I'm new to home care infusion. I'd like to get your opinion regarding protocols upheld as best practices, in a meeting I recently attended - regarding maintenance of pediatric non-infusing/non-therapy central lines, in the home:
1. Verifying line patency/ aspirating for blood return should not be done as part of non-therapy line maintenance. Blood typically seeps into the normal saline syringe when verifying patency, and bloody saline is injected back into the line with the pulse flush. A second saline flush is needed to clear the bloody saline from the line before a heparin lock is done. This requires 3 line accesses, which increases infection risk.
2. A normal saline flush is not needed with non-therapy line maintenance. Instillation of one heparinized (10 u/ml) saline (3ml) syringe can be considered both a flush and a lock in one (because the FDA describes heparinized saline as a "flush/lock"). Flushing with NS, followed by a heparin lock requires 2 line accesses instead of 1 (increasing infection risk).
The final recommendation was that non-infusing pediatric central lines should be "flushed" with 3 ml (10 u/ml) heparin three times a day - in the home.
Although I've taken care of IV lines in many nursing settings - the protocols/rationale put forth in this meeting are unfamiliar to me. Concern over number of IV accesses/infection risk was definitely the priority . (The INS 2016, Standard 40 on flushing and locking was considered in the meeting also).
What would you recommend for addressing the challenge of balancing/prioritizing IV accesses/infection concerns vs. standards for patency checking, flushing, and locking (specifically with non-therapy line maintenance - in the home setting)?
P Schultz
NS is used to assess patency of all CVADs. This is a significant component of complete catheter assessment. You do not need to pull back into the syringe. But you DO need to see blood that is the color and consistency of whole blood! See defnition of blood return in INS glossary. This is a critical step in assessing patency. Read the standard on CVAD Malposition and then find those references. These are medical studies that seriously emphasize the need for checking blood return. There is blood components adhering to the intraluminal walls from the very first moment all CVADs are inserted so I would not be so concerned about a small amount of blood in the saline flush. Locking is done with heparin but NOT flushing. There are far too many concerns about malpositioned CVADs to avoid doing a complete and thorough patency assessment. You did not state the frequency of the locking. For tunneled cuffed CVADs this is most commonly done weekly. It is not needed on a daily basis when nothing is infusing through the CVAD. As soon as therapy is no longer anticipated to resume, that CVAD should be removed.
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,
Thank you for providing the clear and helpful information.
You asked about "the frequency of the locking".
The recommendation was for 3 ml (10 unit/ml) heparin to be pulse "flushed" through non-therapy (pediatric) lines three times a day (q 8 hr).
I realize that technically heparin is a locking solution that should be instilled slowly.
As stated above - the group understands "heparinized saline" to be a flush/lock all in one - and considers that the line has been both flushed and locked by pulsing 3ml of heparin through the line.
The actual policy states that non-infusing lines should be "heparin flushed".
P Schultz
Sad to see your facility is not in agreement with the INS Standards and evidence based practice. 3 times per day is not necessary. Old studies say once per week for tunneled cuffed CVADS. Accessing that many times per day offsets any perceived benefits of not using a saline flush first.
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