Midline catheter placement in an obese patient with difficult venous access

Abstract

Rationale: Obesity is a risk factor for difficult venous access, catheter-related blood stream infections and thrombosis. All venous access devices have some disadvantages in obese patients. The Michigan Appropriateness Guide for Intravenous Catheters recommends choosing the optimal venous access device for each patient individually. Recently, the midline catheter has been considered an attractive alternative to the peripherally inserted central catheter. The appropriateness of midline catheters as venous access devices in obese patients needs further evaluation. Patient concerns: A 76-year-old woman was diagnosed with right breast cancer and scheduled for total mastectomy. The patient was obese (body mass index 37) and had difficult venous access. Diagnosis: After multiple failures of peripheral venous access, cellulitis developed in the left forearm. Interventions: Under ultrasound guidance, a relatively large (7 mm in diameter) and deep (3 cm in depth) basilic vein was found in the left arm and a midline catheter was smoothly placed into the vein (catheter vein ratio 6.3%). Surgery was performed with no adverse events. After surgery the patient was medicated with continuous intravenous administration heparin for thromboprophylaxis due to her having paroxysmal atrial fibrillation. Outcomes: The midline catheter was indwelled for 10 days. The patient was discharged without complications. Lessons: There is no single best choice for venous access in obese patients. The midline catheter is not recommended for venous access in all obese patients. However, some disadvantages may be overcome by careful placement and a strategy to prevent catheter-related thrombosis.