Heparin flushing and other interventions to maintain patency of central venous catheters: a systematic review

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.

Autoimmune Heparin-Induced Thrombocytopenia

Autoimmune thrombocytopenia (aHIT) is a severe subtype of heparin-induced thrombocytopenia (HIT) with atypical clinical features caused by highly pathological IgG antibodies ("aHIT antibodies") that activate platelets even in the absence of heparin. The clinical features of aHIT include: the onset or worsening of thrombocytopenia despite stopping heparin ("delayed-onset HIT"), thrombocytopenia persistence despite stopping heparin ("persisting" or "refractory HIT"), or triggered by small amounts of heparin (heparin "flush" HIT), most cases of fondaparinux-induced HIT, and patients with unusually severe HIT (e.g., multi-site or microvascular thrombosis, overt disseminated intravascular coagulation [DIC]). Special treatment approaches are required. For example, unlike classic HIT, heparin cessation does not result in de-escalation of antibody-induced hemostasis activation, and thus high-dose intravenous immunoglobulin (IVIG) may be indicated to interrupt aHIT-induced platelet activation; therapeutic plasma exchange may be required if high-dose IVIG is ineffective. Also, aHIT patients are at risk for treatment failure with (activated partial thromboplastin time [APTT]-adjusted) direct thrombin inhibitor (DTI) therapy (argatroban, bivalirudin), either because of APTT confounding (where aHIT-associated DIC and resulting APTT prolongation lead to systematic underdosing/interruption of DTI therapy) or because DTI inhibits thrombin-induced protein C activation. Most HIT laboratories do not test for aHIT antibodies, contributing to aHIT under-recognition.

ESPEN guideline on chronic intestinal failure in adults - Update 2023

BACKGROUND & AIMS

In 2016, ESPEN published the guideline for Chronic Intestinal Failure (CIF) in adults. An updated version of ESPEN guidelines on CIF due to benign disease in adults was devised in order to incorporate new evidence since the publication of the previous ESPEN guidelines.

METHODS

The grading system of the Scottish Intercollegiate Guidelines Network (SIGN) was used to grade the literature. Recommendations were graded according to the levels of evidence available as A (strong), B (conditional), 0 (weak) and Good practice points (GPP). The recommendations of the 2016 guideline (graded using the GRADE system) which were still valid, because no studies supporting an update were retrieved, were reworded and re-graded accordingly.

RESULTS

The recommendations of the 2016 guideline were reviewed, particularly focusing on definitions, and new chapters were included to devise recommendations on IF centers, chronic enterocutaneous fistulas, costs of IF, caring for CIF patients during pregnancy, transition of patients from pediatric to adult centers. The new guideline consist of 149 recommendations and 16 statements which were voted for consensus by ESPEN members, online in July 2022 and at conference during the annual Congress in September 2022. The Grade of recommendation is GPP for 96 (64.4%) of the recommendations, 0 for 29 (19.5%), B for 19 (12.7%), and A for only five (3.4%). The grade of consensus is "strong consensus" for 148 (99.3%) and "consensus" for one (0.7%) recommendation. The grade of consensus for the statements is "strong consensus" for 14 (87.5%) and "consensus" for two (12.5%).

CONCLUSIONS

It is confirmed that CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for the underlying gastrointestinal disease and to provide HPN support. Most of the recommendations were graded as GPP, but almost all received a strong consensus.

Pilot Randomized Trial of a Three Times Weekly Heparin Flushing Intervention in Children, Adolescents, and Young Adults With Cancer With Tunneled Central Venous Catheters

Background: Children and adolescents with cancer often undergo aggressive treatment and receive supportive care requiring a long-term tunneled central venous catheter (TCVC). Regular flushing promotes TCVC patency when not in use (i.e., noninfusing). However, TCVC flushing guidelines and the current practice of daily flushing are not based on high-quality evidence. Few studies have compared the effect of less frequent flushing on TCVC patency. The purpose of this study was to evaluate the feasibility of a three times weekly heparin flushing intervention, as compared to daily heparin flushing, in children and adolescents and young adults (AYAs) with noninfusing TCVCs. Methods: Twenty children and AYAs were randomized to one of two groups, standard of care (SOC) (i.e., daily heparin flushing) or intervention (three times weekly heparin flushing) for 8 weeks. Feasibility data (recruitment, retention, acceptability, TCVC patency, and complications) were analyzed descriptively. Results: Twenty of 22 eligible patients were enrolled in the study (90% recruitment rate). Four participants discontinued the study early due to TCVC removal (20% attrition rate). One participant in each group had their TCVC removed due to a central line-associated bloodstream infection, one SOC group participant had their TCVC removed due to damage, and one intervention group participant had their TCVC removed due to discontinuation of treatment. No participants were withdrawn for safety concerns or because they did not find the protocol acceptable. Conclusions: It is feasible to conduct a large-scale randomized controlled trial to investigate a three times weekly heparin flushing intervention in children and AYAs with TCVCs.

Comparison of the Effect of Heparinized Normal Saline Solution Versus Saline Solutions in Arterial and Central Venous Catheters on Complete Blood Count After Cardiac Surgery

Background

Heparinized and saline solutions can prevent clot formation in arterial and central venous catheters. However, heparin can decrease the platelet count and induce thrombocytopenia. Patients undergoing cardiac surgeries are more likely to develop heparin-induced thrombocytopenia.

Objectives

This study aimed to investigate the effect of heparinized and saline solutions of arterial and central venous catheters on complete blood count (CBC) after cardiac surgery.

Methods

This randomized controlled trial was conducted on 100 participants. All subjects underwent cardiac surgery at Rajaie Cardiovascular, Medical, and Research Center, Tehran, Iran. Patients were randomly divided into two groups intervention (A) for whom heparinized normal saline solution was used to maintain central arterial and venous catheters, and control (B) for whom normal saline solution was used. The CBC of subjects was monitored for three days (before surgery and the first and second days after surgery).

Results

In the present study, there were no significant differences between CBC, white blood cell differential count, prothrombin time, partial thromboplastin time (PTT), and international normalized ratio in groups A and B. However, we found significant differences in platelet count (P = 0.049), red blood cell count (P = 0.0001), hemoglobin (P = 0.0001), and hematocrit (P = 0.0001) between before surgery and the second day after surgery in group A. Platelet count (P = 0.027) and PTT (P = 0.0001) before and after surgery were significantly different in group B.

Conclusions

According to the results of this study, normal saline solution catheters have fewer side effects and can be a suitable replacement for heparinized catheters.

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

BACKGROUND

Intermittent locking of central venous catheters (CVCs) is undertaken to help maintain their patency and performance. There are systematic variations in care: some practitioners use heparin (at different concentrations), whilst others use 0.9% sodium chloride (normal saline). This review looks at the effectiveness and safety of intermittent locking with heparin compared to normal saline, to see if the evidence establishes whether one is better than the other. This is an update of an earlier Cochrane Review.

OBJECTIVES

To evaluate the benefits and harms of intermittent locking of CVCs with heparin versus normal saline in adults to prevent occlusion.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 20 October 2021.

SELECTION CRITERIA

We included randomised controlled trials in adults ≥ 18 years of age with a CVC that compared intermittent locking with heparin at any concentration versus normal saline. We excluded studies on infants and children from this review.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were occlusion of CVCs and duration of catheter patency. Our secondary outcomes were CVC-related bloodstream infections and CVC-related colonisation, mortality, haemorrhage, heparin-induced thrombocytopaenia, CVC-related thrombosis, number of additional CVC insertions, abnormality of coagulation profile and allergic reactions to heparin. We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

We identified one new RCT with 30 participants for this update. We included a total of 12 RCTs with 2422 participants. Data for meta-analysis were available from all RCTs. We noted differences in methods used by the included studies and variation in heparin concentrations (10 to 5000 IU/mL), time to follow-up (1 to 251.8 days), and the unit of analysis used (participant, catheter, line access). Five studies included ICU (intensive care unit) patients, two studies included oncology patients, and the remaining studies included miscellaneous patients (chronic kidney disease, haemodialysis, home care patients, etc.). Primary outcomes Overall, combined results may show fewer occlusions with heparin compared to normal saline but this is uncertain (risk ratio (RR) 0.70, 95% confidence interval (CI) 0.51 to 0.95; 10 studies; 1672 participants; low-certainty evidence). We pooled studies that used participant or catheter as the unit of analysis. We carried out subgroup analysis by unit of analysis. No clear differences were detected after testing for subgroup differences (P = 0.23). We found no clear evidence of a difference in the duration of catheter patency with heparin compared to normal saline (mean difference (MD) 0.44 days, 95% CI -0.10 to 0.99; 6 studies; 1788 participants; low-certainty evidence). Secondary outcomes We found no clear evidence of a difference in the following outcomes: CVC-related bloodstream infections (RR 0.66, 95% CI 0.08 to 5.80; 3 studies; 1127 participants; very low-certainty evidence); mortality (RR 0.76, 95% CI 0.44 to 1.31; 3 studies; 1100 participants; very low-certainty evidence); haemorrhage (RR 1.54, 95% CI 0.41 to 5.74; 3 studies; 1197 participants; very low-certainty evidence); or heparin-induced thrombocytopaenia (RR 0.21, 95% CI 0.01 to 4.27; 3 studies; 443 participants; very low-certainty evidence). The main reasons for downgrading the certainty of evidence for the primary and secondary outcomes were unclear allocation concealment, suspicion of publication bias, imprecision and inconsistency.

AUTHORS' CONCLUSIONS

Given the low-certainty evidence, we are uncertain whether intermittent locking with heparin results in fewer central venous catheter occlusions than intermittent locking with normal saline in adults. Low-certainty evidence suggests that heparin may have little or no effect on catheter patency duration. Although we found no evidence of differences in safety (CVC-related bloodstream infections, mortality, or haemorrhage), the combined studies were not powered to detect rare adverse events such as heparin-induced thrombocytopaenia. Further research conducted over longer periods would reduce the current uncertainties.

Nitric Oxide-Releasing Lock Solution for the Prevention of Catheter-Related Infection and Thrombosis

Although frequently used, venous catheters are often associated with serious complications such as infection and thrombosis. Lock solution therapies are clinically used to deter these issues but generally address only infection or thrombosis with limited success. Here, we report the development of a dual-functional lock therapy using nitric oxide (NO) donor molecule, S-nitrosoglutathione (GSNO). NO is a potent, broad-spectrum antimicrobial agent that also temporarily inhibits platelet activation, preventing thrombosis. Furthermore, NO has antibiofilm actions, an ability that traditional antibiotic lock solutions lack, thus limiting their efficacy. In this work, different concentrations of GSNO were characterized via NO analysis to determine a range of NO-releasing lock solution (NOreLS) concentrations to investigate and to demonstrate prolonged potential efficacy. Tested against clinically used vancomycin and gentamicin lock solutions, GSNO-based NOreLS repeatedly outperformed in models of different stages of catheter infections. NOreLS also prevented clot formation when exposed to whole blood, showing increased efficacy compared to a heparin lock solution. Moreover, NOreLS was demonstrated to be biocompatible via hemolysis and cytotoxicity assays. NOreLS has excellent potential for safely and effectively preventing infection and thrombosis related to catheter usage.

ESPEN practical guideline: Clinical nutrition in chronic intestinal failure

BACKGROUND

This practical guideline is based on the ESPEN Guidelines on Chronic Intestinal Failure in Adults.

METHODOLOGY

ESPEN guidelines have been shortened and transformed into flow charts for easier use in clinical practice. The practical guideline is dedicated to all professionals including physicians, dieticians, nutritionists, and nurses working with patients with chronic intestinal failure.

RESULTS

This practical guideline consists of 112 recommendations with short commentaries for the management and treatment of benign chronic intestinal failure, including home parenteral nutrition and its complications, intestinal rehabilitation, and intestinal transplantation.

CONCLUSION

This practical guideline gives guidance to health care providers involved in the management of patients with chronic intestinal failure.

Needle-free connectors to prevent central venous catheter occlusion at a tertiary cardiac center: A prospective before and after intervention study

OBJECTIVES

To evaluate the effectiveness of needle-free connectors to maintain Central Venous Catheter-CVC patency.

BACKGROUND

Loss of patency is a common complication associated with CVC. For patients, this can be stressful and painful, and can result in a delay in infusion therapy. Pressure-activated anti-reflux needle-free connectors are one of the most modern devices; however, no studies have compared this connector with the open-system three-way stopcock in terms of the incidence of CVC occlusion.

METHODS

This study is a prospective before and after intervention study. From March to August 2018, an observation phase was conducted with the three-way stopcock as the standard central venous catheter hub and closure system (phase 1). After implementation of needle-free connectors (phase 2), post-intervention observations were made from September 2019 to January 2020 (phase 3).

RESULTS

Of 199 CVCs analyzed, 41.2% (40/97) occluded in at least one lumen in the first phase, and 13.7% (14/102) occluded after introducing the technological device, absolute risk reduction 27.5% (95% confidence interval 15.6%-39.4%). The lumens supported by needle-free connectors showed a higher probability of maintaining patency compared with three-way stopcocks. No differences were observed in the rate of infection.

CONCLUSIONS

Pressure-activated anti-reflux needle-free connectors are effective and safe devices suitable for the management of vascular access in cardiac patient care. Staff training, even on apparently simple devices, is essential to avoid the risk of infection.

Effects of prolonged flushing interval in totally implantable venous access devices (TIVADs)

Totally implantable venous access device (TIVAD) lumen occlusion is a long-term complication of central venous catheters, associated with risks of infection, therapy interruptions and increased healthcare costs. The role of flushing and locking in maintaining TIVAD patency is paramount. Most flushing protocols are based on manufacturers' recommendations, which indicate that 4 weeks is the safest interval between two consecutive flushing procedures during periods when TIVADs are not in use. Conversely, results of several studies suggest that extended flushing intervals (FIs) do not increase the rate of obstructive or infective complications. The study aimed to describe the effects of prolonged FIs in a cohort of 317 patients with cancer. The authors found no significant difference in terms of TIVAD problems between long (>45 days) and short (≤45 days) FI groups, which raises questions over the validity of current practice.

Heparin flush vs. normal saline flush to maintain the patency of central venous catheter among adult patients: A systematic review and meta-analysis

BACKGROUND

Around the globe, protocols for flushing the catheter to maintain the patency of central venous catheter (CVC) vary by institution to institution or by practitioner to practitioner. Therefore, this review was carried out with the aim of evaluating the efficacy of heparin flush vs. normal saline flush to maintain the patency of CVC among adult patients.

METHODS

We followed the guidelines of Cochrane handbook for interventions and searched in MEDLINE, Embase, Cochrane library, Clinical trials database, and reference list of related articles, which were published from Jan. 2012 to 31 Dec. 2018 in English language. We included only randomized controlled trials, and nine studies were included in this review. The pooled standard mean difference and relative risk were calculated by using Rev Man Review Manager 5.

RESULTS

We identified nine eligible studies with a total number of 3,113 participants. Consolidated results from eight studies conveyed little favorable effect to maintain patency of CVC with heparin when compared with normal saline as evident by risk ratio 0.83, 95% CI 0.50 - 1.40; P = 0.13. We also carried out analysis for secondary outcomes, and there was no evidence that heparin was better than normal saline in terms of safety except heparin-induced thrombocytopenia.

CONCLUSIONS

Heparin has little favorable effects to maintain patency of catheter than normal saline but not in secondary outcomes. As the quality of evidence was very low, therefore, results should be comprehend with care.

Comparison of heparinized saline and 0.9% sodium chloride for maintaining central venous catheter patency in healthy dogs

BACKGROUND

The purpose of this study was to determine whether heparinized saline (HS) would be more effective in maintaining the patency of central venous catheters (CVCs) in dogs compared to 0.9% sodium chloride. This was a prospective randomized blinded study conducted at a University Veterinary Teaching Hospital.

METHODS

A total of 24 healthy purpose-bred dogs were randomized into two groups: a treatment and a control group. A CVC was placed in the jugular vein of each dog. Each dog in the treatment group had their CVC flushed with 10 IU/mL HS, while dogs in the control group had their CVC flushed with 0.9% sodium chloride every 6 h for 72 h. Immediately prior to flushing, each catheter was evaluated for patency by aspiration of blood. The catheter site was also evaluated for phlebitis, and a rectal temperature was obtained in each dog every 6 h. Prothrombin (PT) and activated partial thromboplastin (aPTT) times were evaluated prior to the administration of any flush solution. Results were then compared to values obtained 72 h later.

RESULTS

All CVCs in both groups were patent after 72 h, which was demonstrated by aspiration of blood and ease of flushing the catheter. Two CVCs in the 0.9% sodium chloride group had a negative aspiration at hour 12 and 36, respectively. One CVC in the HS group had a negative aspiration at hour 18. Signs of phlebitis occurred in three dog: two in the 0.9% sodium chloride group and one in the HS group. No dog was hyperthermic (>103 °F). Two catheters were inadvertently removed by dogs in the HS group during the study. There were no significant differences in catheter patency, incidence of phlebitis, or incidence of negative aspirations between both groups. aPTT and PT values remained within the normal reference range for all dogs in both groups. Ultimately, 0.9% sodium chloride was as effective as 10 IU/mL HS in maintaining the patency of CVCs for up to 72 h in healthy dogs. Further evaluation in clinical patients is warranted.

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.

Risk factors for complications in cancer patients with totally implantable access ports: A retrospective study and review of the literature

OBJECTIVES

To analyze the risk factors for complications associated with the use of totally implantable access ports (TIAPs) in cancer patients.

METHODS

Data for 2,713 cancer patients who received a TIAP between January 2010 and September 2016 at a single center were analyzed retrospectively.

RESULTS

The average age of the patients was 54.2 ± 9.92 years, and 1,247 (47.5%) were women. The right subclavian vein was the preferred insertion site. Seventy-seven patients developed early complications and 50 developed late complications. The incidence of complications increased as the number of punctures increased. Percutaneous intervention increased the risk of complications during port insertion, but age, sex, body mass index, and the use of physiological saline solution instead of heparin for washing after port insertion did not increase the risk. The use of ultrasonography during insertion reduced the risk of complications.

CONCLUSIONS

Various factors may affect the function of TIAPs in cancer patients both during insertion and follow-up. Age, sex, body mass index, and the use of physiological saline solution for washing did not affect the incidence of complications, but the use of ultrasonography during insertion did affect the complication rate.

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

BACKGROUND

Intermittent locking of central venous catheters (CVCs) is undertaken to help maintain their patency. There are systematic variations in care: some practitioners use heparin (at different concentrations), whilst others use 0.9% NaCl (normal saline). This review looks at the effectiveness and safety of intermittent locking with heparin compared to 0.9% NaCl to see if the evidence establishes whether one is better than the other. This work is an update of a review first published in 2014.

OBJECTIVES

To assess the effectiveness and safety of intermittent locking of CVCs with heparin versus normal saline (NS) in adults to prevent occlusion.

SEARCH METHODS

The Cochrane Vascular Information Specialist (CIS) searched the Specialised Register (last searched 11 June 2018) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 5). Searches were also carried out in MEDLINE, Embase, CINAHL, and clinical trials databases (11 June 2018).

SELECTION CRITERIA

We included randomised controlled trials in adults ≥ 18 years of age with a CVC that compared intermittent locking with heparin at any concentration versus NS. We applied no restriction on language.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed quality, and extracted data. We contacted trial authors to retrieve additional information, when necessary. We carried out statistical analysis using Review Manager 5 and assessed the overall quality of the evidence supporting assessed outcomes using GRADE. We carried out prespecified subgroup analysis.

MAIN RESULTS

We identified five new studies for this update (six prior studies were included in the original review), bringing the number of eligible studies to 11, with a total of 2392 participants. We noted differences in methods used by the included studies and variation in heparin concentrations (10 to 5000 IU/mL), time to follow-up (1 to 251.8 days), and the unit of analysis used (participant, catheter, line access).Combined results from these studies showed fewer occlusions with heparin than with NS (risk ratio (RR) 0.70, 95% confidence interval (CI) 0.51 to 0.95; P = 0.02; 1672 participants; 1025 catheters from 10 studies; I² = 14%) and provided very low-quality evidence.We carried out subgroup analysis by unit of analysis (testing for subgroup differences (P = 0.23; I² = 30.3%). When the unit of analysis was the participant, results show no clear differences in all occlusions between heparin and NS (RR 0.79, 95% CI 0.58 to 1.08; P = 0.15; 1672 participants; seven studies). Subgroup analysis using the catheter as the unit of analysis shows fewer occlusions with heparin use (RR 0.53, 95% CI 0.29 to 0.95; P = 0.03; 1025 catheters; three studies). When the unit of analysis was line access, results show no clear differences in occlusions between heparin and NS (RR 1.08, 95% CI 0.84 to 1.40; 770 line accesses; one study).We found no clear differences in the duration of catheter patency (mean difference (MD) 0.44 days, 95% CI -0.10 to 0.99; P = 0.11; 1036 participants; 752 catheters; six studies; low-quality evidence).We found no clear evidence of a difference in the following: CVC-related sepsis (RR 0.74, 95% CI 0.03 to 19.54; P = 0.86; 1097 participants; two studies; low-quality evidence); mortality (RR 0.76, 95% CI 0.44 to 1.31; P = 0.33; 1100 participants; three studies; low-quality evidence); haemorrhage at any site (RR 1.32, 95% CI 0.57 to 3.07; P = 0.52; 1245 participants; four studies; moderate-quality evidence); or heparin-induced thrombocytopaenia (RR 0.21, 95% CI 0.01 to 4.27; P = 0.31; 443 participants; three studies; low-quality evidence).The main reasons for downgrading the quality of evidence were unclear allocation concealment, imprecision, and suspicion of publication bias.

AUTHORS' CONCLUSIONS

Given the very low quality of the evidence, we are uncertain whether intermittent locking with heparin results in fewer occlusions than intermittent locking with NS. Low-quality evidence suggests that heparin may have little or no effect on catheter patency. Although we found no evidence of differences in safety (sepsis, mortality, or haemorrhage), the combined trials are not powered to detect rare adverse events such as heparin-induced thrombocytopaenia.

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.

Vascular Access Complications: An Emergency Medicine Approach

Millions of central venous and arterial catheters are placed across the United States annually as mechanisms of obtaining advanced hemodynamic monitoring and facilitating acute resuscitation. Although presumably life saving or sustaining in many circumstances, current literature identifies the preprocedural and postprocedural complications of infection, thrombosis, embolism, and iatrogenic injury as resulting in patient morbidity and mortality. Today, through the application of aseptic technique, performance of operator training, and the utilization of ultrasound, emergency physicians may limit vascular access complications and improve patient outcomes.

Normal saline versus heparin for patency of central venous catheters in adult patients - a systematic review and meta-analysis

BACKGROUND

Heparin saline (HS) is theoretically superior to normal saline (NS) for maintaining the patency of central venous catheters (CVCs), but the comparative efficacy of them remains controversial. The aim of this systematic review and meta-analysis was to assess the efficacy of NS versus HS in the maintenance of the patency of CVCs in adult patients.

METHODS

We searched PubMed, Embase and the Cochrane library databases. Randomized controlled trials (RCTs) evaluating the use of NS vs. HS to maintain the permeability of CVCs among adult patients were included in our meta-analysis. References of relevant papers were reviewed manually. No language restriction was applied. Non-human studies were excluded. Pooled relative risk (RR) was calculated using a Mantel-Haenszel random-effects model. We also performed subgroup analysis examining the effect of the duration of catheter placement on the outcome. All statistical tests were two-sided using a significance level of 0.05.

RESULTS

Ten RCTs involving 7875 subjects (with analysis at patient, catheter, lumen and line access level) were included in this meta-analysis. Whether in terms of pooled or local analysis (RR with 95% confidence interval spans 1), NS can be equally, if not more effective, in keeping the CVCs open. Of studies reporting secondary outcomes (maneuver needed, heparin-induced thrombocytopenia, haemorrhage, central venous thrombosis and catheter-related bloodstream infection), heparinised saline was shown not to be superior to non-heparinised solution. Subgroup analysis in patients with short vs long term CVC placement was consistent with the main outcome partly and in particular for maintenance of catheter patency in patients with a long-term placement i.e. >30 days, the RR was 0.97 (n = 6589; 95% CI = 0.76 to 1.23; P = 0.796). However, for patients in whom the catheter was in place for <30 days, the RR was 1.52 (n = 1286; 95% CI = 1.02 to 2.27; P = 0.041).

CONCLUSIONS

Based on the results of this meta-analysis, HS is not superior to NS in reducing CVCs occlusion. But in the short term, the use of HS is slightly superior to NS for flushing catheters from a statistical point of view.

Catheter-related thrombosis: A practical approach

Catheter-related thrombosis is a relatively common complication of central venous catheter insertion. Central venous catheter use is ubiquitous in the critical care setting and often in patients with multiple risk factors for venous thromboembolism. With a trend towards increased use of peripherally inserted central catheters, the incidence of catheter-related thrombosis is likely to increase further. Despite the scale of the problem, there is a paucity of evidence-based guidelines concerning the management of patients with catheter-related thrombosis, particularly in critically unwell patients. This has led to heterogeneity in clinical practice. In this review, we describe the risk factors for developing catheter-related thrombosis and provide practical advice for clinicians on how to recognise, diagnose and treat this common problem.

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 synthesis activities of a hospital evidence-based practice center and impact on hospital decision making

BACKGROUND

Hospital evidence-based practice centers (EPCs) synthesize and disseminate evidence locally, but their impact on institutional decision making is unclear.

OBJECTIVE

To assess the evidence synthesis activities and impact of a hospital EPC serving a large academic healthcare system.

DESIGN, SETTING, AND PARTICIPANTS

Descriptive analysis of the EPC's database of rapid systematic reviews since EPC inception (July 2006-June 2014), and survey of report requestors from the EPC's last 4 fiscal years.

MEASUREMENTS

Descriptive analyses examined requestor and report characteristics; questionnaire examined report usability, impact, and requestor satisfaction (higher scores on 5-point Likert scales reflected greater agreement).

RESULTS

The EPC completed 249 evidence reviews since inception. The most common requestors were clinical departments (29%, n = 72), chief medical officers (19%, n = 47), and purchasing committees (14%, n = 35). The most common technologies reviewed were drugs (24%, n = 60), devices (19%, n = 48), and care processes (12%, n = 31). Mean report completion time was 70 days. Thirty reports (12%) informed computerized decision support interventions. More than half of reports (56%, n = 139) were completed in the last 4 fiscal years for 65 requestors. Of the 64 eligible participants, 46 responded (72%). Requestors were satisfied with the report (mean = 4.4), and agreed it was delivered promptly (mean = 4.4), answered the questions posed (mean = 4.3), and informed their final decision (mean = 4.1).

CONCLUSIONS

This is the first examination of evidence synthesis activities by a hospital EPC in the United States. Our findings suggest hospital EPCs can efficiently synthesize and disseminate evidence addressing a range of clinical topics for diverse stakeholders, and can influence local decision making.

ESPEN guidelines on chronic intestinal failure in adults

BACKGROUND & AIMS

Chronic Intestinal Failure (CIF) is the long-lasting reduction of gut function, below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation is required to maintain health and/or growth. CIF is the rarest organ failure. Home parenteral nutrition (HPN) is the primary treatment for CIF. No guidelines (GLs) have been developed that address the global management of CIF. These GLs have been devised to generate comprehensive recommendations for safe and effective management of adult patients with CIF.

METHODS

The GLs were developed by the Home Artificial Nutrition & Chronic Intestinal Failure Special Interest Group of ESPEN. The GRADE system was used for assigning strength of evidence. Recommendations were discussed, submitted to Delphi rounds, and accepted in an online survey of ESPEN members.

RESULTS

The following topics were addressed: management of HPN; parenteral nutrition formulation; intestinal rehabilitation, medical therapies, and non-transplant surgery, for short bowel syndrome, chronic intestinal pseudo-obstruction, and radiation enteritis; intestinal transplantation; prevention/treatment of CVC-related infection, CVC-related occlusion/thrombosis; intestinal failure-associated liver disease, gallbladder sludge and stones, renal failure and metabolic bone disease. Literature search provided 623 full papers. Only 12% were controlled studies or meta-analyses. A total of 112 recommendations are given: grade of evidence, very low for 51%, low for 39%, moderate for 8%, and high for 2%; strength of recommendation: strong for 63%, weak for 37%.

CONCLUSIONS

CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for both the underlying gastrointestinal disease and to provide HPN support. The rarity of the condition impairs the development of RCTs. As a consequence, most of the recommendations have a low or very low grade of evidence. However, two-thirds of the recommendations are considered strong. Specialized management and organization underpin these recommendations.

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.

Leakage of central venous catheter locking fluid by hemodynamic transport

Central venous catheters are often filled when not in use with an anticoagulating fluid, usually heparinized saline, known as the locking fluid. However, the use of the locking fluid is associated with known risks because of "leakage" of the lock. A new hypothesis is proposed here to explain the lock fluid leakage: that the leakage is due to advective and diffusive mass transfer by blood flow around the catheter tip in situ. On the basis of previous in vitro experiments, the leakage mechanism has been hypothesized to be fluid motion driven by buoyancy forces between the heavier blood and the lighter locking fluid. The current hypothesis is justified by a simple one-dimensional mass transfer model and more sophisticated three-dimensional computational hemodynamic simulations of an idealized catheter. The results predict an initial, fast (<10 seconds) advection-dominated phase, which may deplete up to 10% of the initial lock, followed by a slow diffusion-limited phase which predicts an additional 1-2% of leakage during a 48 hour period. The current results predict leakage rates that are more consistent with published in vivo data when compared with the buoyancy hypothesis predictions, which tend to grossly overestimate leakage rates.

Convective Leakage Makes Heparin Locking of Central Venous Catheters Ineffective Within Seconds: Experimental Measurements in a Model Superior Vena Cava

Central venous catheters (CVCs), placed in the superior vena cava (SVC) for hemodialysis or chemotherapy, are routinely filled while not in use with heparin, an anticoagulant, to maintain patency and prevent thrombus formation at the catheter tip. The heparin-locking procedure, however, places the patient at risk for systemic bleeding, as heparin is known to leak from the catheter into the blood stream. We provide evidence from detailed in vitro experiments that shows the driving mechanism behind heparin leakage to be convective-diffusive transport due to the pulsatile flow surrounding the catheter. This novel mechanism is supported by experimental planar laser-induced fluorescence (PLIF) and particle image velocimetry (PIV) measurements of flow velocity and heparin transport from a CVC placed inside a model SVC inside a pulsatile flow loop. The results predict an initial, fast (<10 s), convection-dominated phase that rapidly depletes the concentration of heparin in the near-tip region, the region of the catheter with side holes. This is followed by a slow, diffusion-limited phase inside the catheter lumen, where the concentration is still high, that is insufficient at replenishing the lost heparin concentration in the near-tip region. The results presented here, which are consistent with previous in vivo estimates of 24 hour leakage rates, predict that the concentration of heparin in the near-tip region is essentially zero for the majority of the interdialytic phase, rendering the heparin locking procedure ineffective.

Flushing and Locking of Venous Catheters: Available Evidence and Evidence Deficit

Flushing and locking of intravenous catheters are thought to be essential in the prevention of occlusion. The clinical sign of an occlusion is catheter malfunction and flushing is strongly recommended to ensure a well-functioning catheter. Therefore fluid dynamics, flushing techniques, and sufficient flushing volumes are important matters in adequate flushing in all catheter types. If a catheter is not in use, it is locked. For years, it has been thought that the catheter has to be filled with an anticoagulant to prevent catheter occlusion. Heparin has played a key role in locking venous catheters. However, the high number of risks associated with heparin forces us to look for alternatives. A long time ago, 0.9% sodium chloride was already introduced as locking solution in peripheral cannulas. More recently, a 0.9% sodium chloride lock has also been investigated in other types of catheters. Thrombolytic agents have also been studied as a locking solution because their antithrombotic effect was suggested as superior to heparin. Other catheter lock solutions focus on the anti-infective properties of the locks such as antibiotics and chelating agents. Still, the most effective locking solution will depend on the catheter type and the patient's condition.

Normal saline versus heparin solution to lock totally implanted venous access devices: Results from a multicenter randomized trial

PURPOSE

Our aim was to determine the non-inferiority of normal saline flushing compared to heparin flushing in maintaining the patency of totally implanted venous access devices (TIVADs).

METHOD

Four hundred and thirty patients were recruited from 14 Italian centres. Patients were randomized to heparin group or to normal saline group. The primary outcome of the study was TIVAD occlusion.

RESULTS

After randomisation, 203 patients were assigned to normal saline group and 212 to heparin group. Median follow up time was 204 days in normal saline group and 294 in the heparin group. We observed 24 withdrawal occlusions (5.78%): 10 in the heparin group and 14 in the normal saline group. One total occlusion was observed in the normal saline group. Taking as reference the arm treated with heparin, the absolute risk difference was 2.67 with the 90% CI including the non - inferiority margin of 4%. No significant difference between hazards of occlusion was found.

CONCLUSIONS

This study failed to demonstrate that normal saline flushing is not inferior to heparin flushing, even if a significant difference between the two treatments was not found. The use of heparin is controversial and other prospective trials are necessary in this field.

TRIAL REGISTRATION

EudraCT number: 2009-013620-22.

Lack of difference between continuous versus intermittent heparin infusion on maintenance of intra-arterial catheter in postoperative pediatric surgery: a randomized controlled study

OBJECTIVE:

To compare two systems of arterial catheters maintenance in postoperative pediatric surgery using intermittent or continuous infusion of heparin solution and to analyze adverse events related to the site of catheter insertion and the volume of infused heparin solution.

METHODS:

Randomized control trial with 140 patients selected for continuous infusion group (CIG) and intermittent infusion group (IIG). The variables analyzed were: type of heart disease, permanence time and size of the catheter, insertion site, technique used, volume of heparin solution and adverse events. The descriptive variables were analyzed by Student's t-test and the categorical variables, by chi-square test, being significant p<0.05.

RESULTS:

The median age was 11 (0-22) months, and 77 (55%) were females. No significant differences between studied variables were found, except for the volume used in CIG (12.0±1.2mL/24 hours) when compared to IIG (5.3±3.5mL/24 hours) with p<0.0003.

CONCLUSIONS:

The continuous infusion system and the intermittent infusion of heparin solution can be used for intra-arterial catheters maintenance in postoperative pediatric surgery, regardless of patient's clinical and demographic characteristics. Adverse events up to the third postoperative day occurred similarly in both groups. However, the intermittent infusion system usage in underweight children should be considered, due to the lower volume of infused heparin solution [ClinicalTrials.gov Identifier: NCT01097031].

Central venous catheter-related thrombosis

Thrombotic complications associated with the use of central venous catheters (CVCs) are common and lead to distressing patient symptoms, catheter dysfunction, increased risk of infections, long-term central venous stenosis, and considerable costs of care. Risk factors for catheter-related thrombosis include use of larger, multilumen, and peripherally inserted catheters in patients with cancer receiving chemotherapy. Symptomatic catheter-related thrombosis is treated with anticoagulation, generally without removing the catheter. The intensity and duration of anticoagulation depend on the extent of thrombosis, risk of bleeding, and need for continued use of a CVC. To date, the clinical benefit of prophylactic doses of anticoagulant has been disappointing and these agents are not used routinely for this purpose. This chapter focuses on recent evidence, remaining controversies, and practical approaches to reducing the burden of thrombosis associated with CVCs.

Focus on peripherally inserted central catheters in critically ill patients

Venous access devices are of pivotal importance for an increasing number of critically ill patients in a variety of disease states and in a variety of clinical settings (emergency, intensive care, surgery) and for different purposes (fluids or drugs infusions, parenteral nutrition, antibiotic therapy, hemodynamic monitoring, procedures of dialysis/apheresis). However, healthcare professionals are commonly worried about the possible consequences that may result using a central venous access device (CVAD) (mainly, bloodstream infections and thrombosis), both peripherally inserted central catheters (PICCs) and centrally inserted central catheters (CICCs). This review aims to discuss indications, insertion techniques, and care of PICCs in critically ill patients. PICCs have many advantages over standard CICCs. First of all, their insertion is easy and safe -due to their placement into peripheral veins of the arm- and the advantage of a central location of catheter tip suitable for all osmolarity and pH solutions. Using the ultrasound-guidance for the PICC insertion, the risk of hemothorax and pneumothorax can be avoided, as well as the possibility of primary malposition is very low. PICC placement is also appropriate to avoid post-procedural hemorrhage in patients with an abnormal coagulative state who need a CVAD. Some limits previously ascribed to PICCs (i.e., low flow rates, difficult central venous pressure monitoring, lack of safety for radio-diagnostic procedures, single-lumen) have delayed their start up in the intensive care units as common practice. Though, the recent development of power-injectable PICCs overcomes these technical limitations and PICCs have started to spread in critical care settings. Two important take-home messages may be drawn from this review. First, the incidence of complications varies depending on venous accesses and healthcare professionals should be aware of the different clinical performance as well as of the different risks associated with each type of CVAD (CICCs or PICCs). Second, an inappropriate CVAD choice and, particularly, an inadequate insertion technique are relevant-and often not recognized-potential risk factors for complications in critically ill patients. We strongly believe that all healthcare professionals involved in the choice, insertion or management of CVADs in critically ill patients should know all potential risk factors of complications. This knowledge may minimize complications and guarantee longevity to the CVAD optimizing the risk/benefit ratio of CVAD insertion and use. Proper management of CVADs in critical care saves lines and lives. Much evidence from the medical literature and from the clinical practice supports our belief that, compared to CICCs, the so-called power-injectable peripherally inserted central catheters are a good alternative choice in critical care.

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.

[Experience with implanted ports for venous access between 2005 and 2012]

INTRODUCTION

During chemotherapy of cancer patients, vein inflammation may develop which may lead to pain and difficulty in blood sampling. The use of implanted venous access ports may overcome these problems. With a correct use of needles, venous port membrane may be pierced 2000-2500 times.

AIM

The aim of the authors was to analyze their experience with venous access ports and evaluate whether insertion of venous ports occurred in an optimal time.

METHOD

A retrospective study of 63 patients who received venous access ports between 2005 and 2012 was carried out. Complication rate and the time of venous port insertion were analysed.

RESULTS

Of the 63 patients, the venous access port was removed in 22 patients because it was no longer required (n = 14) due to the development of complications (n = 8). 24 patients died from the underlying disease and 17 patients are still alive with the venous port in place.

CONCLUSIONS

In the period studied patients with venous access ports had an improved quality of life. However, the authors conclude that venous access ports were not inserted in an optimal time.

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.

Central Venous Catheter Flushing Recommendations

Background:

Treatment for many children with blood disorders or cancer includes the use of central venous catheters (CVCs). Few prospective studies have been conducted to address flushing guidelines in pediatric hematology oncology patients. Eighteen pediatric hematology oncology units were surveyed regarding current CVC flushing policies and procedures. Results reported extreme variations in CVC flush procedures, which instigated this systematic review.

Aims:

The purpose of this project was to critically review current literature and expert opinion regarding CVC flushing practice in the hopes of reporting standardized recommendations. Dissemination of consistent recommendations may reduce practice variability and complications associated with CVCs as well as increase patient and family confidence and competence in providing CVC care.

Methods:

Literature searches used PubMed, Medline, CINAHL, National Guidelines Clearinghouse, and Cochrane Database of Systematic Reviews. Multiple reviewers evaluated results relevant to CVC flushing procedures. Studies excluded were those that included neonates, peripheral intravenous catheters, dialysis catheters, and valved catheters.

Results:

Evaluation of 5 randomized controlled trials, 3 observational studies, 2 systematic reviews, 7 guidelines, and 1 literature review using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) and Appraisal of Guidelines for Research & Evaluation II (AGREE II) tools, an overall low level of evidence, and weak recommendation for practice was concluded.

Conclusion:

Weak recommendation for daily flushing of noninfusing Broviac/Hickman catheters and accessed implanted ports may be made. There was not sufficient evidence for heparin volume or concentration recommendations. No recommendations can be reported for peripherally inserted central venous catheters. Further research is indicated for CVC flushing procedures in pediatric hematology oncology patients.

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.

Management of central venous catheters in pediatric onco-hematology using 0.9% sodium chloride and positive-pressure-valve needleless connector

PURPOSE

To describe, in a sample of pediatric onco-hematological patients, the rate of occlusions in unused central venous catheters (CVC) flushed once a week with a 0.9% sodium chloride solution through a positive-pressure-valve needleless connector.

METHOD

Retrospective cohort study. Subjects aged 0-17 years were identified through a manual search in medical and nursing records and were observed for two years or until the occurrence of one of the following events: start or resume of continuous infusion; CVC removal; death. The primary study outcome was the frequency of CVC occlusion (partial or complete).

RESULTS

Fifty-one patients were identified (median age 6 years). The median duration of follow-up was 169 days (IQR 111-305). During the follow up period, 14 patients (27%) had one CVC occlusion, in 2 cases (4%) the occlusion was complete, in 12 (23%) partial. All the occlusions were solved without the need for catheter removal. The lumen diameter ≤ 4.2 vs > 4.2 French showed a statistically significant association with occlusion at multivariate analysis (OR 4.0; 95% CI 1.1-14.7).

CONCLUSIONS

Our findings are reassuring with respect to the management of the CVC using the adopted protocol. The study provides useful information for patient care, by verifying the performance of the adopted CVC management protocol and by identifying critical areas for nursing care.

Heparin solution for maintaining peripheral venous catheter patency in children: a survey of current practice in Italian pediatric units

BACKGROUND

Prolonging the duration of peripheral venous catheters (PVC) as long as possible in children is a nursing priority. However, available studies provide conflicting evidence on what kind of flush/lock solution should be used to increase the life of PVCs in children.

OBJECTIVES

To describe the clinical behavior of nurses working in Italian pediatric units with regards to PVCs flushing and locking practices.

METHODS

Cross-sectional study. Nurses were invited to participate using the network of the Italian Society of Pediatric Nursing Science. Those participating completed an online questionnaire available on a website established for this specific purpose. Results: 405 questionnaires were completed.

RESULTS

The majority of nurses reported using Normal saline solution (NS) to flush 22 gauge PVCs: 77.6% in children up to 6 months of age, 74.7% in children 6 months to 2 years, and 74.6% in children over 2 years. Nurses tend to use heparin solutions (HS) more frequently when a smaller gauge PVC is used (24 instead of 22) and when access is less frequent. The use of HS for PVC lock is more common in onco-hematology units (54.5% in children over 6 months with 24 gauge PVC), pediatric surgery units (35%), and in short-stay units (55.6%), whereas NS is used more frequently in Intensive care units (9.4%) and neonatology units (12.2%).

CONCLUSION

Although the majority of respondents use NS, we found a high variability in practices among Italian nurses. More research on the effectiveness and safety of HS in maintaining the patency of PVCs is needed.