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Ziyaeifard M, Ferasat-Kish R, Azarfarin R, Aghdaii N, Nejatisini H, Azadi Ahmadabadi C, Yousefi M. 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. Anesth Pain Med 2022; 12:e113345. [PMID: 37533479 PMCID: PMC10392822 DOI: 10.5812/aapm-113345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 02/28/2022] [Accepted: 03/02/2022] [Indexed: 08/04/2023] Open
Abstract
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.
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Affiliation(s)
- Mohsen Ziyaeifard
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Rasool Ferasat-Kish
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Rasoul Azarfarin
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Nahid Aghdaii
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hasan Nejatisini
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Changiz Azadi Ahmadabadi
- Department of Surgery, School of Medicine, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Marziyeh Yousefi
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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Maurer LR, Luckhurst CM, Hamidi A, Newman KA, Barra ME, El Hechi M, Mokhtari A, Breen K, Lux L, Prout L, Lee J, Bittner EA, Chang D, Kaafarani HMA, Rosovsky RP, Roberts RJ. A low dose heparinized saline protocol is associated with improved duration of arterial line patency in critically ill COVID-19 patients. J Crit Care 2020; 60:253-259. [PMID: 32920504 PMCID: PMC7467123 DOI: 10.1016/j.jcrc.2020.08.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 08/26/2020] [Accepted: 08/30/2020] [Indexed: 01/22/2023]
Abstract
Purpose Critically ill patients with Coronavirus Disease 2019 (COVID-19) have high rates of line thrombosis. Our objective was to examine the safety and efficacy of a low dose heparinized saline (LDHS) arterial line (a-line) patency protocol in this population. Materials and Methods In this observational cohort study, patients ≥18 years with COVID-19 admitted to an ICU at one institution from March 20–May 25, 2020 were divided into two cohorts. Pre-LDHS patients had an episode of a-line thrombosis between March 20–April 19. Post-LDHS patients had an episode of a-line thrombosis between April 20–May 25 and received an LDHS solution (10 units/h) through their a-line pressure bag. Results Forty-one patients (pre-LDHS) and 30 patients (post-LDHS) were identified. Baseline characteristics were similar between groups, including age (61 versus 54 years; p = 0.24), median Sequential Organ Failure Assessment score (6 versus 7; p = 0.67) and systemic anticoagulation (47% versus 32%; p = 0.32). Median duration of a-line patency was significantly longer in post-LDHS versus pre-LDHS patients (8.5 versus 2.9 days; p < 0.001). The incidence of bleeding complications was similar between cohorts (13% vs. 10%; p = 0.71). Conclusions A LDHS protocol was associated with a clinically significant improvement in a-line patency duration in COVID-19 patients, without increased bleeding risk. Critically ill COVID-19 patients have frequent arterial line (a-line) thrombosis. A low dose heparinized saline (LDHS) a-line patency protocol was examined. Two a-line thrombosis cohorts were identified: “post-LDHS” and “pre-LDHS”. A-line patency was longer in post- vs. pre-LDHS patients (8.5 vs. 2.9 d; p < 0.001). Bleeding complications were similar between groups (13% vs. 10%, p = 0.7).
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Affiliation(s)
- Lydia R Maurer
- Department of Surgery, Massachusetts General Hospital, Boston, MA, United States of America
| | - Casey M Luckhurst
- Department of Surgery, Massachusetts General Hospital, Boston, MA, United States of America
| | - Arzo Hamidi
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, United States of America
| | - Kelly A Newman
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, United States of America
| | - Megan E Barra
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, United States of America
| | - Majed El Hechi
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, United States of America
| | - Ava Mokhtari
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, United States of America
| | - Kerry Breen
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, United States of America
| | - Laura Lux
- Department of Nursing, Massachusetts General Hospital, Boston, MA, United States of America
| | - Laura Prout
- Department of Nursing, Massachusetts General Hospital, Boston, MA, United States of America
| | - Jarone Lee
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, United States of America; Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - David Chang
- Department of Surgery, Massachusetts General Hospital, Boston, MA, United States of America; Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Boston, MA, United States of America
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, United States of America
| | - Rachel P Rosovsky
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Russel J Roberts
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, United States of America.
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Sharma SK, Mudgal SK, Gaur R, Sharma R, Sharma M, Thakur K. Heparin flush vs. normal saline flush to maintain the patency of central venous catheter among adult patients: A systematic review and meta-analysis. J Family Med Prim Care 2019; 8:2779-2792. [PMID: 31681643 PMCID: PMC6820433 DOI: 10.4103/jfmpc.jfmpc_669_19] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 08/22/2019] [Accepted: 09/09/2019] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Suresh K. Sharma
- Professor Cum Principal, Center of Excellence in Nursing Education and Research, AIIMS, Rishikesh, Uttarakhand, India
| | - Shiv K. Mudgal
- Nursing Tutor, Center of Excellence in Nursing Education and Research, AIIMS, Rishikesh, Uttarakhand, India
| | - Rakhi Gaur
- Nursing Tutor, Center of Excellence in Nursing Education and Research, AIIMS, Rishikesh, Uttarakhand, India
| | - Rakesh Sharma
- Assist. Professor, Center of Excellence in Nursing Education and Research, AIIMS, Rishikesh, Uttarakhand, India
| | - Maneesh Sharma
- Assist. Professor, Center of Excellence in Nursing Education and Research, AIIMS, Rishikesh, Uttarakhand, India
| | - Kalpana Thakur
- PhD Scholar, College of Nursing, Center of Excellence in Nursing Education and Research, AIIMS, Rishikesh, Uttarakhand, India
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Vose J, Odunayo A, Price JM, Daves M, Schildt JC, Tolbert MK. Comparison of heparinized saline and 0.9% sodium chloride for maintaining central venous catheter patency in healthy dogs. PeerJ 2019; 7:e7072. [PMID: 31183263 PMCID: PMC6546076 DOI: 10.7717/peerj.7072] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 05/06/2019] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Julieann Vose
- Department of Small Animal Clinical Sciences, University of Tennessee—Knoxville, Knoxville, TN, USA
| | - Adesola Odunayo
- Department of Small Animal Clinical Sciences, University of Tennessee—Knoxville, Knoxville, TN, USA
| | - Joshua M. Price
- Office of Information Technology, University of Tennessee—Knoxville, Knoxville, TN, USA
| | - Maggie Daves
- Department of Small Animal Clinical Sciences, University of Tennessee—Knoxville, Knoxville, TN, USA
| | - Julie C. Schildt
- Department of Small Animal Clinical Sciences, University of Tennessee—Knoxville, Knoxville, TN, USA
| | - M. Katherine Tolbert
- Department of Small Animal Clinical Sciences, Texas A&M University, College Station, TX, USA
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A comparison of heparinised and non-heparinised normal saline solutions for maintaining the patency of arterial pressure measurement cannulae after heart surgery. J Cardiothorac Surg 2019; 14:39. [PMID: 30808385 PMCID: PMC6390345 DOI: 10.1186/s13019-019-0860-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 02/17/2019] [Indexed: 11/30/2022] Open
Abstract
Background Heparinized solution (HS) use for the maintenance of arterial cannulas has been associated with coagulation disorders and has not been conclusively shown to confer additional benefits over normal saline (NS) alone. We tested the hypothesis that in adult patients admitted to the cardiac ICU (T0) after cardiac surgery, HS arterial cannulas might be independently associated with increased heparin-induced coagulation disorders and might not be superior to NS arterial cannulas in reducing arterial cannula occlusion. Methods In this cohort study, 170 patients who received NS arterial cannulas during the period from T0 to ICU discharge were included in this study from June 1, 2017, to May 1, 2018 (NS group). There were 2930 patients who used HS (2.5 U/ml) arterial cannulas from January 1, 2015, to December 31, 2016 (heparin group). To address indicated biases, we derived a propensity score that predicted the functions of NS and HS in the patency of arterial cannulas. Results There were 296 patients (148 in the NS group and 148 in the heparin group) with similar risk profiles in the propensity-score matched cohorts. In the propensity-matched patients, the duration of arterial cannulas (P = 0.4) and arterial cannula occlusion (P = 0.5) showed no differences between the NS and heparin groups. However, the heparin group had a significantly increased activated clotting time (P < 0.05), activated partial thromboplastin time (P = 0.01) and allogeneic red blood cell utilization (3.4% vs 10.8%, P < 0.05). Compared with the NS group, the heparin group had more drainage from chest tubes from T0 to T48 (10.6 ± 9.4 ml/kg vs 13.0 ± 7.22 ml/kg, P < 0.05) and had more allogeneic red blood cells transfused (0.1 ± 0.4 U vs 0.4 ± 1.1 U, P < 0.05). Conclusion Based on the results of our study, the addition of heparin to normal saline for flushing arterial pressure monitoring cannulae did not reduce the incidence of catheter thrombosis and result in a very small but statically significant in increase in activated clotting time and activated partial thromboplastin time.
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López‐Briz E, Ruiz Garcia V, Cabello JB, Bort‐Martí S, Carbonell Sanchis R, Burls A. Heparin versus 0.9% sodium chloride locking for prevention of occlusion in central venous catheters in adults. Cochrane Database Syst Rev 2018; 7:CD008462. [PMID: 30058070 PMCID: PMC6513298 DOI: 10.1002/14651858.cd008462.pub3] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Eduardo López‐Briz
- La Fe University HospitalDepartment of Pharmacy & CASP SpainAvda Fernando Abril Martorell 106ValenciaValenciaSpain46026
| | - Vicente Ruiz Garcia
- La Fe University HospitalHospital at Home Unit & CASPe SpainAv Fernando Abril Martorell nº 106ValenciaSpain46026
| | - Juan B Cabello
- Hospital General Universitario de AlicanteDepartment of Cardiology & CASP SpainPintor Baeza 12AlicanteAlicanteSpain03010
| | | | | | - Amanda Burls
- City University LondonSchool of Health SciencesMyddleton StreetLondonUKEC1V 0HB
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Zhong L, Wang HL, Xu B, Yuan Y, Wang X, Zhang YY, Ji L, Pan ZM, Hu ZS. Normal saline versus heparin for patency of central venous catheters in adult patients - a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:5. [PMID: 28063456 PMCID: PMC5219914 DOI: 10.1186/s13054-016-1585-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 12/08/2016] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Lei Zhong
- Department of Intensive Care Units, The First Affiliated Hospital of Jinzhou Medical University, No. 2, The Fifth Section of Renmin Street, Guta, Jinzhou, 121000, Liaoning, China
| | - Hai-Li Wang
- Department of Obstetrics and Gynaecology, The First Affiliated Hospital of Jinzhou Medical University, Jinzhou, 121000, Liaoning, China
| | - Bo Xu
- Department of Intensive Care Units, The First Affiliated Hospital of Jinzhou Medical University, No. 2, The Fifth Section of Renmin Street, Guta, Jinzhou, 121000, Liaoning, China
| | - Yao Yuan
- Jinzhou Medical University, Jinzhou, 121000, Liaoning Province, China
| | - Xin Wang
- Xinxiang Medical University, Xinxiang, 453000, Henan Province, China
| | - Ying-Ying Zhang
- Department of Intensive Care Units, The First Affiliated Hospital of Jinzhou Medical University, No. 2, The Fifth Section of Renmin Street, Guta, Jinzhou, 121000, Liaoning, China
| | - Li Ji
- Department of Intensive Care Units, The First Affiliated Hospital of Jinzhou Medical University, No. 2, The Fifth Section of Renmin Street, Guta, Jinzhou, 121000, Liaoning, China
| | - Zi-Mu Pan
- Department of Intensive Care Units, The First Affiliated Hospital of Jinzhou Medical University, No. 2, The Fifth Section of Renmin Street, Guta, Jinzhou, 121000, Liaoning, China
| | - Zhan-Sheng Hu
- Department of Intensive Care Units, The First Affiliated Hospital of Jinzhou Medical University, No. 2, The Fifth Section of Renmin Street, Guta, Jinzhou, 121000, Liaoning, China.
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