WE currently flush our home care central lines on cath care only (not infusing meds or not infusing daily IV meds)
with 5 mls of 10 units per ml heparinized saline. We are considering flushing the lines with 10 mls NS first, then the heparinized saline as patients going into ambulatory sites are always flushed with saline. The variance is causing patient confusion.
When administering meds, we use SASH. When drawing labs, we flush with 20 mls NS after and then the heparinized saline.
My understanding with the NS is to buffer the heparin to prevent precipitate if there are incompatibility concerns.
My concern with adding saline is the increased infection risk due to accessing each line twice instead of once per day.
This also increases cost, but that is not my driving concern.
Thoughts on best practice for flushing central lines in home care on cath care only. I don't see this addressed in the 2016 INS standards.
Thanks,
K. Charnigo
You need to ALWAYS flush a VAD with saline before and after it is used for intermittent infusion. If your facility has a policy to lock with heparin lock solution, this ALWAYS goes last. Saline does not buffer the heparin. See INS Standard on Flushing and Locking for purposes of these steps. You do NOT need to flush any VAD when doing routine catheter care or on a scheduled time other than when it is used. A med q 8, 12, 24 hours means flushing and locking at the time of those med infusions only! Stop this practice of additional flushing on a schedule or during catheter care and you reduce the number of connections. 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
Lynn,
I think I may not have been clear with my question. When we administer IV antibiotics or any medication or solution in the home, we use SASH flushing.
IF the line has two lumens, we flush the other line that is not being infused, daily with 5 mls 10 units per ml heparinized saline. That is our cath care protocol for daily maintenance of a central line.
My question is should we flush with NS before the heparin on cath care (unused) lumen. My thoughts are no, it is just an additional access to the line and may increase infection. I don't see that addressed in the standards.
I have been a CRNI for many years and in infusion and home infusion over 35 years.
Karen Charnigo, MSN, RN, CRNI
Second message is much more clear! First, if there are no appropriate infusion reasons to have a double lumen PICC, you should work to reduce the frequency of this. The number of lumens is a distinct risk factor for BSI. If infusion therapy demands 2 lumens, then flush each one ONLY before and after use. If you have an unused lumen and cannot get it exchanged for a single lumen, you should maintain that extra lumen with saline followed by heparin lock if that is your policy. You need to be checking for a blood return by aspirating with saline, then give the heparin equal to ~120% of the lumen priming volume. There are no studies to establish the need for saline and that is why it is not addressed in the INS Standards. Without studies, we don't make up the standards to be what we please. It is an evidence based document. I base my recommendation for saline on the standard statement that calls for using saline to assess patency. 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
To be clear, this is for Pediatric patients that often are at home on line maitenance only.
Pediatric Oncology patients will have Broviacs, tunneled catheters, inserted for their infusions and lab draws. Due to their age, size or prescribed therapy, they will not have mediports.
For some patients, a Dual Lumen CVL is inserted secondary to the prescribed treatment the patient will recieve in hospital, but at home, only one lumen will be needed or neither. While we all want the fewest number of lumens necessary to complete the therapy, at times multi-lumen catheters are necessary and will be inserted. Exchanging is not a viable option for some patients or catheters.
These lines are being flushed only to maintain their patency. Is it necessary to flush with Normal Saline prior to the Heparin flush? The desire is to decrease the number times the line is accessed. The lines will be heparin locked as opposed to saline locked.
Moira McErlean
Yes because you should be assessing patency by checking for resistance and aspriating for a blood return. This is done with a 10 mL saline filled syringe first. Then follow with the locking solution.
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
In a hospital setting, we tell our RNs to flush a PICC/ML every 8 hours even despite a running IV infusing to help keep it patent. Is this not recommended because of the frequency in accessing the line?
Thank you,
J. Mathews
J. Matthew,
A PICC and even a ML can be kept patent with a KVO of 0.2 - 0.3 mls/hr... so I'm at a loss to figure out why one would increase manipulation and flush the line with running IVF. Even if they are just flushing to obtain the blood return q shift, that can be easily accomplished by lowering the IV bag to see the blood return in the IV. I would certainly revisit this policy and change it. And, what type of IV catheters are being placed in your facility? If they are Valved, like the Groshong, flushing really only needs to occur q week, or before and after the medication if you're giving a med more frequently.
Please review the purposes of VAD flushing outlined in the INS Standards. Flushing is definitely NOT required on a regular scheduled basis, like q 8 or 12 h. It is certainly not required for continuous infusions. You need to flush and aspirate blood return before each medication infusion and when you suspect problems such as with pump alarms and to prevent contact between 2 incompatible medications. Think about the excessive manipulation for all this unncessary flushing. Manipulation increases contamination.
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
I can't understand?
Liza John is professor and author in the Uk She is running her own company that he helps to a student with their task and provide to the students.
When checking blood return, some aspirated blood typically is drawn up into the saline flush syringe (especially with lines that do not have an extension set - needleless connector attached directly to the hub). This results in bloody saline being injected back into the patient. Does this fact require that a second flush of NS be administered – to clean the line of possible blood left behind by the first saline (blood tainted) flush? Then follow this double NS flush with a heparin lock (in non-therapy lines)?
I'm new to Home Care IV infusion - and was in a meeting recently in which the above practice was stated as rationale for not teaching patients in the home to check for blood return daily for maintenance of non-infusing/non-therapy central lines. The thought being that the line would need to be accessed three times (with 2 saline flushes followed by heparin flush), thus increasing infection risk. Based on this rationale, the final recommendation was that non-infusing/non-therapy lines (in the home) be “flushed/locked” with 10 unit/ml heparin 3 x’s a day. The committee also felt that a separate NS flush (prior to locking) was not needed because the heparinized saline is a combination of a flush and a lock all in one.
I've performed IV care/maintenance in several acute nursing settings, and am unfamiliar with a double saline flush being used when checking blood return in central lines. I’m also not familiar with heparinized saline being considered a combination flush/lock that cancels out the need to perform a flush with NS followed by a lock with heparinized saline.
Thanks for your input regarding these practices in general, and implications for home care (pediatric population specifically) as well.
P Schultz