Does the Midline Peripheral Intravenous Catheter Have a Place in Critical Care?

Background The goals of infusion therapy are to preserve vascular health and safely deliver needed treatment. Achieving these goals is challenging in critical care because of the complexity of the treatment required. Daily justification of retaining an existing central venous catheter also creates urgency to change to a peripheral vascular access device. The midline catheter has had a resurgence in use because of the need for a long-term peripheral vascular access device not linked to central catheter–associated bloodstream infection risk. Objective To review the characteristics of midline catheters, the benefits and risks of midline catheters, and current evidence regarding midline catheter use in critical care. Results Research related to midline catheters has greatly expanded the body of knowledge regarding vascular access device selection and midline catheter use. Discussion Although the quality and results of research on vascular access devices vary widely, a more accurate safety profile is emerging to illustrate how midline catheter use can support the goals of infusion therapy. Conclusions Optimizing vascular access device selection requires recognition that every vascular access device can cause patient harm. Although the midline catheter appears to fill an important niche in infusion therapy, use of the midline catheter should be carefully evaluated. Midline catheters should not be used as a catheter-associated bloodstream infection prevention strategy, should be inserted to administer peripherally compatible solutions, and should be considered for short-term continuous vesicant therapy only in emergent situations until more definitive vascular access can be achieved.

622. Evaluation of Vascular Access Device Selection in Patients Discharged on Outpatient Parenteral Antimicrobial Therapy

Background Selection of a vascular access device (VAD) is an important consideration for patients receiving outpatient parenteral antimicrobial therapy (OPAT). Midline catheters (MC) and peripherally inserted central catheters (PICC) are the most commonly placed VADs, with the former recommended by national guidelines to be used for durations no longer than two weeks. These recommendations, however, are based on limited data from heterogeneous populations. As such, we aim to further characterize VAD-associated complications specifically in patients receiving antimicrobials. Methods We conducted a retrospective cohort study that included adult patients discharged on OPAT with a newly inserted MC or PICC between January 2020 and August 2020. Patients with non-OPAT VAD indications were excluded. The primary outcome was the incidence of VAD-associated complications, which was further assessed by type and severity. The secondary outcome was time to complication. Multivariable Poisson regression was used to assess the association between VAD type and incidence of VAD-associated complications. Results A total of 190 encounters from 181 patients were included for analysis. Baseline demographics are detailed in Table 1. Despite a higher number of complications in the PICC group, rates per 1000 VAD days were not significantly different between VAD types (Table 2). Median time to first complication was 17 days in the overall cohort. Multivariable regression analysis showed those with a dermatologic history had a four-fold increased risk for VAD-associated complications (Table 3). VAD type was not independently associated with the risk of developing a complication. Conclusion Our results suggest that the development of VAD-associated complications was strongly associated with patients’ dermatologic history. To our knowledge, dermatologic history has not been previously identified as a risk factor for VAD-associated complications. Thorough assessment of patient-specific risk factors can inform optimal VAD selection for patients discharged on OPAT. Further studies are needed to assess the safety of MC for extended OPAT use. Disclosures All Authors: No reported disclosures

A cluster of grapes: Right atrial masses of uncertain origin

Implanted ports have provided clinicians with long term venous accessibility, while maintaining comfort and convenience for their patients. One of the most commonly used implanted ports for oncological access is a Mediport (Norfork Medical, Skokie, IL). Guidelines (INS2021) strongly recommend placing central catheter tips at the cavo-atrial junction. In fact, too deep atrium position may be associated with micro-traumatism, possibly leading to a catheter associated right atrial thrombosis (CRAT). No significant literature discusses the possibility of such port masses being seeded by a bacteria, as in the case for endocarditis, which was seen in our patient. In the following case report, we will explore the case of a 41-year-old female with metastatic urothelial carcinoma who developed multiple right atrial masses possibly associated with a deeply seated totally implanted vascular access device (TIVAD) tip within the right atrial wall. These right atrial masses were of unknown origin, and in the setting of MRSA bacteremia, multiple possible etiologies would be discussed. We will also explore ways in which similar complications can be easily prevented in the future.