Health Technology Review

Midline Catheters for Administering Intravenous Infusion Therapy

What Is the Issue?

• Used to administer medications, nutrition, blood products, and other fluids, IV infusion therapy is an important part of clinical care across various health care settings.

• Multiple types of venous access devices are available for IV therapy, including peripheral and central devices. Selecting the most appropriate venous access device is essential for ensuring patient safety and comfort.

• Midline catheters, a type of peripheral venous access device, are increasingly used as an alternative to other peripheral catheters and central venous access devices. However, variations in clinical practice and uncertainty regarding their optimal use create challenges for clinicians and policy-makers in standardizing care.

What Did We Do?

• We prepared this Rapid Review to summarize and critically appraise the available studies on the clinical effectiveness of midline catheters compared to other vascular access devices to support decision-making about the use of midline catheters for administering IV infusion therapy. We also sought to identify evidence-based guidelines regarding the use of midline catheters for administering IV infusion therapy.

• We searched key resources, including journal citation databases, and conducted a focused internet search for relevant evidence published since 2020. Two reviewers screened articles for inclusion based on predefined criteria, critically appraised the included studies, and narratively summarized the findings.

What Did We Find?

• We found 8 systematic reviews (SRs) that evaluated the clinical effectiveness of midline catheters compared to peripherally inserted central catheters (PICCs) (7 SRs) and central venous catheters (1 SR) for administrating IV infusion therapy, as well as 5 evidence-based guidelines that provide recommendations on the appropriate indications for midline catheter use.

• Compared to PICCs, midline catheters may be associated with higher rates of total complications, catheter-related venous thromboembolism, catheter leakage, treatment discontinuation or premature catheter removals, infiltration, and shorter mean catheter dwell times. Midline catheters were also associated with lower rates of catheter-related bloodstream infection. None of the included SRs detected statistically significant differences between midline catheters and PICCs for phlebitis, catheter occlusion, catheter displacement, or mortality.

• Compared to central venous catheters, midline catheters were associated with lower rates of total complications, catheter-related thrombosis, catheter-related infections, and catheter blockage. They also had longer mean catheter dwell times. The SR that examined this comparison did not find significant differences in phlebitis, catheter leakage, or catheter displacement.

• Although some SRs reported statistically significant differences between midline catheters and other venous access devices, these findings were inconsistent across the included studies. Not all SRs detected statistically significant between-group differences for each of these outcomes.

• The quality of the SRs described in this Rapid Review, as well as the quality of primary studies included in the SRs, was limited. Most of the clinical evidence summarized in this review is from low-to-moderate quality nonrandomized studies that may be influenced by selection bias, confounding bias, and performance bias.

• We did not find any studies on the clinical effectiveness of midline catheters versus other peripheral venous access devices for administering IV infusion therapy that met our selection criteria for this review.

• Evidence-based guidelines based mostly on low-quality evidence or expert opinion recommend considering midline catheters as an option in various clinical scenarios, including for children and adults who need longer-term peripheral venous access (e.g., up to 4 weeks). Guidelines also recommend avoiding the use of midline catheters for administering continuous vesicant therapy, parenteral nutrition, or solutions with extremes of pH or osmolarity and for patients with a history of thrombosis, hypercoagulability, decreased venous flow to the extremities, end-stage renal disease requiring vein preservation, or with planned or existing arteriovenous fistula or arteriovenous graft.

What Does This Mean?

• Health care professionals and decision-makers can use this evidence to inform decisions around the appropriate use of midline catheters for administering IV infusion therapy.

• Current evidence-based guidelines support the use of midline catheters in certain clinical scenarios after consideration for the type and anticipated duration of therapy and individual patient needs.

• Further high-quality research from robustly conducted studies with improved reporting is needed to confirm the clinical effectiveness of midline catheters versus other vascular access devices.

Research Questions

1. What is the clinical effectiveness of midline catheters versus other vascular access devices for administering IV infusion therapy?

2. What are the evidence-based guidelines regarding the use of midline catheters for administering IV infusion therapy?

Context and Policy Issues

What Is IV Infusion Therapy?

IV infusion therapy is a common medical technique used to administer medications, nutrition, blood products, or other fluids directly into the bloodstream through a vein. This is typically done using a catheter — a thin, flexible tube that can vary in design, size, length, material, and insertion site.¹ Approximately 80% to 90% of patients who are hospitalized receive some form of IV infusion therapy, with more than 1 billion IV catheters inserted globally in patients who are hospitalized each year.^2,3

Vascular access is broadly categorized into 2 main types: central and peripheral venous access. Central venous access occurs when the catheter’s tip is positioned in the inferior vena cava, superior vena cava, or right atrium.⁴ Central venous catheters are typically inserted at the internal jugular, subclavian, or femoral veins.⁴ For PICCs, a type of central venous access device, insertion sites include the basilic, brachial, or cephalic veins.⁵ In contrast, peripheral venous access is achieved when the catheter tip is located outside of the central veins.⁶ Peripheral venous access devices are usually inserted into the superficial veins of the upper limbs, such as those in the forearm or wrist.⁶

Many factors may influence the selection of a venous access device, including the type and duration of therapy, the risk of complications, and the patient’s medical history, vascular condition, and personal preferences.⁷

What Are Midline Catheters and What Are Their Potential Benefits?

Midline catheters are a type of peripheral venous access device that is longer than other peripheral IV catheters, but does not reach the central circulation.⁸ Introduced to clinical settings in the 1950s, midline catheters were developed as an alternative for patients requiring longer-term IV therapy without the need for central venous access.⁹ They are typically inserted into a vein in the upper arm (e.g., basilic, cephalic, or brachial veins) with the catheter tip positioned at or near the level of the axilla.⁸ Midline catheters are available with either a single or double lumen and range from 10 to 20 cm long, though some sources report variations in the accepted length range.^10,11

Central lines can be technically challenging to place, pose a risk of serious complications, and are associated with considerable health care costs.^12,13 Like other peripheral venous access devices, midline catheters are relatively easy to insert, yet they can potentially dwell longer than short peripheral IV catheters.¹⁴

Why Is It Important to Do This Review?

Selecting an appropriate vascular access device has implications for patient safety, treatment effectiveness, and health care costs.¹⁵ While the use of midline catheters in clinical practice is increasing, there remains uncertainty about their optimal indications and when they should be used as an alternative to central venous catheters or other peripheral venous access devices.⁹

Canada's Drug Agency previously conducted a review¹⁶ on the clinical effectiveness of midline catheters compared to extended dwell catheters for delivering peripherally compatible IV antibiotics to adults. A broader review of the available evidence, including other applications of midline catheters, could provide additional information to help guide informed decision-making on the appropriate use of midline catheters in patient care.

Objective

We prepared this Rapid Review to identify, summarize, and critically appraise the evidence regarding the clinical effectiveness of midline catheters compared to other vascular access devices for IV infusion therapy and to summarize and critically appraise the evidence-based guidelines that provide recommendations on the appropriate indications for midline catheter use.

Methods

An information specialist conducted a customized literature search, balancing comprehensiveness with relevance, of multiple sources and grey literature on January 13, 2025. Two reviewers screened citations and selected studies based on the inclusion criteria presented in Table 1, and critically appraised included publications using established critical appraisal tools. Appendix 1 presents a detailed description of methods and selection criteria for included studies.

Table 1: Selection Criteria

PICC = peripherally inserted central catheter; SR = systematic review.

Summary of Evidence

Quantity of Research Available

This report includes 13 publications that met the inclusion criteria, including 8 SRs^17-24 and 5 evidence-based guidelines.^25-29 Appendix 1 presents the PRISMA³⁰ flow chart of the study selection.

Summary of Study Characteristics

Summaries of study characteristics are organized by research question. Appendix 2 provides detailed characteristics of the included publications.

Included Studies for Question 1: Clinical Effectiveness of Midline Catheters

Eight SRs (7 with meta-analyses)^17-24 were included. Of these, 7 SRs^17,18,20-24 compared midline catheters with PICCs. One SR¹⁹ compared midline catheters with central venous catheters, but the authors did not specify the types of central venous catheters that were eligible or examined in their included primary studies. Five SRs were conducted in China,^19,20,22-24 1 in the US,²¹ 1 in Taiwan,¹⁸ and 1 in Norway.¹⁷ These SRs^17-24 were published between 2022 to 2024, and 5 stated that they received funding.^{17,19,20,23,24} Collectively, the 8 SRs^17-24 evaluated data from 46 unique relevant primary studies. However, there was an overlap of 21 primary studies included in multiple SRs.^17-24 On average, each overlapping primary study appeared in 3 SRs (range, 2 to 5). Therefore, estimates of clinical effectiveness are based on similar data, even though outcomes were not always the same across these publications. Appendix 5 describes the primary study overlap.

Comprehensive participant characteristics, including PROGRESS-Plus criteria,^31,32 were not reported in any of the SRs.^17-24 For example, gender or sex was not reported in 4 SRs.^17,22-24 No included SRs described how gender or sex were defined and did not include gender identities, outside of male and female. The included primary studies across all SRs were a mix of randomized controlled trials and observational studies, while 1 SR¹⁷ did not specify the primary study design of included studies. The population reported among all SRs^17-24 was from patients of any age who were not pregnant ranging from 1 to 101 years, receiving any IV infusion therapy administered via midline catheters, PICCs, or central venous catheters. Of note, 1 SR¹⁷ specifically evaluated data from patients with cancer receiving palliative care. When reported, the proportion of female participants ranged from 23% to 74%, while the proportion of male participants ranged from 31% to 76%. The relevant clinical outcomes reported across the 8 SRs^17-24 were:

• catheter-related complications

• catheter dwell times

• treatment discontinuation

• mortality

• participant satisfaction

• pain.

Included Studies for Question 2: Guidelines Regarding the Use of Midline Catheters

Five evidence-based guidelines,^25-29 published from 2023 to 2024, were relevant for this report. Four guidelines^25,26,28,29 were developed for health care professionals, while 1 guideline²⁷ was developed specifically for health care practitioners, patients, and hospital administrators involved in health care. Two guidelines were developed in the US, (1 by the American College of Radiology²⁸ and 1 by the Infusion Nurses Society [INS]),²⁵ 2 guidelines were developed in Italy by the Catholic University Hospital ‘A. Gemelli,’^26,29 and 1 guideline was developed by the WHO.²⁷

Four guidelines^25,26,28,29 used multiple electronic databases to conduct their literature search for English articles published between 2000 and 2024, and 1 guideline²⁷ searched for articles published between 1980 and 2023 with no language restrictions. The included guidelines varied regarding their target population and approach to reporting: 1 did not specify the target population or clinical setting;²⁵ 1 targeted adults without specifying the clinical setting;²⁹ 1 targeted patients who were hospitalized and not hospitalized, but age was not specified;²⁸ 1 targeted children who were hospitalized and not hospitalized;²⁶ and 1 targeted children (including neonates and adolescents) and adults regardless of the type of care settings.²⁷ The guidelines were developed considering the selection, access, insertion, maintenance, and removal of venous access devices, including peripheral venous access devices (i.e., peripheral IV catheters, midline catheters, arm or chest ports, or short and long peripheral catheters) and central venous access devices (i.e., central catheters, totally implanted venous access devices, femoral inserted central catheters, tunneled and non-tunneled central venous catheters, and PICCs).^25-29

The general outcomes of interest were patient safety,^25,26,28,29 clinical efficacy and effectiveness,^25,29 cost-effectiveness,^25,29 acceptability,²⁵ efficiency,²⁵ and all-cause bloodstream infections related to venous access;²⁷ no other clinical outcomes, such as hospital length of stay or mortality were considered among all guidelines.

Summary of Critical Appraisal

Overall, the level of quality from the included publications (8 SRs [7 with meta-analyses] and 5 evidence-based guidelines) was low to moderate. Appendix 3 presents additional details regarding the limitations and strengths of the included publications.

Systematic Reviews

All SRs^17-24 clearly described their objectives, eligibility criteria (e.g., population, intervention, comparator, and outcome criteria) and all conducted literature searches using multiple databases, improving clarity, reproducibility, transparency and interpretability of findings. However, 7 SRs^17,18,20-24 did not conduct a grey literature search, although they reported appropriate search terms and language restrictions (i.e., English^17,18,20-24 and Chinese^19,22). Excluding grey literature searches can lead to misleading treatment effects when key evidence from these sources is missed and can lead to an increased risk of bias. Limiting study eligibility based on the language of the publication affects the external validity and overall applicability, for example, it potentially excludes high-quality studies published in different languages from research groups or countries with similar or different health care systems. The rationale for not conducting grey literature searches and imposing language restrictions on eligible publications was not discussed in the included SRs.^17,18,20-24

Study selection and data extraction were inconsistent across all studies,^17-24 compromising the validity, reliability, and applicability of the findings:

• one SR¹⁸ justified the inclusion of randomized controlled trials

• one SR¹⁹ provided a list of studies excluded after full-text review with reasons for exclusion

• two SRs^17,20 adequately described included primary studies (e.g., study design, population, or outcomes of interest)

• all SRs^17-24 did not report the PROGRESS-Plus criteria^31,32

• no SRs^17-24 described the statistical methods of primary included studies.

All SRs^17-24 assessed the quality of primary studies using a satisfactory tool and reported no conflict of interests. Seven SRs^17-21,23,24 disclosed funding sources, while the authors of 1 SR²² did not. The funding sources of included primary studies were not reported in all SRs,^17-24 affecting transparency and risk of funding bias. The authors of 4 SRs^18-21 registered their study protocols in PROSPERO, and the completed reviews followed the outlined approaches without any major deviations. This helps reduce potential research duplication, publication bias, and selective reporting of outcomes. Appropriate statistical methods were used in 6 SRs.^18,19,21-24 Four SRs^18,22-24 reported low heterogeneity in their primary analysis, but discussion on this was limited. The authors of 1 SR¹⁷ indicated that meta-analysis was not possible due to the heterogeneity of primary studies. Publication bias was assessed in 5 SRs^19,20,22-24 using funnel plots. However, most included studies had a variable risk of bias, and authors did not examine how risk of bias of the included primary studies could have impacted the results.^17-21,23,24

Evidence-Based Guidelines

All guidelines^25-29 clearly described their scope and purpose, outlining the involvement of relevant professional knowledge users and the target users. Relevant studies were retrieved from multiple databases in all guidelines.^25-29 One guideline²⁷ sought patient involvement, helping to ensure relevance and applicability and incorporate patient-centred perspectives. A high level of rigour in development was observed in 1 guideline.²⁷ One guideline²⁷ did not have geographical or lingual restrictions. However, 4 guidelines^25,26,28,29 did not clearly report the methods of selecting articles (e.g., detailed inclusion and exclusion criteria) to inform their recommendations. All recommendations from all guidelines^25-29 were specific, unambiguous, and were easily identifiable.

Assessment of quality of evidence differed across all guidelines: 3 did not report a tool used to assess the article’s quality,^26,29,33 1 used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology,²⁷ and 1 used the American College of Radiology Appropriateness Criteria Methodology.²⁸ Transparent and consistent reporting of quality assessment tools is necessary to understand if, and how, quality of evidence was assessed. Three guidelines^25,28,29 did not report the methods to achieve consensus, and 3 did not report a guideline validation method.^26,28,29 The applicability of the guidelines was not uniform, and key factors such as facilitators, barriers, monitoring, and auditing criteria were not reported. In 3 guidelines,^25,27,28 it was unclear whether funding influenced the content. However, all guidelines^25-29 reported potential conflicts of interest.

Summary of Findings

Appendix 4 presents additional details regarding the main study findings.

Clinical Effectiveness of Midline Catheters Versus PICCs

Seven SRs (6 with meta-analyses)^17,18,20-24 provided information on the clinical effectiveness of midline catheters versus PICCs for administering IV infusion therapy. There was considerable overlap in the primary studies that were included in these SRs; the pooled estimates from separate reviews thus contain much of the same data (refer to Appendix 5 for details regarding overlap).

Catheter-Related Complications

Total Complications

Two SRs with meta-analyses^18,20 reported on the effect of midline catheters compared to PICCs on total complication rates. One SR,¹⁸ which pooled data from 4 studies, found that midline catheters were associated with a statistically significantly higher total complication rate compared to PICCs. In a separate analysis of a single study involving children, the increased risk of total complications remained significant. A third analysis of 3 studies focusing on adults found no statistically significant difference in total complication rates.

The second SR,²⁰ based on a pooled analysis of 14 studies, found no statistically significant difference in total complications per patient. However, when analyzing per total catheter days (pooled data from 9 studies), there were statistically significantly more total complications observed in the midline catheter group.

Thrombosis

Four SRs with meta-analyses^18,20,21,24 provided mixed results for the clinical effectiveness of midline catheters versus PICCs with respect to thrombosis-related outcomes:

• One SR,²⁴ based on a pooled analysis of 12 studies, reported that midline catheters were associated with statistically significantly higher rates of venous thromboembolism. The authors conducted additional analyses specific to adults (5 studies) and to other age groups (e.g., children and mixed age groups; 7 studies), and reported the difference remained statistically significant for both groups.

• One SR²¹ reported that midline catheters were at a significantly increased risk for superficial vein thrombosis, based on a pooled analysis of 2 studies, but there were no statistically significant differences between midline catheters and PICCs with respect to risk for localized thrombosis (i.e., superficial vein thrombosis, deep vein thrombosis, or other thrombosis), deep vein thrombosis, and pulmonary embolism.

• One SR¹⁸ assessed thrombosis rates in adults (pooled analysis of 4 studies), children (1 study), and in populations of any age (pooled analysis of 5 studies). In all 3 analyses, there were no statistically significant differences between midline catheters and PICCs.

• Findings from the Wen et al. SR²⁰ suggested that the proportion of patients with catheter-related superficial vein thrombosis and the rate of catheter-related deep vein thrombosis or superficial vein thrombosis (analyzed per total catheter days) was higher in patients who had a midline catheter. Rates of other thrombosis-related outcomes, including catheter-related deep vein thrombosis, contralateral and/or bilateral thrombosis, and pulmonary embolism were not statistically significantly different between the 2 groups.

Infection

Four SRs with meta-analyses^18,20-22 described the risk of infection in participants who received IV therapy with midline catheters compared to PICCs:

• One SR²¹ reported that midline catheters were associated with statistically significantly fewer patients with catheter-related bloodstream infections compared with PICCs, based on a pooled analysis of 9 studies. When analyzed per catheter, there was no significant difference between midline catheters and PICCs in risk for catheter-related bloodstream infections.

• Based on a pooled analysis of 10 studies, the SR by Wen et al.²⁰ reported participants who used midline catheters had a significantly lower incidence of catheter-related bloodstream infection compared to participants who used PICCs. When analyzed by total catheter days, there was no statistically significant difference between the 2 groups (7 studies).

• One SR²² reported no differences in the proportion of participants with catheter-related bloodstream infection, based on a pooled analysis of 11 studies. However, findings from a sensitivity analysis that excluded low quality studies indicated that the incidence of catheter-related bloodstream infection in the midline catheter group was statistically significantly lower than that in the PICC group. There were no statistically significant differences in the number of participants with catheter-related bloodstream infection in 2 additional analyses that were specific to adults (6 studies) and studies that included children, mixed age groups, and those that did not report age (5 studies).

• The fourth SR¹⁸ reported no differences in the number of catheter-related bloodstream infections, based on a pooled analysis of 5 studies. There were no differences in the number of catheter-related bloodstream infections in 2 additional analyses that were specific to children and adults.

Phlebitis

Pooled estimates from 3 SRs^20,21,23 indicated no statistically significant difference in phlebitis rates between participants who received IV therapy using midline catheters and those using PICCs.

Catheter Occlusion

Two SRs with meta-analyses^20,21 found no statistically significant difference in catheter occlusion rates between midline catheters and PICCs. These findings were consistent in analyses conducted both per participant and per catheter (e.g., the number of occlusions per total catheter days).

Catheter Leakage

One SR²⁰ with meta-analysis compared the incidence of leakage between midline catheters and PICCs. The results indicated that midline catheters had a statistically significantly higher rate of leakage compared to PICCs, both when analyzed per participant (based on a pooled estimate from 5 studies) and per total catheter days (based on a pooled estimate from 4 studies).

Catheter Displacement

One SR²⁰ with meta-analysis found no statistically significant difference in the rates of catheter displacement between the midline catheter and PICC groups.

Infiltration

One SR with meta-analysis²⁰ evaluated the incidence of infiltrations among participants who received therapy with either midline catheters or PICCs. A pooled analysis of 6 studies found that participants with midline catheters had statistically significantly higher incidence of infiltration. When analyzed by total catheter days, there was no statistically significant difference in the number of catheters with infiltration between the 2 groups (based on a pooled estimate from 5 studies).

Catheter Fracture

The SR by Urtecho et al.²¹ found no statistically significant differences between the midline catheter and PICC groups in the number of participants with a fractured catheter or the number of catheters that fractured.

Catheter Dwell Time

Two SRs^17,18 provided information on the effect of midline catheters versus PICCs on catheter dwell times. One SR,¹⁸ which pooled data from 4 studies, found that midline catheters were associated with statistically significantly shorter mean dwell time. Similarly, the authors’ analysis of a single study involving children indicated a significantly shorter mean dwell time for midline catheters. A third analysis of 3 studies focusing on adults found no statistically significant difference in mean catheter dwell time between midline catheters and PICCs.

The second SR¹⁷ included a prospective case series that reported catheter dwell times for participants who received a midline catheter or a PICC. The median dwelling time was 50.5 days in the midline group and 102 days in the PICC group; however, no statistical analysis was conducted to determine whether the between-group difference was significant.

Treatment Discontinuation

Three SRs with meta-analyses^18,20,21 provided mixed results for measures of treatment discontinuation:

• One SR¹⁸ reported that the mean number of premature catheter removals per 1,000 catheter days was statistically higher with midline catheters compared to PICCs based on their analyses of studies of any population age (3 studies) and studies of adults (2 studies), but that there was no statistically significant between-group difference in their analysis of studies specific to children (1 study).

• Based on a pooled analysis of 6 studies, findings from the SR by Urtecho et al.²¹ indicated that the use of midline catheters was associated with more participants discontinuing therapy compared with PICCs. When evaluated per catheter, no difference was observed between the number of treatment discontinuations between the midline catheter and PICC groups (based on a pooled analysis of 3 studies).

• One SR²⁰ found no statistically significant difference between midline catheters and PICCs in the proportion of participants with premature catheter removal (based on a pooled estimate from 5 studies) and the number of premature catheter removals when analyzed by total catheter days (based on a pooled estimate from 4 studies).

Mortality

One SR with meta-analysis²¹ found no statistically significant difference in mortality between participants who received IV therapy with midline catheters versus PICCs, based on an analysis that included 1 primary study.

Other Outcomes

Based on an analysis of 1 primary study, the Wen et al. SR²⁰ reported that participants treated with a PICC had a statistically significantly higher rate of dissatisfaction. Additionally, the authors of the SR²⁰ found no statistically significant between-group differences in pain (whether assessed per participants or per catheter) or participant satisfaction rates. The authors did not provide information on how dissatisfaction, satisfaction, or pain were defined or measured.

Clinical Effectiveness of Midline Catheters Versus Central Venous Catheters

One SR¹⁹ provided information on the clinical effectiveness of midline catheters versus central venous catheters for administering IV infusion therapy.

Catheter-Related Complications

Total Complications

A pooled analysis of 10 studies from the SR¹⁹ found that the total complication rate was statistically significantly lower in the midline catheter group compared to the central venous catheter group.

Thrombosis

The SR,¹⁹ based on a pooled analysis of 8 studies, found that catheter-related thrombosis occurred less frequently in the midline catheter group than in the central venous catheter group, with a statistically significant difference.

Infection

Based on a pooled analysis of 8 studies,¹⁹ the incidence of catheter-related infection was statistically significantly lower in participants who received therapy with midline catheters compared to those with central venous catheters.

Phlebitis

The SR¹⁹ found no statistically significant difference in the occurrence of phlebitis between midline catheters and central venous catheters (meta-analysis of 8 studies).

Catheter Occlusion

The SR,¹⁹ based on a pooled analysis of 6 studies, found a statistically significant difference in catheter blockage between the 2 groups, with midline catheters having a lower incidence rate.

Catheter Leakage

Based on a pooled analysis of 7 studies, the SR¹⁹ found no statistically significant difference in the occurrence of leakage between the midline catheter and central venous catheter groups.

Catheter Displacement

A pooled analysis of 3 studies in the SR¹⁹ indicated that there was no statistically significant difference in the occurrence of catheter displacement between the midline catheter and central venous catheter groups.

Catheter Dwell Time

The SR,¹⁹ which pooled data from 3 studies, found that midline catheters were associated with statistically significantly longer mean catheter dwell times.

Guidelines Regarding the Use of Midline Catheters

We identified 5 evidence-based guidelines^25-29 that provide recommendations on the appropriate use of midline catheters. Of these, 2 guidelines^25,29 focus on adults, 1 guideline²⁶ addresses children, 1 guideline²⁷ applies to both adults and children, and 1 guideline²⁸ does not specify the patient age to which its recommendations apply. Table 19 provides detailed recommendation statements and supporting evidence.

Recommendations for Adults

The INS guidelines²⁵ recommend using midline catheters for adults who are hospitalized, require peripherally compatible therapy, and have an anticipated duration of therapy of 5 to 14 days. Additionally, the INS guidelines²⁵ provide further guidance on the appropriate use of midline catheters:

• Avoid using midline catheters as a strategy to prevent central line-associated bloodstream infections when central venous access is indicated.

• Do not use midline catheters for continuous infusion of vesicant therapy, parenteral nutrition, or other infusates (i.e., fluids given through IV) with extreme pH or osmolarity (from original source).

• Avoid midline catheters in patients with a history of thrombosis, hypercoagulability, decreased venous flow to the extremities, or end-stage renal disease requiring vein preservation.

• For patients with a planned or existing arteriovenous fistula or arteriovenous graft, avoid inserting midline catheters and PICCs whenever possible due to an increased risk of thrombosis.

• While midline catheters may be labelled for obtaining blood samples, further high-quality research is needed to establish a standard procedure for blood sampling with midline catheters.

• Remove midline catheters in pediatric and adult patients based on site assessment and clinical signs or symptoms of systemic complications rather than solely on catheter dwell time.

• Consider the risk for catheter-associated thrombosis when using midline catheters.

• Do not use midline catheters for continuous infusions of antineoplastic vesicants.

• Do not use midline peripheral catheters placed in deep peripheral vessels for continuous vesicant therapy.

The developers of the INS guidelines²⁵ assigned a level of evidence to their recommendations based on study design, ranging from the highest level I (e.g., based on a meta-analysis) to the lowest level of V (e.g., based on case reports). However, they did not specify the strength of individual recommendations, and the process for achieving committee consensus for each recommendation was not reported.

The guidelines by Pittiruti et al. (2023)²⁹ stated that the indications for specific peripheral venous access devices in adults are mainly based on the expected duration of treatment, and that midline catheters are appropriate when the expected duration is more than 4 weeks. This guideline did not report the strength of the recommendation, the quality of evidence informing the recommendation, or the methods for achieving committee consensus.

Recommendations for Children

The guidelines by Pittiruti et al. (2024)²⁶ recommend that midline catheters may be taken into consideration in some selected cases of children who are not hospitalized and who need peripheral venous access for less than 4 weeks. This recommendation qualified as having strong agreement, as 19 of the 20 committee members voted in agreement (1 member was uncertain). The strength of the recommendation and the quality of evidence informing this recommendation were not reported.

Recommendations for Adults and Children

In adults and children requiring longer term IV access, the WHO guideline²⁷ recommends the use of either a PICC or midline vascular catheter (conditional recommendation based on very low certainty evidence).

Without specifying patient age, the American College of Radiology²⁸ guidelines state that midline catheters may be appropriate for patients who are acutely ill and are requiring infusion of an irritant medication, hemodynamic monitoring, or frequent blood draws for 2 weeks or less. The strength of the recommendation and the quality of evidence informing this were not reported.

Limitations

Evidence Gaps

We identified no evidence that examined the clinical effectiveness of midline catheters versus another type of peripheral venous access device (i.e., peripheral IV catheters), or versus specific types of central venous catheters, including tunneled and non-tunneled central venous catheters and totally implanted venous access devices. Therefore, no conclusions can be made on the clinical effectiveness of midline catheters compared to these devices.

The included studies provided limited information on the effect of midline catheters on patient-reported outcome measures, such as health-related quality of life, functional status, and patient experience of care. One SR²⁰ provided data for pain, patient satisfaction, and patient dissatisfaction; however, information on how these outcomes were defined and measured was not reported, making it difficult to interpret their findings.

Although many clinical outcomes showed statistically significant differences between participants who used midline catheters and those who used other venous access devices, none of the included studies discussed minimum clinically important difference values for any of the reported outcomes. As a result, it remains unclear whether the observed differences are meaningful to patients, clinicians, or policy-makers in real-world practice.

Study Quality

In addition to the included SRs^17-24 being of limited quality, the primary studies within these SRs also had several methodological limitations. In total, the 8 included SRs analyzed data from 46 relevant primary studies. Although we did not conduct our own critical appraisal of these primary studies, most were observational and may be influenced by selection bias, confounding bias, and performance bias. In the case of randomized controlled trials included in the SRs, the authors of the SRs often provided inadequate reporting of their methodology and other key considerations (e.g., randomization methods, masking of participants and care providers, and primary study authors’ potential conflicts of interest and funding sources). This lack of primary study information limits the reliability of the findings reported in the SRs.

The authors of the included SRs^17-24 performed their critical appraisals using various tools, including the Downs and Black checklist, the Cochrane Risk of Bias tool, the Jadad scale, the Newcastle-Ottawa Scale, and the Effective Public Health Practice Project Quality Assessment Tool for quantitative studies. This variability in assessment methods limits comparability across studies. However, primary studies were generally rated as low to moderate in quality and at moderate to high risk of bias due to concerns related to external validity (e.g., the representativeness of study populations), confounding (e.g., the comparability between treatment groups), and reporting quality. Additionally, none of the included SRs reported the funding sources of individual primary studies, so the potential for sponsorship bias is unclear.

Generalizability

The authors of the included SRs^17-24 analyzed data from a relatively large number of primary studies with high numbers of participants which were conducted in many different countries, including Australia, Canada, China, the Czech Republic, Denmark, England, Italy, South Korea, the UK, and the US. For example, the SR by Lu et al. (2022b)²³ included data from 12 primary studies, comprising 40,871 participants, for their analysis of venous thromboembolism. Large participant numbers from studies conducted in various locations may increase the generalizability of the findings.

However, the reporting of primary study participants’ characteristics and care settings was generally poor across all 8 SRs. We used PROGRESS-Plus^31,32 to guide data extraction and to provide insights into whether the analyses from the relevant SRs included data from diverse patient populations who could be representative of those in Canada. While some SRs provided basic demographic details, such as the mean age and the proportion of male or female participants, many important characteristics were not described.

Furthermore, when participant sex or gender were reported, the SRs^17-24 did not include any information on how they were defined or measured, and it was unclear how gender diversity was considered. To improve generalizability to clinical practice settings in Canada, the analyses could have included participants with diversity across characteristics that stratify health opportunities and outcomes, such as race, ethnicity, place of residence, occupation, and socioeconomic status. Because these aspects were underreported in the included SRs, generalizability is uncertain.

In addition to participant characteristics, care indications and settings were also underreported. Apart from the SR by Gravdahl et al.,¹⁷ which focused on patients with cancer receiving palliative care, none of the included SRs clearly described the types of care indications that were examined across their included primary studies. The clinical effectiveness of catheters for IV infusion may vary depending on the types of medical conditions they are used to manage, as well as the availability of health care personnel and resources, such as clinicians who specialize in catheter insertion (e.g., PICC nurses), imaging equipment for guided placement (e.g., ultrasound or fluoroscopy), and infection control professionals.^5,34,35 Without more detailed information, it is unclear whether the findings are generalizable to all care indications and settings, including less-resourced settings.

None of the included evidence-based guidelines were developed for use in Canada, which may limit the applicability of the recommendations summarized in this report in the health care context in Canada.

Conclusions and Implications for Decision- or Policy-Making

This Rapid Review evaluated the literature regarding the clinical effectiveness of midline catheters compared to alternative venous access devices for administering IV infusion therapy, as well as evidence-based guidelines related to the use of midline catheters for administering IV infusion therapy. The evidence summarized in this report is drawn from SRs^17-24 with substantial overlap in primary studies, meaning that data from the same participants were included in more than 1 SR. Appendix 5 provides a citation matrix illustrating the degree of primary study overlap. As a result, some evidence may be disproportionally represented in the overall conclusions.

Summary of Evidence

Evidence from the 7 SRs (6 with meta-analyses)^17,18,20-24 suggest that, compared to PICCs, midline catheters may be associated with lower rates of catheter-related bloodstream infections but higher rates of total complications, catheter-related venous thromboembolism, catheter leakage, infiltration, treatment discontinuation or premature catheter removals, and shorter mean catheter dwell times. There was no evidence to indicate any detected statistically significant differences between midline catheters and PICCs for phlebitis, catheter occlusion, catheter displacement, or mortality.

• When compared to central venous access catheters, midline catheters were associated with lower rates of total complications, catheter-related thrombosis, catheter-related infections, catheter blockage, as well as longer mean catheter dwell times. The SR with meta-analysis¹⁹ that examined this comparison did not detect any statistically significant differences in phlebitis, catheter leakage, or catheter displacement.

The 5 evidence-based guidelines^25-29 summarized in this review made recommendations on when midline catheters can be considered an appropriate option for administering IV infusion therapy. For example, guidelines support the use of midline catheters for both children and adults who need longer-term IV access (e.g., up to 4 weeks), after consideration for the type of therapy and individual patient needs. The guidelines^25-29 also recommend against using midline catheters for administering continuous vesicant therapy, parenteral nutrition, or solutions with extremes of pH or osmolarity and for patients with a history of thrombosis, hypercoagulability, decreased venous flow to the extremities, end-stage renal disease requiring vein preservation, or with planned or existing arteriovenous fistula or arteriovenous graft.

The limitations of the included literature should be considered when interpreting the findings of this report. None of the included guidelines^25-29 were specifically designed for use in Canada, and the SRs^17-24 provided limited information on the characteristics of primary study participants and clinical settings. As a result, the applicability of the guidelines^25-29 and generalizability of findings from the SRs^17-24 is unclear. Additionally, the included SRs^17-24 synthesized data from primary studies that evaluated midline catheters across a wide range of care indications and patient populations. While these analyses provide estimates for the overall effect of midline catheters, they do not clarify the specific clinical scenarios in which midline catheters may be most appropriate. Furthermore, the quality of studies included in the SRs and informing the evidence-based guidelines tended to be low, and there is uncertainty as to whether the statistically significant changes in outcome measures observed in the SRs translate into clinically meaningful differences.

We did not identify evidence on the clinical effectiveness of midline catheters versus other peripheral IV catheters. All comparative data within the included SRs compared midline catheters to central venous access devices. As a result, no conclusions can be drawn for this comparison.

Considerations for Future Research

To improve understanding of the role of midline catheters in patient care, robustly designed clinical studies with low risk of bias are needed. Future studies should apply methods to control for confounding factors, such as patient characteristics, severity of illness, infection control practices, and clinician expertise, through experimental design (e.g., randomization) or through statistical analysis. Standardizing how outcome measures are defined and reported could help reduce heterogeneity and improve the comparability of results across clinical studies. High-quality primary studies would enable the development of more robust guidelines and SRs that could provide stronger recommendations and more certain estimates of treatment effects.

Investigators of future primary studies and SRs could consider collecting and reporting patient-reported outcome data, which may provide unique information on the impact of midline catheters from the patients' perspective.³⁶ Additionally, study authors may consider reporting detailed participant characteristics across dimensions of diversity such as age, religion, gender, ethnicity, mental and physical ability, place of residence (or other PROGRESS-Plus criteria)^31,32 to provide a better understanding of how the results of their study may generalize to other populations.

Considerations for Decision-Making or Policy-Making

The findings of this Rapid Review suggest that midline catheters may be a suitable venous access device for people requiring IV infusion therapy. However, decision-makers should be aware that the evidence summarized in this review is of limited quality.

In addition to the relevant recommendations outlined in this Rapid Review, we identified 2 additional guidelines^37,38 that provide information on the appropriate use of midline catheters. These guidelines were not included because their relevant guidance was not a part of the formal recommendations. However, the information may still be useful to clinicians and decision-makers.

The Registered Nurses' Association of Ontario guidelines³⁷ indicate that midline catheters may be considered when the duration of therapy is less than 4 weeks and when the medications or solutions being administered are well tolerated by peripheral veins, such as antimicrobials, fluid replacement, and analgesics. They also state that midline catheters should not be used for continuous vesicant therapy, parenteral nutrition, or infusates with an osmolarity greater than 900 mOsm/L. The Agency for Clinical Innovation guidelines³⁸ indicate that midline catheters can be used to infuse solutions with an osmolarity of less than 900 mOsm/L when the duration of therapy ranges from 14 days to 4 weeks. The guidelines³⁸ advise against midline catheter use in patients with a history of thrombosis, hypercoagulability, end-stage renal disease requiring vein preservation, and decreased vascular flow to the extremities. The practice advice from both guidelines^37,38 align with the recommendations from the evidence-based guidelines included in this Rapid Review.

Although it did not meet the inclusion criteria for our Rapid Review, we also identified an SR³⁹ that examined the impact of midline catheter tip positioning on clinical outcomes. The authors concluded that, compared to placement in the axillary vein, placing the catheter tip in the subclavian vein was associated with lower complication rates and a reduced incidence of catheter-related thrombosis. However, the effect of tip location on catheter dwell time and the rates of other complications remained unclear.³⁹ While these additional sources many provide useful information, the quality of the evidence informing these additional guidelines^37,38 and the conclusions made by the authors of the SR³⁹ were not assessed.

Clinicians and other decision-makers can use the evidence summarized in this review to inform their decisions about the appropriate use of midline catheters for administering IV infusion therapy. When making these decisions, careful consideration for factors such as the type of therapy, its physical and chemical properties (e.g., pH or osmolarity), the anticipated duration of therapy, the potential risk of complications, the availability of resources, and individual patient needs is needed.

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Appendix 1: Detailed Methods and Selection of Included Studies

Please note that this appendix has not been copy-edited.

Literature Search Methods

An information specialist conducted a literature search on key resources including MEDLINE, the Cochrane Database of Systematic Reviews, the International HTA Database, the websites of health technology assessment agencies in Canada and major international health technology assessment agencies, as well as a focused internet search. The search approach was customized to retrieve a limited set of results, balancing comprehensiveness with relevance. The search strategy comprised both controlled vocabulary, such as the National Library of Medicine’s MeSH (Medical Subject Headings), and keywords. Search concepts were developed based on the elements of the research questions and selection criteria. The main search concept was midline catheters. Search filters were applied to limit retrieval to health technology assessments, systematic reviews, meta-analyses, or indirect treatment comparisons. An additional search was also conducted with the search concept of venous catheters; for this search, search filters were applied to limit retrieval to guidelines. The searches were completed on January 13, 2025, and limited to English-language documents published since January 1, 2020.

Selection Criteria and Methods

Two reviewers screened citations and selected studies. In the first level of screening, they independently screened titles and abstracts of all retrieved citations for relevance following a liberal-accelerated approach, whereby a single reviewer was required to include a study and exclusion by both reviewers was needed to exclude a study. Full texts of titles and abstracts that were judged to be potentially relevant by at least 1 reviewer were retrieved and independently assessed by 2 reviewers for inclusion based on the inclusion criteria presented in Table 1. Discrepancies between reviewers at the full-text level were discussed until consensus was reached.

Exclusion Criteria

Articles were excluded if they did not meet the selection criteria outlined in Table 1 or were duplicate publications. We excluded SRs in which all relevant studies were captured in other more recent or more comprehensive SRs. Guidelines with unclear methodology were also excluded.

Data Extraction

One reviewer extracted data directly into tables created in Microsoft Word, which were developed, piloted, and modified, as necessary. Two additional reviewers independently verified the study characteristics and outcomes data for accuracy and completeness. Disagreements were resolved through discussion.

Relevant information that was extracted included study characteristics, methodology (e.g., study design), population, intervention, comparator, and results regarding the outcomes of interest. When reporting on sex or gender in this Rapid Review, we retained the language used by the original study authors, and whenever possible, we referred to these groups based on guidance from Canada’s Drug Agency Style: A Guide for Authors and Editors⁴⁰ at the time this Rapid Review was conducted, with an understanding that language is constantly evolving.

Critical Appraisal of Individual Studies

The included publications were critically appraised by 1 reviewer using the following tools as a guide: A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2)⁴¹ for SRs and the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument⁴² for guidelines. A second reviewer verified the critical appraisal results for accuracy and consistency. Any disagreements were resolved through discussion. Summary scores were not calculated for the included studies; rather, the strengths and limitations of each included publication were described narratively.

Figure 1: Selection of Included Studies

Appendix 2: Characteristics of Included Publications

Please note that this appendix has not been copy-edited.

Table 2: Characteristics of Included Systematic Reviews

BMI = body mass index; NR = not reported; PICC = peripherally inserted central catheter; RCT = randomized controlled trial; SD = standard deviation; SR = systematic review.

^aFor SRs with broader inclusion criteria than this report, participant characteristic data (e.g., age, sex) from the subset of studies relevant to the current report were summarized.

^bThe main PROGRESS-Plus criteria include place of residence, race, ethnicity, culture, language, occupation, gender, sex, religion, education, socioeconomic status, social capital, personal characteristics associated with discrimination (e.g., age, disability), features of relationships, and time-dependent relationships.^31,32

^cThe scope of this SR was broader than that of this report and included additional interventions and comparators. Only the comparisons relevant to this report are included.

^dThis SR included 1 primary study that used IV therapy administered using conventional catheters as the control group, which included peripheral venous catheters, central venous catheters, and PICCs.

^eBased on the reporting in the SR, it was unclear whether the summary values for participant age in primary studies were reported as means, but they were assumed to be.

Table 3: Characteristics of Included Guidelines

ACR = American College of Radiology; EHHP = Effective Public Health Practice Project; GRADE = Grading of Recommendations Assessment, Development and Evaluation; INS = Infusion Nurses Society; NR = not reported; PICC = peripherally inserted central catheter; PIVC = peripheral IV catheter; RAND = Research and Development; RCT = randomized controlled trial; RoB = Risk of Bias; ROBINS-I = Risk Of Bias In Nonrandomized Studies of Interventions; SR = systematic review; UCLA = University of California Los Angeles.

Appendix 3: Critical Appraisal of Included Publications

Please note that this appendix has not been copy-edited.

Table 4: Strengths and Limitations of Systematic Reviews Using AMSTAR 2⁴¹

AMSTAR 2 = A Measurement Tool to Assess Systematic Reviews 2; GRADE = Grading of Recommendations Assessment, Development and Evaluation; PROSPERO = International Prospective Register of Systematic Reviews; RCT = randomized controlled trial; RoB = Risk of Bias.

Table 5: Strengths and Limitations of Guidelines Using AGREE II⁴²

ACR = American College of Radiology; AGREE II = Appraisal of Guidelines for Research and Evaluation II.

^aWe retained the domain names that are included in the original AGREE II checklist, which includes the terminology stakeholder (i.e., domain 2), to be clear that we assessed the strengths and limitations of guidelines using AGREE II.⁴² However, Canada’s Drug Agency understands that language is constantly evolving and the word stakeholder has association with colonialism; whenever possible, Canada’s Drug Agency does not use this word in our reports

Appendix 4: Main Study Findings

Please note that this appendix has not been copy-edited.

Table 6: Summary of Findings by Outcome — Total Complications^a

CI = confidence interval; DVT = deep vein thrombosis; MA = meta-analysis; NA = not applicable; NR = not reported; OR = odds ratio; PICC = peripherally inserted central catheter; RR = risk ratio; SD = standard deviation; SR = systematic review; SVT = superficial vein thrombosis; vs. = versus.

^aThe specific types of complications included in this composite outcome were not explicitly defined in the included SRs^18-20 and may vary across studies.

^bOne primary study included in this analysis (Nielson et al. [2021]) used a conventional IV catheter control group, which included peripheral venous catheters, central venous catheters, and PICCs.

^cThe findings from Wen et al.²⁰ were calculated using PICC as the intervention compared to midline catheters. To align with the direction of this review (i.e., midline catheters compared to PICC) the effect estimates were inverted by taking the reciprocal of the risk ratio and the bounds of the confidence interval. The findings as reported in the SR were: number of total complications, RR = 1.00 (95% CI, 0.70 to 1.41); number of total complications, expressed as the number of events per total catheter days, RR = 0.51 (95% CI, 0.26 to 0.99).

Note: There was overlap in the primary studies that were included in the SRs; the pooled estimates from separate reviews presented in this table thus contain some of the same data. Refer to Appendix 5 for a citation matrix illustrating the degree of overlap.

Table 7: Summary of Findings by Outcome — Thrombosis

CI = confidence interval; DVT = deep vein thrombosis; MA = meta-analysis; NR = not reported; OR = odds ratio; PICC = peripherally inserted central catheter; RCT = randomized controlled trial; RR = risk ratio; SR = systematic review; SVT = superficial vein thrombosis; vs. = versus.

^aOne primary study included in this analysis (Nielson et al. [2021]) used a conventional IV catheter control group, which included peripheral venous catheters, central venous catheters, and PICCs.

^bThe findings from Wen et al.²⁰ were calculated using PICC as the intervention compared to midline catheters. To align with the direction of this review (i.e., midline catheters compared to PICC) the effect estimates were inverted by taking the reciprocal of the risk ratio and the bounds of the confidence interval. The findings as reported in the SR were: participants with catheter-related DVT or SVT, RR = 1.06 (95% CI, 0.69 to 1.61); participants with catheter-related DVT, RR = 1.09 (95% CI, 0.71 to 1.68); participants with catheter-related SVT, RR = 0.42 (95% CI, 0.28 to 0.64); participants with contralateral DVT or SVT, RR = 0.84 (95% CI, 0.51 to 1.37); participants with contralateral DVT, RR = 0.85 (95% CI, 0.41 to 1.78); participants with contralateral SVT, RR = 0.83 (95% CI, 0.43 to 1.62); participants with contralateral and/or bilateral DVT or SVT, RR = 0.76 (95% CI, 0.54 to 1.08); participants with contralateral and/or bilateral DVT, RR = 0.74 (95% CI, 0.43 to 1.28); participants with contralateral and/or bilateral SVT, RR = 0.70 (95% CI, 0.46 to 1.07); participants with pulmonary embolism, RR = 1.15 (95% CI, 0.71 to 1.86); incidence of catheter-related DVT or SVT, expressed as the number of events per catheter day, RR = 0.41 (95% CI, 0.18 to 0.95); incidence of catheter-related DVT, expressed as the number of events per catheter day, RR = 0.40 (95% CI, 0.11 to 1.41); incidence of pulmonary embolism, expressed as the number of events per catheter day, RR = 0.66 (95% CI, 0.28 to 1.58).

^cThis value was reported as OR = 0.87 (95% CI, 0.53 to 31.44) in the main text of the SR by Urtecho et al.,²¹ but as OR = 0.87 (95% CI, 0.53 to 1.44) in the supplementary materials.

Note: There was overlap in the primary studies that were included in the SRs; the pooled estimates from separate reviews presented in this table thus contain some of the same data. Refer to Appendix 5 for a citation matrix illustrating the degree of overlap.

Table 8: Summary of Findings by Outcome — Infection

CI = confidence interval; MA = meta-analysis; OR = odds ratio; PICC = peripherally inserted central catheter; RR = risk ratio; SR = systematic review; vs. = versus.

^aOne primary study included in this analysis (Nielson et al. [2021]) used a conventional IV catheter control group, which included peripheral venous catheters, central venous catheters, and PICCs.

^bThe findings from Wen et al.²⁰ were calculated using PICC as the intervention compared to midline catheters. To align with the direction of this review (i.e., midline catheters compared to PICC) the effect estimates were inverted by taking the reciprocal of the risk ratio and the bounds of the confidence interval. The findings as reported in the SR were: participants with catheter-related bloodstream infection, RR = 1.95 (95% CI, 1.15 to 3.32); catheters with an associated bloodstream infection, expressed as the number of events per total catheter days, RR = 0.89 (95% CI, 0.35 to 2.31).

Note: There was overlap in the primary studies that were included in the SRs; the pooled estimates from separate reviews presented in this table thus contain some of the same data. Refer to Appendix 5 for a citation matrix illustrating the degree of overlap.

Table 9: Summary of Findings by Outcome — Phlebitis

CI = confidence interval; MA = meta-analysis; OR = odds ratio; PICC = peripherally inserted central catheter; RR = risk ratio; SR = systematic review; vs. = versus.

^aThe findings from Wen et al.²⁰ were calculated using PICC as the intervention compared to midline catheters. To align with the direction of this review (i.e., midline catheters compared to PICC) the effect estimates were inverted by taking the reciprocal of the risk ratio and the bounds of the confidence interval. The findings as reported in the SR were: participants with phlebitis, RR = 1.22 (95% CI, 0.51 to 2.92); number of phlebitis complications, expressed as the number of events per total catheter days, RR = 1.82 (95% CI, 0.50 to 6.56).

Note: There was overlap in the primary studies that were included in the SRs; the pooled estimates from separate reviews presented in this table thus contain some of the same data. Refer to Appendix 5 for a citation matrix illustrating the degree of overlap.

Table 10: Summary of Findings by Outcome — Catheter Occlusion

CI = confidence interval; MA = meta-analysis; OR = odds ratio; PICC = peripherally inserted central catheter; RR = risk ratio; SR = systematic review; vs. = versus.

^aThe findings from Wen et al.²⁰ were calculated using PICC as the intervention compared to midline catheters. To align with the direction of this review (i.e., midline catheters compared to PICC) the effect estimates were inverted by taking the reciprocal of the risk ratio and the bounds of the confidence interval. The findings as reported in the SR were: participants with catheter occlusion, RR = 1.69 (95% CI, 0.81 to 3.53); number of catheters with occlusion, expressed as the number of events per total catheter days, RR = 0.58 (95% CI, 0.23 to 1.44).

Note: There was overlap in the primary studies that were included in the SRs; the pooled estimates from separate reviews presented in this table thus contain some of the same data. Refer to Appendix 5 for a citation matrix illustrating the degree of overlap.

Table 11: Summary of Findings by Outcome — Leakage

CI = confidence interval; MA = meta-analysis; OR = odds ratio; PICC = peripherally inserted central catheter; SR = systematic review; vs. = versus.

^aThe findings from Wen et al.²⁰ were calculated using PICC as the intervention compared to midline catheters. To align with the direction of this review (i.e., midline catheters compared to PICC) the effect estimates were inverted by taking the reciprocal of the risk ratio and the bounds of the confidence interval. The findings as reported in the SR were: participants with leakage, RR = 0.16 (95% CI, 0.05 to 0.53); number of catheters with leakage, expressed as the number of events per total catheter days, RR = 0.17 (95% CI, 0.05 to 0.64).

^bThis value was reported as OR = 0.50 (95% CI, 0.22 to 0.12) in the main text of the SR by Li et al.,¹⁹ but as OR = 0.50 (95% CI, 0.22 to 1.12) in the associated figure.

Table 12: Summary of Findings by Outcome — Catheter Displacement

CI = confidence interval; OR = odds ratio; MA = meta-analysis; PICC = peripherally inserted central catheter; SR = systematic review; vs. = versus.

^aThe findings from Wen et al.²⁰ were calculated using PICC as the intervention compared to midline catheters. To align with the direction of this review (i.e., midline catheters compared to PICC) the effect estimates were inverted by taking the reciprocal of the risk ratio and the bounds of the confidence interval. The findings as reported in the SR were: participants with catheter displacement, RR = 0.84 (95% CI, 0.45 to 1.58); number of catheters with displacement, expressed as the number of events per total catheter days, RR = 0.52 (95% CI, 0.14 to 1.89).

Table 13: Summary of Findings by Outcome — Infiltration

CI = confidence interval; MA = meta-analysis; PICC = peripherally inserted central catheter; RR = risk ratio; SR = systematic review; vs. = versus.

^aThe findings from Wen et al.²⁰ were calculated using PICC as the intervention compared to midline catheters. To align with the direction of this review (i.e., midline catheters compared to PICC) the effect estimates were inverted by taking the reciprocal of the risk ratio and the bounds of the confidence interval. The findings as reported in the SR were: participants with infiltration, RR = 0.27 (95% CI, 0.12 to 0.62); number of catheters with infiltration, expressed as the number of events per total catheter days, RR = 0.29 (95% CI, 0.05 to 1.81).

Table 14: Summary of Findings by Outcome — Catheter Fracture

CI = confidence interval; MA = meta-analysis; NR = not reported; OR = odds ratio; PICC = peripherally inserted central catheter; SR = systematic review; vs. = versus.

Table 15: Summary of Findings by Outcome — Catheter Dwell Time

CI = confidence interval; DVT = deep vein thrombosis; MA = meta-analysis; MD = mean difference; NA = not applicable; NR = not reported; PICC = peripherally inserted central catheter; RR = risk ratio; SD = standard deviation; SR = systematic review; SVT = superficial vein thrombosis; vs. = versus.

^aThis value was reported as an odds ratio in the main text of the SR by Li et al.,¹⁹ but as a MD in the associated figure.

^bConventional IV catheters included peripheral venous catheters, central venous catheters, and PICCs.

Table 16: Summary of Findings by Outcome — Treatment Discontinuation

CI = confidence interval; MA = meta-analysis; MD = mean difference; NR = not reported; OR = odds ratio; PICC = peripherally inserted central catheter; RR = risk ratio; SR = systematic review; vs. = versus.

^aThe findings from Wen et al.²⁰ were calculated using PICC as the intervention compared to midline catheters. To align with the direction of this review (i.e., midline catheters compared to PICC) the effect estimates were inverted by taking the reciprocal of the risk ratio and the bounds of the confidence interval. The findings as reported in the SR were: participants with premature catheter removal, RR = 0.81 (95% CI, 0.40 to 1.62); number of premature catheter removals, expressed as the number of events per total catheter days, RR = 0.30 (95% CI, 0.21 to 0.45).

Note: There was overlap in the primary studies that were included in the SRs; the pooled estimates from separate reviews presented in this table thus contain some of the same data. Refer to Appendix 5 for a citation matrix illustrating the degree of overlap.

Table 17: Summary of Findings by Outcome — Mortality

CI = confidence interval; MA = meta-analysis; NR = not reported; OR = odds ratio; PICC = peripherally inserted central catheter; SR = systematic review; vs. = versus.

Table 18: Summary of Findings by Outcome — Other Outcomes

CI = confidence interval; MA = meta-analysis; NR = not reported; OR = odds ratio; PICC = peripherally inserted central catheter; RR = risk ratio; SR = systematic review; vs. = versus.

^aThe SR by Wen et al.²⁰ included no information on how pain, patient satisfaction, and dissatisfaction were measured (e.g., the types of scales, questionnaires, surveys, or other tools used).

^bThe findings from Wen et al.²⁰ were calculated using PICC as the intervention compared to midline catheters. To align with the direction of this review (i.e., midline catheters compared to PICC) the effect estimates were inverted by taking the reciprocal of the risk ratio and the bounds of the confidence interval. The findings as reported in the SR were: participants with pain, RR = 0.77 (95% CI, 0.35 to 1.68); number of catheters with pain, expressed as the number of events per total catheter days, RR = 0.65 (95% CI, 0.08 to 5.42); participant satisfaction rate, RR = 0.92 (95% CI, 0.56 to 1.51); participant dissatisfaction rate, RR = 4.77 (95% CI, 2.33 to 9.77).Table 19: Summary of Recommendations in Included Guidelines

Table 19: Summary of Recommendations in Included Guidelines

ACR = American College of Radiology; INS = Infusion Nurses Society; NA = not applicable; NR = not reported; PICC = peripherally inserted central catheter; RCT = randomized controlled trial; SR = systematic review.

Appendix 5: Overlap Between Included Systematic Reviews

Please note that this appendix has not been copy-edited.

Table 20: Overlap in Relevant Primary Studies Between Included Systematic Reviews