PICC Line vs Central Line vs Midline: Essential Insights and Central Line Care for Nurses

Understanding the diverse central vascular access options available to nurses is paramount for ensuring effective patient care delivery. These access devices play a critical role in delivering medications and fluids, and obtaining blood samples, particularly in patients requiring long-term intravenous therapy.

Given the multitude of options: PICC line vs central line vs midline, nurses must possess a comprehensive understanding of each device’s strengths, limitations, and associated complications. This knowledge forms the foundation for making informed decisions regarding device selection tailored to individual patient needs.

An in-depth comparison of central vascular access options and adherence to standardized care guidelines is imperative for ensuring safe and effective patient care.

Understanding Vascular Access Lines

Central Line Care for Nurses

A central line is a catheter inserted into a major vein in the neck, chest, or groin. You can check out Wikipedia for the definition and also for accurate pictures of the different types of central lines. 

Patients in critical care often need them, but they might also keep them when they move to regular hospital rooms.

• These lines usually have 1-3 lumens/ports.
  • When a lumen/port is not in use, a “cap” is placed on the end of the tube. This creates a one-way valve and prevents blood leaks and bacteria from entering the lumen.
  • You give meds and take blood samples through these ports.
  • You must clean them well every time you use them. “Scrub the hub” means cleaning the cap thoroughly with an alcohol swab for 10-15 seconds. Joint Commission’s informational flyer on how to “Scrub the Hub”.
• Different sites for insertion include the subclavian, internal jugular, and femoral veins. Think of it as an extended IV, beginning outside the skin and terminating around the superior vena cava (SVC).
• If you’re unsure whether it’s truly a central line, review a chest X-ray to dertermine where the tip ends.
• It’s a direct line from the external environment to the patient’s heart, making infection a significant concern.

Can Nurses Place Central Lines?

Insertion is performed by a physician, a nurse with specialized training, or an advanced practice provider (PA, NP). Here is a video showing how one is inserted.

Common Uses Of Central Lines

Inserted for a variety of purposes, such as long-term antibiotic therapy, administration of vasoactive medications, total parenteral nutrition (TPN) infusion, monitoring central venous pressure (although newer, more precise technologies are available for this purpose), large-volume fluid administration, and other indications.

Also, central lines are great for drawing blood for laboratory testing, reducing the need for repeated venipunctures, which is convenient for both patients and staff, and for giving multiple medications at the same time.

Why are CVCs Needed for Vasoactive Meds?

Well, these lines reach right into the superior vena cava. And what’s right after that? Yup. The right atrium! The right atrium is packed with blood. So, when these meds go in through a central line, they get diluted immediately in a large amount of blood.

It’s not the size of the catheter that matters, but the fact that the meds get mixed with blood right off the bat makes it safe to give these meds through these lines.

Nuances of Care for Central Lines

These involve several key considerations for nurses:

1. Infection Prevention: Be Mr. Clean with central lines. This responsibility weighs heavily on nursing staff because while infections can stem from improper insertion, they are more often caused by insufficient care.
   • This is essential to minimize the risk of bloodstream infections. It includes proper hand hygiene, sterile draping, and site preparation with antiseptic agents.
2. Dressing Maintenance: You must ensure the dressing covering the central line site remains intact.
   • Dressings are typically changed every 7 days unless compromised. If the dressing is falling off, it puts the patient at risk of infection.
   • Check and document the dressing’s condition regularly, especially when receiving a report on a patient with a central line, to see if the dressing needs changing.
   • It’s important not to change the dressing every time the antibiotic patch gets slightly wet, as this increases the risk of infection by exposing the site unnecessarily.
   • Refer to your hospital’s policies and procedures for guidance on when to change the dressing before its scheduled time.
3. Check the Caps: Ensure that the caps are securely tightened. If one comes off unnoticed, it could lead to a significant spillage of blood on the bed.
4. Maintain Patency of the Line: To keep the line open and flowing smoothly, it needs to be flushed regularly with saline, often followed by a heparin flush if suitable for the patient. If you encounter difficulty flushing a port or find all lumens blocked, notify the doctor. They may prescribe a tPA/alteplase flush to dissolve the blockage, if appropriate, enabling you to resume using the port.
5. Ensure Blood Return Each Time Using the Catheter:  If there’s no blood return, it indicates a clot has formed at the catheter’s end. While you can still infuse fluids, the clot prevents blood withdrawal. This is concerning because the clot could dislodge and migrate. Refrain from using the catheter and promptly contact the MD or follow established policy in such cases.
6. Proper Removal of the Central Line: Never remove a central line with the patient sitting up. They must be lying flat to prevent the risk of an air embolism, which could lead to a code situation or even death. This precaution is crucial, as patients have died due to central line removal while sitting up, even just before discharge. Regardless of what your preceptor or floor practices may suggest, always prioritize patient safety by following this protocol. You can check this information to understand how important this is.

Also, you need to be familiar with your hospital’s policy. Seriously, know it inside out.

• Sample Hospital Policy Here

Complication Management

Nurses play a crucial role in monitoring for complications. The main complications are a collapsed lung (pneumothorax), a central line infection, and thrombus formation. 

1. Central line infection (CLABSI): CLABSI is one of the most serious complications associated with central lines. It occurs when bacteria or fungi colonize the catheter and enter the bloodstream, leading to systemic infection. Symptoms may include fever, chills, hypotension, and signs of sepsis. Management involves timely initiation of broad-spectrum antibiotics, removal of the infected catheter, if necessary, and implementation of infection control measures to prevent further spread.
   • Here is a useful resources about these: Strategies to Prevent Central Line-Associated Bloodstream Infections
2. Catheter-related Thrombosis: Thrombosis can occur within the central venous catheter or in the surrounding veins, leading to partial or complete occlusion of blood flow. Patients may present with swelling, pain, or discoloration of the affected limb. Management may include anticoagulant therapy, catheter removal in severe cases, and measures to promote venous patency, such as warm compresses and elevation of the affected limb.
3. Pneumothorax: Pneumothorax can occur as a complication of central line insertion, particularly when the subclavian or internal jugular veins are accessed. Nurses should monitor for signs of pneumothorax, such as dyspnea, chest pain, and diminished breath sounds on the affected side. Management may involve notifying the healthcare provider, obtaining a chest X-ray for confirmation, and implementing appropriate respiratory support measures.

In addition to these complications, nurses should also be vigilant for signs of local site infection, catheter migration, air embolism, and other potential issues associated with central lines. To learn more you can see my video regarding central line basics. 

PICC Lines

PICC lines (Peripherally Inserted Central Catheter) have become a mainstay in vascular access for patients requiring long-term intravenous (IV) therapy. Let’s delve into the specific situations where they shine, explore their advantages for extended treatment, and highlight key considerations for monitoring and maintenance.

Specific Indications for PICC Lines

• Long-term IV therapy: PICC lines are ideal for patients needing continuous or frequent IV medication administration over weeks to months. This can include:
  • Chemotherapy
  • Antibiotics
  • Parenteral nutrition (providing nutrients directly into the bloodstream)
  • Pain management medications
  • Blood product transfusions (in some cases)
• Difficult Peripheral Access: For patients with fragile or damaged veins in the arms or hands, PICC lines offer a reliable alternative to peripheral IVs, which are prone to complications and frequent replacements.
• Administering Incompatible Medications: Certain medications, like concentrated solutions or those irritating to peripheral veins, necessitate central access. PICC lines provide a safe and convenient option for such medications.

Advantages of PICC Lines for Long-term Treatment

• Durability: PICC lines are constructed with long-lasting materials, designed to withstand extended use. This minimizes the need for frequent replacements, reducing discomfort and potential complications associated with reinsertions.
• Reduced Risk of Phlebitis: Compared to peripheral IVs, PICC lines have a lower risk of phlebitis (inflammation of the vein). This is because the catheter tip is positioned in a larger central vein, minimizing irritation to the smaller peripheral veins.
• Improved Patient Mobility: PICC lines offer greater freedom of movement for patients compared to central lines. The insertion site in the arm allows for a wider range of motion and easier participation in daily activities.
• Ambulatory Care: PICC lines can be used for patients requiring outpatient treatment or those who need to be mobile within the healthcare facility.

Key Considerations for Monitoring and Maintenance

• Dressing Changes: PICC lines require regular dressing changes with aseptic technique to prevent infection. The frequency of changes depends on the facility’s protocol and the patient’s condition.
• Flushing: Maintaining catheter patency is crucial. Nurses flush the PICC line with appropriate solutions at prescribed intervals to prevent blood clots from forming within the catheter.
• Insertion Site Monitoring: Nurses vigilantly monitor the insertion site for signs of infection, such as redness, swelling, or drainage. Early detection and intervention are vital to prevent complications.
• Catheter Migration: Proper securement of PICC lines is important to prevent the catheter from slowing moving out of the vein. Regularly check to see that no length of catheter is extruding from the insertion site.
• Catheter Integrity: Regular checks for signs of damage or leakage are essential. A compromised catheter can lead to infection or malfunction.
• Patient Education: Educating patients on proper PICC line care, including signs of potential problems.

Midlines

A midline is a shorter catheter inserted into the arm by a specially trained nurse or advanced practice provider.

Essentially, a midline functions like a large IV, and the care and removal procedures are similar to those for a central line. However, certain medications like TPN or potent vasoactive drugs cannot be administered through a midline.

Midline’s Role in Patient Care

• Short-term to Intermediate-term Access: Midlines provide reliable access for patients requiring intravenous (IV) therapy for durations ranging from days to weeks. This timeframe is suitable for administering:
  • Antibiotics
  • Fluids and electrolytes
  • Blood products (in some cases)
  • Chemotherapy (depending on the medication)
• Reduced Risk Profile: Compared to central lines, midlines offer a lower risk of complications due to their placement above the central circulation. This translates to:
  • Lower risk of bloodstream infections
  • Less chance of pneumothorax (collapsed lung)
• Improved Patient Comfort: Midlines are generally more comfortable for patients than central lines due to their shallower placement. This can be particularly beneficial for patients with limited mobility or undergoing frequent position changes.

Ideal Situations for Midlines

• Patients needing IV therapy for a period exceeding peripheral IV access viability (typically lasting days) but not requiring long-term access like PICC lines.
• Situations where central line risks outweigh the benefits, such as patients with fragile veins or a high risk of bleeding.
• Administering compatible medications that are not concentrated or irritating to peripheral veins.

Management Differences

• Insertion: Midline insertion is a less invasive procedure compared to central lines, often requiring only local anesthesia. This can be performed by nurses with specialized training, depending on facility protocols.
• Catheter Care: Similar to PICC lines and central lines, midlines require meticulous daily care routines to prevent infection.
• Monitoring: Nurses play a crucial role in monitoring for signs of infection, such as redness, swelling, or fever, at the insertion site. Additionally, they monitor for malfunction or infiltration (leakage of medication outside the vein).
• Removal: Midline removal is a simpler procedure compared to central lines, typically requiring less specialized training for nurses.

Choosing the Right Line

PICC Line vs Central Line vs Midline

Feature	PICC line	Central Line	Midline
Insertion Site	Arm vein, threaded to a central vein	Large vein near the heart (subclavian, jugular, femoral)	Less invasive than central line, similar to PICC line
Insertion Procedure	Less invasive, often performed by interventional radiologists	Most invasive, typically by physicians using fluoroscopy	Less invasive than central line, similar to PICC line
Catheter Length	Longer than Midline catheter	Depends on insertion site location (IJ, SC, or Femoral) and type of catheter chosen	Shorter than PICC line
Duration of Use	Ideal for long-term therapies (weeks to months)	Short-term to long-term (days to months)	Short-term to intermediate-term (days to weeks)
Medication Compatibility	Wide range, including concentrated solutions	Widest range, including all medication types	Compatible with most medications except concentrated or irritating solutions
Advantages	Less invasive, good for long-term use	Highest flow rate, widest medication compatibility	Less invasive than central line, easier insertion than PICC line
Disadvantages	More complex insertion than midline	Most invasive, higher risk of complications	Less flow rate than central line, limited medication compatibility

Central Line vs Midline

The key difference between a central line and a midline lies in the catheter tip location. A central line reaches a large vein near the heart, while a midline terminates in a vein above the central circulation. This distinction impacts:

• Medication Compatibility: Central lines can handle a wider range, including concentrated solutions, which can otherwise damage peripheral veins.
• Flow Rate: Central lines offer the highest flow rate for rapid fluid resuscitation or blood product administration.
• Risk of Complications: Central lines carry a higher risk of complications due to their deeper placement.

The decision hinges on several factors:

• Treatment Duration: PICC lines excel for long-term needs, while midlines are suited for shorter durations.
• Medication Type: Concentrated solutions or those irritating to peripheral veins necessitate central or PICC lines.
• Patient Factors: Mobility and vein health influence the choice.

Central Line Care: Best Practices for Nurses

Nurses play a critical role in implementing best practices for central line care. Here are some of those best practices:

• Remove central lines as soon as they’re no longer necessary; only use them when absolutely needed.
• Inspect the dressing regularly and change it every 7 days—or as per policy—to reduce infection risks associated with frequent changes.
• Consider using antimicrobial patches at the insertion site.
• Replace caps when drawing blood.
• Check if gauze covering the insertion site can be changed before 7 days if policy allows, as it may hinder visibility.
• Thoroughly clean the hub by scrubbing it for 10 – 15 seconds before accessing or using caps.
• Use new IV tubing when a new central line has been inserted; don’t connect older tubing to a new central line.
• Educate patients and their families on infection risks and encourage them to avoid touching the line. Instruct them to report any pain, tenderness, or redness.
• Discontinue according to policy.
  • Ensure the patient lies flat during removal.
  • Stop if you encounter resistance while pulling.
• General IV care:
  • Label tubing.
  • Know the recommended tubing change frequency; typically, it’s every 72-96 hours for continuous use and 24 hours for intermittent use.
  • Change tubing and fluid bags before shift changes if necessary.
  • Ensure patients have adequate tubing and full bags before shift changes as a courtesy.

Procedural Focus: Safe Removal Practices

Safe central venous catheter removal is crucial to prevent complications such as air embolism and ensure patient safety.

How to Remove a Central Line

1. Preparation:
   • Gather all necessary equipment, including sterile gloves, antiseptic solution, sterile dressings, and suture removal kit if applicable.
   • Verify the patient’s identity and ensure informed consent for the procedure.
   • Position the patient lying flat to minimize the risk of air embolism.
2. Dressing Removal:
   • Remove the dressing covering the central line insertion site carefully, taking care not to dislodge the catheter or introduce contaminants.
   • Cleanse the area around the insertion site with an antiseptic solution and allow it to dry.
3. Catheter Removal:
   • Ensure the patient is lying flat and adequately sedated if necessary.
   • Remove securement device or clip the sutures if applicable.
   • With one hand, stabilize the catheter at the insertion site to prevent movement.
   • With the other hand, gently remove the catheter using a slow, steady motion.
   • Instruct the patient to take a deep breath and hold it (Valsalva maneuver) and remove the catheter while the patient is holding their breath. Doing this during catheter removal will reduce the risk of air embolism.
   • Apply pressure to the insertion site immediately after catheter removal to minimize bleeding.
   • Don’t forget to tell the patient to breathe once pressure is applied to the insertion site.
4. Inspection and Documentation:
   • Inspect the catheter tip for intactness and completeness to ensure no fragments remain in the vein.
   • Assess the insertion site for signs of bleeding, hematoma, or other complications.
   • Document the procedure, including the date, time, catheter type, length, and condition upon removal.
   • Monitor the patient closely for signs of air embolism during and after catheter removal, such as dyspnea, chest pain, and altered mental status.
   • Promptly notify the healthcare provider if signs of air embolism or other complications occur and initiate appropriate interventions.

Nursing Responsibilities and Education

The nurse’s role in vascular access device management encompasses various responsibilities, starting from the initial selection and insertion process to ongoing care, monitoring, and patient education:

1. Selection: Nurses collaborate with the healthcare team to assess patient needs and determine the most appropriate vascular access device based on factors such as treatment requirements, duration, and patient preferences.
2. Insertion: Nurses with specialized training may be responsible for inserting certain vascular access devices, such as peripherally inserted central catheters or midlines, ensuring proper technique and adherence to infection control protocols.
3. Care: Nurses are responsible for maintaining the integrity and function of vascular access devices by following established care protocols, including dressing changes, flushing, and catheter patency assessment.
4. Monitoring: Nurses regularly monitor vascular access sites for signs of complications such as infection, thrombosis, or catheter malfunction. Timely recognition and intervention are essential to prevent adverse outcomes.
5. Patient and Family Education: Nurses play a crucial role in educating patients and their families about vascular access device care, including proper hygiene, signs of complications, and steps to take in case of emergency. Empowering patients with knowledge helps promote self-care and reduces the risk of complications.

Final Thoughts

Understanding the nuances of central line care for nurses is an essential skill. Selecting the right device for each patient hinges on factors like treatment duration, medication compatibility, and individual needs. PICC lines excel in long-term care, central lines reign supreme for critical situations and medication versatility, while midlines provide a less invasive option for shorter durations. This knowledge empowers you to confidently navigate these vascular access decisions, paving the way for optimal patient outcomes.

Nurses are the cornerstone of safe and competent vascular access management. Your expertise spans the entire process. You’ll collaborate in device selection, meticulously implementing daily care routines, vigilantly monitoring for complications, and educating patients on proper care. By mastering these aspects, you become an irreplaceable contributor to your patient’s well-being.

More Resources

1. New ICU Nurse Master List – Medications, Skills, Procedures, Diagnostics and Diagnoses
2. Medication Administration for Nurses & Nursing Students
3. Mastering CVP Monitoring: Setup, Understanding, and Best Practices