Pediatric midline catheters: should you add it to your armamentarium?
Myron Yaster MD and Lynne G. Maxwell MD
Admittedly, I was not a very good pediatric resident. In the 1970s, when I did my internship and residency, there were no IV teams, no blood drawing teams and 36+ hour call periods were the norm. One of the worst parts of my experience involved placing IV catheters in crying, really screaming kids. Patients were physically restrained and rarely, if ever, received local anesthesia or any form of sedation (it’s really no wonder I became a pediatric anesthesiologist!) The smallest IV catheters were 22 gauge and the only thing available for smaller veins was a 25 g butterfly needle. None of these lasted more than 2-3 days. Further, if you can believe it, if by some miracle an IV lasted longer, some attendings, particularly oncologists, wanted IVs pulled after 24-48 hours to prevent infection. Of course, the attendings didn’t have to replace these IVs and the responsibility of placing the IVs in the first place or replacing IV catheters fell to the intern (me).
There were times that I felt I was torturing my patients. And then in the early 1980s a miracle occurred, namely, silicone central line catheters like the Hickman, usually placed by surgeons, lasted for weeks or months. Multiple venipunctures became less and less common. Over time, peripherally inserted central lines (PICCs), often placed by bedside nurses or nursing specialists, became routine. Even anesthesiologists got into the act. One of my former colleagues at Johns Hopkins, Dr. Debra Schwengel, demonstrated that PICC lines could be easily and successfully placed intraoperatively in patients in whom a long hospitalization or need for long term (>3-5 day) IV medications would be needed.1 Unfortunately, this anesthesia practice disappeared because the follow-up and removal of these catheters postoperatively became the responsibility of the anesthesia team that placed them, which was essentially impossible. Further, early on it became a turf war between radiology, the PICC line teams, and surgery; a war that we as anesthesiologists could simply not win. Thus, when I saw today’s PAAD by Östlund et al.2 I was intrigued and thought you might be too. Myron Yaster MD
Original article
Östlund Å, Fläring U, Norberg Å, Kaisere S, Frisk T, Larsson P, Andersson A. Complications of Pediatric Midline Catheters: A Prospective Observational Pilot Study. Anesth Analg. 2024 Mar 1;138(3):572-578. doi: 10.1213/ANE.0000000000006328. Epub 2022 Dec 12. PMID: 36729761.
First some definitions: our regular peripheral IV catheters (PIVs) are 2-6 cm in length whereas long peripheral IV catheters (LPCs) are 6-15 cm in length.3,4 LPCs are commonly inserted into the forearm, antecubital fossa or upper arm using a direct Seldinger technique and significantly increase catheter survival time when compared to PIVs. Leakage, infiltration, thrombophlebitis, swelling of the extremity, pain, erythema, accidental dislodgement, occlusion, and bloodstream infection are the most frequent causes of failure.3,4 On the other hand, central venous catheters (CVCs) which are commonly placed in the OR or in interventional radiology suites “provide reliable venous access with the possibility to draw blood samples but carry a greater risk of severe complications compared to a PIVC. The rate of CVC-related venous thromboembolic (VTE) events is high in children,5 and CVC-related VTE accounts for the majority of all pediatric VTEs.”
“Midline catheters are peripherally inserted catheters in which the catheter tip is not located in the central circulation. There is no need for x-ray confirmation of tip position, thereby reducing radiation exposure. Moreover, midline catheters can often be inserted after application of anesthetic cream and with only light sedation of the child. The expected dwell time for pediatric midline catheters is not well defined, but a recent small randomized controlled trial (RCT) concluded that the dwell time of midlines was superior to that of PIVCs in children.”2,4
In today’s PAAD, “midline catheter insertion was routinely performed under sterile conditions using the Seldinger technique and with real-time ultrasound guidance.[82/100 catheters were placed perioperatively with the patient under general anesthesia]. According to institutional guidelines, the diameter of the cannulated vein was measured with ultrasonography (US) at the intended puncture site before catheter insertion, if the clinical situation allowed for this. The vein was measured with the patient in the supine horizontal position, without stasis and while avoiding compression of the vein. Based on the measured vein diameter and the diameter of the midline catheter, the catheter/vein diameter ratio was calculated. The catheters used in this study were either Vygon Leaderflex (Vygon) catheters (2, 3, or 4 Fr catheters, catheter length 4–10 cm) or Arrow (Teleflex Medical Inc) catheters (3 Fr, 10 cm or 4 Fr, 12 cm catheters). The choice of catheter size, length, and site was at the clinician’s discretion.”2
What did they find? A venous thromboembolic event “was diagnosed in 30 (30%; 95% confidence interval [CI], 21%–40%) cases, corresponding to an incidence rate of 39 (95% CI, 26–55) cases per 1000 catheter days. Eight of 14 saphenous vein catheters were complicated by VTE compared to 22 of 86 arm vein catheters, suggesting an imbalance in favor of arm vein insertion site. Two patients needed anticoagulation therapy due to catheter-related VTE. Thirty (30%) catheters were removed unintentionally or due to complications, 22 [of these patients] needed additional IV access to complete the intended therapy. No catheter-related bloodstream infection (95% CI, 0%–4%) occurred. Mechanical complications occurred in 33 (33%; 95% CI, 24%–43%) midline catheters.”2 The need for anticoagulation therapy was determined after consultation with the pediatric coagulation team. Most VTE were asymptomatic and were found by ultrasound following removal of the midline catheter, which was a component of the study design. VTE was confined to the peripheral vein and did not extend into the central circulation.
The authors conclude: “thrombotic and mechanical complications of midline catheters are common, but only few VTEs are severe enough to warrant anticoagulation therapy. Systemic infectious complications are rare. Seventy-eight percent of patients did not need additional venous access to complete short-term IV therapy. Considering the rate of clinically relevant complications and the catheter dwell time, pediatric midline catheters could be an alternative to central venous access for short-term (5–10 days) IV therapy.”2
The rate of thromboembolic events seems to be high, indeed, much higher than we expected, and is really concerning to us. Is this technique safer or better than PICC or CVCs which have similar rates of VTE events. We wonder if the rate of thromboembolic events would have been significantly lower if silicone catheters were used instead of polypropylene (Vygon) or siliconized poly vinyl chloride (Teleflex) based catheters?
What do you think? Are you ready to start doing this in your practice or are you already doing this? Send your comments and experiences to Myron who will post in a Friday reader review.
References
1. Schwengel DA, McGready J, Berenholtz SM, Kozlowski LJ, Nichols DG, Yaster M. Peripherally inserted central catheters: a randomized, controlled, prospective trial in pediatric surgical patients. AnesthAnalg 2004;99(4):1038-43, table.
2. Östlund Å, Fläring U, Norberg Å, et al. Complications of Pediatric Midline Catheters: A Prospective Observational Pilot Study. Anesthesia and analgesia 2024;138(3):572-578. (In eng). DOI: 10.1213/ane.0000000000006328.
3. Qin KR, Ensor N, Barnes R, Englin A, Nataraja RM, Pacilli M. Standard Versus Long Peripheral Catheters for Multiday IV Therapy: A Randomized Controlled Trial. Pediatrics 2021;147(2) (In eng). DOI: 10.1542/peds.2020-000877.
4. Qin KR, Ensor N, Barnes R, Englin A, Nataraja RM, Pacilli M. Long peripheral catheters for intravenous access in adults and children: A systematic review of the literature. J Vasc Access 2021;22(5):767-777. (In eng). DOI: 10.1177/1129729820927272.
5. Östlund Å, Fläring U, Norberg Å, et al. Incidence of and risk factors for venous thrombosis in children with percutaneous non-tunnelled central venous catheters. British journal of anaesthesia 2019;123(3):316-324. (In eng). DOI: 10.1016/j.bja.2019.04.055.