Efficacy of Normal Saline Versus Heparinized Saline Solution for Locking Catheters of Totally Implantable Long-Term Central Vascular Access Devices in Adult Cancer Patients

Preventing adverse events during paediatric cancer treatment: protocol for a multi-site hybrid randomised controlled trial of catheter lock solutions (the CLOCK trial)

INTRODUCTION

Central venous access devices (CVADs) are commonly used for the treatment of paediatric cancer patients. Catheter locking is a routine intervention that prevents CVAD-associated adverse events, such as infection, occlusion and thrombosis. While laboratory and clinical data are promising, tetra-EDTA (T-EDTA) has yet to be rigorously evaluated or introduced in cancer care as a catheter lock.

METHODS AND ANALYSIS

This is a protocol for a two-arm, superiority type 1 hybrid effectiveness-implementation randomised controlled trial conducted at seven hospitals across Australia and New Zealand. Randomisation will be in a 3:2 ratio between the saline (heparinised saline and normal saline) and T-EDTA groups, with randomly varied blocks of size 10 or 20 and stratification by (1) healthcare facility; (2) CVAD type and (3) duration of dwell since insertion. Within the saline group, there will be a random allocation between normal and heparin saline. Participants can be re-recruited and randomised on insertion of a new CVAD. Primary outcome for effectiveness will be a composite of CVAD-associated bloodstream infections (CABSI), CVAD-associated thrombosis or CVAD occlusion during CVAD dwell or at removal. Secondary outcomes will include CABSI, CVAD-associated-thrombosis, CVAD failure, incidental asymptomatic CVAD-associated-thrombosis, other adverse events, health-related quality of life, healthcare costs and mortality. To achieve 90% power (alpha=0.05) for the primary outcome, data from 720 recruitments are required. A mixed-methods approach will be employed to explore implementation contexts from the perspective of clinicians and healthcare purchasers.

ETHICS AND DISSEMINATION

Ethics approval has been provided by Children's Health Queensland Hospital and Health Service Human Research Ethics Committee (HREC) (HREC/22/QCHQ/81744) and the University of Queensland HREC (2022/HE000196) with subsequent governance approval at all sites. Informed consent is required from the substitute decision-maker or legal guardian prior to participation. In addition, consent may also be obtained from mature minors, depending on the legislative requirements of the study site. The primary trial and substudies will be written by the investigators and published in peer-reviewed journals. The findings will also be disseminated through local health and clinical trial networks by investigators and presented at conferences.

TRIAL REGISTRATION NUMBER

ACTRN12622000499785.

A Spectrum of Chemoport-Associated Complications and Their Management in Cancer Patients

INTRODUCTION

Chemotherapy is part and parcel of the multimodality approach to cancer treatment. Chemoports are frequently used to administer chemotherapy, preventing complications associated with the use of peripheral lines. However, chemoports have their own set of complications and can be very debilitating at times. Accurate knowledge and correct technique can help prevent and manage these complications properly.

METHODS

We retrospectively analyzed all patients who underwent chemoport insertion for chemotherapy infusion over three years between July 2020 and June 2023. The patient's profile, type of cancer, the technique of chemoport insertion, complications related to chemoport, and its management were recorded retrospectively from patient records.

RESULTS

The total number of patients in our study was 119. The age group of patients ranged from 13 years to 76 years. Of the 119 patients, 55 had breast cancer, 23 had ovarian cancers, 29 had GI cancers including gastroesophageal junction (GEJ)/ stomach/periampullary/colorectal, and 12 had leukemias. The most common intraoperative complication was catheter tip malposition (9.2%). The most common postoperative complications were infection (7.5%), followed by drug extravasation (5.0%), thrombosis (3.3%), wound dehiscence (2.5%), and skin necrosis (0.8%) in decreasing order of frequency. Serious complications such as hemothorax, pneumothorax, air emboli, brachial plexus injury, and pericardial tamponade, commonly reported in the literature, were not seen in any of our cases.

CONCLUSION

 Totally implanted venous access devices (TIVAD)/chemoports are indispensable in the management of cancer patients, especially in patients requiring long duration of infusion and prolonged treatment. Although chemoports are associated with a spectrum of complications, proper technique of implantation and use makes it a safe and reliable tool.

Three-Dimensional Simulation Training for Oncology Nurses to Address Pitfalls in Current Irrigation Strategy for Intravenous Ports: Repeated Measurements Study

OBJECTIVE

We designed an interactive visual training course and three-dimensional (3-D) simulator for participants and used verified questionnaires as tool to evaluate the efficacy of the education course.

DATA SOURCES

From August 2020 to December 2021, 159 nursing staff who received the interactive visual training course and completed validated questionnaires before and after the course were included. The efficacy of the course was evaluated by comparing the pre- and post-course questionnaires.

CONCLUSION

The interactive visual training course, including maintenance lectures and practice with a 3-D simulator, improved consensus among the nursing staff and increased the willingness of oncology nurses to perform the proposed port irrigation procedure.

IMPLICATIONS FOR NURSING PRACTICE

An implanted intravenous port cannot be directly seen by nursing staff and can only be identified through manual palpation. This lack of visibility may result in individual variations in port identification during daily practice, potentially leading to malpractice. To minimize these individual variations, we have designed an interactive visual training course. We used validated questionnaires before and after the course to analyze its efficacy in practical education.

Implementation of an Evidence-Based Practice Change Removing Heparin From Implanted Vascular Access Devices

The objective of this article was to describe the implementation and outcomes of an evidence-based practice change to remove heparin from implanted vascular access device (IVAD) management. An extensive search of the literature was performed, and articles were appraised and synthesized to determine the best practice. A common theme emerged from the literature, showing that 0.9% sodium chloride alone can be as effective as heparin in preventing occlusion in IVADs. In this nurse-led initiative, heparin was successfully removed from the IVAD deaccess process and replaced with a 0.9% sodium chloride flush using a pulsatile flushing technique. Alteplase administration rates were used to measure success of the project, with no statistically significant change observed in alteplase rates 6 mo postimplementation. Successful implementation of this practice change demonstrates that 0.9% sodium chloride may be used for IVAD lock when deaccessing.

Analysis of related complications of totally implantable venous access ports in children's chemotherapy: Single center experience

Totally implantable venous access port (TIVAP) has become an important infusion channel for children who need chemotherapy. With the popularization of TIVAP, its related complications have gradually received clinical attention. However, there are few studies on the complications of TIVAP in children. Therefore, this study intends to analyze the risk factors of complications in children's infusion port, so as to provide basis for guiding clinical prevention and intervention. This paper retrospectively analyzed 182 children who received TIVAP implantation in our hospital from January 2018 to January 2021. According to the demographic data, basic disease status and operation related data obtained through Hospital Information System and manual follow-up, the complications and related influencing factors after implantation and implantation were summarized and analyzed. SPSS software was used to analyze the influencing factors between the complication group and the control group. There were 182 cases of children implanted in intravenous infusion port, of which 71 cases had complications, infection was the most common complication in 50 cases, followed by catheter blockage in 23 cases. Among the infection factors, catheter-related blood stream infection accounted for the highest proportion in 31 cases (17.0%), and Staphylococcus epidermidis was the most common pathogen. A total of 19 cases were pulled out early, and the unplanned pullout rate of catheter-related blood stream infection was the highest. In the analysis of influencing factors, age had significant differences in catheter-related infection, all complications and no complications (P < .05). The overall incidence of complications in the use of TIVAP in children with chemotherapy is high, and infection is the most common complication, among which catheter-related blood stream infection is the most common cause of unplanned pullout. Lower age may be associated with a higher incidence of complications.

Heparin versus normal saline locking for prevention of occlusion, catheter-related infections and thrombosis in central venous catheter in adults: Overview of systematic reviews

Venous access devices are used in health care. To prevent occlusions the evidence confirmed the need for routine catheter flushing before and after infusion as well as at the end of use. To date, the efficacy of heparin has not been demonstrated. The aim of this study was to evaluate the effectiveness of the locking of central venous catheters with heparin versus normal saline in adults to prevent occlusion, catheter-related infections and thrombosis in adults. A literature search using Medline, Embase, Cochrane Library and Cinahl was performed to identify all meta-analyses addressing the effectiveness of heparin versus normal saline in locking central venous catheters in adults. Four reviewers independently selected publications assessed quality and extracted data. Parameter estimates regarding occlusion, catheter- related infections and thrombosis were pooled using an umbrella review. We identified 6356 references. Seven systematic reviews were included in the study. Most of the studies included in the systematic reviews were conducted in oncohaematology departments, intensive care and cardiac surgery units among patients with multiple diseases and chronicity. Most studies report a heparin concentration of 10 to 5000 IU/ml versus normal saline and other solutions. There was no evidence that heparin was more effective than normal saline in reducing complications such as occlusion, catheter-related infections and thrombosis. No statistically significant difference was found between heparin and normal saline in reducing catheter occlusion. Heparin is not superior compared to normal saline.

“Evidence On Port-locking With Heparin versus Saline in Cancer Patients Not Receiving Chemotherapy. Randomized Clinical Trial”

Objective

To assess the safety and efficacy of port-locking with heparin every 2 months vs. every 4 months and vs. saline solution every 2 months in patients with cancer not receiving active chemotherapy. The hypothesis stated that locking with heparin at four-month intervals and saline at two-month intervals would not increment > 10% of port obstructions.

Methods

Multicentre, phase IV parallel, post-test control group study took place at the two chemotherapy units of oncology hospitals. Included patients with cancer with ports that completed the chemotherapy treatment but still having port maintenance care or blood samples taken up to four months. A sample of 126 patients with cancer in three arms was needed to detect a maximum difference of 10% for bioequivalence on the locking methods. Consecutive cases non-probabilistic sampling and randomized to one of the three groups; group A: received heparin 60 IU/mL every two months (control) vs. group B heparin every four months and vs. saline every two months in group C. Primary variables were the type of locking regimen, port obstruction, and absence of blood return, port-related infection, or venous thrombosis during the study period. Clinical and sociodemographic variables were also collected.

Results

A total of 143 patients were randomly assigned; group A, 47 patients with heparin every 2 months, group B, 51 patients with heparin 4 months, and group C, 45 patients with saline every 2 months. All participants presented an adequate blood return and no obstructions, until the month of the 10th, when one participant in the group A receiving was withdrawn due to an absence of blood flow (P ​= ​0.587).

Conclusions

Port locks with heparin every 4 months or saline every 2 months did not show differences in safety maintenance, infection, or thrombosis compared to heparin every 2 months.

Routine Catheter Lock Solutions in Pediatric Cancer Care: A Pilot Randomized Controlled Trial of Heparin vs Saline

BACKGROUND

Central venous access devices (CVADs) are integral to cancer care provision. Despite the high prevalence of CVAD complications in children with cancer, preventative strategies are understudied.

OBJECTIVE

The aim of this study was to assess study feasibility, occlusive events, thrombolytic use, adverse events, and direct costs of catheter lock solutions.

METHODS

A single-center, parallel-group, pilot randomized controlled trial was undertaken at a tertiary-referral pediatric hospital in Australia. Children 18 years or younger with an oncological or malignant hematological condition and a CVAD were eligible. Participants were 1:1 randomized to (1) normal or (2) heparinized (10-100 U/mL; CVAD-type dependent) saline lock solutions.

RESULTS

Of 217 children assessed for eligibility, 61 were recruited and randomized to normal (n = 30; 3850 CVAD days) or heparinized (n = 31; 4036 CVAD days) saline. Eligibility (52%) and recruitment (54%) feasibility targets were not met. Protocol adherence was high (95% assessments), with no attrition. Parent/clinician satisfaction of interventions was high (median, 10/10 clinicians/parents). Complete CVAD occlusion occurred in heparin only (n = 2, 6.7% CVADs; incidence rate [IR], 0.49/1000 CVAD days [0.06-1.78]). Central venous access device partial occlusion was detected in 23.3% of CVADs in heparin (n = 7; IR, 2.73/1000 CVAD days [1.36-4.87]) and 13.8% of CVADs in normal saline (n = 4; IR, 2.59/1000 CVAD days [1.24-4.77]). Thrombolytic agents were used in 16.7% heparin (5 CVADs) and 3.5% normal saline (1 CVAD). Adverse events did not differ between groups.

CONCLUSION

Multisite randomized controlled trials examining CVAD locks are safe, but strategies and resources to increase recruitment and eligibility are required.

IMPLICATIONS FOR PRACTICE

Both routine CVAD lock solutions seem safe but may not prevent all forms of CVAD-associated harm.

Prolonging the flush-lock interval of totally implantable venous access ports in patients with cancer: A systematic review and meta-analysis

BACKGROUND

Recently, some studies have shown that prolonging flush interval is safe and feasible for patients who complete chemotherapy. However, there is no consensus about the optimal flush interval for those patients.

OBJECTIVE

The purpose of this review was to evaluate whether the flush interval could be prolonged based on monthly interval for regular maintenance and to explore the optimal flush interval.

DATA SOURCES

We searched the following databases for articles published between 1 January 1982 and 21 February 2020: PubMed, Cochrane Library, Web of Science, EMBASE, CINAHL, and Ovid.

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials, retrospective and prospective cohort studies of flush interval less than 4 weeks versus longer than 4 weeks for patients who completed chemotherapy, were included.

RESULTS

Two reviewers extracted information and assessed the quality of the articles independently. In total, 389 articles were retrieved, and 4 studies including 862 cases fulfilled the inclusion criteria. There was no statistical heterogeneity (I² = 0, p > 0.05) among the included studies. Hence, the fixed-effects model was used for the meta-analysis. The meta-analysis showed that the total complication rate associated with longer than 4-week interval was higher than that associated with less than 4-week interval. Nevertheless, there was no significant difference between the two groups (7.2% vs 7.6%, p = 0.83). Moreover, the meta-analysis showed that the total complication and catheter occlusion rates associated with the 4-week interval were higher than those associated with the 8-week interval. However, there was no significant difference between the two groups (total complications: 11.4% vs 9.5%, p = 0.68; catheter occlusions: 4.9% vs 4.1%, p = 0.89).

LIMITATIONS

Only four non-randomized controlled studies were included, and the outcomes of the included studies were reported incompletely.

CONCLUSION

Extending the flush interval to longer than 4 weeks is safe and feasible. Based on previous studies, extending the flush interval to 8 weeks might not increase the incidence of total complications and catheter occlusions. However, there is no conclusion on whether the flush interval could be extended to 3 months or longer.

A retrospective observational study on maintenance and complications of totally implantable venous access ports in 563 patients: Prolonged versus short flushing intervals

Objectives

To assess whether the extension of the flushing interval will increase risks of complications associated with totally implantable venous access port (TIVAP) in the off-treatment period.

Methods

A retrospective single-center observational study was performed. Patients with a TIVAP in the off-treatment period that underwent regular flushing in our clinic were included. Data concerning patients and their TIVAPs were recorded. Patient baseline characteristics and TIVAP-related complications were analyzed. Continuous variables were analyzed by ANOVA or the Kruskal-Wallis H test. To compare the occurrence of TIVAP-related complications, the chi-square test was used; if needed, Fisher’s exact test was used.

Results

Totally 607 patients were reviewed, and 563 patients were finally included. Thirteen complications were recorded, including 11 cases of catheter occlusion (1.95%), one case of port cannula rotation (0.18%), and one case of catheter tip malposition (0.18%). No device-related infection or venous thrombosis was recorded. Among these patients, the average flushing interval was 35.27 ± 13.09 days. Patients were divided into three groups according to the flushing interval: every 28 days or less (Group 1, n = 133); every 29–44 days (Group 2, n = 350); and every 45 days or more (Group 3, n = 80). No significant difference in catheter-related complications was found among the three groups (P > 0.05).

Conclusions

In the TIVAP off-treatment period, patients without any history of TIVAP-related complications during approximately one year can attempt to prolong the flushing interval to more than 4 weeks; we further suggest that 5–6 weeks may be an appropriate option for these patients.

Comparison between the effects of normal saline with and without heparin for the prevention and management of arterial catheter occlusion: a triple-blinded randomized trial

PURPOSE

We aimed to compare the effects of saline with and without heparin on the catheter-occlusion rate and coagulation-related blood test results for the management of arterial catheters among patients admitted to a short-term intensive care unit postoperatively.

METHODS

This prospective, triple-blinded, randomized controlled study recruited patients aged 20-90 years scheduled to undergo radial arterial catheter insertion and postoperative intensive care unit admission between February and August 2019. Patients were randomly allocated to two groups (1:1 ratio) depending on the use of heparin: study (normal saline with heparin, 3000 units to 500 ml of normal saline) and control (normal saline without heparin) groups with arterial catheters. The allocated management method was employed immediately after intensive care unit admission. Occlusion assessment (every 12 h), arterial blood gas tests (every 6 h), and blood sample collection (every 24 h) were performed. The occlusion of arterial catheter was assessed using occlusion rate, and blood test results were assessed using a linear mixed model.

RESULTS

There were 147 patients in the arterial catheter groups. There were no significant differences in occlusion rates and changes in platelet counts and activated partial thromboplastin time between the groups with arterial (p = 0.98, 0.16, and 0.32, respectively) catheters during the first 6 days after intensive care unit admission.

CONCLUSION

Normal saline with and without heparin showed similar efficiency for both the prevention of occlusion and the results of coagulation.

Heparin versus 0.9% saline solution to maintain patency of totally implanted venous access ports in cancer patients: A systematic review and meta-analysis

AIM

The use of heparin and 0.9% saline solution is always controversial for central venous catheters. However, there is no systematic review or guideline about whether saline solution can replace heparin solution in adult cancer patients with totally implantable venous access ports (TIVAPs). The purpose of this review is to evaluate whether saline solution can replace heparin saline to lock TIVAPs.

METHODS

The following databases were searched: PubMed, the Cochrane Library, Web of Science, Embase, CINAHL and Ovid (January 1, 1982, and February 21, 2020). All statistical analyses of the meta-analysis were completed using the Review Manager 5.3.

RESULTS

A total of 201 studies were identified from these databases after initial review, and four studies met inclusion criteria, including 2652 cases. There was little heterogeneity among the included studies (I² < 30%), and all analyses were conducted by the fixed-effects model. The total complications, catheter occlusions, catheter-related bloodstream infections and other complication rates in the heparin solution group were higher than in the saline solution group. In the subgroup analysis of heparin concentration, total complication rates in the saline solution group were higher than with 50 U of heparin and lower than with 100 U of heparin. However, the differences in these complications were small, and no significant difference was observed (all P > 0.05).

CONCLUSIONS

Based on existing clinical studies, we recommend that saline solution can replace 50 or 100 U/ml of heparin as a safe and effective flush solution for TIVAPs.

Prolonged flushing and locking interval for totally implantable vascular access device: A systematic review and meta-analysis

The objective of this systematic review is to evaluate the safety ad feasibility of the totally implantable vascular access devices (TIVADs) flushed more than 4 weeks. We searched the following electronic databases from the date their build-up to February 2020: PubMed, EMBASE, The Cochrane Central Register of Controlled Trials (CENTRAL), and CINAHL. The final selection resulted in 14 trials fulfilling the inclusion criteria and being included in our review. A pooled frequency of port-related late complications with longer flushing intervals (>4 weeks) was 8.0%, and the pooled frequency of occlusions, infections, and mechanical complications was 5.0%, 2.0%, and 3.0%, respectively. Then, we compared the frequency of port-related complications between standard and longer flushing intervals. There were no differences between the group's changes in the frequency of total late complications, occlusions, infections, and mechanical complications. This systematic review and meta-analysis demonstrates that longer flushing intervals for ports are safe. However, more prospective, power appropriated randomized trials are needed to explore the specific flushing time for ports.

Heparin solution in the prevention of occlusions in Hickman® catheters a randomized clinical trial

OBJECTIVE

to evaluate the effectiveness of the 50 IU/mL heparin solution compared to the 0.9% isotonic saline solution in preventing occlusion of the double lumen Hickman® catheter, 7 and 9 French, in patients undergoing hematopoietic stem cell transplantation.

METHOD

a triple-blind randomized clinical trial. 17 double-lumen catheters (heparin group: n=7 and 0.9% isotonic saline group: n=10) were analyzed in which the two catheter routes were evaluated separately, totaling 34 lumens. The outcome variables were occlusion without reflux and complete occlusion. Descriptive analyses were performed using the Chi-square test and, of survival, according to the Kaplan-Meier test.

RESULTS

the mean number of days until the occlusion outcome was 52 in the heparin group and 13.46 in the 0.9% isotonic saline group in the white catheter route (p<0.001). In the red route, the mean follow-up days in the heparin group were 35.29, with no occlusion and 22.30 in the 0.9% isotonic saline group until the first occlusion (p=0.030).

CONCLUSION

blocking with 50 IU/mL heparin solution is more effective than 0.9% isotonic saline in preventing occlusion of the Hickman® catheter. Brazilian Registry of Clinical Trials: RBR-3ht499.

Safe use of Peripherally Inserted Central Catheters for chemotherapy of solid malignancies in adult patients: A 1-year monocentric, prospectively-assessed, unselected cohort of 482 patients

INTRODUCTION

Aim of this study was to analyze the overall complication and failure rates of Peripherally Inserted Central Catheters (PICCs), in a 1-year consecutive unselected cohort of 482 adult patients, affected by non-hematological malignancies undergoing chemotherapy.

METHODS

Adult outpatients (aged 18-75 years), with an Eastern Cooperative Oncology Group (ECOG) performance status of 0-2, bearing solid tumors and candidates for intravenous chemotherapy were eligible for the study. Exclusion criteria were active infections, coagulopathy (defined as platelet count <50,000/μL and/or prothrombin time more than 18 s), life expectancy <6 months, or inability to give written informed consent. Devices were all implanted in an outpatients' hospital facility, following predefined evidence-based institutional guidelines and protocols by a PICC-dedicated team at the European Institute of Oncology in Milan, Italy, during the 12-month period from January 1 to December 31, 2019.

RESULTS

Five-hundred PICCs were implanted in a cohort of 482 patients during the time interval of this study. Thirty devices were overall removed (6.2%), 23 as a consequence of a complication occurred, and seven inadvertently. The inserted PICCs accounted for a total of 49,718 catheter days in situ, median duration was 85.5 days [interquartile range (IQR): 56-146]. Overall there were 42 (8.7%) complications, corresponding to 0.84 catheter-adverse events (CAE)/1000 PICC-days (95% CI: 0.61-1.14). There were N = 13 (2.7%) thromboses, N = 11 (2.3%) irreversible occlusions, N = 7 (1.5%) accidental removals, N = 5 (1.0%) infections [two Catheter Related Blood Stream Infection (CRBSI) and three exit site/local infection], N = 3 (0.6%) ruptures and N = 3 (0.6%) primary or secondary malpositions.

CONCLUSION

This large prospective study supports the increasing use of PICCs in adult oncology outpatients treated in specialized centers with chemotherapy for non-hematological malignancies. In this clinical setting, PICC failure occurred in 6% only of the inserted devices.

Dosage of heparin for patency of the totally implanted central venous catheter in cancer patients

OBJECTIVE

to analyze the evidence available in the literature about the lowest necessary dose of heparin to maintain the patency of the totally implanted central venous catheter in adult cancer patients.

METHOD

an integrative literature review, carried out in the following databases: Literatura Latino-Americana e do Caribe em Ciências de Saúde, Sciverse Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, including thirteen studies.

RESULTS

the evidence showed that the dose of heparin (300 IU/ml) is the most used in maintaining the patency of the totally implanted central venous catheter.

CONCLUSION

according to the selected studies, the lowest dose of heparin found in maintaining the patency of the totally implanted central venous catheter in cancer patients was 10 UN/ml with a volume of 5 ml of the heparin solution.

Normal saline (0.9% sodium chloride) versus heparin intermittent flushing for the prevention of occlusion in long-term central venous catheters in infants and children

BACKGROUND

Guidelines and clinical practice for the prevention of complications associated with central venous catheters (CVC) around the world vary greatly. Most institutions recommend the use of heparin to prevent occlusion; there is debate, however, regarding the need for heparin and evidence to suggest normal saline (0.9% sodium chloride) may be as effective. The use of heparin is not without risk, may be unnecessary and is also associated with increased cost. This is an update of the review published in 2015.

OBJECTIVES

To assess the clinical effects (benefits and harms) of intermittent flushing of normal saline versus heparin to prevent occlusion in long-term central venous catheters in infants and children.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases; World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials register to 9 April 2019. We also undertook reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared the efficacy of intermittent flushing with normal saline versus heparin to prevent occlusion of long-term CVCs in infants and children aged up to 18 years of age. We excluded temporary CVCs and peripherally inserted central catheters (PICC).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial inclusion criteria, trial quality and extracted data. We assessed study quality with the Cochrane 'Risk of bias' tool. For dichotomous outcomes, we calculated the rate ratio (RR) and corresponding 95% confidence interval (CI). We pooled data using a random-effects model; and we used GRADE to assess the overall certainty of the evidence supporting the outcomes assessed in this review.

MAIN RESULTS

We identified one new study for this update, bringing the total number of included studies to four (255 participants). The four trials directly compared the use of normal saline and heparin; the studies all used different protocols for the intervention and control arms, however, and all used different concentrations of heparin. Different frequencies of flushes were also reported between studies. In addition, not all studies reported on all outcomes. The certainty of the evidence ranged from moderate to very low because there was no blinding; heterogeneity and inconsistency between studies was high; and the CIs were wide. CVC occlusion was assessed in all four trials. We were able to pool the results of two trials for the outcomes of CVC occlusion and CVC-associated blood stream infection. The estimated RR for CVC occlusion per 1000 catheter days between the normal saline and heparin groups was 0.75 (95% CI 0.10 to 5.51; 2 studies, 229 participants; very low certainty evidence). The estimated RR for CVC-associated blood stream infection was 1.48 (95% CI 0.24 to 9.37; 2 studies, 231 participants; low-certainty evidence). The duration of catheter placement was reported to be similar for the two study arms in one study (203 participants; moderate-certainty evidence), and not reported in the remaining studies.

AUTHORS' CONCLUSIONS

The review found that there was not enough evidence to determine the effects of intermittent flushing with normal saline versus heparin to prevent occlusion in long-term central venous catheters in infants and children. It remains unclear whether heparin is necessary to prevent occlusion, CVC-associated blood stream infection or effects duration of catheter placement. Lack of agreement between institutions around the world regarding the appropriate care and maintenance of these devices remains.

An Implanted Magnetic Microfluidic Pump for In Vivo Bone Remodeling Applications

Modulations of fluid flow inside the bone intramedullary cavity has been found to stimulate bone cellular activities and augment bone growth. However, study on the efficacy of the fluid modulation has been limited to external syringe pumps connected to the bone intramedullary cavity through the skin tubing. We report an implantable magnetic microfluidic pump which is suitable for in vivo studies in rodents. A compact microfluidic pump (22 mm diameter, 5 mm in thickness) with NdFeB magnets was fabricated in polydimethylsiloxane (PDMS) using a set of stainless-steel molds. An external actuator with a larger magnet was used to wirelessly actuate the magnetic microfluidic pump. The characterization of the static pressure of the microfluidic pump as a function of size of magnets was assessed. The dynamic pressure of the pump was also characterized to estimate the output of the pump. The magnetic microfluidic pump was implanted into the back of a Fischer-344 rat and connected to the intramedullary cavity of the femur using a tube. On-demand wireless magnetic operation using an actuator outside of the body was found to induce pressure modulation of up to 38 mmHg inside the femoral intramedullary cavity of the rat.

Peripherally inserted central venous catheter (PICC) in outpatient and inpatient oncological treatment

Purpose

So far there is little evidence on peripherally inserted central venous catheter (PICC) in radiation oncology patients maintaining the access during the periods of ambulatory and hospital treatment.

Methods

A total of 522 PICC placements in 484 patients were performed between 11/2011 and 07/2016 at the Department of Radiation Oncology and analysed retrospectively for complications and treatment- and patient-related factors during ambulatory and hospital inpatient use. On initial hospitalization, all patients received a multimodal radio-oncological treatment consisting of radiation and intravenous therapy administered via the PICC.

Results

A total of 18,292 catheter days were documented. Median follow-up from catheter insertion to their removal was 37 days (1–97). The overall complication rate was 4.1 per 1000 catheter days (n = 75, 14.4%). Complications were similar between the cohort of outpatient 3.6 per 1000 catheter days and the cohort of inpatient 4.8 per 1000 catheter days (OR 0.976; 95% CI [0.598; 1.619]; p = 0.924). Severe bloodstream infections occurred at a rate of 0.60 per 1000 catheter days (n = 11, 2.1%), deep vein thrombosis at a rate of 0.82 per 1.000 catheter days (n = 15, 2.9%) and local inflammation at a rate of 1.26 per 1.000 catheter days (n = 23, 4.4%). Only immunotherapy could be identified as an independent risk factor for complications (OR 5.6; 95% CI [2.4; 13.1]; p < 0.001).

Conclusion

Using PICC in outpatients is not associated with an elevated risk of complications. Particular attention should be payed to early identification of PICC associated bloodstream infections. Immunotherapy is an independent risk factor for local skin complication.

Electronic supplementary material

The online version of this article (10.1007/s00520-019-05276-0) contains supplementary material, which is available to authorized users.

PICC-PORT totally implantable vascular access device in breast cancer patients undergoing chemotherapy

BACKGROUND AND OBJECTIVES

The increasing use of arm totally implantable vascular access devices for breast cancer patients who require chemotherapy has led to a greater risk of complications and failures and, in particular, to upper extremity deep vein thrombosis. This study aims to investigate the outcomes of the arm peripherally inserted central catheter-PORT technique in breast cancer patients.

METHODS

The peripherally inserted central catheter-PORT technique is an evolution of the standard arm-totally implantable vascular access device implant based on guided ultrasound venous access in the proximal third of the upper limb with subsequent placement of the reservoir at the middle third of the arm. A prospective study was conducted on 418 adult female breast cancer patients undergoing chemotherapy. The primary study outcome was peripherally inserted central catheter-PORT failure.

RESULTS

Median follow-up was 215 days. Complications occurred in 29 patients (6.9%) and failure resulting in removal of the device in 11 patients (2.6%). The main complication we observed was upper extremity deep vein thrombosis, 10 (2.4%); all patients were rescued by anticoagulant treatment without peripherally inserted central catheter-PORT removal. The main reason for removal was reservoir pocket infection: 4 (0.9%) with an infection rate of 0.012 per 1000 catheter days. Cumulative 1-year risk of failure was 3.6% (95% confidence interval, 1.3%-7.1%). With regard to the patients' characteristics, body mass index <22.5 was the only significant risk for failure (p = 0.027).

CONCLUSION

The peripherally inserted central catheter-PORT is a safe vascular device for chemotherapy delivery that achieves similar clinical results as traditional long-term vascular access devices (peripherally inserted central catheter and arm totally implantable vascular access device, in particular) in breast cancer patients.

Heparin Versus Normal Saline: Flushing Effectiveness in Managing Central Venous Catheters in Patients Undergoing Blood and Marrow Transplantation

BACKGROUND

Patients undergoing blood and marrow transplantation (BMT) use a central venous catheter (CVC); heparin is often employed to maintain patency but may increase the risk of complications. Research has not provided conclusive differences in efficacy and safety regarding heparin flushing versus normal saline flushing in CVC maintenance. Minimal research is specific to this patient population.

OBJECTIVES

This study aimed to determine if differences exist in CVC patency, tissue plasminogen activator usage, and the incidence of central line-associated bloodstream infections when flushing with normal saline only versus heparin and normal saline among patients undergoing BMT.

METHODS

A convenience sample of 30 patients undergoing allogeneic or autologous transplantation with a new non-port/non-peripherally inserted CVC were evaluated.

FINDINGS

Elimination of routine heparin use could positively affect outcomes in this patient population.

A comparison of heparinised and non-heparinised normal saline solutions for maintaining the patency of arterial pressure measurement cannulae after heart surgery

Background

Heparinized solution (HS) use for the maintenance of arterial cannulas has been associated with coagulation disorders and has not been conclusively shown to confer additional benefits over normal saline (NS) alone. We tested the hypothesis that in adult patients admitted to the cardiac ICU (T0) after cardiac surgery, HS arterial cannulas might be independently associated with increased heparin-induced coagulation disorders and might not be superior to NS arterial cannulas in reducing arterial cannula occlusion.

Methods

In this cohort study, 170 patients who received NS arterial cannulas during the period from T0 to ICU discharge were included in this study from June 1, 2017, to May 1, 2018 (NS group). There were 2930 patients who used HS (2.5 U/ml) arterial cannulas from January 1, 2015, to December 31, 2016 (heparin group). To address indicated biases, we derived a propensity score that predicted the functions of NS and HS in the patency of arterial cannulas.

Results

There were 296 patients (148 in the NS group and 148 in the heparin group) with similar risk profiles in the propensity-score matched cohorts. In the propensity-matched patients, the duration of arterial cannulas (P = 0.4) and arterial cannula occlusion (P = 0.5) showed no differences between the NS and heparin groups. However, the heparin group had a significantly increased activated clotting time (P < 0.05), activated partial thromboplastin time (P = 0.01) and allogeneic red blood cell utilization (3.4% vs 10.8%, P < 0.05). Compared with the NS group, the heparin group had more drainage from chest tubes from T0 to T48 (10.6 ± 9.4 ml/kg vs 13.0 ± 7.22 ml/kg, P < 0.05) and had more allogeneic red blood cells transfused (0.1 ± 0.4 U vs 0.4 ± 1.1 U, P < 0.05).

Conclusion

Based on the results of our study, the addition of heparin to normal saline for flushing arterial pressure monitoring cannulae did not reduce the incidence of catheter thrombosis and result in a very small but statically significant in increase in activated clotting time and activated partial thromboplastin time.

Comparison between Saline Solution Containing Heparin versus Saline Solution in the Lock of Totally Implantable Catheters

BACKGROUND

There are only 3 studies comparing the efficacy of 2 different types of lock used in totally implantable catheters regarding occlusion or reflux dysfunction. The present study contains the largest published casuistry (862 patients) and is the only one that analyzes 3 parameters: occlusion, reflux dysfunction, and flow dysfunction.

METHODS

This was a retrospective study of patients operated at a large oncology center and followed up in the outpatient clinic between 2007 and 2015. The patients were divided into 2 groups according to the type of lock: the Hep group (heparine), whose lock was composed of saline solution 0.9% with heparin (100 IU/mL) and the SS group (saline solution), whose lock was composed of saline solution 0.9%.

RESULTS

The Hep group was composed of 270 patients (31%) and the SS group of 592 patients (69%). Regarding occlusion, there were 8 cases in the Hep group (2.96%) and 8 in the SS group (1.35%; P = 0.11); in relation to reflux dysfunction, there were 8 cases in the Hep group (2.96%) and 8 in the SS group (1.35%; P = 0.11); in relation to flow dysfunction, there was 1 case in the Hep group (0.37%) and 4 cases in the SS group (0.68%; P = 1).

CONCLUSIONS

There was no statistically significant difference between the groups regarding occlusion, reflux dysfunction, and flow dysfunction.

Incidence and Determinants of Port Occlusions in Cancer Outpatients: A Prospective Cohort Study

BACKGROUND

Normal saline is considered a safe alternative for heparin as a locking solution in totally implantable venous access devices. The incidence rate of partial occlusion with the use of normal saline (easy injection, impossible aspiration) is estimated at 4%.

OBJECTIVE

The aim of this study was to investigate determinants of partial occlusions with the use of normal saline solution and the maintenance of positive pressure in the catheter.

METHODS

We enrolled 218 patients with different solid tumors who underwent pharmacologic treatment through the port with different frequencies: from once every week to at least once every month. The port was flushed with normal saline solution keeping a positive pressure in the catheter.

RESULTS

We performed 4111 observations and documented normal port functioning in 99% of observations (n = 4057) and partial occlusions in 1% of observations (n = 54). Partial occlusions were significantly associated with frequency of port flushing (P < .05), chemotherapy (P < .001), and blood sample collection (P < .001).

CONCLUSIONS

The use of positive pressure in addition to normal saline reduces the incidence rate of partial occlusions. The type of treatment, blood sample collection, and treatment schedule are important determinants of partial occlusions.

IMPLICATIONS FOR PRACTICE

Nurses play a key role in maintaining a functioning port using positive pressure during the flushing techniques. Certain risk factors must be monitored to prevent partial occlusions, and certain patients are more likely to present with port-related problems.

Heparin-Induced Thrombocytopenia

Heparin-induced thrombocytopenia (HIT) is an immune-mediated complication of heparin therapy. The use of heparin to flush some vascular access devices makes HIT a concern for infusion nurses. This article reviews the risk factors for, pathophysiology of, and management of HIT.

Port in oncology practice: 3-monthly locking with normal saline for catheter maintenance, a preliminary report

INTRODUCTION

Patients with cancer need stable venous access using central vascular devices like central venous ports and peripherally inserted central catheters that can be used for a wide range of indications. Numerous flushing protocols exist including different frequencies for catheter locking to maintain catheter patency. The aim of this retrospective study was to evaluate the incidence of lumen occlusion of central venous ports in a group of adult cancer patients, adopting a policy of locking with normal saline every three months.

METHODS

This is a single-center retrospective observational study. During follow-up, we analyzed adult cancer patients who had undergone port insertion from January 1st, 2007 to August 31st, 2014. Flushing and locking were performed every three months with a syringe containing normal saline.

RESULTS

We collected data from 381 patients with ports inserted in subclavian vein (379 patients) and in the right jugular vein (2 patients). Locking was performed during 3-monthly follow-up visits. Median follow-up was 810 days (90-2700 days). Among 381 ports, 59 were removed; the reasons for removal were: end of use (45 cases), catheter rupture (9 cases), dislocation (3 cases) and catheter-related bloodstream infection (2 cases). We had no reports of lumen occlusion.

CONCLUSIONS

Our data suggest that locking ports with normal saline every three months is not associated with an increased risk of lumen occlusion.

Comparative Efficacies of Antimicrobial Catheter Lock Solutions for Fungal Biofilm Eradication in an in Vitro Model of Catheter-Related Fungemia

Fungal catheter-related bloodstream infections (CRBSIs)-primarily due to Candida species-account for over 12% of all CRBSIs, and have been progressively increasing in prevalence. They present significant health and economic burdens, and high mortality rates. Antimicrobial catheter lock solutions are an important prophylactic option for preventing fungal CRBSIs. In this study, we compared the effectiveness of two FDA-approved catheter lock solutions (heparin and saline) and three experimental antimicrobial catheter lock solutions-30% citrate, taurolidine-citrate-heparin (TCH), and nitroglycerin-citrate-ethanol (NiCE)-in an in vitro model of catheters colonized by fungi. The fungi tested were five different strains of Candida clinical isolates from cancer patients who contracted CRBSIs. Time-to-biofilm-eradication was assessed in the model with 15, 30, and 60 min exposures to the lock solutions. Only the NiCE lock solution was able to fully eradicate all fungal biofilms within 60 min. Neither 30% citrate nor TCH was able to fully eradicate any of the Candida biofilms in this time frame. The NiCE lock solution was significantly superior to TCH in eradicating biofilms of five different Candida species (p = 0.002 for all).

[Effectiveness of heparin versus 0.9% saline solution in maintaining the permeability of central venous catheters: a systematic review]

OBJECTIVE

Determining which is the most effective solution (heparin flush compared to 0.9% saline flush) for reducing the risk of occlusions in central venous catheters (CVC) in adults.

METHOD

The systematic review followed the principles proposed by the Cochrane Handbook; critical analysis, extraction and synthesis of data were performed by two independent researchers; statistical analysis was performed using the RevMan program 5.2.8.

RESULTS

Eight randomized controlled trials and one cohort study were included and the results of the meta-analysis showed no difference (RR=0.68, 95% CI=0.41-1.10; p=0.12). Analysis by subgroups showed that there was no difference in fully deployed CVC (RR=1.09, CI 95%=0.53-2.22; p=0.82); Multi-Lumen CVC showed beneficial effects in the heparin group (RR=0.53, CI 95%=0.29-0.95; p=0.03); in Double-Lumen CVC for hemodialysis (RR=1.18, CI 95%=0.08-17.82; p=0.90) and Peripherally inserted CVC (RR=0.14, CI 95%=0.01-2.60; p=0.19) also showed no difference.

CONCLUSION

Saline solution is sufficient for maintaining patency of the central venous catheter, preventing the risks associated with heparin administration.

Peripherally inserted central catheters (PICCs) in cancer patients under chemotherapy: A prospective study on the incidence of complications and overall failures

BACKGROUND AND OBJECTIVES

The increasing use of peripherally inserted central venous catheters (PICCs) for chemotherapy has led to the observation of an elevated risk of complications and failures. This study investigates PICC failures in cancer patients.

METHODS

A prospective study was conducted at a single cancer institution on 291 PICC placement for chemotherapy. The primary study outcome was PICC failure.

RESULTS

Median follow-up was 119 days. PICC complications occurred in 72 patients (24.7%) and failures with removal in 44 (15.1%). Reasons for failures were upper extremity deep venous thrombosis (UEDVT) 12 (4.1%), central line associate bloodstream infection (CLABSI) 5 (1.7%) with an infection rate of 0.95 per 1,000 catheter days, exit site infection 9 (3.1%) with a rate of 1.46 per 1,000 catheter days, catheter dislodgment 11 (3.8%), and occlusion 7 (2.4%). Statistically significant risk factors were previous DVT (HR 2.95, 95%CI 1.33-6.53), reason for PICC implant (HR 3.65, 95%CI 1.12-10.34) and 5-fluorouracil, oxaliplatin and bevacizumab based chemotherapy (HR 3.11, 95%CI 1.17-8.26).

CONCLUSIONS

PICC is a safe venous device for chemotherapy delivery. Nevertheless, a 15% rate of failure has to be taken in account when planning PICC insertion for chemotherapy purposes. J. Surg. Oncol. 2016;113:708-714. © 2016 Wiley Periodicals, Inc.

Heparin versus 0.9% sodium chloride intermittent flushing for the prevention of occlusion in long term central venous catheters in infants and children: A systematic review

BACKGROUND

Around the world, guidelines and clinical practice for the prevention of complications associated with central venous catheters (CVC) vary greatly. To prevent occlusion, most institutions recommend the use of heparin when the CVC is not in use. However, there is debate regarding the need for heparin and evidence to suggest normal saline may be as effective. The use of heparin is not without risk, may be unnecessary and is also associated with increased costs.

OBJECTIVES

To assess the clinical effects (benefits and harms) of heparin versus normal saline to prevent occlusion in long-term central venous catheters in infants, children and adolescents.

DESIGN

A Cochrane systematic review of randomised controlled trials was undertaken.

DATA SOURCES

The Cochrane Vascular Group Specialised Register (including MEDLINE, CINAHL, EMBASE and AMED) and the Cochrane Register of Studies were searched. Hand searching of relevant journals and reference lists of retrieved articles was also undertaken.

REVIEW METHODS

Data were extracted and appraisal undertaken. We included studies that compared the efficacy of normal saline with heparin to prevent occlusion. We excluded temporary CVCs and peripherally inserted central catheters. Rate ratios per 1000 catheter days were calculated for two outcomes, occlusion of the CVC, and CVC-associated blood stream infection.

RESULTS

Three trials with a total of 245 participants were included in this review. The three trials directly compared the use of normal saline and heparin. However, between studies, all used different protocols with various concentrations of heparin and frequency of flushes. The quality of the evidence ranged from low to very low. The estimated rate ratio for CVC occlusion per 1000 catheter days between the normal saline and heparin group was 0.75 (95% CI 0.10 to 5.51, two studies, 229 participants, very low quality evidence). The estimated rate ratio for CVC-associated blood stream infection was 1.48 (95% CI 0.24 to 9.37, two studies, 231 participants; low quality evidence).

CONCLUSIONS

It remains unclear whether heparin is necessary for CVC maintenance. More well-designed studies are required to understand this relatively simple, but clinically important question. Ultimately, if this evidence were available, the development of evidenced-based clinical practice guidelines and consistency of practice would be facilitated.

Evidence-Based Criteria for the Choice and the Clinical use of the Most Appropriate Lock Solutions for Central Venous Catheters (Excluding Dialysis Catheters): A GAVeCeLT Consensus

Background

The most appropriate lock solution for central venous access devices is still to be defined. GAVeCeLT – the Italian group for venous access devices – has developed a consensus on the evidence-based criteria for the choice and the clinical use of the most appropriate lock solution for central venous catheters (excluding dialysis catheters).

Method

After the constitution of a panel of experts, a systematic collection and review of the literature has been performed, focusing on clinical studies dealing with lock solutions used for prevention of occlusion (heparin, citrate, urokinase, recombinant tissue plasminogen activator [r-TPA], normal saline) or for prevention of infection (citrate, ethanol, taurolidine, ethylene-diamine-tetra-acetic acid [EDTA], vancomycin, linezolid and other antibiotics), in both adults and in pediatric patients. Studies on central lines used for dialysis or pheresis, on peripheral venous lines and on arterial lines were excluded from this analysis. Studies on lock solutions used for treatment of obstruction or infection were not considered. The consensus has been carried out according to the Delphi method.

Results

The panel has concluded that: (a) there is no evidence supporting the heparin lock; (b) the prevention of occlusion is based on the proper flushing and locking technique with normal saline; (c) the most appropriate lock solution for infection prevention should include citrate and/or taurolidine, which have both anti-bacterial and anti-biofilm activity, with negligible undesired effects if compared to antibiotics; (d) the patient populations most likely to benefit from citrate/taurolidine lock are yet to be defined.

Conclusions

The actual value of heparinization for non-dialysis catheters should be reconsidered. Also, the use of lock with substances with anti-bacterial and anti-biofilm activity (such as citrate or taurolidine) should be taken into consideration in selected populations of patients.

Heparin versus 0.9% sodium chloride intermittent flushing for the prevention of occlusion in long term central venous catheters in infants and children

BACKGROUND

Guidelines and clinical practice for the prevention of complications associated with central venous catheters (CVC) around the world vary greatly. Most institutions recommend the use of heparin to prevent occlusion, however there is debate regarding the need for heparin and evidence to suggest 0.9% sodium chloride (normal saline) may be as effective. The use of heparin is not without risk, may be unnecessary and is also associated with increased cost.

OBJECTIVES

To assess the clinical effects (benefits and harms) of intermittent flushing of heparin versus normal saline to prevent occlusion in long term central venous catheters in infants and children.

SEARCH METHODS

The Cochrane Vascular Trials Search Co-ordinator searched the Specialised Register (last searched April 2015) and the Cochrane Register of Studies (Issue 3, 2015). We also searched the reference lists of retrieved trials.

SELECTION CRITERIA

Randomised controlled trials that compared the efficacy of normal saline with heparin to prevent occlusion of long term CVCs in infants and children aged up to 18 years of age were included. We excluded temporary CVCs and peripherally inserted central catheters (PICC).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial inclusion criteria, trial quality and extracted data. Rate ratios were calculated for two outcome measures - occlusion of the CVC and central line-associated blood stream infection. Other outcome measures included duration of catheter placement, inability to withdraw blood from the catheter, use of urokinase or recombinant tissue plasminogen, incidence of removal or re-insertion of the catheter, or both, and other CVC-related complications such as dislocation of CVCs, other CVC site infections and thrombosis.

MAIN RESULTS

Three trials with a total of 245 participants were included in this review. The three trials directly compared the use of normal saline and heparin, however, between studies, all used different protocols for the standard and experimental arms with different concentrations of heparin and different frequency of flushes reported. In addition, not all studies reported on all outcomes. The quality of the evidence ranged from low to very low because there was no blinding, heterogeneity and inconsistency between studies was high and the confidence intervals were wide. CVC occlusion was assessed in all three trials (243 participants). We were able to pool the results of two trials for the outcomes of CVC occlusion and CVC-associated blood stream infection. The estimated rate ratio for CVC occlusion per 1000 catheter days between the normal saline and heparin group was 0.75 (95% CI 0.10 to 5.51, two studies, 229 participants, very low quality evidence). The estimated rate ratio for CVC-associated blood stream infection was 1.48 (95% CI 0.24 to 9.37, two studies, 231 participants; low quality evidence). The duration of catheter placement was reported to be similar between the two study arms, in one study (203 participants).

AUTHORS' CONCLUSIONS

The review found that there was not enough evidence to determine the effects of intermittent flushing of heparin versus normal saline to prevent occlusion in long term central venous catheters in infants and children. Ultimately, if this evidence were available, the development of evidenced-based clinical practice guidelines and consistency of practice would be facilitated.

Heparinized and Saline Solutions in the Maintenance of Arterial and Central Venous Catheters After Cardiac Surgery

Background:

Heparinized saline solution is used to prevent occlusion in the arterial catheters and central venous pressure monitoring catheters. Even at low dose, heparin administration can be associated with serious complications. Normal saline solution can maintain patency of arterial catheters and central venous pressure monitoring catheters.

Objectives:

The current study aimed to compare the efficacy of normal saline with that of heparinized one to maintain patency of arterial and central venous catheters after cardiac surgery.

Patients and Methods:

In the current randomized controlled trial, 100 patients, with an age range of 18 - 65 years of valve and coronary artery surgery were studied in Rajaie heart center, Tehran, Iran. Patients were randomized to receive either heparinized saline (n = 50) or normal saline flush solutions (n = 50). In the study, arterial catheters and central venous pressure monitoring catheters were daily checked for any signs of occlusion in three postoperative days as primary end-point of the study.

Results:

According to the information obtained from the study, four (8%) arterial catheters in the saline group (P value: 0.135) and three (6%) arterial catheters in the heparin group (P value = 0.097) were obstructed. Statistical analysis showed that the incidence of obstruction and changes in all other parameters between the two groups during the three-day follow-up was not significant (all P values > 0.05).

Conclusions:

It seems that there is no difference in the use of heparinized and normal saline solutions to prevent catheter occlusion of arterial and central venous pressure.

Avoiding Heparinization of Arterial Line and Maintaining Acceptable Arterial Waveform After Cardiac Surgery: A Randomized Clinical Trial

Background:

Invasive and continuous blood pressure (BP) monitoring is crucial after cardiac surgery. Accuracy of BP measurement mostly depends on patency of arterial catheter and acceptable waveform. Heparinized saline flush usually used for this purpose may be accompanied by potential heparin adverse effects.

Objectives:

The aim of this study was to compare heparinized and non-heparinized saline flush to maintain acceptable arterial waveform after cardiac surgery.

Materials and Methods:

In a double blind randomized trial study, 100 patients undergoing elective cardiac surgery were randomized to using heparinized (n = 50) or non-heparinized (normal) saline flush (n = 50) to maintain patency of arterial catheter after operation. Indwelling arterial catheters were checked daily for acceptable arterial waveform for three days as primary outcome measures.

Results:

Frequency of acceptable arterial waveform ranged from 66% to 80%, in first, second and third postoperative days. There were no statistically significant differences between heparinized and non-heparinized saline groups regarding acceptable arterial waveforms in all the three postoperative days (all P values > 0.05).

Conclusions:

Using non-heparinized normal saline is suitable to maintain acceptable arterial waveform for short-term (three days) after adult cardiac surgery considering potential adverse effects of heparin.

[Heparin for clearance of peripherally inserted central venous catheter in newborns: an in vitro study]

Objective:

To compare the efficacy of two concentrations of heparin to clear the lumen of in vitro clotted neonatal peripherally inserted central catheters (PICCs).

Methods:

This is an in vitro, experimental quantitative study of 76 neonatal 2.0-Fr PICCs coagulated in vitro. The catheters were divided into two groups of 38 PICCs each. In both groups an infusion of low molecular weight heparin was administered with a dose of 25IU/mL for Group 1 and 50IU/mL for Group 2. The negative pressure technique was applied to the catheters of both groups at 5, 15 and 30min and at 4h to test their permeability. Kaplan-Meier survival analysis was used to verify the outcome of the groups according to time intervals.

Results:

The comparison between both groups in the first 5min showed that more catheters from Group 2 were cleared compared to Group 1 (57.9 vs. 21.1%, respectively). Kaplan-Meier survival analysis showed that less time was needed to clear catheters treated with 50IU/mL of heparin (p<0.001).

Conclusions:

The use of low molecular weight heparin at a concentration of 50IU/mL was more effective in restoring the permeability of neonatal PICCs occluded in vitro by a clot, and the use of this concentration is within the safety margin indicated by scientific literature.

Heparin versus 0.9% sodium chloride intermittent flushing for prevention of occlusion in central venous catheters in adults

BACKGROUND

Heparin intermittent flushing is a standard practice in the maintenance of patency in central venous catheters. However, we could find no systematic review examining its effectiveness and safety.

OBJECTIVES

To assess the effectiveness of intermittent flushing with heparin versus 0.9% sodium chloride (normal saline) solution in adults with central venous catheters in terms of prevention of occlusion and overall benefits versus harms.

SEARCH METHODS

The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched December 2013) and the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 11). Searches were also carried out in MEDLINE, EMBASE, CINAHL and clinical trials databases (December 2013).

SELECTION CRITERIA

Randomised controlled trials (RCTs) in adults 18 years of age and older with a central venous catheter (CVC) in which intermittent flushing with heparin (any dose with or without other drugs) was compared with 0.9% normal saline were included. No restriction on language was applied.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed trial quality and extracted data. Trial authors were contacted to retrieve additional information, when necessary.

MAIN RESULTS

Six eligible studies with a total of 1433 participants were included. The heparin concentrations used in these studies were very different (10-5000 IU/mL), and follow-up varied from 20 days to 180 days. The overall risk of bias in the studies was low. The quality of the evidence ranged from very low to moderate for the main outcomes (occlusion of CVC, duration of catheter patency, CVC-related sepsis, mortality and haemorrhage at any site).Combined findings from three trials in which the unit of analysis was the catheter suggest that heparin was associated with reduced CVC occlusion rates (risk ratio (RR) 0.53, 95% confidence interval (CI) 0.29 to 0.94). However, no clear evidence of a similar effect was found when the results of two studies in which the unit of analysis was the participant were combined (RR 0.21, 95% CI 0.03 to 1.70), nor when findings were derived from one study, which considered total line accesses (RR 1.08, 95% CI 0.84 to 1.40). Furthermore, results for other estimated effects were found to be imprecise and compatible with benefit and harm: catheter duration in days (mean difference (MD) 0.41, 95% CI -1.29 to 2.12), CVC-related thrombosis (RR 1.22, 95% CI 0.74 to 1.99), CVC-related sepsis (RR 1.02, 95% CI 0.34 to 3.03), mortality (RR 0.77, 95% CI 0.45 to 1.32) and haemorrhage at any site (RR 1.37, 95% CI 0.49 to 3.85).

AUTHORS' CONCLUSIONS

We found no conclusive evidence of important differences when heparin intermittent flushing was compared with 0.9% normal saline flushing for central venous catheter maintenance in terms of efficacy or safety. As heparin is more expensive than normal saline, our findings challenge its continued use in CVC flushing outside the context of clinical trials.

A Prospective, Randomized Comparison of three different types of Valved and Non-Valved Peripherally inserted Central Catheters

Purpose

Few randomized studies have investigated the impact of valved and non-valved power-injectable peripherally inserted central catheters (PICCs) in terms of incidence of occlusion, infection, malfunction and venous thrombosis.

Methods

We have prospectively compared three types of third-generation polyurethane PICCs. One hundred and eighty adult patients candidate to chemotherapy were randomized into three groups: power-injectable PICCs with Solo-2 proximal valve (Bard); power-injectable PICCs with PASV (Pressure Activated Safety Valve) proximal valve (Navilyst); and non-valved power-injectable PICCs (Medcomp). All PICCs were single lumen 4Fr, inserted according to a well-defined protocol - maximal barrier precautions, ultrasound guidance, intracavitary electrocardiography (IC-ECG), and so on - and managed according to the recommendations of the most recent guidelines (antisepsis with 2% chlorhexidine, transparent dressing, sutureless device, strict ‘scrub the hub’ policy, neutral displacement needle-free connectors and so on). All catheters were flushed with 10 ml saline before and after each infusion, or with 20 ml saline after blood sampling or infusion of blood products. No heparin was used.

Results

We detected no complications at insertion; no PICC-related bloodstream infections; no dislocations; five cases of transient occlusion and two cases of persistent withdrawal occlusion, evenly distributed among the groups; one episode of complete irreversible obstruction (group A); four episodes of asymptomatic peripheral venous thrombosis; one episode of symptomatic, severe central vein thrombosis (group B). In 31% of PICCs in group A (19/61) and in 65% of group B (39/60), difficulties with gravity infusion were reported; three PICCs of group A were complicated by rupture of the intravascular tract during pump infusion. Five PICCs were removed because of complications, four in group A (one obstruction; three ruptures) and one in group B (central venous thrombosis).

Conclusion

We found no clinical advantages of valved vs. non-valved PICCs.

Nurses' knowledge regarding the handling of the totally-implanted venous access device

In the light of nurses' questions regarding the handling of the totally-implanted venous access device, this study aimed to evaluate these professionals' knowledge. This is a descriptive study with a qualitative approach, whose sample was made up of 28 nurses working on the Internal Medicine ward and in the Emergency Room. The study was undertaken in two stages: interviewing, to evaluate knowledge regarding the handling of the implanted port; and an integrative review to clarify the doubts identified. The results indicated that the nurses' knowledge was inadequate regarding when to use the implanted port, its purpose, the puncture technique, maintenance and handling. It is concluded that the knowledge of the subjects evaluated is inadequate, and that it is necessary for these professionals' clinical skills to be standardized and for them to receive theoretical-practical training.

Flushing the central venous catheter: is heparin necessary?

PURPOSE

The aim of this systematic review was to assess the efficacy of heparin flushing in the lock of central venous catheters.

METHODS

We searched MEDLINE and CINAHL databases. Eligible studies were randomized controlled trials evaluating the use of heparin versus normal saline or other solution in the flushing of central catheter among adult patients. No language restrictions were applied. Two reviewers independently screened titles and abstracts in order to identify relevant publications. The same two reviewers retrieved and evaluated full texts. Parameter estimates regarding catheter occlusion were pooled using network meta-analysis with Bayesian hierarchical modeling.

RESULTS

We identified 462 references. Eight studies were included. There was no evidence that heparin was more effective than normal saline in reducing occlusions. It was unclear whether urokinase and lepirudin were more effective than heparin in reducing occlusions. Vitamin C solution does not appear to prolong catheter patency.

CONCLUSIONS

There is no evidence of a different effectiveness between heparin flushing and normal saline or other solutions in reducing catheter occlusions. Due to the little and inconclusive evidence available in this field, further studies might be necessary.

Maintaining patency in totally implantable venous access devices (TIVAD): a time-to-event analysis of different lock irrigation intervals

PURPOSE

To evaluate the effectiveness of irrigating totally implantable venous access devices (TIVADs) every eight weeks instead of every four in maintaining the patency of the device.

METHODS

An explorative, pragmatic, prospective study design was conducted in two day hospital centres located in the northeast of Italy, from January 2011 to September 2012. Twenty patients who had skipped an appointment and were thus washing their TIVAD every eight weeks (exposed) were included, as were 17 patients following the typical wash regimen of every four weeks (controls). TIVAD occlusion-defined as the inability of the device to aspirate blood and/or the inability to properly irrigate the device-was the principal study end-point.

RESULTS

A total of six occlusions were documented in six patients. Four cases were observed among the exposed group (4/20; 20.0%), while two were observed among the control group (2/17; 11.7%). No statistically significant differences were observed in the occurrence of occlusion between the groups (RR: 1.29, 95%CI: 0.67-2.50, p = 0.49). No statistically significant differences emerged between groups in the time that elapsed from study inclusion to occlusion occurrence according to the time-to-event analysis performed using the Kaplan-Meier estimation model (Log Rank [Mantel-Cox] = χ(2) 0.284, df 1, p = 0.594).

CONCLUSIONS

Within the limitations of the study which should be addressed with further research based on double-blinded randomised clinical trials, postponing the irrigation regimen of TIVADs to eight weeks seems to be sufficient to maintain device patency.

Comparing normal saline versus diluted heparin to lock non-valved totally implantable venous access devices in cancer patients: a randomised, non-inferiority, open trial

BACKGROUND

Heparin has been used for years as a locking solution in totally implantable venous access devices. Normal saline (NS) might be a safe alternative for heparin. However, evidence of non-inferiority of NS versus heparin is lacking.

PATIENTS AND METHODS

We randomly allocated 802 cancer patients with a newly inserted port either to heparin lock (300 U/3 ml) or to NS lock groups in a 1:1 assignment ratio. The primary outcome was the number of functional complications, which was defined as 'easy injection, impossible aspiration' at port access. Secondary outcomes included all functional problems and catheter-related bacteraemia. We hypothesised that NS locks do not cause more functional problems and catheter-related bacteraemia than heparin locks. Non-inferiority is established if the upper limit of the confidence interval (CI) for the relative risk of NS versus heparin is <1.4.

RESULTS

Three hundred and eighty-two patients from the NS group and 383 from the heparin lock group were included in the analysis. The incidence rate of our primary outcome (easy injection, impossible aspiration) was 3.70% (95% CI 2.91%-4.69%) and 3.92% (95% CI 3.09%-4.96%) of accesses in the NS and heparin groups, respectively. The relative risk was 0.94% (95% CI 0.67%-1.32%). Catheter-related bloodstream infection was 0.03 per 1000 catheter days in the NS group and 0.10 per 1000 catheter days in the heparin group.

CONCLUSION

NS is a safe and effective locking solution in implantable ports if combined with a strict protocol for device insertion and maintenance.

[Indications, technique and complications of port implantation]

Implanted central venous access devices are becoming increasingly more important in oncology as an important tool for therapists and patients. As an intracorporeal system with reduced risk of infection compared to percutaneous tunnelled catheters they ensure a permanent and safe access to the central venous system. However, they can be associated with risks and sometimes severe complications which should not be underestimated so that planning and performance of the implantation require a high level of care and attention. Postoperative care and the correct allocation of all groups of persons involved in the therapy can reduce complication rates and are thus of prognostic relevance.