Who Puts in a Midline? A Guide to Midline Catheter Placement

Midline catheters are increasingly used for intermediate-term intravenous therapy, offering a safe alternative to standard peripheral IVs and more invasive central lines. So, who puts in a midline? The procedure is performed by specifically trained and certified healthcare professionals, primarily advanced practice nurses and vascular access specialists.

Quick Summary

Specially trained nurses, physician assistants, and vascular access teams are the primary healthcare professionals who insert midline catheters using sterile techniques. The specific personnel and requirements vary depending on the healthcare institution's policies and the practitioner's credentials.

Key Points

• Trained Professionals: Midline catheters are inserted by specially trained nurses, physician assistants, and vascular access specialists.

• Specialized Skills: The procedure requires advanced training in sterile technique and, often, ultrasound guidance, distinguishing it from standard IV insertion.

• Role Varies: The specific type of professional depends on the institution's policies and the provider's specific training and certifications.

• Team Approach: Many hospitals have dedicated vascular access teams responsible for placing midlines and other specialized IVs.

• Safer Alternative: Midlines offer a safer, longer-lasting option for IV therapy compared to standard peripheral IVs, but without the central line risks.

Understanding Midline Catheter Placement

A midline catheter is a long IV catheter, typically 3 to 8 inches in length, that is inserted into a large superficial vein in the upper arm, most commonly the basilic, cephalic, or brachial vein. The tip of the catheter terminates below the armpit (axilla) but does not enter the central venous system, distinguishing it from a PICC (peripherally inserted central catheter). They are used when intravenous access is needed for a period longer than a standard peripheral IV can safely remain in place, but where a central line is not necessary.

The insertion of a midline is a specialized procedure that requires specific training due to its technical nature and the potential risks involved. Unlike a standard IV, which can be placed by any qualified nurse, a midline requires advanced skills in vascular access, vein selection, and sterile technique to ensure patient safety and proper placement. The use of ultrasound guidance is now the standard of care for many institutions, further requiring advanced training.

The Healthcare Professionals Who Put in a Midline

The team responsible for midline insertion is a specialized group of clinicians, ensuring expertise and precision. The specific roles and titles can vary by hospital or healthcare system, but generally include:

Vascular Access Specialists (VAS)

Many hospitals employ dedicated vascular access teams whose sole responsibility is to manage all aspects of intravenous access, including the insertion of midlines and PICC lines. These teams are typically composed of highly experienced and specially trained nurses, often with additional certifications in vascular access. Their extensive experience allows them to handle complex cases and difficult venous access situations with higher success rates.

Advanced Practice Nurses (APNs)

Nurse practitioners (NPs) and clinical nurse specialists (CNS) who have received specific, certified training in vascular access are often authorized to place midlines. Their scope of practice, which is defined by state regulations and hospital policy, frequently includes advanced procedures that require a higher level of clinical judgment and skill.

Physician Assistants (PAs)

Under the supervision of a physician, physician assistants are also trained and qualified to perform minor surgical and procedural tasks, including the placement of midlines. PAs who specialize in specific areas like surgery or critical care often have these skills as part of their procedural toolkit.

Specialized Registered Nurses (RNs)

Some registered nurses, while not APNs, receive extensive training and certification specifically for placing midlines. These nurses often work on the vascular access team or in specialty areas like intensive care units (ICUs) or emergency departments (EDs) where this skill is frequently required. The training includes theoretical knowledge of anatomy, sterile technique, and hands-on practice with ultrasound guidance.

The Midline Insertion Procedure

The process of inserting a midline is a careful, multi-step procedure that requires a high degree of sterility and precision. It involves:

1. Patient Assessment: The healthcare provider assesses the patient's medical history, condition, and venous anatomy to determine if a midline is the appropriate choice and to identify the best vein.
2. Vein Selection: Using ultrasound guidance, the clinician identifies a suitable vein in the upper arm, typically the basilic vein due to its size and straight path.
3. Sterile Preparation: The insertion site is cleaned with an antiseptic solution, and a sterile drape is used to create a sterile field, minimizing the risk of infection.
4. Local Anesthesia: A local anesthetic is administered to numb the area, ensuring the patient's comfort during the procedure.
5. Catheter Insertion: With ultrasound guidance, the midline catheter is inserted into the vein and advanced to the correct position. The catheter is measured and secured once placed.
6. Confirmation: The catheter's position is verified, often with a chest X-ray or other imaging, to ensure the tip is in the correct location and not in a central vessel.

Midline vs. PICC vs. Peripheral IV: A Comparison

Feature	Midline Catheter	PICC Line	Peripheral IV
Catheter Length	Medium (~3–8 inches)	Long (~20–24 inches)	Short (~1–1.5 inches)
Tip Location	Superior Vena Cava (SVC)	Distal to the axilla	Local vein (hand/arm)
Duration	Intermediate (1–4 weeks)	Long-term (weeks–months)	Short-term (<6 days)
Who Inserts?	Specially trained RNs, PAs, APNs	Specially trained RNs, PAs, APNs, Physicians	RNs, LPNs, Phlebotomists
Medication Type	Non-irritating, pH-neutral	All types (irritating, high osmolarity)	Non-irritating
Insertion Site	Upper arm	Upper arm	Hand, arm, foot
Required Training	Advanced vascular access	Advanced vascular access	Standard nursing skills

For more detailed information on vascular access standards and guidelines, please consult the Infusion Nurses Society.

Conclusion

In summary, while a standard IV can be placed by many healthcare professionals, the midline catheter requires a higher level of training and specialization. The procedure is typically performed by advanced practice nurses, physician assistants, or dedicated vascular access specialists who have undergone specific training and certification. This ensures the procedure is carried out safely and effectively, minimizing risks and improving patient outcomes. If a midline is required for your treatment, you can be confident that a skilled and experienced professional will be managing your care.

Frequently Asked Questions

Can any nurse put in a midline?

No, not any nurse can insert a midline. The procedure requires specialized training and certification that goes beyond standard nursing education. Only nurses with advanced skills in vascular access, often certified as vascular access specialists, perform midline insertions.

Is putting in a midline a painful procedure?

The procedure is performed using a local anesthetic to numb the insertion site, which helps to minimize discomfort. Patients may feel a pinch or sting when the anesthetic is administered, but the actual catheter insertion should not be painful.

How is a midline different from a PICC line?

The key difference is the tip location. A midline's tip ends in a large vein below the armpit, whereas a PICC line's tip goes further, into the central venous system (the superior vena cava). This difference dictates which medications can be administered through the catheter.

How long can a midline stay in?

A midline catheter is typically used for intermediate-term intravenous therapy and can remain in place for approximately one to four weeks, depending on the patient's clinical needs and the integrity of the catheter.

Do I need a chest X-ray after a midline is inserted?

While it is standard practice to confirm the placement of a PICC line with a chest X-ray, it is not always required for a midline. However, some institutions may use imaging to confirm the tip is not located in a central vessel.

What kind of training is required to put in a midline?

Training typically involves a combination of didactic learning and hands-on practice. This includes understanding venous anatomy, mastering sterile technique, and proficiency in using ultrasound guidance for vein selection and visualization during insertion.

What is the primary reason for choosing a midline?

A midline is chosen when IV access is needed for a longer duration than a standard peripheral IV can provide, but the patient does not require the administration of medications (like chemotherapy or high-osmolarity fluids) that necessitate a central line.