Midline catheters (MCs), also known as medium-length catheters, are emerging, cost-effective, and safe peripheral intravenous devices. Currently, several international societies have published guidelines or consensus statements to guide clinical vascular access practices; however, there are relatively few recommendations specifically addressing midline catheters, particularly regarding catheter occlusion.
To identify the best evidence for the prevention of midline catheter occlusion, this study systematically reviewed domestic and international literature related to adult midline catheters, summarized the evidence on occlusion prevention, and conducted expert panel discussions for validation. The aim is to provide reliable evidence-based support for developing adult midline catheter occlusion prevention strategies and to promote the standardized clinical application of midline catheters.
This study summarized 48 pieces of best evidence for preventing adult midline catheter occlusion across nine domains:
1. Catheter occlusion recognition
2. Risk assessment
3. Catheter insertion
4. Accessory selection
5. Catheter tip positioning
6. Catheter securement
7. Flushing and locking
8. Patient education
9. Organizational policies
Table 3 Summary of the Best Evidence for the Prevention of Midline Catheter Occlusion
Evidence Theme |
Evidence Content |
Evidence Level |
Recommendation Grade |
Catheter Occlusion Recognition |
1. Recognize the manifestations of partial or complete catheter occlusion: inability to aspirate blood return or slow blood return; slow infusion rate; inability to flush or unsmooth infusion; frequent occlusion alarms of the infusion pump; exudation, swelling or leakage at the infusion site. [7] |
Level 5 |
A |
Risk Assessment |
2. Assess whether the patient has risk factors for catheter occlusion: a history of deep vein thrombosis or a family history; patients undergoing high - risk surgery for deep vein thromboembolism and complex trauma patients; patients with coagulation disorders; patients in pregnancy or taking oral contraceptives; abnormal catheter insertion history; having other catheter - related complications. [9] |
Level 5 |
A |
3. Assess the patient's treatment plan: the type, nature, dose, frequency, duration, infusion method and infusion risk of infused drugs and blood products, as well as different drug interaction schemes. Do not use midline catheters for continuous ambulatory peritoneal dialysis (CAPD) treatment, enteral nutrition, drugs with extreme pH or osmotic pressure for infusion. [6] |
Level 1 |
A |
|
4. When flushing with irritating and foaming agents, the catheter should be locked by positive pressure. [6] |
Level 1 |
B |
|
5. When evaluating the vascular anatomy before catheterization, vascular visualization technology should be used to identify whether there are abnormalities (such as occlusion or thrombus formation) in the blood vessel. [6] |
Level 1 |
A |
|
6. Evaluate the diameter of the blood vessel before catheterization, measure the ratio of the catheter to the blood vessel (< 45%), and choose the device with the smallest outer diameter, the least number of lumens, and the least trauma. [6] |
Level 1 |
A |
|
Catheter Insertion |
7. After catheterization, assess the integrity of the local skin at the puncture site at least once a day, check for signs of inflammation such as redness, swelling, heat, and pain, and whether the circumferences of the upper arms on both sides are consistent. [6] |
Level 1 |
A |
8. It is recommended to assess the function of the catheter at least once a day after catheterization to identify the risk of catheter occlusion. [6] |
Level 1 |
A |
|
9. It is recommended that catheter insertion be performed by trained and qualified professionals. [6] |
Level 1 |
A |
|
10. The preferred puncture site is the upper arm, followed by the antecubital fossa area, and the area 1/3 between the antecubital fossa and the axilla is the best. [7] |
Level 4 |
A |
|
11. Catheterization should be performed through the basilic vein, cephalic vein or brachial vein, and the basilic vein is the best. [6] |
Level 5 |
A |
|
12. When puncturing, the following areas should be avoided: areas that are painful on palpation; areas with open wounds; infected areas; damaged blood vessels and areas planned for surgery. [6] |
Level 5 |
A |
|
13. Avoid catheterization in the areas of breast surgery, lymph node dissection or edema, hemiplegia, areas with dialysis fistulas or transplant flaps. [6] |
Level 1 |
B |
|
14. For patients with poor vascular conditions, it is recommended to use vascular visualization technology to assist in vein identification and selection. [6] |
Level 1 |
A |
|
15. It is recommended to use modified Seldinger technique or modified Seldinger technique for catheterization. [6] |
Level 5 |
A |
|
16. It is recommended to choose catheters made of polyurethane and silicone materials. [6] |
Level 1 |
B |
|
17. It is recommended to use needle - free positive pressure or positive pressure needle - free infusion connectors. [7] |
Level 1 |
A |
|
18. The frequency of needle - free infusion connector replacement is generally ≥ 96 h. [6] |
Level 5 |
A |
|
19. Timing of needle - free infusion connector replacement: when removed for any reason; when there is residual blood or other residue;before blood sampling for blood culture; when it is determined to be contaminated; in accordance with organizational policies, practice guidelines, and product instructions. [6] |
Level 4 |
A |
|
Tip Position |
20. Avoid using needle - free infusion connectors for rapid infusion of crystalloid solutions and red blood cells. [6] |
Level 1 |
B |
21. Ensure that the tip position of the catheter is correct. Use body surface measurement to predict the length from the puncture point to the tip of the catheter and record it. [7] |
Level 4 |
B |
|
22. When the patient is transferred from other medical institutions, it is necessary to assess the tip position of the catheter; check for resistance during blood aspiration and flushing; check whether the exposed length is consistent with the record at the time of catheterization. [6] |
Level 1 |
B |
|
Catheter Fixation |
23. The appropriate fixation method should be selected according to the patient's age, the integrity of the skin at the puncture site, whether there is swelling or exudation, etc. [6] |
Level 4 |
A |
24. It is recommended to use a catheter fixation device to fix the catheter, and avoid using sutures and non - sterile tape. [6] |
Level 1 |
A |
Evidence Theme |
Evidence Content |
Evidence Level |
Recommendation Grade |
Flushing and Locking |
25. Timing of flushing: Before and after medication administration; after blood collection; before and after transfusion of blood products; when switching from continuous therapy to intermittent therapy; before and after intermittent therapy sessions [6]. |
Level 1 |
A |
26. Adopt pulse - style flushing and positive - pressure locking techniques [6]. |
Level 1 |
A |
|
27. If there is resistance during flushing or no blood return upon aspiration, do not forcefully inject [9]. |
Level 1 |
B |
|
28. Use sterile normal saline for flushing before and after intravenous bolus injection of drugs. If incompatibility exists, first use 5% dextrose solution, then normal saline for flushing [6]. |
Level 1 |
A |
|
29. If heparinized saline is used for locking, aspirate the residual heparinized saline in the catheter before re - administration [3]. |
Level 1 |
A |
|
30. When using antimicrobial locking solution, enhance monitoring of catheter function [6]. |
Level 1 |
B |
|
31. Flushing devices: Recommend using a 10 - mL pre - filled catheter flusher or a syringe with a larger diameter for flushing; infusion bags or bottles must not be used [7]. |
Level 1 |
A |
|
32. Flushing volume: When selecting the flushing volume, consider catheter type/size, patient age, and infusion therapy type. The recommended minimum volume is twice the internal volume of the catheter system (e.g., catheter + additional devices). At least 5 mL of 0.9% sodium chloride solution should be used for flushing. Increase the flushing volume after infusing blood components, parenteral nutrition, contrast agents, or other viscous solutions [6]. |
Level 1 |
A |
|
Flushing and Locking |
33. For catheters not in temporary use, flush at least once every 24 hours [9]. |
Level 4 |
A |
34. Clamp the catheter and disconnect the syringe according to the manufacturer’s instructions. If no instructions are available, proceed by infusion connector type: a. Negative pressure – flush, clamp, disconnect; b. Positive pressure – flush, disconnect, clamp; c. Constant pressure – no specific sequence required [16]. |
Level 1 |
A |
|
Patient Education |
35. Assess patients’ and caregivers’ cognitive, communication, and learning abilities; develop personalized health education plans; and implement education through multiple channels [4]. |
Level 1 |
B |
36. Patient education content should include: Restrictions on daily activities with the catheter, catheter maintenance methods/precautions, complication prevention, clinical indicators requiring reporting, how to report, and where to report [7]. |
Level 3 |
A |
|
37. Encourage non - pharmacological measures to prevent thrombotic catheter occlusion (e.g., early mobilization of the catheterized limb, adequate fluid intake) [8,18]. |
Level 1 |
A |
|
38. When performing other nursing activities, instruct patients to protect the vascular access device and additional devices [6]. |
Level 4 |
A |
|
39. Encourage patients to report any catheter - related discomfort to professionals [5]. |
Level 1 |
A |
|
40. Periodically evaluate the effectiveness of health education for patients and caregivers [9]. |
Level 5 |
B |
|
Organizational Policies |
41. Health authorities at all levels should develop policies for intravenous therapy [3]. |
Level 1 |
A |
42. Medical institutions at all levels should develop intravenous therapy safety plans to reduce the number, risk, and cost of adverse events (e.g., catheter occlusion) [6]. |
Level 1 |
A |
|
43. Regulate the qualifications and scope of practice for specialized nurses in intravenous therapy [6]. |
Level 4 |
A |
|
44. Healthcare providers involved in midline catheter insertion and maintenance must receive training on intravenous therapy theory and skills, and pass assessments [18]. |
Level 1 |
A |
|
45. Principles and practices of intravenous therapy should be integrated into school education and continuing education courses [3]. |
Level 1 |
2025-08-18
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