Forum topic

 I'm revising policies involving the same issue - heparin vs saline flushes.  Our hospital uses Bard valved piccs with Baxter neutral displacement connectors (I'm working on moving to MaxPlus Mini).  I'd like to have a consistent policy for all PICCs, but we do get outside lines with clamps.  Please share your wisdom!

 Flushing and locking are 2 distinctly separate purposes. Using saline to lock a PIV has been the standard for more than 20 years. Using saline to lock a CVAD is controversial. There are 4 new studies addressing this issue. 3 are RCTs, 1 is a before/after trial. 2 are using implanted ports. 1 is for multilumen CVADS in ICU patients, 1 is one PICCs in home care using 3 locking solutions - saline, 10 unit heparin and 100 unit heparin. 

PICC home care study showed less frequent unplanned home visits, I think my memvory is correct, when using 10 units per mL of heparin. All other studies showed eqiuvalance between heparin and saline for locking purposes, so not difference in outcomes. Current INS standards call for CVAD locking with 10 units heparin. These studies came out after the current SOP and I am not sure how this will be changed for the next edition in 2016. 

If saline and heparin are equivalant to each other, then I think we have a long way to go to have the most effective catheter locking solution. 

Remember that differences in outcomes can easily be tracked to incorrect flush-clamp-disconnect sequence for the type of needleless connector in use. 

All CVADs should have the same policy for locking and it should not be applied only to PICCs. 

All VADs require a clamp regardless of the type of NC in place. Luer lock connections can be accidentaly loosend or totally removed. Without a clamp, an air emboli is going to ccour with a CVAD and bleeding can occur with a PIV. 

Lynn

I agree that all open ended, non-valved IV catheters require a clamp on said catheter regardless of what type of needleless connector is on its end, however, I don't believe that valved IV catheters need to have an additional ext set added to them. As long as that catheter's valve is patent, one shouldn't have to worry about air embolism/blood issues.

 This should be each facility's decision about clamps, however there is documentation of venous air emboli with a Groshong valved catheter due to the fact that serium proteins built up around the valve holding it permanently open. This may be less likely with a valve in the external hub. But I strongly think that all VADs require a closed clamp on the catheter extension leg when not infusing given these facts:

1. venous air embolism can cause death

2. venous air embolism can lead to a serious life-altering outcome due to movement to the brain 

3. there is no payment to the hospital for treatment of an air embolism, so the hospital eats the costs of everytihing which could be the rest of the patient's life in a nursing home

Lynn

 The extension leg is built onto the catheer and is not an added piece. It is the part between the wings at the insertion site and the catheter hub. You are correct that some of the catheters with an intergral valve do not have this clamp added to the extenion leg, but I have serious concerns about leaving catheters unclamped, especially in hime care. We now emphasize a clear needleless connector. Many times a patient may accidently remove the needleless connector when disconnecting the IV set because the set and connector are both clear. The standard is for a luer locking connection but the connection may not be made correctly or completely and it becomes loose allowing air to enter the line. Given the fact that VAE can and does kill, I want to take every precaution and I would not rely completely on the presence of an integral valve to prevent VAE. In fact, the catheter manufacturers are very careful in their language about this claim. I don't think any of them state that VAE is prevented by their valve. Lynn

I work in  IV Therapy in a hospital and we do not use Heparin in our CVAD's , except for portacath when deaccessed prior to discharge.  We only use NaCl for all lines.  A lot of our PICC patients do go home with their PICC and most all use Heparin to lock the line.  It is rare for them to have problems with blood return until they return to hospital.  We use a lot of Activase on our PICC lines in the hospital.  We are trying to change our needleless connector too,  however we are getting resistance. We have the PICC  with the integrated valve on the extension and no clamps.  If given the choice, I would use PICC with clamps  and clear needleless connector and Heparin 10units/ml after saline flushing for locking the PICC. I need to research this further to have evidence of these  as more effective practices. Any suggestions appreciated. 

I don't think Angiodynamic's PASV valved PICCs come with a clamp in place. If these catheters are used, would it be prudent to place a clamp on the catheter?

 This morning I looked at the websites for PASV, SOLO, and Groshong valved catheters. None of them make any statements on their website about venous air embolism. I have not had a chance to look at their complete IFU yet. But none of these catheter companies are making any marketing claims about preventing or reducing the risk of VAE. Therefore the use of a clamp is a decision that should be made by the policy makers in your facility and everyone should be consistently practicing in the same manner. I am not sure how you would add a slide clamp to the extension leg or if you can even purchase these clamps separately. So the question is - does your facility want to take the added risk of the chance of VAE due to catheter damage, disconnected needleless connectors, etc with the risk of VAE associated with each of these issues. Lynn

Ann, the conversation seemed to drift away from your original question...SAS or SASH?? I work in both home care, hospitals and LTC's. We have better patency and use less cath flo when SASH is used for all types of catheters. We use the 10u/ml heparin flush. (100u/ml- for ports)