Authors: Mantri T et al.
Cureus 17(11): e97014. DOI: 10.7759/cureus.97014
This report describes two adult ICU patients with extremely difficult venous access in whom clinicians used a 4 Fr, 8 cm pediatric double-lumen central venous catheter as a midline substitute when standard midlines were unavailable. Because pediatric CVCs share similar dimensions with short midlines, inserting them under ultrasound into the basilic vein and ensuring the catheter tip remains in the proximal peripheral venous system allowed safe, durable access for non-vesicant therapy.
In Case 1, a patient with neuromuscular disease, severe dyspnea, and an inability to lie flat could not tolerate central line placement or repeated peripheral attempts. Real-time ultrasound enabled basilic vein cannulation, guidewire insertion, and advancement of the pediatric catheter with the tip positioned distal to the axillary vein. The device functioned reliably for medication delivery and blood draws without thrombosis or infection.
Case 2 involved a patient with severe necrotizing myopathy, multiple prior CVCs, extensive venous thrombosis, and line-associated bacteremia. With nearly all superficial veins unusable and midlines out of stock, clinicians again used a pediatric double-lumen CVC placed via ultrasound into the basilic vein. The dual-lumen design allowed antibiotics, fluids, and peripheral TPN administration. No catheter-related complications occurred.
The authors emphasize that ultrasound mapping, optimal vein selection, and confirmation of peripheral tip location are essential. Pediatric CVCs offer higher flow and durability than standard peripheral IVs while avoiding central-line risks such as CLABSI and pneumothorax. Clear labeling as a peripheral-terminating device is critical to prevent misuse. Although off-label, this approach provides a practical alternative in resource-limited settings or during supply shortages and may expand safe options for patients with difficult IV access.
What You Should Know
• Pediatric CVCs can function as midline substitutes when placed under ultrasound and kept peripheral
• Useful for adults with difficult venous access when standard midlines are not available
• Provides durable access for non-vesicant therapy with lower complication risk than central lines
• Requires meticulous technique, peripheral tip confirmation, and clear labeling to avoid misuse
• May help reduce CLABSI exposure and repeated painful peripheral attempts in complex patients
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