finding the evidence for

8/4/2019 Finding the Evidence For

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Finding the Evidence for

Maintaining the

Patency in Peripheral IntravenousIntermittent Catheters

ROSELLE MARIE D. AZUCENA,RN,MAN


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STANDARDS IN FLUSHING AND

LOCKING


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LOCKING

Vascular Access Devices shall be flushed prior

to each infusion as part of the steps to assess

catheter function


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LOCKING

Vascular Access Devices shall be flushed after

each infusion to clear the infused medication

from catheter lumen, preventing contact

between incompatible solutions


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LOCKING

Vascular access device shall be locked after

completion of the final flush solution to

decrease risk of occlusion


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LOCKING

Flushing and Locking of all vascular access

devices shall be established in organizational

policies, procedures and/or practice guidelines


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PRACTICE CRITERIA

A-W


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PRACTICE CRITERIA

A. Single-use systems include single-dose vils

and prefilled syringes and are the preferred

choice for flushing and locking.

If multi-dose containers must be used, each

container should be dedicated to a single

patient


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PRACTICE CRITERIA

B. Flushing is accomplished with preservative free 0.9%sodium chloride (USP).

When medication is incompatible with preservativefree 0.9%, 5% dextrose in water should be used andfollowed by flushing with preservative free 0.9%sodium chloride and/or heparin lock solutions.

Dextrose should be flushed from the catheter lumenbecause it can provide nutrients for biofilm growth


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PRACTICE CRITERIA

C. Bacteriostatic 0.9% sodium chloride contains

benzyl alcohol as the preservative.

The maximum volume that can be tolerated by

adult and pediatric patients is undetermined;

however, one study suggests that this should

not exceed 30 ml in a 24- hour period for

adults.


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PRACTICE CRITERIA

D. The minimum volume of preservative free 0.9%

sodium chloride for catheter flushing depends

upon the type and size of catheter, age of the

patient and type of infusion therapy being given.

A minimum volume of twice the internal volume

of the catheter system is recommended; howevera larger volume may be needed for blood

sampling or blood transfusion procedures.


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PRACTICE CRITERIA

E. The nurse should aspirate the catheter for

blood return as a component of assessing

catheter function prior to administration of

medications and solutions.

( see standard 61, Parenteral Medications and

Solution Administration)


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PRACTICE CRITERIA

F. Due to varying degrees of physiologic maturity

for drug metabolism and excretion in the

neonate, solutions used for flushing and/or

locking catheters should not contain thepreservative benzyl alcohol


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PRACTICE CRITERIA

G. If resistance is met and/or no blood return

noted, the nurse should take further steps to

assess patency of the catheter prior to

administration of medications and solutions.The catheter should not be forcibly flushed

(Standard 56, Catheter clearance)


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PRACTICE CRITERIA

H. To prevent catheter damage, the size of the syringeused for flushing and locking should be in accordancewith the catheter manufacturers directions for use.

Patency is assessed with a minimum 10 ml syringe filledwith preservative free 0.9% sodium chloride.

Flush syringes holding a smaller volume and/ordesigned to generate lower amounts of pressure mayalso be used to assess patency,


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PRACTICE CRITERIA

Administration of small quantities of

medication should be given in a syringe

appropriately sized for the dose required

following confirmation of catheter lumenpatency


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PRACTICE CRITERIA

I. Prefilled syringes filled with preservative free

0.9% sodium chloride should not be used for

dilution of medications. Due to risk of serious

medication errors, syringe to syringe drugtransfer is not recommended


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PRACTICE CRITERIA

J. Short peripheral catheters should be locked

with preservative free 0.9% sodium chloride

following each catheter use in adults and

children


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PRACTICE CRITERIA

K. No specific recommendation can be made

about the use of heparin lock solution or

preservative-free 0.9% sodium chloride for

locking short peripheral catheters in neonatalpatients. Data are inconsistent and inadequate

to make specific recommendations.


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PRACTICE CRITERIA

L. The nurse should assess for contraindications

for the use of heparin lock solution including,

but not limited to, presence or risk for

heparin-induced thrombocytopenia, heparinsimpact on laboratory studies drawn from the

catheter, and systemic anticoagulation.


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PRACTICE CRITERIA

Heparininduced thrombocytopenia has beenreported with the use of heparin flushsolutions, although the exact rates are

unknown.

All patients should be monitored closely for

signs and symptoms of HIT. If present orsuspected, heparin and all sources of heparinshould be discontinued


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PRACTICE CRITERIA

M. For post-operative patients receiving heparinlock solutions of any concentration, monitoringplatelet counts for heparin-induced

thrombocytopenia is recommended every 2-3days from day 4 through day 14 or until heparin isstopped.

For medical patients receiving heparin locksolutions, routine platelet count monitoring is notrecommended


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PRACTICE CRITERIA

N. The use of preservative-free 0.9% sodiumchloride for locking catheters with an integralpressure-sensitive valve system is recommendedby manufacturers directions for use, although

the continued use of heparin lock solution hasalso been suggested.

There are multiple designs of these valves located

on the internal catheter tip and the externalcatheter hub. Available data are inconclusive andconflicting


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PRACTICE CRITERIA

O. While many studies report equivalent outcomesin central vascular access catheters when lockedwith heparin lock solution or preservative free

0.9% sodium chloride, others have reportedgreater complications with saline locking.

Due to the risks and cost associated with central

vascular access device insertion, heparin locksolution 10 unit/ml is the preferred lock solutionafter each intermittent use.


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PRACTICE CRITERIA

P. Before removal of an access needle from an

implanted port and/or for periodic access and

flushing, the device should be locked with

heparin lock solution 100 units/ml


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PRACTICE CRITERIA

Q. Catheters used for Hemodialysis should be

locked with heparin lock solution 1000

units/ml after each use.


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PRACTICE CRITERIA

R. Catheters used for apheresis procedures are

large bore catheters and require rapid flow

rates; the procedures has an impact on

coagulation factors.

The flushing and locking procedures for these

catheters should follow the same practices as

hemodialysis catheters


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PRACTICE CRITERIA

S. Patency of arterial catheters used for hemodynamicmonitoring is greater when heparin solution is infused,although existing studies are inconclusive due tovariations in the catheters location ( peripheral vs

pulmonary), duration of catheter use, and differencesin patency measurement.

The decision to use preservative free 0.9%NaCl insteadof heparin infusion should be based on the clinical risk

of catheter occlusion, the anticipated length of timethe arterial catheter will be required, and patientfactors such as heparin sensitivities.


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PRACTICE CRITERIA

T. Concentrations of heparin greater than or

equal to 1 unit/ml should be used as an

infusion in umbilical arterial catheters in

neonates; however heparinized flush orlocking solution is not effective


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PRACTICE CRITERIA

U. Positive fluid displacement within the lumen

of the catheter should be maintained to

prevent reflux of blood upon luer

disconnection.

This is accomplished with either a flushing

technique or a needleless connector designed

to overcome blood reflux


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PRACTICE CRITERIA

V. Alternative locking solutions may be consideredin patients with HIT including but not limited to,ethanol, sodium citrate, taurolidine,ethylenediamine- tetraacetate (EDTA), or

combinations of these solutions.

These solutions are not commercially available insingle-use containers and do not have a labeled

indication for maintaining catheter patency.These locking solutions should be obtained froma compounding pharmacy.


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PRACTICE CRITERIA

Drug precipitation is possible when heparin is added tothese lock solutions.

The length of dwell time for the lock solution and the

duration of treatment depends on the need to use thecatheter for infusion and the clinical response.

Use of lock solution is not recommended as a routine

prophylactic measure due to the possibility ofdevelopment of resistant strains of microorganismsand adverse reactions to the high concentration of locksolution.


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PRACTICE CRITERIA

Prophylactic use my be considered in patients

with a history of catheter related bloodstream

infections or those with other risk factors such

as prosthetic heart valve.


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References

Journal of Infusion Nursing, January-February

2011 Vol34,Number 1S,ISSN 1533-1458

www.journalofinfusionnursing.com
http://www.journalofinfusion/http://www.journalofinfusion/

finding the evidence for

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