Infiltration and Extravasation Risk with Midline Catheters: A Narrative Literature Review.

Midline catheters have recently gained popularity in clinical use, with a common reason being the reduction of central venous catheter use and central line-associated bloodstream infections. At the same time, the number of nononcology vesicant medications has increased, and midline catheters are frequently being used for infusions of vesicant medications. The Infusion Nurses Society (INS) Vesicant Task Force identified midline catheter use as a possible risk factor for extravasation and concluded that a thorough literature review was necessary. This review highlights the variations in catheter terminology and tip locations, the frequency of infiltration and extravasation in published studies, and case reports of infiltration and extravasation from midline catheters. It also examines the many clinical issues requiring evidence-based decision-making for the most appropriate type of vascular access devices. After more than 30 years of clinical practice with midline catheters and what appears to be a significant number of studies, evidence is still insufficient to answer questions about infusion of vesicant and irritant medications through midline catheters. Given the absence of consensus on tip location, inadequate evidence of clinical outcomes, and importance of patient safety, the continuous infusion of vesicants, all parenteral nutrition formulas, and infusates with extremes in pH and osmolarity should be avoided through midline catheters.

Development of an Evidence-Based List of Non-Antineoplastic Vesicants: 2024 Update.

Infiltration of a vesicant, called extravasation, can result in severe patient injuries. Recognition of vesicants and their relative risk of injury is essential to extravasation prevention, early recognition, and appropriate treatment. In this article, the Vesicant Task Force (VTF) updates the previously published Infusion Nurses Society (INS) vesicant list from 2017. The 2024 INS list diverges from earlier vesicant lists, such as the 2017 VTF list, by adopting a risk stratification approach based upon documented patient outcomes, in contrast to the reliance on expert consensus or only surrogate risk indicators, such as pH and osmolarity. The methodology used to create the updated list is explained, and the criteria for high- and moderate-risk vesicants and cautionary vesicants are defined.

Midline Catheters: Could They Replace a Central Vascular Access Device?

In the past 30 years, midline catheter use has grown rapidly. For several reasons, many providers and facilities are attempting to reduce the number of central venous catheters and subsequent central line-associated bloodstream infections (CLABSIs) by using midline catheters. Vessel preservation requires attention to all vascular access device (VAD)-associated complications and not only central line bloodstream infection. There is still much confusion about the appropriate tip location and the characteristics of fluids and medications that can safely be infused through a midline catheter residing in a peripheral vein. The Infusion Therapy Standards of Practice (the Standards) focuses on assessment of characteristics of infusion therapies that must be considered for VAD selection as an evidence-based list of fluids and medications for infusion through peripheral veins has yet to be established. This review of midline catheter studies evaluates the evidence regarding the substitution of a midline catheter for a central venous catheter. Many issues need to be addressed, such as studies that include an outcome list that mixes defined clinical complications (eg, thrombosis) with signs and symptoms of complications (eg, leaking). Another issue is basing a major change of clinical practice on retrospective chart reviews. Although a midline catheter may be appropriate for some patients, additional studies of a higher level of evidence are needed before this major practice change should occur.

WoCoVA consensus on the clinical use of in-line filtration during intravenous infusions: Current evidence and recommendations for future research.

The need for filtering intravenous infusions has long been recognized in the field of venous access, though hard scientific evidence about the actual indications for in-line filters has been scarce. In the last few years, several papers and a few clinical studies have raised again this issue, suggesting that the time has come for a proper definition of the type of filtration, of its potential benefit, and of its proper indications in clinical practice. The WoCoVA Foundation, whose goal is to increase the global awareness on the risk of intravenous access and on patients' safety, developed the project of a consensus on intravenous filtration. A panel of experts in different aspects of intravenous infusion was chosen to express the current state of knowledge about filtration and to indicate the direction of future research in this field. The present document reports the final conclusions of the panel.

Stopcocks for Infusion Therapy: Evidence and Experience.

Stopcocks have been used for decades to deliver infusion therapy in patients of all ages and in all health care settings. During the past 20 years, a growing number of studies have validated concern about the risk of the open lumen allowing intraluminal contamination. Additional studies highlight fluid flow dynamics associated with stopcocks. This integrative literature review and clinician practice survey analyzes the published evidence and reports of actual practices with stopcocks, and raises issues about practice changes that could reduce these risks.

Infiltration and extravasation.

The Infusion Nurses Society's national standards of practice require that a nurse who administers IV medication or fluid know its adverse effects and appropriate interventions to take before starting the infusion. A serious complication is the inadvertent administration of a solution or medication into the tissue surrounding the IV catheter--when it is a nonvesicant solution or medication, it is called infiltration; when it is a vesicant medication, it is called extravasation. Both infiltration and extravasation can have serious consequences: the patient may need surgical intervention resulting in large scars, experience limitation of function, or even require amputation. Another long-term effect is complex regional pain syndrome, a neurologic syndrome that requires long-term pain management. These outcomes can be prevented by using appropriate nursing interventions during IV catheter insertion and early recognition and intervention upon the first signs and symptoms of infiltration and extravasation. Nursing interventions include early recognition, prevention, and treatment (including the controversial use of antidotes, and heat and cold therapy). Steps to manage infiltration and extravasation are presented.

Technology of flushing vascular access devices.

Maintenance of catheter lumen patency is an ongoing challenge. Catheter flushing is the primary nursing intervention used to prevent lumen occlusion from thrombotic and precipitate causes. The catheter and all devices attached to it must be regarded as a system in which each component directly affects the others. The technology of catheter flushing includes the flush solution itself, the source of these solutions, syringe design, mechanical pumps, needleless injection systems, and the design of the catheter. Effective catheter flushing is a combination of a technique and technology that requires an understanding of how both must work together.

Skin flora and infection.

Human skin provides a great living environment for the growth of microbes. The types and numbers of microbes vary according to the part of the human body and the age and gender of the individual. These microbes have a definite impact on the incidence of catheter-related infections. By understanding the process of how infections develop, appropriate choices can be made for techniques and methods that prevent these infections.

Vancomycin: new perspectives on an old drug.

The use of vancomycin continues to be prevalent in all clinical settings. However, many questions persist about infusion techniques. According to the Infusion Nursing Standards of Practice, peripheral catheters are not the best choice for infusing this drug because of its pH. The key to reducing risk of peripheral phlebitis and extravasation injury is choosing a more appropriate vascular access device. Many healthcare providers correlate systemic side effects with the infusion rate and concentration, although many reports cannot support this correlation. New technologies of vascular access and infusion controlling devices are changing old, established practices. This update provides an examination of the current literature on all aspects of infusing vancomycin and monitoring patients.

Short peripheral intravenous catheters and infections.

The rate of infections associated with short peripheral intravenous catheters is thought to be very low, even rare. Approximately 330 million peripheral catheters are sold annually in the United States. Although the rate may be low, the actual number of infections could be relatively high, with most going undetected because of short dwell times and early patient discharges. A recent estimate reported as many as 10000 Staphylococcus aureus bacteremias from peripheral catheters annually in the United States. This integrative literature review identified soft tissue, bone, and bloodstream infections. Analysis of 45 studies revealed significant knowledge gaps and inadequate clinical practices associated with one of the most common devices used in all health care settings.

Needleless connectors for IV catheters.

OVERVIEW: Needleless devices for connecting IV catheters, administration sets, and syringes were introduced in the early 1990s for the purpose of reducing the risk of needlestick injuries among health care providers. Although needleless connectors serve that purpose, their use has been associated with an increase in such complications as catheter-related bloodstream infection and catheter lumen occlusion. Complications may be related to design characteristics, user knowledge deficits, poor practices, or some combination thereof. The author describes the connectors in current use, how they differ in design and function, the potential complications associated with various models and practices, and the nursing interventions that can reduce the risk of these complications.

Needlestick injuries, short peripheral catheters, and health care worker risks.

Percutaneous exposure (PCE) and mucocutaneous exposure (MCE) to blood and blood-containing body fluids pose risks to health care workers worldwide. Although PCEs have been greatly reduced in the United States, they have not been eliminated and continue to be a significant problem worldwide. MCE seems to be a much smaller problem than PCE; however, the data are limited and confusing. Venipuncture procedures can easily be associated with PCE, but there are no published reports of MCE occurring during insertion, use, and removal of peripheral catheters. This integrative, systematic literature review identifies the risks associated with venipuncture and the insertion of short peripheral catheters.