When approaching the epidural space from a posterior midline approach, three ligaments are traversed from superficial to deep the supraspinous ligament, the interspinous ligament, and the ligamentum flavum. Within the epidural space lies epidural veins, fat, lymphatics, and nerve roots.Įpidural catheter placement can be performed in a sitting or lying position at the cervical, thoracic, lumbar, or sacral levels. The epidural space exists circumferentially between the dura mater and the ligamentum flavum, extending from the foramen magnum to the sacral hiatus. Nerve roots emerge bilaterally at each vertebral level to innervate their respective dermatomes.Įpidural catheters are placed within the epidural space. It is surrounded by three meningeal layers: the pia, arachnoid, and dura. The spinal cord runs through the vertebral canal, extending from the foramen magnum to roughly the L1 level in most adults. This includes 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 4 coccygeal. Limitations to the analysis included its reliance on medical records and the potential for unmeasured confounders, including difference among specific devices used in the 48 hospitals, which, the authors noted, could well affect risks of adverse outcomes.The spine consists of 33 bony vertebrae. Only five bloodstream infections were seen with midlines used for antibiotics, versus 72 in the PICC group this gap was much smaller, though still substantial and in favor of midlines, in the difficult-access patients. About two-thirds of patients needing lines for antibiotics received PICCs, while midlines were preferred in a 3:2 ratio for patients with difficult access.Īs well, DVT was more common in the PICC group when used for IV antibiotics, whereas the reverse was seen in the difficult-access group. Swaminathan and colleagues noted some differences in device type and outcomes depending on whether catheter placement was for difficult access versus IV antibiotics. Adjustments in the statistical analyses included many factors including demographics, comorbidities, DVT/PE history, catheter lumen, and dwell time. The study's primary outcome was major complications, defined as catheter occlusion, catheter- or central line-related bloodstream infection, DVT, and pulmonary embolism (PE). What these data for DVT really mean, the team added, is that they serve "as a reminder to not dismiss the risk of thrombosis associated with midlines, especially in patients with hypercoagulability or preexisting risk factors," and that catheters of all types shouldn't be kept in place any longer than necessary. Whatever difference there was may have "reflect the higher number of events occurring over fewer total catheter days in midlines compared with PICCs," the researchers wrote. The odds ratio for DVT did not differ (OR 0.93, 95% CI 0.63-1.37). The study results showed that DVT rates were substantially lower with PICCs versus midline catheters (HR 0.53, 95% CI 0.38-0.74), but Swaminathan and co-authors argued that this wasn't definitive evidence for a genuine risk difference. One lingering question, however, is whether there's a difference in risk for deep vein thrombosis (DVT). The rates of device occlusion were lower by more than two-thirds with midlines (2.1% vs 7.0%) and bloodstream infections were lower by three-quarters (0.4% vs 1.6%, both P<0.001), the researchers reported in JAMA Internal Medicine.
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