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kejeemdnd
High Flow Catheters

What are the criteria that determine when a catheter is a high flow catheter? I am confused by the INS standard that lumps HD and apheresis catheters under this heading. Many catheters are marketed as HD catheters and many are marketed as central VADs that happen to be appropriate for apheresis. Is there a criteria for determining when a catheter should be packed with 10, 100, 100units/ml heparin or something else? I'm concerned that if this isn't more clear, patients will be inadvertently bolused with therpeutic doses of heparin during routine dressing changes because of confusion over the type of line that is in place. IFUs are not helpful as they invariably refer back to hospital policy for packing solutions.

One fix is to always require that staff aspirate twice the volume of the catheter prior to flushing, but I still think it would be helpful to know what criteria determines the ideal solution/concentration of packing solution.

What does everyone think?

 

Thank you!

lynncrni
 I only found the term "high

 I only found the term "high-flow catheter" in the standard on apheresis and ultrafiltration. Hemodialysis SOP does not include that term so I am confused by your statement. An HD catheter is a type of CVAD. Lumen size is used by the manufacturer to deterimine in vitro flow rate. In vivo there are numerous factors that affect flow rate. Generally speaking apheresis requires flow rates of around 70 mL per minute while HD requires flow rates of 300 mL per minute. I am assuming that you are using "packing solution" to mean locking solution, which is the term used in the INS standards. In the 2011 standards, PIVs are locked with saline; CVADS are locked with 10 units per mL of heparin; implanted ports are locked with 100 units per mL only when needle access is removed; hemodialysis catheters are locked with 1000 units per mL. See SOP for those references. HD may be locked with 5000 units per mL or 4% sodium citrate dependent upon the LIP orders. SHEA now recommends locking HD caths once per week with rt-PA. As I write this, I am buried in a stack of articles and working on the revisions to the Flushing and Locking Standards for INS. I can not say what those changes will be because they have not been decided yet. A literature search will bring up the same articles I am finding. Each facility is responsible for providing clearly written policies and procedures based on their patient populations. In addition, they are required to provide education and competency assessment for all staff performing these procedures. If this is followed there should be no lack of clarity on what each facility should be doing. Lynn

Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

kejeemdnd
 Thank you Lynn for

 Thank you Lynn for responding. To clarify, my confusion comes from Standard 45.R, which says, "Catheters used for apheresis procedures are large-bore catheters and require rapid flow rates...The flushing and locking procedures for these catheters should follow the same practices as hemodialysis catheters." In your response you said that hemodialysis catheters are locked with 1000units per ml and two sentences later you said, "HD may be locked with 5000units per ml or 4% sodium citrate dependant..." This is the nature of my confusion. My hospital locks its HD catheters with 5000u heparin and gentamycin. The INS standard states that apheresis catheters should follow the same flushing and locking procedures as HD catheters. That is a contradiction to your statement that apheresis catheters should be locked with heparin 1000units/ml. All I'm suggesting is that INS standards tie HD and apheresis catheters to closely when they obviously have different maintenance procedures. Standards such as 45.R suggest they should be handled the same, when in reality, that is not the case. Thanks!

Keith W. Gilchrist, MSN, RN, PHN, OCN, CRNI, VA-BC
Oncology Nurse Navigator, David Grant Medical Center
Travis AFB, CA

lynncrni
 Keith, you are correct about

 Keith, you are correct about the confusion, however the 2011 standards were writting according to the available evidence at that time. I have just completed a literature review for flushing and locking and there are NO strong recommendations still. Mulitple RCTs have shown now that hepairn and saline for locking CVADs produces equivalent outcomes. The only recommendations comes from ASFIN for use of heparin 1000 units per mL or 4% citrate for locking hemodialysis catheters. There are studies about using citrate or acid-citrate-dextrose (same anticoagulant as what is used in a unit of blood) for locking apheresis catheters. Just yesterday I gave a presentation at an AVA seminar on flushing and locking. The ideal lock solution is yet to be recommended, studies, and made commercially available. They all have limitations. For instance, there is now multiple reports of gentamincin resistance caused by gentamicin lock solution. Lynn

Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

kejeemdnd
 This is very helpful. Thank

 This is very helpful. Thank you, Lynn!

Keith W. Gilchrist, MSN, RN, PHN, OCN, CRNI, VA-BC
Oncology Nurse Navigator, David Grant Medical Center
Travis AFB, CA

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