2021 Update: What are considerations for determining whether a drug may be administered via a midline catheter? | Drug Information Group (2023)

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Midline catheters represent a unique vascular access device (VAD) for patients requiring intravenous (IV) administration of drugs or other infusates.1,2After their introduction in the 1950s, hypersensitivity and phlebitis reactions to the manufacturing materials led to a temporary decline in the use of midline catheters through the 1990s; however, a redesign of these products in recent years has led to their renewed adoption. Midline catheters have properties that differ from both those of traditional peripheral IV catheters and central venous catheters (CVCs). Therefore, questions often arise regarding the appropriateness of administering specific drugs via midline catheter. This review provides an overview of midline catheters and a summary of properties that influence the determination of whether a drug is appropriate for administration via midline catheter.

Properties of midline catheters
Midline catheters differ from other VADs with regard to their insertion and termination sites.1,3Midline catheters are inserted peripherally into the antecubital fossa or upper arm via the basilic, cephalic, or brachial vein, and extend from 8 to 20 cm centrally, where the catheter tip terminates at or below the axillary vein. Because this termination site is distal to those of CVCs and peripherally inserted central catheters (PICCs), midline catheters are not considered to dwell in the central circulation.1Whereas the central termination site of CVCs and PICCs provide the ability to administer a wider range of infusates (eg, vesicants), this is not recommended with VADs terminating distal to the central circulation. Central VADs may also be more appropriate in patients needing longer-term therapy.3 Although some evidence has supported lower thrombosis risk with midline catheters compared with CVCs,1 a recent systematic review of 12 studies in 40,871 patients found that risk of venous thromboembolism was significantly higher with a midline catheter compared with a PICC (3.97% versus 2.29%; relative risk, 1.53; 95% CI, 1.33 to 1.76; p<0.00001).4 However, evidence evaluating the risk of catheter-related bloodstream infections (CRBSI) continues to find similar or improved rates of infection with midline catheters compared with PICCs.5

(Video) What is a peripherally inserted central catheter?

Compared with midline catheters, peripheral IV catheters are inserted more distally and most often utilize veins of the dorsum of the hand for cannulation.1-3Peripheral IV catheters have high first-attempt failure rates (26% in adults, 54% in children) and often require recannulation in larger more proximal sites.1,2Therefore, midline catheters may reduce the need for recannulation and thereby afford a longer dwell time. Additionally, patient mobility is greater with midline catheters because of the location of their insertion site.2 Lastly, compared with drug administration via peripheral IV catheter, the risk of phlebitis may be reduced with administration via midline catheter because of its termination in an area with a higher rate of blood flow.2The rates of CRBSI have also been reported to be lower with midline versus peripheral catheters (0 to 0.2 versus 0.5 per 1,000 catheter days).1

Overall, the properties of midline catheters may make them preferable for specific durations of therapy. In 2021 the Infusion Nurses Society (INS) updated their 2016 guidelines and recommended consideration of midline catheters when the anticipated duration of therapy was 5 to 14 days with a preference for peripheral catheters for shorter durations of therapy and CVCs when longer durations of therapy are required.6 A recent study supports use of midline catheters for prolonged courses of therapy up to 14 days, but there remains limited data for use of midline catheters beyond 2 weeks.7 Currently, the CDC recommends consideration of midline catheters when the duration of IV therapy is likely to exceed 6 days.1,8

Considerations for drugs administered via midline catheter
The main consideration in determining whether a drug is appropriate for administration via midline catheter is its propensity for causing phlebitis.2Phlebitis is inflammation of a vein caused by damage to the tunica intima, which may be accompanied by erythema, swelling, pain, heat, and a palpable cord if thrombosis is present.If chemical phlebitis occurs, consideration should be given to the need for alternative vascular access, an alternative medication, a slower infusion rate, or further dilution of the medication.6

Chemical phlebitis may be caused by drugs that irritate the vasculature, usually because of extremes of pH or osmolarity.3Infusates with an osmolarity over 600 mOsm/L are associated with symptoms when extravasation occurs, and those over 800 mOsm/L are usually recommended to be given via a CVAD.9 Infusates with a pH between below 5.5 or above 8.5 can cause tissue damage, with alkaline agents generally producing worse toxicity than acidic agents.The 2021 INS guidelines recommend against the use of midline catheters for continuous administration of vesicant therapy, parenteral nutrition, or other infusates with “extremes” of pH or osmolarity.6 Although the “extremes” are not further defined, the guidelines specifically recommend central lines for parenteral nutrition formulas with osmolarity exceeding 900 mOsm/L.Lastly, they recommend avoidance of midline catheters in patients with a history of thrombosis, hypercoagulability, venous stasis, or with a need to preserve vein integrity, such as in patients with end-stage renal disease.

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There is not a comprehensive list of drugs that are appropriate for administration via midline catheter. Clinicians considering drug administration via this VAD should review the chemical properties of the drug under consideration from reputable resources (eg, prescribing information) to compare them with the guidance above. Nonetheless, a review of literature of known vesicants and drugs reported to cause vascular injury or extravasation indicates some drugs that may present higher risk when administered via midline catheter. For example, many cytotoxic agents (ie, chemotherapy) are considered vesicants and should not be administered via midline catheters according to INS standards.10,11Additionally, in 2017, the INS assigned a Vesicant Task Force to publish a list of noncytotoxic vesicant medications and solutions.11The Table below, while not exhaustive, details drugs from this list, as well as drugs that have extremes of pH or osmolarity that have been associated with vascular injury or extravasation.8,9

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Table. Noncytotoxic vesicants and drugs with extremes of pH or osmolarity reported to cause vascular injury or extravasation.3,6,9,11,12
Noncytotoxic vesicants
Hyperosmolar agents
Acidic and alkaline agents
Risk levela
Calcium chloride 10%
Calcium gluconate
Varies by concentration
Calcium chloride
Contrast media
Calcium gluconate
Dextrose 10%-50%
Contrast media, nonionic
Diazepam 0.5%
Dextrose ≥10%-12.5%
Hypertonic saline
Varies by concentration
Dextrose ≥12.5%
Magnesium sulfate 15%-50%
Mannitol 20%
Potassium ≥60 mEq/L
Mannitol ≥20%
Sodium bicarbonate 8.4%
Nafcillin sodium
Commonly >900

Pentamidine isethionate

Sodium thiopental
Pentobarbital sodium

Phenobarbital sodium


Potassium ≥60 mEq/L
Sodium bicarbonate
Sodium chloride ≥3%
TPN >900 mOsm
aRisk level was assigned based on literature reports of peripheral administration. Risk level of red indicates higher risk and greater literature documenting tissue damage upon extravasation. Risk level of yellow indicates intermediate risk and less literature documenting tissue damage upon extravasation.
bOsmolarity varies. For further information, see American College of Radiology guideline.13
Abbreviations: NR=not reported; TPN=total parenteral nutrition.

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One drug that has generated controversy regarding its appropriateness for administration via midline catheter is vancomycin.Based on the range of pH values generally considered appropriate for midline administration, vancomycin would be excluded because of its pH of 4. However, the INS Task Force identified limited literature describing extravasation of vancomycin. Furthermore, in vitro evidence suggested that vancomycin-associated endothelial damage is caused by factors other than pH. Additionally, the risk of cytotoxicity is reduced by intermittent compared with continuous infusion, as well as by dilution of vancomycin to concentrations of 2 to 5 mg/mL. One randomized controlled trial found that the incidence of total complications, phlebitis, and thrombosis did not significantly differ when vancomycin was administered for less than 6 days via midline catheter versus PICC.3,14

Midline catheters have properties unique from those of peripheral and central VADs. Determinations regarding the administration of drugs via midline catheter should consider properties of each drug individually because no definitive guidance is available to list the appropriateness of all drugs. Generally, drugs that are vesicants or have extremes of pH or osmolarity should not be administered via midline catheters.


  1. Adams DZ, Little A, Vinsant C, Khandelwal S. The midline catheter: A clinical review.J Emerg Med. 2016;51(3):252-258. doi:10.1016/j.jemermed.2016.05.029
  2. Griffiths V. Midline catheters: indications, complications and maintenance.Nurs Stand. 2007;22(11):48-58. doi:10.7748/ns2007.
  3. Gorski L, Hadaway L, Hagle ME, McGoldrick M, Orr M, Doellman D. Infusion therapy standards of practice.J Infusion Nurs.2016;39(1S):S1-159.
  4. Lu H, Yang Q, Yang L, et al. The risk of venous thromboembolism associated with midline catheters compared with peripherally inserted central catheters: A systematic review and meta-analysis [published online ahead of print, 2021 May 15].Nurs Open. 2021;10.1002/nop2.935. doi:10.1002/nop2.935
  5. Lu H, Hou Y, Chen J, et al. Risk of catheter-related bloodstream infection associated with midline catheters compared with peripherally inserted central catheters: A meta-analysis [published online ahead of print, 2020 Dec 29].Nurs Open. 2020;8(3):1292-1300. doi:10.1002/nop2.746
  6. Gorski LA, Hadaway L, Hagle ME, et al. Infusion therapy standards of practice. J Infus Nurs. 2021;44(suppl 1):S1-S224. doi:10.1097/NAN.0000000000000396
  7. Seo H, Altshuler D, Dubrovskaya Y, et al. The safety of midline catheters for intravenous therapy at a large academic medical center.Ann Pharmacother. 2020;54(3):232-238. doi:10.1177/1060028019878794
  8. Intravascular catheter-related infection (BSI). Centers for Disease Control and Prevention. Updated July 2017. Accessed August 2, 2021. https://www.cdc.gov/infectioncontrol/guidelines/BSI/index.html
  9. David V, Christou N, Etienne P, et al. Extravasation of noncytotoxic drugs.Ann Pharmacother. 2020;54(8):804-814. doi:10.1177/1060028020903406
  10. Boulanger J, Ducharme A, Dufour A, et al. Management of the extravasation of anti-neoplastic agents.Support Care Cancer. 2015;23(5):1459-1471. doi:10.1007/s00520-015-2635-7
  11. Gorski LA, Stranz M, Cook LS, et al. Development of an evidence-based list of noncytotoxic vesicant medications and solutions.J Infus Nurs. 2017;40(1):26-40. doi:10.1097/NAN.0000000000000202
  12. Reynolds PM, MacLaren R, Mueller SW, Fish DN, Kiser TH. Management of extravasation injuries: a focused evaluation of noncytotoxic medications.Pharmacotherapy. 2014;34(6):617-632. doi:10.1002/phar.1396
  13. ACR Committee on Drugs and Contrast Media. ACR manual on contrast media. American College of Radiology. Updated January 2021. Accessed August 2, 2021. https://www.acr.org/-/media/ACR/Files/Clinical-Resources/Contrast_Media.pdf
  14. Caparas JV, Hu JP. Safe administration of vancomycin through a novel midline catheter: a randomized, prospective clinical trial.J Vasc Access. 2014;15(4):251-256. doi:10.5301/jva.5000220

Prepared by:
Ryan Rodriguez, PharmD, BCPS
Clinical Associate Professor, Drug Information Specialist

(Video) Peripherally inserted central catheter (PICC) removal; Revised: August 20, 2020

January 2018

Updated by:
Courtney Krueger, PharmD, BCPS
Clinical Assistant Professor, Drug Information Specialist
University of Illinois at Chicago College of Pharmacy

September 2021

The information presented is current as of August 2, 2021. This information is intended as an educational piece and should not be used as the sole source for clinical decision making.

(Video) What Care & Maintenance is Required of a Midline?


When is an indication for a midline catheter? ›

Midline catheters are appropriate for patients who need I.V. therapy for more than 5 but fewer than 28 days, so the typical medical/surgical patient hospitalized for less than 5 days probably isn't a good candidate for midline placement.

What drugs can be given via midline? ›

The most common medications infused through midline were electro- lytes (ie, magnesium, potassium), vancomycin, and cepha- losporins.

How do you confirm midline placement? ›

Midline Catheter Placement is usually performed using an Ultrasound as a reliable way to view and guide the needle.

Can you push meds through a midline? ›

A midline is used to give medications or fluids through a vein. Midlines can stay in place for several weeks and can meet short term intravenous requirements at home.

What is a common complication of a midline catheter? ›

Most important peripherally inserted central catheter (PICC) and Midline complications are thrombosis and catheter related blood stream infections.

Why use a midline instead of a PICC? ›

Conclusions and Relevance In this cohort study among patients with placement of midline catheters vs PICCs for short-term indications, midlines were associated with a lower risk of bloodstream infection and occlusion compared with PICCs.

Can you give fluids through midline? ›

A midline catheter is a small, thin tube that is inserted into a vein in the upper arm or at the bend in the elbow. A midline catheter may be used to give IV fluids or nutrients, give medicines, draw blood, give blood back to the body, inject a dye for a CT scan, or provide IV access for treatment that lasts 1–4 weeks.

Can a nurse pull a midline? ›

Removal of a midline/PICC catheter shall be performed by an RN on the order of the physician.

Is a midline catheter considered a central line? ›

While a PICC is a Central Venous Catheter Line and a Midline is not a Central Venous Catheter Line, the care and maintenance of each is approximately the same as each has an external component covered by a sterile dressing.

What is the difference between a midline catheter and a PICC line? ›

The only difference between a midline catheter and a PICC is the length of the catheter. A midline catheter is about half the length of a PICC and so the end of a midline catheter lies within a vein close to your shoulder. Your doctor or nurse will explain how to use your IV catheter at home.

How can you tell if its a midline or a PICC line? ›

A PICC catheter is applied through a vein located in one arm. This is then guided along the larger vein to your chest. On the other hand, a midline catheter is inserted through the upper arm or the elbow region. PICC lines are longer than midline because of the regions that they pass through.

Why do you need a midline? ›

A midline (also called a midline catheter) is a long, thin, flexible tube that is inserted into a large vein in the upper arm. It is used to safely administer medication into the bloodstream, similar to a cannula (a small tube that is inserted into a vein, usually in the back of your hand or arm).

What is the difference between A midline catheter and a central line? ›

In the case of midlines, position tip does not need to be confirmed as the catheter tip is positioned in a peripheral vein. The PICC is a peripherally inserted central venous catheter meaning that it enters a peripheral vein in the arm but the tip terminates centrally near the heart.


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