Preservative-free 0.9% sodium chloride for flushing and locking peripheral intravenous access device: a prospective controlled trial

Effectiveness and Safety of Measures to Prevent Infections and Other Complications Associated With Peripheral Intravenous Catheters: A Systematic Review and Meta-analysis

BACKGROUND

Peripheral intravenous catheters (PIVCs) contribute substantially to the global burden of infections. This systematic review assessed 24 infection prevention and control (IPC) interventions to prevent PIVC-associated infections and other complications.

METHODS

We searched Ovid MEDLINE, Embase, Cochrane Library, WHO Global Index Medicus, CINAHL, and reference lists for controlled studies from 1 January 1980-16 March 2023. We dually selected studies, assessed risk of bias, extracted data, and rated the certainty of evidence (COE). For outcomes with 3 or more trials, we conducted Bayesian random-effects meta-analyses.

RESULTS

105 studies met our prespecified eligibility criteria, addressing 16 of the 24 research questions; no studies were identified for 8 research questions. Based on findings of low to high COE, wearing gloves reduced the risk of overall adverse events related to insertion compared with no gloves (1 non-randomized controlled trial [non-RCT]; adjusted risk ratio [RR], .52; 95% CI, .33-.85), and catheter removal based on defined schedules potentially resulted in a lower phlebitis/thrombophlebitis incidence (10 RCTs; RR, 0.74, 95% credible interval, .49-1.01) compared with clinically indicated removal in adults. In neonates, chlorhexidine reduced the phlebitis score compared with non-chlorhexidine-containing disinfection (1 RCT; 0.14 vs 0.68; P = .003). No statistically significant differences were found for other measures.

CONCLUSIONS

Despite their frequent use and concern about PIVC-associated complications, this review underscores the urgent need for more high-quality studies on effective IPC methods regarding safe PIVC management. In the absence of valid evidence, adherence to standard precaution measures and documentation remain the most important principles to curb PIVC complications.

CLINICAL TRIALS REGISTRATION

The protocol was registered in the Open Science Framework (https://osf.io/exdb4).

Guidelines for Central Venous Port Placement and Management (Abridged Translation of the Japanese Version)

The central venous port has been widely used for patients who require long-term intravenous treatments, and the number of palcement has been increasing. The Japanese Society of Interventional Radiology developed a guideline for central venous port placement and management to provide evidence-based recommendations to support healthcare providers in the decision-making process regarding the central venous port. The guideline consisted of two parts: (i) a comprehensive review of topics including preoperative preparation, techniques for placement or removal, complications, and maintenance methods and (ii) recommendations for the six clinical questions regarding blood vessels for central venous port placement, port implantation site, prophylactic antibiotic therapy, imaging guidance for puncture, disinfectant prior to accessing the central venous port, and the optimal procedure at the end of drug administration via the central venous port, generated on the basis of the rating quality of evidence by systematic review.

Risk factors for peripheral venous catheter failure: A prospective cohort study of 5345 patients

PURPOSE

The objective of this study was to determine the independent risk factors associated with peripheral venous catheter (PVC) failure and develop a model that can predict PVC failure.

METHODS

This prospective, multicenter cohort study was carried out in nine tertiary hospitals in Suzhou, China between December 2017 and February 2018. Adult patients undergoing first-time insertion of a PVC were observed from catheter insertion to removal. Logistic regression was used to identify the independent risk factors predicting PVC failure.

RESULTS

This study included 5345 patients. The PVC failure rate was 54.05% (n = 2889/5345), and the most common causes of PVC failure were phlebitis (16.3%) and infiltration/extravasation (13.8%). On multivariate analysis, age (45-59 years: OR, 1.295; 95% CI, 1.074-1.561; 60-74 years: OR, 1.375; 95% CI, 1.143-1.654; ⩾75 years: OR, 1.676; 95% CI, 1.355-2.073); department (surgery OR, 1.229; 95% CI, 1.062-1.423; emergency internal/surgical ward OR, 1.451; 95% CI, 1.082-1.945); history of venous puncture in the last week (OR, 1.298, 95% CI 1.130-1.491); insertion site, number of puncture attempts, irritant fluid infusion, daily infusion time, daily infusion volume, and type of sealing liquid were independent predictors of PVC failure. Receiver operating characteristic curve analysis indicated that a logistic regression model constructed using these variables had moderate accuracy for the prediction of PVC failure (area under the curve, 0.781). The Hosmer-Lemeshow goodness of fit test demonstrated that the model was correctly specified (χ² = 2.514, p = 0.961).

CONCLUSION

This study should raise awareness among healthcare providers of the risk factors for PVC failure. We recommend that healthcare providers use vascular access device selection tools to select a clinically appropriate device and for the timely detection of complications, and have a list of drugs classified as irritants or vesicants so they can monitor patients receiving fluid infusions containing these drugs more frequently.

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.

The Efficacy of Normal Saline (N/S 0.9%) Versus Heparin Solution in Maintaining Patency of Peripheral Venous Catheter and Avoiding Complications: a Systematic Review

INTRODUCTION

Heparin is a sulfated polysaccharide belonging to the glycosaminoglycan family with strong anticoagulant activity. It has been widely used to maintain intravascular catheters in patients requiring intravenous medication. It is believed that heparin prevents thrombus formation in the intravascular catheter, but since the 1980s, the necessity of the heparin solution for peripheral intravenous catheter (PIVC) flushing has been questioned in several clinical trials. According to the Institute for Safe Medication Practices (ISMP), there are four special categories of High Alert Medications (HAMs), including heparin.

AIM

The aim of this systematic review was to investigate the efficacy of normal saline versus heparin solution in maintaining the patency and functionality of the PIVC and avoiding complications.

METHODOLOGY

A systematic review using PubMed and Cochrane Library databases was conducted. Original research studies of hospitalized patients with PIVC, regardless of age, published in English, over the last decade (2009-2019) were eligible for inclusion.

RESULTS

The review concluded in 10 studies that met the inclusion criteria. From these studies, it appears that it is not fully documented whether the normal saline (N/S 0,9%) is superior to heparin solution (H/S) in the flushing of the PIVC for maintaining its patency and prevent complications. Researchers tend to support the use of N/S 0,9% due to safety, error avoidance, efficiency, ease of use and cost-effectiveness. Concern about the possible complications of the heparin solution was the cause of guidelines development for N/S 0,9% in countries such as Australia.

CONCLUSIONS

The use of normal saline seems to outweigh the heparin solution in maintaining the patency of PIVC.

Perceptions of risk factors for phlebitis among Malaysian nurses

BACKGROUND

Intravenous therapy is an integral part of professional nursing practice. Nurses have a responsibility to recognise risk factors for phlebitis.

AIMS

To investigate nurses' perceptions of risk factors for phlebitis in a tertiary teaching hospital in north-east Peninsular Malaysia.

METHODS

A cross-sectional study of 199 randomly selected nurses were surveyed for their perceptions of risk factors for phlebitis using a self-administered questionnaire.

FINDINGS

More than half of the nurses (56.8%) had a good perception levels of risk factors for phlebitis. There was a significant association between the clinical area and nurses' perceptions of risk factors for phlebitis (p=0.04). Nurses working in medical, orthopaedic, and surgical areas had slightly better perceptions than nurses working in multidisciplinary and oncology areas.

CONCLUSION

These findings suggest that nurses need to continually improve their knowledge about risk factors for phlebitis to ensure safer nursing practice.

Accidental overdose of intravenously injected unfractionated heparin followed by prolonged clotting times in an anaesthetised Shetland pony

A six-year-old Shetland pony stallion was presented for elective castration. During surgical preparations, undiluted heparin (120 iu/kg) was unintentionally used for intravenous catheter flushing instead of heparinised saline solution. Surgery was cancelled for that day. Thromboelastography was used to monitor blood coagulation immediately after the accidental heparin overdose and on the following days. Three days after the heparin overdose, the coagulation parameters had returned to normal values and the pony was castrated. Anaesthesia and surgery were uneventful without any signs of coagulopathy. One day after surgery, the pony started to show signs of colic and was further diagnosed with colitis, most likely unrelated to heparin but due to repeated administration of penicillin and anaesthesia. Despite intensive treatment, the pony deteriorated progressively and was euthanased due to poor prognosis. Drug overdose is an example of medication error and is one of the most common errors in medicine.

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.

TAXA DE INCIDÊNCIA E O USO DO FLUSHING NA PREVENÇÃO DAS OBSTRUÇÕES DE CATETER VENOSO PERIFÉRICO

RESUMO Objetivo: avaliar a incidência cumulativa de obstrução do cateter venoso periférico e identificar o uso do flushing para prevenção das obstruções. Método: método misto, com estudo de coorte descritivo com seguimento de 110 pacientes de uma clínica médica de Portugal. A coleta de dados envolveu entrevistas com 22 enfermeiros, análise documental e observação participante. Realizada análise temática dos achados qualitativos e análise descritiva para os dados quantitativos. Resultados: a incidência cumulativa de obstrução foi 50%. As categorias temáticas desvelaram que o flushing era um cuidado para prevenção da obstrução do cateter venoso e realizado antes e/ou após a administração dos medicamentos. O volume de solução fisiológica utilizado no flushing variou entre 3 e 10 ml. Verificaram-se, também, situações de não adesão ao flushing e fatores que influenciavam nesta adesão, a saber: o tempo para realizar os cuidados, a complexidade e o grau de dependência dos pacientes, o volume de trabalho e o número de enfermeiros para prestar os cuidados. Conclusão: o flushing é um cuidado de enfermagem para a prevenção da obstrução do cateter venoso periférico, no entanto, as práticas de enfermagem para implementação não são uniformes quanto a frequência e volume de solução fisiológica. A ausência de um protocolo de enfermagem, a complexidade e o grau de dependência dos pacientes, o volume de trabalho e o número de enfermeiros são fatores capazes de influenciar na adesão à prática do flushing e consequentemente na incidência de obstrução do cateter venoso periférico e na segurança do paciente e qualidade dos cuidados.

Heparinized saline versus normal saline for maintaining peripheral venous catheter patency in China: An open-label, randomized controlled study

Objective

To evaluate the effects of heparin saline versus normal saline as locking solution for maintaining patency in peripheral venous catheters in Chinese patients.

Methods

This open-label, randomized controlled study was conducted in two hepatobiliary surgery wards, where patients received identical treatments, at a tertiary referral hospital. Patients were randomly divided into a normal saline group (NS, 3 ml) or a heparin saline group (HS, 50 IU/ml, 3 ml) for catheter sealing.

Results

The study enrolled 286 patients and 609 peripheral venous catheters were included in the analysis. The patients in the two groups had no local infections or catheter-related bloodstream infections. There were no significant differences between the two groups in terms of the rate of catheter obstruction, duration time, or the rates of phlebitis, infiltration, and accidental catheter removal.

Conclusions

No significant differences in the peripheral venous catheter sealing effects were observed between normal saline and heparin saline usage in Chinese patients.

Nursing Care: Care of the Perioperative Patient

This article provides a general overview of nursing care principles including an approach to developing a nursing care plan using the nursing process as its foundation. The nursing process is a problem-solving approach used in planning patient care. This article also focuses on nursing care as it pertains to the respiratory, cardiovascular, and renal systems (fluid balance) as well as care of the recumbent patient. Knowledge of nursing care techniques and risk factors for complications puts the care provider in a position of being proactive rather than reactive to patient care needs.

Heparin Saline Versus Normal Saline for Flushing and Locking Peripheral Venous Catheters in Decompensated Liver Cirrhosis Patients: A Randomized Controlled Trial

A prospective randomized, controlled, single-blinded trial to compare the effectiveness and safety of heparin saline (HS) to those of normal saline (NS) as flushing and locking solutions for peripheral venous catheter (PVC) in decompensated liver cirrhosis (DLC) patients.Patients with DLC at our institution between April 2012 and March 2013 were enrolled after obtaining informed consent. The patients were randomly allocated into 2 groups: the NS group received preservative-free 0.9% sodium chloride as the flushing and locking solution, while the HS group received HS (50 U/mL). PVC-related events and the duration of PVC maintenance were compared between the 2 groups. Moreover, the preinfusion and postinfusion levels of prothrombin time (PT), activated partial thromboplastin time (APTT), and platelet (PLT) were also compared.A total of 32 and 36 DLC patients in the NS (125 PVCs) and HS (65 PVCs) groups, respectively, were analyzed. Baseline characteristics, including gender, age, Child-Pugh grade, PVC type and administration of anticoagulant, and irritant agents, were comparable between the 2 groups (P > 0.05). The maintenance times of the HS and NS groups were 80.27 ± 26.47 and 84.19 ± 29.32 hours, respectively (P = 0.397). Removal of PVC for abnormal reasons occurred in 30.7% and 22.4% of patients in the HS and NS groups (P = 0.208). The PVC occlusion rates were 6.2% and 5.6% in the HS and NS groups, respectively (OR = 1.11, 95% CI 0.31-3.92). The PT, APTT, and PLT levels were comparable between the 2 groups both before and after infusion (P > 0.05). Incremental analyses showed that Child-Pugh grade C might be a risk factor for the suppression of PLT in the HS group.We consider NS to be as effective as and safer than conventional HS for flushing and locking PVC in decompensated liver cirrhosis patients.

Risk factor for phlebitis: a questionnaire study of nurses' perception

OBJECTIVES

to assess nurses' perceptions of risk factors for the development of phlebitis, with a special focus on the perception of phlebitic potentials of some infusion medications and solutions.

METHOD

a cross-sectional questionnaire study, which included a sample of 102 nurses.

RESULTS

Nurses recognized some factors that may reduce the incidence of phlebitis; however, more than half of the nurses were unaware that the material and diameter of the cannula can affect the incidence rate of phlebitis. Furthermore,underlying disease and high pH of medications or solutions were identified as potential risk factors, whereas low pH and low osmolality were not. Nurses identified Vancomycin and Benzylpenicillin antibiotics with the strongest phlebitic potential. Among other medications and intravenous fluids, Aminophylline, Amiodaronehydrochloride and Potassium chloride 7.4% were identified as potentially causing phlebitis.

CONCLUSION

predisposing factors for phlebitis relating to patients and administered therapy were identified by nurses, while some cannula related risk factors, in particular its physicochemical properties and the time for cannula replacement, were not fully perceived.

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.