Last updated on December 28th, 2023

Midline catheters and peripherally inserted central catheters (PICC) are both vascular access devices (VAD) used for infusion therapies. However, the uses of both devices are quite different.

In this article, we’ll discuss the similarities and differences of midline catheters and PICCs.

Additionally, we’ll look into:

indications, advantages, and contraindications of both midline catheter and PICCs
medications that should not be administered via midline catheter
care, management, and removal of both devices

Midline Catheter

According to Infusion Nurses Society, midline catheter is defined as a vascular access device which is inserted into a peripheral vein (namely, basilic, cephalic, or brachial vein), and the tip of it is at or near axilla level, and distal to the shoulder.

The midline catheters can remain in-situ up to 30 days.

How to choose the appropriate size of midline catheter?

To choose appropriate size, estimate the distance between the axilla and the insertion site.

The length of the midline catheter ranges from 10 to 20cm, and it can have a single lumen or double lumen.

midline-catheters-vs-picc-peripherally-inserted-central-catheters-piccs-catheter-image-sizes — Midline Catheters (*Source*)

What are the indication for midline catheter insertion?

Use of midline catheters are indicated when a patient requires intravenous therapies and blood sampling for about 2 to 4 weeks.

Other uses of midline catheters include:

Difficult peripheral venous access
Frequent phlebotomy
Limited venous access on admission
Steroids
Fluid restricted patients
IV drug abuse
Diabetic patients
Receiving multiple drugs
Multiple hospital admissions
Obese patients

What are the advantages of mIdline catheter?

Use for alternate infusion therapy
Reduce repeated venipunctures which would compromise venous access
Can be used for 2-4 weeks
Infusion of antibiotics, hydration, and pain medication
Venous sampling

Source

What are the contraindications of midline catheter?

History of venous thrombosis

Restricted blood flow to the extremities
End-stage renal disease that requires peripheral vein preservation
Known or suspected infection, bacteremia, or septicemia related to the device
Known or suspected allergies

Source

Medications that CANNOT be administered via midline catheters

Continuous vesicant infusions
Total Parenteral Nutrition (TPN)
Chemotherapy
Solutions greater than 600 mOsm/L
Infusions that requires central line-only administration
Dextrose concentration ≥10%

List of common drugs that should be avoided in midline catheters

Acyclovir	Fosphenytoin*	Phenobarbital
Amiodarone	Ganciclovir	Phenylephrine
Amphotericin B*	Gentamicin*	Phenytoin
Ampicillin/sulbactam*	Iron dextran*	Potassium chloride (≥40 mEq)
Azithromycin*	Levofloxacin*	Promethazine
Calcium chloride	Mannitol ≥20%	Protein solutions >5%
Calcium gluconate	Meropenem*	Sodium bicarbonate
Caspofungin*	Morphine sulfate*	Sodium chloride ≥3%
Contrast media – nonionic*	Nafcillin*	Sulfamethoxazole/Trimethoprim*
Dexrazoxane*	Norepinephrine	Tobramycin*
Dextrose concentration ≥10%	Oxacillin*	TPN, exceeding 600mOsm/L
Dobutamine	Pamidronate*	Vancomycin*
Epinephrine	Pentamidine	Vasopressin
Foscarnet*	Pentobarbital	Zidovudine*

Table 1

*may be ok with short courses of therapy (not to exceed 3 days) with close monitoring.

ALSO, this is NOT an exhaustive list. Just examples of common medications that should not be administered via midline catheters. For specific drugs not found on this list, refer to medication package inserts or contact the pharmacy. Source

What are the complications of midline catheter?

Infiltration
Phlebitis
Catheter dislodgement

Peripheral thrombosis
Pain
Ecchymosis
Edema
Leaking

Insertion related midline catheter complications are:

Accidental arterial puncture during insertion
Unsuccessful procedure
Hematoma
Symptomatic deep vein thrombosis

Peripherally inserted central catheters (PICCs)

As the name stated, peripherally inserted central catheters (PICCs) are peripherally accessed central lines which are used for long term intravenous therapies and blood sampling.

Indications for peripherally inserted central catheters (PICC)

Certain therapies require a central line, such as TPN and chemotherapies.
Irritant therapies that over time can cause chemical phlebitis such as Vancomycin and Nafcillin
Therapies lasting longer than 4 weeks
Frequent phlebotomy

Other uses of PICC are the same as midline catheters.

Advantages of peripherally inserted central catheters (PICC)

Administration of fluid, blood, medications in patients who do not have suitable veins for repeated access
Preserves the peripheral veins
Reduces the risk of phlebitis
Decreases the risk of infiltration
Improves comfort
Reduces stress and pain associated with multiple venipunctures
Eliminate complications, such as pneumothorax and great vessel perforation associated with insertions in the neck and chest regions.
Administration of chemotherapy and parenteral nutrition therapies
Reduced risk of air embolism
Can be used for CVP
Lowest incidence of complications compared to other devices

Source

Contraindications of peripherally inserted central catheters (PICC)

History of venous thrombosis
History of vascular surgical procedures at the prospective placement site
Known or suspected infection, bacteremia, or septicemia related to the device
Known or suspected allergies
Past irradiation of the prospective insertion site

Preexisting skin infections
Presence of severe peripheral edema
Local tissue factors will prevent proper device stabilization or device access

Source

midline-catheters-vs-picc-peripherally-inserted-central-catheters-piccs-location — *Source*

Similarities of midline catheter and peripherally inserted central catheters (PICC)

Both are vascular access devices.
Both can be used to draw blood samples.

Both catheters are inserted via the same veins. Namely, cephalic, basilic, brachial, or median cubital veins in the upper arm.
Both procedures must be performed using aseptic techniques with maximal sterile barrier precautions.

Differences between midline catheter and peripherally inserted central catheters (PICC)

Midline Catheter	Peripherally Inserted Central Catheters (PICC)
Peripheral line	Central line
Catheter tip is at or near axilla level and distal to the shoulder	Catheter tip is located in the lower segment of the superior vena cava
Used when intravenous therapies required for less than 30 days	Used when longer lengths of intravenous therapy are needed
CANNOT administer certain medications (Refer to Table 1)	Can administer all types of medications
Radiologic confirmation is not needed before use	Chest x-ray is needed to confirm placement, unless tip locator technology is used during insertion
Catheter length is shorter	Catheter length is longer
Can’t measure CVP	CVP can be measured

Table 2

Midline Catheter and PICC Care and Management

Flush with 5cc NS before and after routine IV/medications
Flush with 10cc NS before and after blood draws

Flush with 10cc NS before and after TPN (PICC only)
Flush with 20cc NS after administering blood products
Heparin lock and flush if no continuous infusion and not used daily
Initially change dressing 24 hours after insertion
Then every 7 days (use an antibacterial and antimicrobial agent to clean as per the institute’s guideline)
Change cap every 7 days or whenever removed
Blood pressure cuffs or tourniquets should not be used on the arm where a midline catheter has been placed
Make sure to infuse the right and compatible drugs via midline catheter

Midline Catheter and PICC Removal

Explain the procedure to the patient
Gather supplies
Remove dressing
Gently pull out the line from arm
Apply pressure to site
Cover with gauze and apply occlusive dressing
Final measurement of removed catheter
Document the procedure

Bonus Tips

Method to choose best site for midline catheters

Basilic vein is usually the best vein because it’s large and far from the brachial artery.
The basilic and brachial are preferred over the cephalic vein because their higher flow ensures lower complication rates.
Avoid the cephalic vein because its flow rate is usually lower, and gets narrower proximally.
Avoid the cubital fossa as this site is associated with higher infection and thrombosis rates due to friction with movement.
The ideal insertion site is proximal enough to the elbow to ensure easy elbow flexion distal enough form the axilla to ensure a 8 or 12cm midline will not cross the axilla
Release the tourniquet until the sterile set up on the chosen arm is undertaken

Source