By Theresa Lombardo, DNP, APRN, AGACNP-BC
Lead Advanced Practice Provider, MICU and Inpatient Lung Transplant, Division of Pulmonary and Critical Care, Northwestern Memorial Hospital, Chicago
SYNOPSIS: In this study evaluating safety outcomes of infusing vasopressors through a midline catheter, there was no increase in catheter-related complications when comparing administration of vasopressors through a midline to administration through a peripherally inserted central catheter (PICC) or when compared to midline use with vasopressor infusion via a different catheter. There was an overall greater risk of systemic thromboembolism when midlines were used for vasopressor administration vs. PICCs or midlines with vasopressors administered through a different catheter.
SOURCE: Gershengorn HB, Basu T, Horowitz JK, et al. The association of vasopressor administration through a midline catheter with catheter-related complications. Ann Am Thorac Soc 2023;20:1003-1011.
This cohort study was conducted in 39 hospitals across Michigan between December 2017 and March 2022. At total of 2,831 adult intensive care unit (ICU) patients who received a midline or peripherally inserted central catheter (PICC) and had vasopressors administered were included in the study. Vasopressors used included norepinephrine, epinephrine, vasopressin, phenylephrine, dopamine, and dobutamine (due to vesicant properties). Exclusion criteria were patients who were younger than 18 years of age, pregnant, admitted to non-medicine services, and admitted under observation status. Of the patients who were included, 287 patients received vasopressors through midline catheters, 1,660 patients received vasopressors through PICCs, and 884 had midlines in place but received vasopressors through a different catheter.
The primary outcome of the study was the development of catheter-related complications defined as central line-associated bloodstream infection (CLABSI) in the setting of PICCs, catheter-related bloodstream infection in the setting of midlines, superficial thrombophlebitis, exit site infection, or catheter occlusion. Secondary outcomes included the primary outcome plus new post-catheter development of ipsilateral upper extremity (UE) deep venous thrombosis (DVT) (likely to be catheter-related), new post-catheter development of ipsilateral UE DVT alone, new post-catheter development of any VTE, each complication included in the primary outcome, extravasation (for midlines and those with midlines receiving vasopressors elsewhere), and mortality.
Descriptive statistics were used to identify cohort characteristics, and chi-square and Wilcoxon rank-sum tests were used to define outcomes across the three subgroups. Mixed effects logistic regression models then were used to evaluate the independent association of the three subgroups with each outcome. Age and gender were similar across all subgroups. When comparing the use of midlines vs. PICCs for vasopressor administration, there were fewer catheter-related complications in patients who received vasopressors through midlines (5.2% vs. 13.4%; P < 0.001), and after adjustment there was no association between midline use for vasopressors and catheter-related complications (adjusted odds ratio [aOR] confidence interval [CI], 0.65 [0.31-1.33]; P = 0.23). When comparing midlines to PICCs for vasopressor administration, there were no statistically significant catheter-related complications plus ipsilateral UE DVT (aOR [95%CI], 0.88 [0.47-1.64]; P = 0.67), catheter occlusion (0.37 [0.13-1.09]; P = 0.07), or ipsilateral UE DVT (2.35 [0.83-6.63]; P = 0.10). However, there was a higher odds of superficial thrombophlebitis (3.79 [1.15-12.44]; P = 0.030), any VTE (2.69 [1.31-5.49]; P = 0.008), and lower odds of mortality (0.30 [0.21-0.45]; P ≤ 0.001).
When comparing midline catheters used for vasopressor administration vs. midline catheters with vasopressors administered through another catheter, catheter-related complications were similar (5.2% vs. 6.3%; P = 0.49). After adjustment, there was no association with catheter-related complications of midline use vs. having a midline and vasopressors administered through another catheter (aOR [95% CI], 0.85 [0.46-1.58]; P = 0.59) in addition to no association with catheter-related complications plus ipsilateral UE DVT (aOR [95% CI], 1.09 [0.93-1.87]; P = 0.76), superficial thrombophlebitis (1.69 [0.61-4.70]; P = 0.31), catheter occlusion (0.60 [0.23-1.56]; P = 0.29), midline extravasation (1.17 [0.41-3.32]; P = 0.76), or odds of 30-day mortality (1.26 [0.94-1.70]; P = 0.11). There was an overall higher odds of any systemic VTE (2.42 [1.29-4.54]; P = 0.008) for patients who had midline catheters used for vasopressors.
COMMENTARY
While central lines are important and necessary for monitoring and medication administration for certain patient populations, their use does not come without risk. Depending on the location of the central line, associated immediate and delayed complications include bleeding, vascular complications, pneumothorax, and infection.1 In addition, placement of central lines usually is done by physicians or advanced practice providers, which can create a possible delay in treatment because of the availability of trained providers to place the line.
Data on administration of vasopressors through midlines have been limited; however, this study adds to recent research highlighting that midlines can be a safe alternative to central venous lines in the administration of vasopressors.2 This study is helpful in not only assessing complications of using midlines for vasopressor use, but comparing those complications to those of PICCs and showing no association with midline use for vasopressors and midline extravasation, another common concern when using midlines for vasopressor administration.
Additional research is warranted into the reported increased odds of VTE. It is difficult to determine whether this is a true increased risk related to receiving vasopressors through a midline catheter or whether this stems from an increased VTE risk overall for critically ill patients and/or those with a midline catheter in place. A larger comparison of complications, including those related to peripheral intravenous and other central venous lines (such as triple lumen catheters), would be helpful to provide more support for using non-centrally placed catheters as a safe alternative for vasopressor administration.
REFERENCES
- Patel AR, Patel AR, Singh S, et al. Central line catheters and associated complications: A review. Cureus 2019;11:e4717.
- Prasanna N, Yamane D, Haridasa N, et al. Safety and efficacy of vasopressor administration through midline catheters. J Crit Care 2021;61:1-4.
