations for its specific tip position and safe use in antimicrobial therapy are not well established, which increases the risk of catheter-related complications.

OBJECTIVE

This study aimed to provide evidence for selecting MC tip positions for safe use in antimicrobial therapy.

DESIGN

This prospective, randomized controlled trial compared catheter-related complications with different tip positions. Participants were assigned to three different catheter tip groups, and the relationship between the tip position and catheter-related complications was observed during antimicrobial therapy.

SETTING

Multicenter trial based in intravenous therapy centers at six Chinese hospitals.

PARTICIPANTS

A fixed-point continuous convenience sampling method was used to enroll 330 participants. Three different study groups with equal numbers of participants (n = 110) were established using a randomization technique.

METHODS

The incidence of catheter-related complications and catheter retention time was compared among the three groups. The catheter measurement data between the three groups were compared using one-way ANOVA or the Kruskal-Wallis tests. Counting data were compared using chi-square tests, Fisher's exact tests, and Kruskal-Wallis tests. Post-hoc tests were conducted to compare the incidence of complications among the three groups. We followed a time-to-event analysis approach and used Kaplan-Meier curves and log-rank tests to analyze the relationship between catheter-related complications and different tip positions.

RESULTS

The total incidence of catheter-related complications in Experimental Groups 1 and 2 as well as the control group were 10.09%, 17.98%, and 33.73%, respectively. Statistically significant differences existed between the groups (p < 0.0001). In pairwise comparisons of the three groups, significant differences were evident in the incidence of complications between Experimental Group 1 and the control group (RD 19.40%, confidence interval 7.71-31.09). No statistical significance in the incidence of complications between Experimental Group 1 and Experiment Group 2 (RD -4.93%, confidence interval -14.80-4.95) and in the incidence of complications between Experimental Group 2 and the control group (RD 14.47%, confidence interval 1.82-27.12) were noted.

CONCLUSION

Catheter-related complications were reduced when the tip of the Midline Catheter was located in the subclavian or axillary vein of the chest wall.

TRIAL REGISTRATION

NCT04601597(https://clinicaltrials.gov/ct2/show/NCT04601597). Registration date: September 1, 2020.

Usefulness of Midline Catheters versus Peripheral Venous Catheters in an Inpatient Unit: A Pilot Randomized Clinical Trial

Canalization of vascular accesses is one of the most used techniques in hospitalization units. When talking about peripherally inserted catheters, we can differentiate between peripheral intravenous catheters (PIVC), midline catheters, and long peripheral catheters (LPC). Midline catheters are rarely used despite being recommended for intravenous therapies lasting more than six days. This research is a pilot study of a longitudinal clinical trial. It aims to compare the complications associated with intravenous therapy between the control group (CG) with a PIVC and the experimental group (EG) with a midline in an Internal Medicine Unit of a Spanish hospital for three months. In this study, 44 subjects participated, 25 in the CG and 19 in the EG. The duration of cannulation was longer in the experimental group (8.13 days vs. 3.22, p < 0.001), and the appearance of phlebitis was more significant in the control group (19 patients in CG and 25 patients in EG). Midlines have presented a longer duration of cannulation and fewer complications than the PIVC. This protocol was registered with ClinicalTrials.gov (NCT05512117).

First-line Vasopressor Use in Septic Shock and Route of Administration: An Epidemiologic Study

RATIONALE

Norepinephrine is a first-line agent for treatment of hypotension in septic shock. However, its frequency of use, and potential barriers to its use are unclear.

OBJECTIVES

To evaluate the frequency of use of norepinephrine in septic shock, to identify potential barriers to its use, and to evaluate trends in use of vasopressors over time.

METHODS

Retrospective population-based cohort study of patients with septic shock in Alberta, Canada between July 1, 2012 and December 31, 2018. The primary outcome was receipt of a first-line vasopressor other than norepinephrine ("non-norepinephrine vasopressor"). Predictors of receiving a non-norepinephrine vasopressor were assessed using a multivariable-adjusted, multilevel logistic regression model with intensive care unit (ICU) as a random effect.

RESULTS

Among 6343 patients with septic shock, the proportion of patients receiving non-norepinephrine vasopressors as first-line treatment decreased steadily from 11.5% in 2012 to 3.0% in 2018. Two factors most strongly associated with their receipt were having peripheral intravenous access only (adjusted odds ratio (aOR) 6.15, 95% confidence interval (CI) 4.58-8.26, p<0.001) and year of admission (aOR 0.74 per year after 2012, 95% CI 0.69-0.80, p<0.001). Other factors that had associations after adjustment included admission to a non-teaching hospital (aOR 2.19, 95% CI 1.23-3.89, p=0.007), admission to a coronary care unit (aOR 2.56, 95% CI 1.001-6.54, p=0.05), SOFA score (aOR 0.92 per unit increase, 95% CI 0.88-0.96, p<0.001) and heart rate (aOR 0.92 per 10 beat per minute increase, 95% CI 0.87-0.97, p=0.002).

CONCLUSIONS

In a large cohort of patients in Alberta, Canada, we found a steady decrease in use of first-line vasopressors other than norepinephrine in septic shock. The strongest factor associated with their use was the presence of only peripheral venous access, suggesting this may still be considered a barrier to administration of norepinephrine.

Evaluation of the safety of a novel peripheral vasopressor pilot program and the impact on central line placement in medical and surgical intensive care units

Purpose

The purpose of this quality improvement project was to evaluate the safety and feasibility of peripheral vasopressor administration in an attempt to minimize the placement and improve early removal of unnecessary central lines to reduce central line–associated bloodstream infection (CLABSI) rates.

Methods

A retrospective chart review was conducted on patients who received vasopressors via peripheral infusion over 3 months, starting at the time of guideline implementation.

Results

We identified 129 vasopressor orders among 79 patients that were administered peripherally. Among these orders, 3 events were documented as possible extravasation events. Forty-five patients (57%) did not require central line placement due to increasing vasopressor requirements. Standard utilization ratio data suggest minimal central line impact of the protocol implementation. December 2020 to February 2021 was associated with a large second peak of coronavirus disease 2019 (COVID-19) in our region. Utilization of central lines was less than predicted in December 2020 to February 2021 in 2 of our 3 intensive care units (ICUs); however, the differences were statistically significant on only 3 occasions. In the third ICU, utilization was greater than predicted, but this unit housed a majority of the most critically ill patients with COVID-19.

Conclusion

This study suggests that short-term use of select vasopressors at conservative doses is safe for peripheral administration and points toward efficacy at preventing central line placement. Further analysis is required to confirm efficacy.

A Meta-Analysis of Incidence of Catheter-Related Bloodstream Infection with Midline Catheters and Peripherally Inserted Central Catheters

In order to provide reference for the prevention and treatment of CRBSI during clinical intravenous infusion therapy, this paper investigates the incidence of catheter-related bloodstream infection (CRBSI) in the treatment of midline catheters (MCs) and peripherally inserted central catheters (PICCs) by intravenous infusion. Web of Science, PubMed, Scopus, Embase, Cochrane Library, and ProQuest are searched to collect CRBSI-related studies on MC and PICC. The retrieval time is from the database construction to August 2020. Two researchers independently searched and screened literature quality evaluation and extracted data according to inclusion and exclusion criteria, and RevMan 5.3 software was used for analysis. Eleven studies are included, with a total of 33809 patients. The incidence of CRBSI in the MC group is 0.599% (43/7079), and that in the PICC group is 0.4993% (133/26630). Meta-analysis showed that the incidence of CRBSI in the MC group is higher than that in the PICC group (OR = 0.72, 95% CI = 0.43–1.08, P=0.11), and the difference is statistically significant when low-quality studies are excluded (OR = 0.60, 95% CI = 0.39–0.93, P=0.02). There is no significant difference in the incidence of CRBSI between MC group and PICC group (P > 0.05), American subgroup (OR = 0.52), and British subgroup (OR = 4.86), the results of the two groups are opposite, and the incidence of CRBSI between the MC group and PICC group is statistically significant. There is no significant difference in the incidence of CRBSI between the adult and other subgroups (all P > 0.05). There is no significant difference in the incidence of CRBSI between the MC group and the PICC group (P > 0.05). Overall, the inter-study stability is general, the quality is good and the medium is good, and there is no obvious publication bias. The risk of CRBSI in MC and PICC is systematically evaluated and meta-analyzed for the first time. The incidence of CRBSI in MC group is lower than that in PICC group during intravenous infusion therapy. Under the same conditions, MC patients can be given priority for intravenous infusion therapy. More high-quality and child-related studies are needed to further evaluate and explore the risk of CRBSI between MC and PICC.

Does the Midline Peripheral Intravenous Catheter Have a Place in Critical Care?

BACKGROUND

The goals of infusion therapy are to preserve vascular health and safely deliver needed treatment. Achieving these goals is challenging in critical care because of the complexity of the treatment required. Daily justification of retaining an existing central venous catheter also creates urgency to change to a peripheral vascular access device. The midline catheter has had a resurgence in use because of the need for a long-term peripheral vascular access device not linked to central catheter-associated bloodstream infection risk.

OBJECTIVE

To review the characteristics of midline catheters, the benefits and risks of midline catheters, and current evidence regarding midline catheter use in critical care.

RESULTS

Research related to midline catheters has greatly expanded the body of knowledge regarding vascular access device selection and midline catheter use.

DISCUSSION

Although the quality and results of research on vascular access devices vary widely, a more accurate safety profile is emerging to illustrate how midline catheter use can support the goals of infusion therapy.

CONCLUSIONS

Optimizing vascular access device selection requires recognition that every vascular access device can cause patient harm. Although the midline catheter appears to fill an important niche in infusion therapy, use of the midline catheter should be carefully evaluated. Midline catheters should not be used as a catheter-associated bloodstream infection prevention strategy, should be inserted to administer peripherally compatible solutions, and should be considered for short-term continuous vesicant therapy only in emergent situations until more definitive vascular access can be achieved.