Jeffrey R. Davis P.A., a Miami Medical Malpractice law firm, handles cases involving injuries from peripheral intravenous devices, mid-lines, central catheters, ports and other catheters. Jeffrey R. Davis has handled medical malpractice cases in Miami-Dade County, Broward County, West Palm Beach County, Monroe County and throughout Florida.
There are many different types of procedures for health-care providers to obtain vascular access to administer drugs, medications and other solutions. Intravenous devices are also utilized to draw blood and other fluids. Although routine in clinical practice, these procedures and devices require use by a skilled health-care provider in order to avoid injury, infection and other serious complications.
Jeffrey R. Davis, P.A. has handled many cases involving injuries and illness caused by errors in the use and management of these devices. Our firm has assisted clients who have developed infections, suffered nerve injuries, developed hematomas, blood clots and other significant injuries from mismanagement, medical errors and untrained personnel utilizing intravenous devices and catheters.
A brief summary of these various devices and their purposes may be of assistance:
Peripheral Intravenous Device (PIV)
A peripheral intravenous device is typically used for short-term intravenous therapy lasting less than 5 days. Mostly, PIVs are utilized for receiving isotonic solutions and medications with non-irritant properties. The healthcare provider utilizing a PIV must be aware of contra-indications for use such as:
• Localized area of skin excoriation
• Localized edema
• Previous vein puncture site.
There are vein selection considerations the health-care professional must recognize. Additionally, different vessels have different flow rates. Typically, a small vessel such as those found in the hands may flow at 10ml per minute. A large vessel like the superior vena cava may flow as fast as 2,000 ml per minute. These are just some of the various issues that your health-care provider must identify before utilizing a peripheral intravenous device.
There are specific techniques for a PIV insertion. Improper insertions can cause a multitude of complications including infiltration, phlebitis, infection, extravasations and others. It is essential that the health-care provider utilizing a PIV be familiar with these complications and identify them as soon as is practicable.
• Thrombosis (mural thrombus, intraluminal thrombus, peri-catheter thrombus, total venous thrombus)
• Phlebitis (mechanical, chemical)
• Local infection
• Venous spasm
• Air embolism
• Catheter embolism
Mid-lines are usually indicated for short-term IV therapy lasting less than 4 weeks. Oftentimes, mid-lines are needed where a patient has poor venous access or has had frequent lab draws. The solutions and medications used in mid-lines are similar to that of peripheral intravenous devices.
A mid-line is a narrow, short flexible tube that is typically inserted into the cephalic vein below the axillary vein or the basilic vein. The catheter is either made of silicone or polyurethane. It can be either dual lumen or single lumen. In use, the catheter tip should be distal to the shoulder and deltoid muscle.
Some of the uses of mid-lines include lab draws, pain control, anti-microbial agents, multiple medication administration, obese patients, diabetic patients and patients with low platelet counts.
The advantages of a mid-line are that it can be inserted at bedside, it comes with low insertion risks, it is a low-cost device and can be used for home infusions. The disadvantages of mid-lines are it cannot be used for TPN, medications and solutions with an extreme PH and/or osmolality or for continuous vesicant therapy. Mid-lines require the same maintenance and management as PIVs and come with the same complications.
Peripherally Inserted Central Catheters (PICC)
A PICC line is a long, flexible, narrow tube that is inserted into an appropriate vessel. As long as it is properly cared for, it can remain in place indefinitely. The tip is threaded through an appropriate vein to either the superior or inferior vena cava. It can be used for the administration of hyperosmolar, irritants or vesicant medications.
The advantages of a PICC line is that it does not require surgery to place, it is a reliable venous access for the duration of the therapy, the patient does not need more veni-puncture for IV starts, most lab work can be drawn from the PICC line and it does not have the risk that placement of other types of CVC devices have such as the collapse or puncture of the lung or major blood vessels or the nerves in the chest.
PICC lines do have significant risks; these include, but are not limited to,
1. Risk of clotting the access vein (thrombosis)
2. The catheter itself can clot off or it can move into an unintended vein with vigorous movement or coughing
3. Catheter leakage or breakage
4. Risk of infection, usually due to the underlying treatment or disease
5. Risk of unintended injury in nerve or surrounding structures during placement
PICC lines must be placed by a nurse or other healthcare provider that is specifically trained in the use of this device. There are significant PICC considerations that begin with selecting a vein for catheter placement. Things that are commonly used are both superficial veins and deep veins such as the cephalic, basilic, external jugular, axillary, femoral and popliteal.
Like PIVs, there are contra-indications for use of a vein that must be addressed. A skilled PICC line inserter must be extremely familiar with the viscosity of fluid to be used in the PICC line. It is essential that manufacturers’ recommendations be addressed during the use and placement of a PICC line. PICCs range in catheter size as well. Catheters are designated by French or gauge and range in size from 1.1 or 28 gauge to 6 French dual or triple lumen or 18 gauge. There are various catheter materials as well. They include durathane, polyurethane and silicone. There are also different types of PICCs including open vs. closed tip, Groshong catheters.
PICC lines are typically introduced utilizing ultrasound.
This brief article is not designed to address or cover the comprehensive and voluminous considerations that accompany use of a PICC line. PICC lines have a significant array of complications relating to insertion, catheter mal-position, difficulty with removing the stylette, bleeding, hematoma, arterial puncture, cardiac dysrhythmias, nerve injury and damage, nerve irritation, catheter embolism, air embolism and others. Typically PICC lines require radiographic confirmation and placement. There is also a whole host of maintenance and management issues associated with PICC lines including flushing, lab draws, removal, repair, exchange, PICC line dressing change and others. Lastly, there are post-insertion complications associated with PICC lines such as drainage, phlebitis, cellulitis, thrombosis and others. Unlike other peripherally inserted devices, PICC lines have significant potential fatal complications which are rare, but include, pericardial perforation, tamponade, plural effusion, hydrothorax, hemothorax.
An implanted port is thin device that consists of two parts; the catheter and the port. Ports are popular for use in oncology patients. They can remain in a patient for years. Ports can be used for the administration of various types of medications and for lab draws. The components of an implanted port are a soft flexible tube that is inserted into a vein in the chest or arm and has an opening/access just under the skin.
Implanted ports are used for patients that have active lifestyles. Patients that swim or participate in sports are an example. They require lower maintenance than other access systems and are used for longer term indications. Additionally, these lines are more discrete than other types of central lines and also cost less to maintain. They provide the lowest risk for infection of all central venous catheter types. The disadvantages of a port are they must be surgically inserted and removed and the patient still must endure needle sticks. The risks associated with implanted ports include infection (either in or around the port), risk of clotting (both in the vein in or around the catheter), risk of pneumothorax and risk of separation of the port and the catheter.
Ports do require some maintenance and management including flushing, de-clotting, accessing the port, de-accessing the port and eventually removing the port. Ports also have post-insertion complications that should be contemplated.
Another device used for surgical procedures is a tunneled catheter. A tunneled catheter is a flexible, soft, plastic tube that is inserted and tunneled under the skin (usually on the chest, groin, neck or abdominal area into the venous system). Tunneled catheters carry the risk of life threatening air embolism if they break or become damaged. In fact, patients with tunneled catheters should always carry with them a pair of hemostats.
The advantages of a tunneled catheter are no more vena punctures for PIV starts, most lab work can be drawn from the line, they are a reliable source of access for the duration of therapy and the device can usually be covered by clothing. The disadvantages of a tunneled catheter are that they are surgically inserted and removed, there is a risk of infection, there is a risk of the catheter moving from proper position if it is pulled on and there is a risk of hemothorax or puncture of a major blood vessel or nerve in the chest when inserting the line.
There are also non-tunneled catheters which are directly inserted into an appropriate vein and is used for short-term access (less than 2 weeks). Non-tunneled catheters do not require surgery. Unfortunately, this type of catheter has the highest infection rate of all central venous insertion devices.
Hopefully this short article has provided some basic information about catheters, the various types available and the advantages and disadvantages associated with each. If you suspect that you have become injured or have suffered damage following the insertion or use of any of these devices, you should immediately contact your physician for further advice. The law firm of Jeffrey R. Davis, P.A. is available to discuss these types of cases and has worked with highly trained experts in the field of phlebotomy, nursing and vascular surgery to review and advise on catheter related cases.