We have a patient with a port who has been diagnosed with heparin induced thrombocytopenia. I have reviewed S78 (INS 2016) which states to use an alternative to heparin. I am looking for guidance and information on what others use and what Lynn Hadaway would recommend. 4% Citrate? Cath-Flow? Normal Saline is what Hematology recommended. Worried that deaccessing port with NS would result in an occlusion. He will be transferring to a long term care facility.
Thank you,
Terry
Studies have shown that outcomes are equivalent when heparin 10 units/mL and normal saline are used to lock all CVADs including implanted ports. So I would recommend nornal saline. See INS SOP #40 Flushing and Locking, these statements and the references are all there.
You mentioned this was going to be done in a long term care facility. I think the greatest influence over VAD patency comes from technique and NOT the solution used. Make sure the staff knows what type of needleless connector is being used when the port is accessed, and know and use the correct sequence for disconnection and clamping when the final solution is injected. For deaccessing the port, make sure they are using a positive pressure flushing technique when the port access needle is removed. This can be trickly to do now that we are required to use access needles with a safety device and that often requires 2 hands. Flushing with the lock solution as the needle is withdrawn is important to prevent backflow of any blood into the lumen. But again, studies have shown there is no difference in outcomes when comparing heparin lock solution to normal saline as a locking 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
Thank you, you are an invaluable resource!!!!!
Lynn,
In some oncology patients, increased intrathoracic pressure results from coughing (lung ca, pneumonitis) or vomiting. This seems to drive blood into the catheter lumen. Would you still recommend NS for flush in these circumstances? I have been accessing a patient's port who recently developed pneumonitis from some radiation treatments. The last two months, when initiall checking for blood return, I have pulled back initial brown blood reeturn from his lumen. This had not happened before. I fear that without heparin in his catheter, that brown blood would be an intraluminal clot.
D. Fritz, Onc CNS
See the statements in INS SOP 40 Flushing and Locking, Practice criteria I. Those statements are based on 3 systematic literature reviews from a wide variety of patients, CVAD types and healthcare venues. I am convinced that the solution is not the total answer to ensuring lumen occlusion. Syringe-induced reflux, disconnection reflux based on the type of needleless connector will cause blood in the lumen. Some patients are more hypercoagulable that others. Then there is the issue of locking solution density compared to blood density. The studies show there are equivalent outcomes with use of heparin and saline - no difference. One solution has not proven to be superior to the other. To me, this says there are many more factors than the type of solution alone. If these solutions are equal, then the risk of saline is far less than heparin, so that is the preferred solution we should be using. Each facility has to make their own decision about this issue based on the evidence that shows equivalent outcomes,
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