What do you mean by heparin-free? I am not sure this is possible. The only way to eliminate heparin from catheter flushing is to use a technology that has a saline-only instruction for use. Even this is not great because many facilities still have a great problem with occlusion. There are no alternative catheter locking solutions that have been through the FDA processes and on the US market yet. You will find alternatives for therapeutic anticoagulation at the ASHP website - www.ashp.org
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Office Phone 770-358-7861
Lynn, maybe I should have been more specific. It appears that there is a tendency to move away from heparin for flushing, and using saline only. I guess this brings up a variety of questions: is it usu. about cost? fear of HIT? You alluded to the fact that there is a great problem with occlusion. Is it a teaching and comlpliance issue, or is it that saline is not the greatest method for keeping a line open. I had looked into swithching to a valved catheter so as to eliminate the need for heparin at least in PICC lines, and then decided that there would be too much confusion in which lines need heparin and which ones don't, so I did not pursue that. Any thoughts on this whole subject would be appreciated.
There is not a lot of published data yet on outcomes with the saline-only needleless devices. Eliminating the heparin requires the use of either a valved catheter or a needleless connector with instructions for saline-only flushing. There was a randomized controlled trial in the last issue of JIN comparing saline and saline plus heparin in a positive displacement needleless device. No statistical differences between the 2 groups but there were 3 caths in the saline only group that clotted. They figured this rate of clotting would make a huge financial difference so decided to continue with heparin. Knowledge and performance of proper flushing technique is only part of the answer. I guess I am not totally convinced that saline only is the best method for maintaining patency regardless of which device you are adding to the catheter. When I asked groups in my classes for a show of hands from those that are saline only and if they are still using a high amount of altepase, I always get a large number saying that they do a lot of declotting. Anecdotal evidence and not scientific, but I do not see a trend of saline only being the best choice. This just addressed the lumen occlusion issue. Then there is the entire piece about infection. 3 of 4 studies published thus far have involved a switch from a blunt cannula system to a mechanical valve system with a dramatic rise in BSI. So there are many things to consider about occlusion and infection risk when choosing the flushing solution and this is dictated by the needleless connector being used. Even with a valved catheter, you must choose a needleless connector to close it off.
There are numerous issues with heparin - drug incompatibility, HIT, heparin supporting the growth of biofilm in in vitro studies, to name a few. I do think an anticoagulant flush solution is necessary but heparin is the only one we have right now. Others are being researched and many are in use in other countries, but there are no alternative solutions on the US market yet. I am referring to EDTA, citrate alone or in combination with taurolidine. Lynn
Maximus Medical recently launched the MaxPlus CLEAR Cap. It is extremely effective in assisting clinicians in solving some of the bedside practice compliance issues. It is just so easy remember how the cap is to be used because you can see the way it works clearly. Of course the hospitals obtaining the best results across the board use the cap on centrals, PICCs and peripherals. Nursing practice in caring for high volume-low risk lines ensures much better maintenance of the high risk-low volume lines. The MaxPlus Clear cap on all lines quickly eliminates occlusions that result because of nurse confusion. Some hospitals still find it challenging to make the switch to peripherals due to GPO contracts, but as the CMS reimbursement plan goes into effect, more clinicians are going the next step when their efforts to improve clinical outcomes are denied.
With the MaxPlus Clear cap, it’s the combination of features that really aids in eliminating occlusions and infections and of course the needle sticks. The Flow rate of the MaxPlus Clear cap is excellent, there is virtually no dead space to harbor bacteria, it has an adequate priming space that creates an effective positive pressure bolus (different from other caps), swabbing actually disinfects it (different from all others) because it is flat and now with the Clear cap the clinician can visually confirm proper line flushing and maintenance due to the crystal clear housing and fluid path. Back to the original subject, heparin is not needed with the MaxPlus Clear cap. I encourage nurses to look to the FDA, Does the device meet 2005 guidelines? and what is the claim regarding saline?
The MaxPlus Clear cap can be used to protect all lines and they can be kept closed much longer.
Chonna Bartholomew RN, BS
Thanks but your message is a product commercial and, in my opinion, not appropriate for this forum. The only real test of the performance of any device comes from published clinical studies. Please let us know when those are available. Lynn
Chonna we currently use the MaxPlus and are changing to the MaxPlus Clear cap, can't wait. We have had great success with the MaxPlus.
We've been a "heparin - free" facility for many years. Meaning we don't use heparin Loc Solution in our peripherl IV's, subclavian CL's or picc lines, mainly becuase it is not needed if flushed using positive pressure or when using a positive pressure valve. We do of course use hep loc solution in our tunneled catheters and mediports.
Bard Access Systems
"These findings suggest saline may be as effective as heparin for maintaining the patency of CVC's"
LC Stephens, WD Haire Tranfus Sci Vol 18 No 2
Although it is not a prospective, randomized study as there are none out there he suggests heparin is not needed to lock any line. I agree. His study was with Hickmans and locking with saline versus heparin. Margy Galloway who should publish but has not at St. Luke's in Kansas City with is at least 360 beds has been heparin free of all central lines for at least three years and no ill effects. Heparin is not needed. I guess I would disagree with Lynn on this one. Ports may be the exception to the rule (I would lock those off label of course with tPA).
This is one study among many that I have looked at for the upcoming INS-sponsored webinars that I am presenting. I am not convinced that saline-only is the best method. It may be the only option in many situations right now, but I do not think it is the best option.