infection control & hospital epidemiology july 2018, vol. 39, no. 7 concise communication


The Risk of Adverse Events Related to Extended-Dwell Peripheral Intravenous Access


Sara Campagna, PhD, RN;1 Silvia Gonella, RN, MSc;2 Pietro Antonio Zerla, RN;3 Gianvito Corona, MD;4 Tiziana Correggia, RN, MSc;2 Baudolino Mussa, MD;2 Paola Berchialla, PhD;5 Valerio Dimonte, RN, MSc1,2


Midline catheters (MCs)may be useful to avoid repeated venipuncture in patients requiring prolonged intravenous infusions with limited adverse events (AEs). We analyzed 2 Italian hospital databases to ascertain the safety of MCs. Among 1,538 adult patients, 154 MC- related AEs (10%; 2.49 AEs per 1,000MC days) were reported.


Infect Control Hosp Epidemiol 2018;39:875–877


positioning PICCs and MCs. All MCs were inserted using ultrasound-guided puncture and were 4–5 French (Fr) in diameter and 20–25 cm in length. Almost all MCs were single lumen; 4 were bilumen. After the catheter insertion, a sterile 5×5-cm gauze dressing was positioned and held in place with a transparent dressing, which was changed the day after insertion. Thereafter, transparent dressings were changed every 7 days. If evidence of hematic or serous leakage was noted, gauze plus transparent dressings were changed every 48 hours. Midline catheters were anchored with an adhesive-based suture-free device. After insertion, MCs were accessed by ward staff, and intravenous sites were inspected once per shift. Midline catheters were left in situ until the end of therapy or


until complications occurred, although MC manufacturers recommend a maximum dwell time of 28 days.2


Data Collection


When selecting the best vascular access device for a patient, the goal is always to choose the one that will best foster vessel health and preservation.1 To improve efficiency in treatment delivery, healthcare professionalsmust select themost appropriate device according to the patient’s needs: peripheral short catheter (PSC), extended-dwell peripheral catheter, peripherally inserted central catheter (PICC), or central venous access device (CVAD).2,3 Compared to PSCs, extended-dwell peripheral intravenous


accesses devices, such as midline catheters (MCs) have been associated with increased dwell time and lower first-attempt failure. Moreover, the use ofMCs avoids complications related to central lines, such as bloodstream infections (BSIs) and catheter-related thrombosis.2,3 With the increasing attention to cost control, MCs (with


their longer dwell-times and low complications rates) may be a viable, cost-saving alternative to central catheters that can also ensure patient safety. In this study, we aimed to ascertain the safety of MCs.


methods


Midline-catheter data from the databases of 2 acute-care public Italian hospitals were analyzed. All inpatients and outpatients (n=1,584) who received a MC between September 2007 to December 2014 were eligible for inclusion. We excluded those who still had the MC inserted (n=5, 0.3%) or for whom no removal date reported (n=41, 2.6%). As part of standard practice, the intravenous site was pre-


pared using an aseptic technique. Midline-catheters were inserted by a member of the MC insertion team, a team of registered nurses with a postgraduate specialization in


Data on patient characteristics, MC characteristics, and cause of MC removal were collected. The causes of MC removal were distinguished in MC-related adverse events (eg, AEs, occlusion, exit-site infection, or symptomatic thrombosis) or other reasons (eg, accidental removal, termination of therapy, natural device expiration, or death of the patient). The following definitions were adopted:


∙ Occlusion: Complete inability to flush, infuse, or aspirate; resistance with flushing and aspiration or sluggish infusion; or ability to flush and infuse but not aspirate.4


∙ Exit-site infection: Presence of tenderness, erythema, and/or purulent discharge at the catheter site.5


∙ Symptomatic thrombosis: Lack of flow or nonpulsatile and nonphasic flow associated with lack of compressibility of the veins, edema, and erythema of the cannulated arm.6 Symptomatic thrombosis was confirmed by ultrasound.


∙ Accidental removal: Unplanned removal of the catheter either by the patient or the staff.7


Primary Outcome Measure


Midline catheter removal due to MC-related AEs was set as the primary outcome measure. Thus, the primary outcome was a composite measure defined as the number of AEs perMCdays (ie, the period an MC was in place) and was presented as per 100 MCs (%) and per 1,000 MC days.


A Posteriori Sample Size Calculation


A power analysis was conducted using AE frequencies from the literature.8 A sample of 1,538 MCs ensured an estimation of 10% of AEs with a precision of ±1.5% at a confidence level of 0.05. Each patient was included in the study only once.


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