Midline venous catheters as an alternative to central line catheter placement: a product evaluation

A peripheral venous catheter (PVC) is the most common vascular access device (VAD) used for short-term therapies. For various reasons, some patients may be unable to sustain a PVC for the duration of therapy, yet do not meet criteria for CVC placement. Chopra et al (2015) determined that peripherally inserted central catheters (PICCs), a type of CVC, were overused in 43% of patients, and midline catheters would have been a more appropriate VAD selection, based on clinical indications. Selecting the appropriate VAD involves multiple factors: patient diagnosis, length of therapy, quality of vascular access, type of infusate (irritant or vesicant), and amount of medications to be administered intravascularly (Anderson et al, 2016). In addition, reducing the incidence of central line-associated bloodstream infections (CLABSI) is both a patient safety and cost saving imperative for healthcare organisations. For every 1000 in-hospital CLABSI cases, there are 150 excess deaths; each CLABSI event is estimated to cost $48 108 (Agency for Healthcare Research and Quality (AHRQ), 2017).

Health professionals are faced with a risk:benefit ratio when determining the appropriate VAD given the multiple factors for device selection. Commonly, health professionals weigh the choice to place a CVC and risk complications such as thrombosis and infection, or use multiple PVCs to complete therapy, compromising the patient's vascular health. Although not without its own complications, the midline catheter may be an alternative in the traditional device selection calculation. This article seeks to define the midline venous catheter, and to describe the experience using a specific type of midline catheter (Powerwand^®; Smith Medical, Minneapolis, MN) at a paediatric tertiary care facility in the USA. Case studies from other centres will also be discussed.

What is a midline catheter?

A midline venous catheter is a peripheral device defined by the position of its tip, which is just distal to the axillary fold (Gorski et al, 2021). The position of its tip promotes increased haemodilution, which helps prevent phlebitis, infiltration/extravasation and discomfort during administration of medication (Adams et al, 2016).

Veins commonly used in children and adults are the basilic, brachial and cephalic (Adams et al, 2016). For neonates, in addition to the arm veins, middle catheters may be inserted via a scalp vein, with the catheter tip located in the jugular vein above the clavicle or in the lower extremity with the distal tip located below the inguinal crease (Gorski et al, 2021). The tip of a midline catheter terminates distal to the axillary fold (Gorski et al, 2021). A midline catheter is therefore classified as a peripheral VAD. For this reason, if a bloodstream infection, attributable to the midline occurs, the infection would be considered a catheter-associated bloodstream infection (CABSI), rather than a CLABSI, according to the US National Healthcare Safety Network definition (Agency for Healthcare Research and Quality, 2017). This still has important patient safety consequences and efforts to reduce infection related to intravenous catheters should be implemented.

When assessing a patient for a midline, the health professional should evaluate the predicted difficulty of IV access, length of therapy, type of therapy, and skin integrity. Criteria for midline placement should include patients with expected therapy duration of greater than 6 days, increased difficult intravenous access (DIVA) scores, infusate with osmolarities <600 and pH in the range 5-9, non-vesicants, and failed PVCs or more than two attempts at insertion (Adams et al, 2016; Anderson et al, 2016). Midlines are recommended for use when a therapy exceeds approximately 6 days, preferably up to 14 days, and can be removed when therapy is completed or complications arise (Moureau and Chopra, 2016). Midlines are contraindicated in certain patient populations, as outlined in Table 1.

Ultrasound assessment of a patient's vasculature is the optimal way to determine if an appropriate patient is a candidate for a midline, via evaluation of vessel size and integrity. Ultrasound assessment will also allow for determination of an appropriate midline catheter length for placement (Moureau et al, 2015).

The Powerwand^®

A substantial portion of PVCs used on patients worldwide are composed of polyurethane, a material that poorly inhibits bacterial growth; additionally, additives in polyurethanes facilitate bacterial attachment (Pathak et al, 2018). The Powerwand midline catheter is made of both polyurethane and polycarbonate, known as the ChronoFlex-C with BioGUARD technology. ChronoFlex-C technology inhibits bacterial attachment and biofilm formation, with five times greater bacterial adherence to a polyurethane catheter versus a midline with ChronoFlex-C technology (Pathak et al, 2018).

An in vitro study by Pathak et al (2018) demonstrated that the Powerwand with ChronoFlex-C technology inhibited bacterial attachment and biofilm formation. With fluorescence microscopy, they were able to demonstrate that over five times more bacteria were able to attach and grow on the control polyurethane material than on the catheter with ChronoFlex-C technology (Pathak et al, 2018). The surface of the Powerwand has micro-patterning, which decreases the surface area on which bacteria can attach (Pathek et al, 2018; DeVries et al, 2019). Furthermore, Pathek et al (2018) reported that, when bacteria did attach to the ChronoFlex-C, there was 1.5 times greater likelihood of bacteria dying. Studies have reported no bloodstream infections with use of the Powerwand (Caparas and Hung, 2017; DeVries et al, 2019).

The Powerwand is a non-trimmable device. Cut lines can scrape the vessel wall, damaging the intimal layer, causing inflammation, and leading to the development of thrombophlebitis (Figure 1). The Powerwand thermoformed catheter tip advances over a guidewire and avoids damaging the vascular intima. The Powerwand comes in a variety of sizes: 3 French (6 cm length), 4 Fr (8 cm or 10 cm), and 5 Fr (8 cm or 10 cm) (not all all Powerwand products are available in all geographical regions). It can deliver up to 180 ml/minute and has a power injection rate of 8 ml/second or 325 psi. There are two Powerwand kit types available, component-based kits and all-in-one device.

Figure 1. Dangers of inserting cut catheters versus the Powerwand insertion method

Insertion technique

Three insertion techniques can be used for midline catheters: the modified Seldinger technique (MST), the accelerated Seldinger technique (AST) and the Seldinger technique (Table 2). The MST has shown to improve outcomes with ultrasound guidance for long-term IV therapy needs, assist in early detection of guidewire malposition, and reduce time to venous cannulation (Thaut et al, 2019). The all-in-one Powerwand is placed using the AST, which allows for increased safety with reduced risk of contamination, wire migration, and air embolism (Stoker, 2009), as well as reduced procedure time compared with MST (Thaut et al, 2019). The component-based Powerwand XL does not have a peel away sheath and is placed using the ST.

Ensuring proper placement of the midline, optimally the middle one-third of the upper arm, will prevent catheter dislodgement and vein disruption. Performing ultrasound-guided needle access of the vein may help to minimise vessel trauma. It is also recommended to examine vein size and location to determine the best catheter-to-vein ratio. Using a midline rather than a PVC may allow an increased amount of catheter to reside in the vessel, possibly allowing for a longer dwell time (Thaut et al, 2019).

Institutional experience

A paediatric vascular access team of registered nurses performed an evaluation of the Powerwand from September 2018 through December 2018 at a large tertiary care freestanding children's hospital in the USA. Powerwand midlines were placed in patients within intensive care and acute care units. Technical factors related to Powerwand placement were tracked (Table 3), with additional metrics reviewed, including inserter satisfaction, patient satisfaction, and cost effectiveness.

Thirty-four patients received a total of 44 Powerwand midlines between September 2018 and December 2018. The primary setting was the paediatric intensive care unit (PICU) with an expansion to acute care units, specifically a neurology/endocrinology unit and paediatric surgery/transplant unit. Six patients had two Powerwands inserted during their stay and four patients had three Powerwands placed during their stay. Patient ages ranged from 5 months to 23 years, with the average age being 10.7 years old. Patient weights ranged from 3.8 kg to 100 kg, with the average weight 43.7 kg. For infants, Powerwand was placed in the lower leg and upper arm. For toddlers and older patients, Powerwand was placed in the forearm or upper arm. Patients were spared an average of 12 vascular access attempts, during their hospitalisation, when Powerwand was used. Fifty-two percent of patients completed therapy, with one patient (2%) achieving the maximum dwell time of 29 days. At this institution, dwell time did not exceed 29 days due to Food and Drug Administration (FDA) regulation. There was a variation in the reason for removal, provided in Table 4. Extravasation was the most common removal reason (n=7), with mechanical and chemical issues both contributing to the reason for extravasation equally. The Powerwand extravasation rate was 1.00/1000 patient days compared with 3.26/1000 patient days in PVCs during the same period. Midline infections were monitored throughout the trial; no infections were noted.

Fifteen registered nurses evaluated the Powerwand on product quality, product performance, ease of use and education provided (Figure 2). Eighty-six percent of nurses surveyed recommended the Powerwand for use. A cost analysis found one Powerwand was $137.70 more expensive than one PVC, on average. However, a cost saving of $2 892.45 was calculated when considering the number of PVCs avoided on average thanks to placement of a single Powerwand (Table 5).

Figure 2. Evaluation responses from nurses at large tertiary care freestanding children's hospital in USA, following trial period of Powerwand use, September–December 2018

Case studies

The following case studies from several different hospitals provide examples of Powerwand use across a diverse patient population. The cases reflect current practice in the individual case study authors' setting and country, and thus are indicative of the variations in clinical approaches that occur across different sectors of nursing. It should also be noted that local policies can often vary or be adapted in accordance with individual patient requirements, if necessary.

Case study 1

A 5-year-old male with history of mild asthma was admitted to the paediatric intensive care unit with new onset refractory status epilepticus, post tracheostomy and gastric tube. The patient required IV therapy for management of status epilepticus with multiple medications. At the time of vascular access assessment, the duration of therapy to control the status epilepticus was unknown. Ultrasound assessment showed the patient had healthy veins. However, the patient required 12 PVCs during 11 days of hospitalisation, related to repeated extravasations, resulting in decreased vascular availability. After assessment and consultation with the medical team, a Powerwand 3Fr, 6 cm XL was placed using the ST in the left upper extremity (basilic vein). The patient was paralysed and sedated during the procedure because of their clinical status. The insertion was successful on first attempt. The procedure lasted 20 minutes from supply set up to dressing application. The Powerwand lasted for 29 days with blood return throughout the duration of the line and was removed at 29 days per FDA recommendation. The patient was unable to express discomfort with the line or insertion. However, the parent was pleased that their son avoided additional peripheral vascular access attempts throughout the 29-day duration of the Powerwand. The medical team appreciated that the placement of a Powerwand prevented the placement of a CVC. The removal of the line was performed by the bedside nurse and was the same as removing a PVC. In this case, the use of Powerwand exceeded expectations compared to PVC or CVC based on its dwell time with blood return (29 days), complications (none observed), and decrease in need for peripheral insertion attempts.

Tricia Kleidon, Nurse Practitioner, Queensland Children's Hospital, Brisbane, Australia: Case study 2

Girl K is a 35 kg, 13-year-old teenager with a diagnosis of Miller-Dieker Syndrome (MDS). MDS is a rare disorder of childhood characterised by a pattern of abnormal brain development known as lissencephaly type I and a distinctive facial appearance that may include prominent forehead, bitemporal hollowing and micrognathia (small lower jaw) (Wakiguchi et al, 2015). Additional co-morbidities include laryngomalacia, left bronchomalacia with bronchiectasis, refractory epilepsy, gastro-oesophageal reflux disease with previous fundoplication, aspiration pneumonia, osteoporosis, and scoliosis. Before elective admission for a lengthy, orthopaedic procedure (triple arthrodesis) Girl K presented for a PICC insertion to facilitate a 2-week course of IV antibiotic therapy to optimise her respiratory function. To ensure compliance with the procedure and comfort during PICC insertion, the local protocol is for most PICCs to be inserted under general anaesthesia, and almost always in young children or children who are developmentally delayed. Pre-anaesthetic examination revealed oxygen saturations of 90% on room air. Her mother reported that Girl K can become hypoxic especially when ‘gurgly’ or after a recent seizure, and she had had a seizure earlier that day. A collaborative conversation (anaesthetist, respiratory physician, vascular access specialist and Girl K's mother) discussed the increased risk of adverse respiratory events during general anaesthesia for PICC insertion compared with insertion of an interim vascular access device (midline) without the need for general anaesthesia. The insertion of a temporary device would enable the start of antibiotic therapy to improve respiratory function with a view to PICC insertion later in the week.

A 4 Fr Powerwand midline catheter was inserted, with ultrasound guidance, into the 3.8 mm-diameter right basilic vein. The procedure was uneventful, and Girl K was commenced on daily ceftriaxone (3500 mg), as an intermittent syringe pump infusion, via the Powerwand midline and discharged from hospital within 24 hours to continue this regimen via hospital in the home. The catheter was secured with cyanoacrylate tissue adhesive at the insertion site, a sterile, pressure-relieving foam pad and an integrated securement and dressing. It was flushed with 10 ml sodium chloride 0.9% before and after IV medication administration.

The previous plan to electively replace the midline catheter with a PICC when medically stable was cancelled as the midline remained functional with no signs of complication throughout the planned 2-week chest optimisation. On re-admission for planned orthopaedic surgery, the midline remained functional and was used as the primary source of vascular access with the addition of an 18 G PVC in the event emergent volume replacement was required. The postoperative period on this occasion was complicated by respiratory deterioration prompting admission to the paediatric intensive care unit for additional respiratory support including supplemental oxygen and IV piperacillin + tazobactam (3600 mg) and cefotaxime (1760 mg) four times a day. The Powerwand midline catheter remained in situ and was used to administer the IV antibiotics for the duration of the admission and subsequently removed on day 35, prior to discharge from hospital without complication.

Louise Freeney, Clinical Nurse Educator for Vascular Access, pfm medical UK: Case study 3

A 34-year-old male was admitted to hospital with a 7-week history of severe pain in the right hip, reduced mobility and bilateral leg swelling extending into the inguinal area. On admission to the emergency department (ED) the patient had a peripheral cannula inserted with much difficulty due to his presenting compliant (sepsis, dehydration) and current history of illicit IV drug use (lack of visible and palpable veins), resulting in the peripheral veins becoming severely damaged and inaccessible, which led to administering the illicit drugs into his right iliac vein. Over time, the peripheral veins had become severely damaged, less visible and inaccessible, which led to administering into his right iliac vein. The peripheral blood cultures that were taken on admission grew Staphylococcus aureus, full blood tests including inflammatory markers and other tests to identify any infectious diseases were positive for hepatitis B and C. A right hip X-ray was ordered and taken, the patient also attended the radiology department for an ultrasound scan, which ruled out thrombosis formation around both hip joints. The patient was given a diagnosis of septic arthritis of the right hip and prescribed 6 weeks of empirical IV vancomycin.

Due to the difficulty of vascular access, which was identified by the clinicians in the ED, the patient was referred to the IV team for assessment. On this occasion, the vessel health and preservation protocol recommended a mid-term IV device, which in this case was a 4 Fr (18 G) 8 cm CT-compatible power-injectable Powerwand midline catheter.

In this hospital, Powerwand is routinely inserted into one or both upper limbs in the mid-zone using ultrasound guidance. The veins of choice would be basilic or brachial due to ease of access; it should also be inserted away from the area of high flexion, such as the ante-cubital. Therefore, inserting a Powerwand catheter into a deeper vessel was the most effective and overall reduced the risk of associated complications. The device was also chosen for the simplicity of insertion with the AST, and the benefits of reduced steps for insertion during the procedure in comparison with standard midlines inserted using the MST. It did not require an incision to the skin, meaning a reduction in bleeding from the exit site on insertion and no need to return to the patient the following day to carry out a dressing change, leading to reduction in nursing time, in addition to success of blood drawability, durability and ease of removal.

Due to the patient's current and active use of IV drugs he did not fit the criteria to be discharged home to receive IV therapy in the community, therefore he remained in hospital for the duration of his treatment. The total dwell time was 54 days—the device would have been removed sooner and as recommended by manufacturer's guidelines if it were clinically indicated to do so. The reason for a long dwell time was the meticulous care and maintenance including visual infusion phlebitis (VIP) scoring by the nursing staff. Care and maintenance is a vital part of the use of any vascular access device including observation every 8 hours, weekly dressing, catheter securement and needle-free connector changes with regular positive pressure lock and flushing of all catheters.

Case study 4

In this case study, a 64-year-old female received inpatient treatment including surgery for a spinal abscess. Following peripheral assessment in accordance with the vessel health and preservation framework widely used within the Trust, a 4 Fr (18 G) 8 cm Powerwand catheter was inserted. The IV team attended to the patient before she went to theatre, which enabled the induction of anaesthesia, and the prescribed IV piperacillin + tazobactam was administered uninterrupted for 8 weeks and on this occasion, the VAD was not required for blood sampling. The patient was discharged to her own home under the care of the community nursing team for the continuation of required IV therapy. In this case the Powerwand catheter was the VAD of choice and used widely across the Trust. Even though Powerwand is a CT-compatible device the benefit of this was not applicable in this case.

To accommodate the IV therapy administration, which was given on a daily basis, placing the Powerwand catheter in a deeper vessel in the upper limb would offer stability and durability, and reduce the risk of chemical phlebitis due to the pH of the medication. Inserting a mid-term VAD under ultrasound guidance also reduces the risk of CVC bloodstream infections. The community team closely monitored the device ensuring the highest standard of care, maintenance and provided detailed information to the relevant multidisciplinary teams in accordance with local policies.

The IV therapy was completed as prescribed and the total dwell time for this device exceeded the recommended manufacturer guidelines. Local policies were followed to monitor and prevent any signs of infection. This was high priority for the patient being looked after in the community and equally important for the nursing team to ensure the patient remained in her own home, rather than being readmitted to hospital to insert another IV device.

The key message from these case studies and probably the most important aspect is the emphasis of meticulous care and maintenance. The use of regular positive pressure flushing before and after all IV therapy as per local policies, semipermeable transparent dressing changes, needle-free connector and securement changes, which should be carried out on a weekly basis (as per manufacturer's guidelines) unless otherwise clinically indicated. Plus, the use of surveillance and VIP scoring are all pivotal points for the longevity of Powerwand and other VADs.

Nicola York, Clinical nurse educator vascular access, pfm medical: Case study 5

Mrs X, an 83-year-old female with end-stage heart failure, was referred to the vascular access service via electronic patient records (EPR) for a 4 Fr Powerwand insertion. The patient required a further 5 days administration of IV furosemide as a bolus once daily in her home. The patient had previously been receiving furosemide as part of her treatment plan in the community through PVCs. However, her vascular access was now becoming challenging for both the patient and the community nurses.

The patient presented on the day case unit with dyspnoea and bilateral leg oedema. Her past medical history, in addition to the end-stage heart failure, revealed hypertension, ischaemic heart disease and diabetes and she confirmed no history of thrombosis. The risks and benefits of the procedure were explained to Mrs X and her daughter, although initially the patient was reluctant for the device to be inserted. The signs and symptoms of the risks associated with a Powerwand were explained and Mrs X was encouraged to inform the nurses administering her IV therapy of any concerns she may have. It was explained that the procedure for inserting a Powerwand used an accelerated Seldinger technique, which meant that no dermatotomy was required and so it was easy and quicker to place. However, on further discussion and allowing Mrs X to ask questions, she realised the benefits as she would no longer need multiple cannulas and the nurses would be able to take blood from the device. Informed consent was given.

Ultrasound was used to ascertain which arm would be used and to guarantee that the catheter-to-vein ratio was appropriate, in size and depth, to ensure success when the midline was inserted thereby promoting vessel health preservation. It was noted that the patient's skin appeared friable and there was the presence of multiple bruises from previous failed attempts at vascular access. On ultrasound assessment of the right upper arm, the basilic vein appeared compressible and patent. It was decided to use a 4 Fr single-lumen 8 cm Powerwand as the patient potentially only required a further 5 days of IV furosemide.

A surgical aseptic non-touch technique, ultrasound and the administration of local anaesthetic was used to insert the Powerwand via the right basilic vein with the tip of the Powerwand terminating in the axillary vein or just below. Once the Powerwand was successfully inserted blood was aspirated and it was then flushed with 10 ml 0.9% normal saline to check for patency. A catheter securement device and semipermeable dressing were then applied to ensure that the Powerwand did not migrate out. The labels stating ‘Powerwand not a PICC’ were applied to the extension tubing and it was highlighted to Mrs X's clinical team that it was a Powerwand and only suitable for peripheral medication. The procedure was documented in the patient's EPR. Afterwards, the patient and her daughter expressed their surprise at how straightforward and pain-free the insertion had been.

Mrs X completed her IV therapy and the Powerwand was removed with no complications. Reflecting on this case study, the appropriate vascular access device had been selected and the procedure performed correctly for the treatment pathway. However, further education and training was required for the multidisciplinary team regarding adhering to vessel health preservation and to ensure patients with difficult venous access were referred to the vascular access team earlier.

Case study 6

Mrs C, a 32-year-old female, had been admitted as a day patient for a CT scan. She was referred urgently via EPR to the vascular access team for a short-term VAD for difficult access while she was on a gastroenterology ward. The medical and nursing team were struggling to gain vascular access due to the patient's lack of visible or palpable peripheral veins and her habitus.

The patient presented upset and frustrated with ‘being used as a pin cushion’. On discussion with the patient it was explained that a 4 Fr Powerwand would allow the CT scan with contrast to take place and allow bloods to be taken. Mrs C agreed to the procedure and the risks and benefits were explained. The patient's arms were assessed using ultrasound and the only vein found to be suitable was the cephalic vein.

The insertion of the Powerwand was straightforward, therapeutic phlebotomy was taken, using a syringe, from the Powerwand and it was then flushed with 10 ml 0.9% normal saline. The Powerwand was secured with a catheter securement device and semipermeable dressing and the identification labels were applied. On completion of the procedure, advice was given to the patient about the need to inform the multidisciplinary team of being a difficult intravenous access (DIVA) patient, so that they could refer her directly to the vascular access team as opposed to suffering multiple attempts to cannulate. This was documented in the patient's EPR. The patient went home later that day after having her CT scan with contrast via her Powerwand, which was later removed without incident.

Reflecting on this case study, the Powerwand was deemed the most appropriate vascular access device to be inserted as it was reliable and as Mrs C did not require long-term access. This device would allow bloods to be taken initially and it is also power injectable, which would enable Mrs C to have contrast to be administered when she had her scan. It was important that Mrs C was given the appropriate advice about her DIVA status and the pathway that should be followed if she ever requires vascular access in the future.

Discussion

For patients who require a VAD but do not need a CVC, a PVC is often the access of choice. As venous access becomes more difficult, and treatment duration increases, PVCs may not be sufficient for the length of therapy and the type of infusate. Additionally, a midline catheter may allow the patient to complete therapy with fewer vascular access events than with PVCs.

Complications related to CVCs lead to increased mortality rates and increased healthcare burden, leading to a higher cost for care (Pathak et al, 2015). Additionally, in some patients affected by CVC complications the CVC may not have been necessary for treatment. It has been reported that PICCs, a type of CVC, were overused in up to 43% of patients (Chopra et al, 2015), and that midline catheters would have been a more appropriate VAD choice, based on clinical indications. Seo et al (2020) evaluated the efficacy and safety of midlines compared specifically with PICCs. The most common midline-associated complications reported included phlebitis, dislodgement, and infiltration. There was one CLABSI reported in the PICC group, with no CABSIs reported in the midline group. Midline outcomes from another series were reported by DeVries et al (2019). In a 24-month span, no midline catheter infections were noted. Dislodgement, occluded lines, and kinked lines were the most contributing factors for catheter complications (DeVries et al, 2019). Xu et al (2016) found that there were more minor complications in midlines compared with PICCs; however, the midline complications did not lead to any infections, suggesting that the risk-benefit ratio may favour increased use of midlines.

A retrospective chart review of 1086 patients receiving vancomycin via a midline catheter was reviewed by Caparas and Hung (2017). If midlines were replaced with PICCs for this sample size, approximately 16 patients would have reported a CLABSI. According to Caparas and Hung (2017), unreimbursable costs associated with treating 16 patients with CLABSIs would have been $896 000. In addition, there was also a hard-cost saving of $90 per procedure, resulting in savings of $97 740 (Caparas and Hung, 2017: 40). Organisations have shown decreased CLABSI rates after implementing a midline catheter placement practice, with zero infections attributed to midline catheter insertions (Moureau et al, 2015; Pathak et al, 2015). CLABSI rates dropped from 1.7 to 0.2 per 1000 catheter days at one institution, resulting in an estimated annual cost saving of $531 570 (Moureau et al, 2015).

Incidence of CABSI should, however be monitored in patients with PVCs and midlines. One institution reported that all patients with MRSA bloodstream infections had undergone at least five PVC placements prior to the infection (Bierman, 2017), highlighting the risk for CABSIS related to multiple PVC placements. Pathak et al (2018) reported 16.7% incidence of staphylococcal infection with PVC placement, despite the use of aseptic technique, appropriate barrier protection and chlorhexidine as an antiseptic cleaning agent.

Conclusion

Midline catheters may be an effective alternative to CVCs and PVCs if a patient's access needs and vascular health allows for their use. Benefits of midline catheters relative to CVC use include the avoidance of insertion of higher risk CVC. Benefits of midline catheters relative to PVCs include avoidance of multiple insertions to complete treatment. A specific midline catheter, the Powerwand, provides additional benefits of decreased biofilm, decreased thrombus formation, and rapid flow rates. The paediatric tertiary care centre evaluation of Powerwand discussed here demonstrated an increase in patient satisfaction related to decreased attempts, longer dwell times as compared with PVCs, provider satisfaction and overall cost savings. The Powerwand was removed prior to treatment completion in 20 patients with 16% of the complications representing extravasation. Effectiveness as it relates to quality of care and decreased CLABSI rates is difficult to correlate in the evaluation. It is essential decision making about the selection and use of a VAD takes into account individual patient needs and adheres to local protocols. As such, treatment plans need to be both practical and sufficiently flexible, in order to respond to the medical need of the patient. The Powerwand midline catheter may be an effective option for patients and the evaluation here suggests it may be an option for longer, more reliable peripheral venous access in adults and children.

KEY POINTS

• Midline catheters are becoming more prevalent in both inpatient and outpatient settings
• Midline catheters are an alternative to central venous catheters and peripheral venous catheters as hospitals seek to avoid central line infections and PVC complications
• The Powerwand provides additional benefits from other midline catheters available related to the product composition and insertion technique
• The Powerwand is available in several sizes allowing for use in a range of patient populations

CPD reflective questions

• Considering your patient population, what ways could midline catheters optimise their care compared with other venous access devices?
• How might implementation of a midline catheter benefit your organisation? Consider quality of care, cost savings and patient satisfaction.
• Compare and contrast the modified Seldinger technique (MST) and accelerated Seldinger technique (AST). How would inserters with MST experience use the AST insertion?