I just returned from a meeting, and was told that you never, under any circumstances, put a clave on the port tubing. I was told that even if I sent a person home with a port accessed and no infusion running I was not to use a clave, but to use a syringe cap. The reason given was the negative preasure clave would pull blood into the catheter and cause clotting. I mentioned that using the correct technique would solve that problem. I was told that was the theory, but it didn't work in reality. We have only one type of clave in our system, the old-fashioned negative clave. We are not allowed to use the positive preasure claves, the powers that be say they contribute to clotting lines. I am beginning to rave a little, I suspect, please forgive.
Anyhow,I would like a little feedback from you friendly folks. Any thoughts?
Thanks,
Gail
If you use positive pressure flushing and use the clamp on non-valved devices and/or extension sets, there would be no reflux with the Clave, which is a negative displacement needleless connector. Conversely, there could be reflux even with a positive displacement connector or a syringe cap if the line was unclamped with changes in the patient's intrathoracic pressure (coughing, straining, etc.).
Follow the manufacturer's instructions for use, and you should be fine. In fact - your clinical rep for the NC that you use might be very helpful to you.
Be careful about the word "clave". It is a brand name of a specific needleless connector and the term shouldn't be used generically. Kleenex is to tissue what Clave is to needleless connectors. Clave just happens to be one of the earliest needleless connector devices manufactured, and everything gets lumped under that name.
It's very important to know that there are significant differences between needleless connectors - search this forum and you'll find lots of lively discussions!
Mari Cordes, BS RN
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center
I totally agree with Mari. We must use correct terminology if we are ever going to have correct communication. Clave is a brand name. Your instructions to use a syringe cap is absolutely wrong. Where is this syringe cap coming from? If they are expecting you to reuse the cap from the flushing syringe you just used, this is completely out of the question because those caps are for a single use only. Once you have removed it from the syringe, it must be discarded and not used again.
All needleless connectors that have a negative displacement will cause blood reflux **unless** the proper flushing technique is used. Also, the use of saline only flushing in a positive displacement needleless connector is not the answer. I recently found another large randomized study showing a complication rate with saline and the CLC2000 to be twice that of heparin in a "standard cap", the language used in the study. Here is the reference:
1. Cesaro S, Tridello G, Cavaliere M, et al. Prospective, randomized trial of two different modalities of flushing central venous catheters in pediatric patients with cancer. J Clin Oncol. Apr 20 2009;27(12):2059-2065.
This study had more than 75,000 catheter days in tunneled catheters. I had serious doubts about the use of saline alone for catheter flushing but now I strongly believe that saline alone is not the answer even with a positive displacement connector.
Lynn Hadaway, M.Ed., RN, BC, CRNI
www.hadawayassociates.com
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
Thank you so much for all the info. We actually do still use the old real "clave" claves! I always appreciate the support I get with this forum. I appreciate that new information from Lynn about the Heparin.
Thanks,
Gail
Gail McCarter, BSN,CRNI
Franklin, NH
That's great, Gail - we used the Clave for a long time as well.
Thanks for the article, Lynn - good find!
Mari Cordes, BS RN
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center
Hi,
sorry if this is a stupid question, but why are there negative displacement devices?
To me it seems that they just add an extra occlusion risk by pulling in blood into the catheter if you don't clamp before removing your syringe.
What is the good thing about negative displacement?
Mats
There is a great deal of controversy about all needleless connectors. There are several reports of increased risk of CRBSI associated with positive displacement connectors, and there are lower rates reported with the split septum systems. So I am not ready to move totally away from the negative displacement devices yet. I would agree that their patency depends on flushing technique, and requires skillful nurses to ensure the correct technique. This can lead to increased occlusions. We do not have the total answer for this yet, so we must have all options right now. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
www.hadawayassociates.com
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
Thanks Lynn,
I still have difficulty in seing the logic behind why there is an increased infection risk if the device injects that last portion of saline a second or two after I have injected into the line. And if one dislikes the idea of positive displacement, I don't see why negative displacement (with the extra occlusion risk) adds any benefit compared with a neutral valve.
Just an extra bit of info from Sweden: Connectors that require needles have never been used much in Sweden (I have never used them in 20 years as a nurse), so the term needleless connectors would puzzle most Swedish nurses, as most will not know that there is any other kind.The standard procedure has "always" been to just attach the syringe directly to a chlorhexidine alcohol swabbed luer lock three-way stop-cock. Different kinds of (needleless) connectors have been coming to us the last 5-10 years or so.
Mats
In the US, we stopped the routine use of stopcocks many years ago. In fact, there is a statement in the Infusion Nursing Standards of Practice against their use. There are numerous studies pointing to an increased risk of infection associated with them, probably because we did not do a good job of keeping them closed.
The use of stopcocks on CVCs is quite common in Europe and the main reason that studies of needleless connectors from these countries cannot easily be used to support US practices.
Lynn Hadaway, M.Ed., RN, BC, CRNI
www.hadawayassociates.com
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
Great discussion! Thanks, Lynn for the new article reference. I am anxious to read it. I hesitate to agree that saline-only flushing cannot be used. The study you mentioned is done on patients with cancer, which is documented as a frequently hypercoagulable state. These patients will be more prone to clotting/occlusions than patients without cancer. I have been a part of a facility that has successfully used saline only on all catheters except dialysis with a very low occlusion rate. I am working on a proposal for a blind randomized research study on a generalized population to evaluate the system. With the problems with HIT in critical care, it would be nice to have good evidence to support a system that, when used in conjunction with a CRBSI prevention program could use a saline-only flush and continue to have low occlusion/CRBSI rates. I am always hopeful.
Julie Shomo BS, BSN, RN, CRNI
Infusion Solution LLC
Julie Shomo BS, BSN, RN, CRNI
Infusion Solution LLC
New studies on HIT have found that the incidence is far lower than originally thought. So this may not be a valid reason to abandon heparin before there is another anticoagulant to take its place. I would encourage you to do your research and publish it. From what I have read so far about the issue, I am still not convinced that saline-only in the currently positive and neutral displacement needleless connectors in common use currently is the best approach to maintain catheter patency.
Lynn Hadaway, M.Ed., RN, BC, CRNI
www.hadawayassociates.com
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