EDUCATION & TRAINING
Making Midlines Mainstream SAEM PULSE | NOVEMBER-DECEMBER 2022
By Michael Sherman, MD, MA, and Alexandra Nordberg, MD, on behalf of the SAEM Education Committee
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Difficult venous access is a daily problem encountered in the emergency department (ED), and emergency medicine (EM) has been at the forefront of this field since its inception. In the past, the expanding use of ultrasound guided IVs (US-IVs) was shown to decrease the placement of central lines needed for simple venous access; however, US-IVs continue to be plagued by a high failure rate. In recent years, midline catheters have enjoyed a renaissance, to provide reliable vascular access for patients with difficult venous access who would otherwise require multiple venipunctures or the use of central lines to obtain and maintain access.
History
Midline placement has been used clinically since the 1950s. These older midlines were usually upsized peripheral IV’s. As Seldinger technique revolutionized the placement of central lines, central line placement became commonplace. This procedure was then augmented by ultrasound guidance as a safe and reliable way to obtain venous access, and midlines fell to the wayside in clinical practice. Because of this, most of the guidelines and policy statements surrounding midlines comes from the days prior to Seldinger technique and the routine use of ultrasound for vascular access.
As the placement of central lines became routine, it became common to place central lines when faced with difficult venous access; this, however, exposed patients to the mechanical and infectious risks of central access, among other risks such as patient discomfort. In fact, some hospital systems required that patients with central femoral access to be on bedrest; national focus from the Centers for Medicare & Medicaid Services (CMS) began to highlight the morbidity and mortality associated with Central LineAssociated Bloodstream Infections (CLABSIs). Given the advent of bedside ultrasound, routine use of ultrasound guided IVs was shown to decrease the
