Optimizing Peripheral Outcomes: Short, Long, Midline Peripheral Catheters

The peripheral intravenous catheter (PIVC) is ubiquitous in healthcare as the preferred initial vascular access device for the majority of infusion needs.¹ Options within the category of peripheral vascular access device (VAD) are the most commonly used short PIVC (superficial veins); the long PIVC (often placed in a deeper peripheral vein using visualization); and the midline PIVC (a longer catheter placed in a vein of the upper arm with a distal tip placed near the axillary fold).² There are many benefits to the use of PIVCs for the delivery of infusates:  lower cost, avoidance of central line-related complications, ease of training and the longer dwell options (long PIVC, midline) that may allow for one PIVC for the entire duration of therapy. However, despite the prevalence of PIVC use within all clinical settings and patient populations, the failure rate (e.g., early removal due to a complication) is unacceptably high, and an accurate picture of PIVC-related patient outcomes remains elusive.^1,3

Accurate PIV outcome measurement is a critical gap in clinical knowledge because of the nearly universal impact on the patients served, but also because of the significant shift from the use of central venous access devices (CVAD) to the use of PIVCs, especially the midline PIVC, as a central line-associated bloodstream infection (CLABSI) prevention strategy in the U.S.⁴ The gap in knowledge regarding PIVC patient outcomes is multi-faceted: generalized lack of standardized education on safe PIVC management (from nursing programs to onboarding to ongoing competency); lack of a standard PIVC site assessment structure; inadequate ongoing assessment of PIVCs based on patient/infusate risk; a sense that PIVC failure is inevitable; overlapping signs/symptoms of PIVC outcomes; well-documented inadequate documentation throughout the life of the PIVC worldwide; and significant heterogenicity in PIVC research methodology and parameters (e.g., PIVC characteristics, infusates, dwell time).^2,5-10 Given these substantial limitations and the retrospective nature of a large percentage of PIVC research studies, a true understanding of the safety profile of PIVC management has not been established to the extent that would inform practice and provide effective vessel health and preservation.

Despite the gaps in knowledge, there are clear evidence-based recommendations to improve PIVC management. Many of these recommendations are listed in the 2021 Infusion Nurses Society Infusion Therapy Standard of Practice.² Clinicians should be trained in proper care of PIVCs from insertion to maintenance to removal, and this education should be targeted to the unique vulnerabilities of PIVCs. This education should then inform and establish competency measurement in:

• Optimal placement of PIVC catheters (avoiding high complication sites such as areas of flexion, and those distal to injury or with decreased sensation).
• Escalation to an expert when PIVC placement exceed the clinician’s skill set.
• Optimal infusates that are considered peripherally compatible (avoiding extremes of pH and osmolarity and limiting continuous infusions to non-irritant, non-vesicant infusates well-tolerated by peripheral vessels).
• Consistent assessment of PIVC insertion sites based on patient and infusate risks (extremes of pH, osmolarity, cytotoxicity which can damage vessel endothelium and surrounding tissue).
• Recognition of PIVC complications with accurate documentation.
• Provider notification and available treatment protocols for PIVC complications (extravasation, compartment syndrome, phlebitis, catheter-related thrombosis).
• Ongoing PIVC management, including aseptic access of the PIVC administration set, site care, site securement, tubing change, accurate and safe delivery of medications using infusion devices.
• A process for regular review of line necessity to reduce PIVC continuation when no longer clinically needed.²

Essentially, the standard of care for PIVCs should be as high as that of CVADs since PIVC-related outcomes can progress to serious localized or systemic complications.

To better understand the true patient impact of PIVC-related outcomes, there are several recommendations for further high-quality research. Areas of crucial need include:

• Establishment of clear PIVC outcome definitions that are validated for use with specific patient populations (e.g., pediatrics, elderly, critically ill).
• Validation of a “difficult IV access” (DIVA) scale for large patient populations to improve escalation to expert inserters.
• Establishment of a PIVC management bundle proven to reduce PIVC failure.
• Validation of daily review resources that improve PIVC management and measure the efficacy of interventions.
• Identification of the impact of specific infusates on peripheral vessel health to add clarity to the term “peripherally compatible”.
• Establishment of accurate outcomes regarding the current utilization of the midline peripheral catheter.
• Accurate measurement of patient cost (emotional, physical, financial) of PIVC failure.^11-19

With a sharper focus on PIVC outcomes, we will close the knowledge gap and truly work to improve patient outcomes.

References

1. Marsh N, Webster J, Ullman AJ, Mihala G, Cooke M, Chopra V, Rickard CM. Peripheral intravenous catheter non-infectious complications in adults: A systematic review and meta-analysis. J Adv Nurs. 2020 Dec;76(12):3346-3362. doi: 10.1111/jan.14565. Epub 2020 Oct 5. PMID: 33016412.
2. Gorski LA, Hadaway L, Hagle ME, Broadhurst D, Clare S, Kleidon T, Meyer BM, Nickel B, Rowley S, Sharpe E, Alexander M. Infusion Therapy Standards of Practice, 8th Edition. J Infus Nurs. 2021 Jan-Feb 01;44(1S Suppl 1):S1-S224. doi: 10.1097/NAN.0000000000000396. PMID: 33394637.
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