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Michael Hunt
Max Plus Clear
Has anyone seen these yet?  Sure, they're clear, but it doesn't make sense to me.  It was white before, and now they change?  If you want to see the entire cap, you need to twist it around because of the blue parts in the middle.  It's just causing confusion among my nurses as to which cap to grab, and the part-timers are looking for the white cap.  I don't like them, because of the confusion.  The white worked fine.
rivka livni
According to the company

According to the company they changed to clear because some nurses were complaining that they cannot see if blood "pools" in the cap, rendering the cap "dirty" and in need of a change.

I agree, the white cap is fine, if everyone followed the policy of when to change them there will be no need for questioning when to change.

Of course the white one

Of course the white one works fine and the same is with the clear one. There is nothing confusing with the clear one, I believe so. Since we changed to the clear one nurses replace the LAD's more frequently or let's say the way they should. A policy is fine when everyone works with or in the policies. The same is with scope of practice and basic nursing care. All it takes is some education so nurses see the benefit from a clear LAD.


Michael Hunt
All true, but doesn't a
All true, but doesn't a proper flush eliminate the need to see the components of the cap, because it's a positive pressure cap?  So the responses above says they change them "the way they should," why is there an apparent laziness in practice?  I agree that policies are good, and this should be a policy gaining more attention, especially come the time when hospitals are no longer reimbursed on BSI's.  If you can't follow the policy, get off the bus, and go home.
Alison Sanders
Maximus launched the MaxPlus
Maximus launched the MaxPlus Clear device after conducting 2 years of beta site testing with this device in strategic accounts. The beta site testing revealed that providing a clear housing enhanced nursing practice and assisted in improving compliance with flushing protocols, which resulted in a reduction of bloodstream infections, false positive blood cultures and catheter occlusions.  Typically, our customers will select either the Clear Connector (MaxPlus Clear) or the White Connector (MaxPlus) and carry one or the other in inventory. From your post it appears that your facility may be inventorying both Clear and White connectors and this had led to some confusion. If you are able to provide your facility name and contact information, I will be happy to contact your local Clinical Nurse and Sales Representative so they may meet with your facility to address this.    My name is Alison Sanders, I am the Product Manager at Maximus Medical, [email protected] 800-780-0012
Nancy Rose RN IV Team VA

Nancy Rose RN IV Team VA Medical Center Wilmington, DE (800) 461-8262 ext 4830

A few months ago we began using the Max Plus clear. Occasionally, 2 10ml flushes won't clear the cap. When that happens, I change the cap. If the housing was not clear, I would not have known I needed to change the cap.

I've  heard comments like, "I don't like seeing all that blood in the cap." Makes them want to flush until clear. I think it is a great product with good benefits. 

Nancy Rose 

I just came across this post
I just came across this post and dont understand how going beyond current nursing protocol to satisfy a device is a good thing.  How is extra flushing to clear a cap of blood or changing it when it cant be flushed which only adds burden to nursing and patient bsi risk an improvement?
I am close to trialing this

I am close to trialing this product.  The rep. states the cap through their research does not have to be changed before 7 days and do not have to be changed after blood draws.

For those that are using this product what is your policy?  How often are you changing these caps and how are your infection rates?

I am currently in the
I am currently in the process of trialing new caps.  I have had first hand experience with the white and clear.  Since using the clear, I now see that clearing the cap of blood is not always possible with 10ml of saline.  It shocks me to think of all the possible "dirty" caps I've left behind because I flushed according to policy, but could never see if it was effective.  I am referring to times when you aspirate to check for blood return.  I usually aspirate all the way into the syringe to assess flow.  Should policy be changed to state that anytime blood enters the line, it should be flushed with 20cc saline?
This is my point exactly

This is my point exactly Kevers.  NO we SHOULD NOT be changing policy just because a cap that cant be flushed.  and your right, the very first thing we do is aspirate for access up to the syringe and fill it with blood.  so does this mean you should change the cap immediately because we cant flush it??  please. and this isn't even a blood draw yet.

making it clear only means that the old one likely stayed on with blood and caused a lot of infection.  that makse me cringe.  its hard enough to monitor compliance in our nurses with a 10 ml flush and if its even being done.  now we're supposed to flush with 20?  all this shows me is that the old maxplus and the new clear dont work and never have.  someone speak up who thinks this is a solution and what are you doing that is working?

There are several studies

There are several studies available and 4 additional reports of an increase in BSI rates when hospitals changed products. 3 of those 4 reports were changes from a split septum device to a mechanical valve device. These studies and those 4 reports (plus there will be additional ones at AVA) show that BSI rates are lower with split septum systems however the occlusion is higher. With mechanical valves, the infection rates are higher but the occlusions are less. You can find all of these studies discussed in the series of webinars I did for INS. In additional to residual blood, there are numerous other factors such as failure to adequately disinfect the needleless connectors and using intermittent tubing for extended periods with questionable practice of how that tubing is managed between uses. CDC guidelines state to access all needleless systems with a sterile device, but an intermittent tubing really can not be called sterile after its first use. The bottom line is that purchasing decisions and processes vary greatly and you may not have control over what you are using. But you must be monitoring rates of infection and occlusion to know what works for your facility. 


Lynn Hadaway, M.Ed., RN, BC, CRNI

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

Clean the Hub
Which mechanical valves and

Which mechanical valves and which split septum valves were involved in these studies? It is important not to lump all valves into these categories. There are too many differences between the way they are designed and work. For instance, the Q-site and Interlink are lumped into the split septum category. Interlink had very low bsi rates because it had a great cleaning surface and it kept the bacteria out. Q-site calls itself a split septum device even though it is accessed without a blunt cannula, and piggybacks off of the low bsi rate data for split septum devices that Interlink was most likely responsible for. Why wouldn't all valves be called split septum? After all, every one has some opening that allows passage of fluids,just different shapes.

The same is true for mechanical valves. In these "studies", there is one positive pressure device named more frequently that saw increased bsi rates when hospitals swiched to it. This data is then applied to all positive pressure devices and gives them a bad name. How can anyone say a valve is bad from studies that it was not involved in, and thus no data suporting general claims that all positive pressure or mechanical valves increase BSI rates?

  This is like saying, "There is a study showing that Pit Bulls are shown to attack children." The news then reports the study saying that medium sized dogs are attaking children; nothing about Pit Bulls. After hearing this, I'm having second thoughts about my new yellow lab puppy around my kids because he will be medium sized too. When in reality, it had nothing to do with the size of dog, but the breed. It is not a factual or logical argument. (by the way, I don't have anything against Pit Bulls)

 My point is that industry leaders need to stop lumping everything into these categories that lead to making clinicians believe something that there is no real evidence to support.

Thank you all for the

Thank you all for the info.  but the point of my question and the post is because the maxplus clear cant be flushed without changing practice then what are facilities doing about it?  can anyone offer anything that is relevant?

I can just repeat:

I can just repeat: Everything stays and falls with bedside nursing! You can have a 500$ LAD ( Luer activated device) on your Picc, as long as your nurse is not cleaning the LAD you will get your infection.

I change the cap after blood draws, with every 6 day dressing change and every 3 day tubing change.

My infection rate is 0.2 and it stays there since a while.

The question is how do you flush the line? 10 ml straight, or pump/pause technique?

Now we can see what we missed over the last years and now we start blaming the cap? Kind of blaming the camera because the picture is bad.

Can we flush to much?

Andre Schotte


We have to do education, education and one more time, education.

The previous poster is

The previous poster is engaging in the "guns don't kill people, people kill people" fallacy.  With all due respect the device does play a role in the delivery of care in this case and you should know this as a clinician yourself.  Do you mean to suggest that all of us on these posts, and the many nurses and MDs who are questioning how these devices might be flawed, are delusional?

The issue is effective flushing.  I don't know what kind of unit you work on, but expecting my midnight shift nurses to consistently flush-until-clear a device when the lights are out and they can't even see it OR just keep flushing in order to clear it is hardly a solution to the problem.  every single device in our CVC bundle, whether drapes, UST, chg disks, scrubs, catheters and connectors SHOULD be designed with a ease of use in mind and not be dependent on hyper-intensive nursing education or a repetition of procedures that DO work when done the first time on other products.  A connector that cannot be flushed with only 10 ml is a liability.  Period.

Education and practices ARE critical to success. but we should be implementing products that support practice, not products that need to be SUPPORTED by redundancy and a flushing-until-dawn mentality.  I can name several devices circa 1990s that can at least be flushed the first time.

Andre, my colleagues tell me you are closely associated with a certain manufacturer on the west coast.  Shouldn't you disclose this COI?

I place my name under my

I place my name under my emails because I don't have to hide behind a foreign name.

I have no relation to any mfg at that point. I only tell my experience and what works for me and still tell people the options.

If you question my integrity and my work at least be man/woman enough to sign this email with your name.

There is no COI because I support all positive pressure devices. Maybe we should stick to the facts and keep this webpage clean!

I am more than happy to answer any emails.

[email protected]

Looking at all these posts I

Looking at all these posts I have come to one very obvious conclusion, those of you who post using an alias must work for a manufacturer which markets and promotes these devices. In fact, it appears as if one person may post under several aliases as the tone of many of these posts appears to be the same.  

Why would someone so vehemently dislike one product to the point they are slandering it on a forum like this? The answer is a financial relation to a product that is competing with the one they are slandering. 

Nursing practice is key to better patient care. Products and policies that enhance that practice do enhance outcomes.  An article published in the American Journal of Nursing in September 1997 clearly discusses best nursing practices as it relates “How to Manage PICC’s”. In this article, Denise Macklin, suggests that catheter occlusions can be prevented. She states, “Proper flushing technique with the correct volume of saline is critical. The volume used should be sufficient to clean the catheter – at least 20ml after blood withdrawal or medication administration. Problems may occur with too little flush not with too much. When flushing, use a pulsating motion to create enough turbulence to allow the solution to “scrub” the catheter wall. If a catheter is not constricted, it’s difficult to generate high pressure using this method. Maintain positive pressure on the syringe barrel and close the clamp (either on the PICC extension or on the extension tube) before removing the syringe to minimize blood reflux into the catheter tip.”  

The suggestions listed in this article are good practice and help maintain the patency of PICC lines with a pulsating flush and positive pressure.  After all, what are we really concerned about? The cap or the catheter? The goal is to maintain the catheter (to prevent contamination of the line and to maintain a patent line). The device that allows you to do that the best is the device you should use.  It is best to test and evaluate them yourself.

I agree with all you and

I agree with all you and Denise have stated except for one point. There is no scientific evidence that I have ever found to indicate that turbulent flushing technique "scrubs" the catheter wall. In fact, there is information in the biofilm literature in conflict with this theory. Biofilms formed at very high flow rates have very high tensile strengths and can not be easily removed. And do you really want to remove this biofilm because causing it to break off and float freely into the bloodstream is what produces the bloodstream infection. Turbulent technique could be beneficial immediately after you have aspirated blood into the catheter and flush to remove the whole blood well before the fibrin has attached, but there is not one clinical study on this flushing technique that I have ever found. I have found many how-to articles and opinions based on the theory of fluid flow, but I am asking for a clinical study. Sure wish someone would do it. 


Lynn Hadaway, M.Ed., RN, BC, CRNI

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

Question:  Why would

Question:  Why would someone so vehemently dislike one product to the point they are slandering it on a forum like this?  (I think you meant to write "libel" and not "slander."  Neither apply, however, as each refers to defamation of a person, not of inanimate objects, such as IV connectors.)

Answer:  Because products do affect outcomes inasmuch as they either cause or are dependent upon a variance of nursing practice; and certain products can and DO cause harm.  ALL is not dependent upon practice.  If products didn't matter, the FDA would have no purview.  Those who choose to ignore this do so to the potential detriment of their own patients and with callous disregard.

Is this libelous?  Where is the profit motive here?  There isn't always another agenda or competitive interest.  Healthcare providers should be cognizant of and unbiased to other viewpoints, information, and evidence.

A clinician knowing anything about risk management and/or liability exposure should be very hesitant to defend the use of any device in this class.  Or at least he/she should come to the table armed with more than paranoid and defensive replies to other posts when their own are clearly unaccepting and devoid of all the facts.

Clean the Hub
When you posted the links to

When you posted the links to the VA website that pointed to an article about positive pressure devices, you did not mention for some reason the name of the positive pressure device being scrutinized. Don't you think this leads others to false conclusions regarding all positive pressure connectors?

You are correct in that some products do in fact cause harm, but you are irresponsible to use this info from the VA to create the impression that all products in the same category also cause harm. Just so you know are informed, there are VA's using a positive pressure device other than the one implicated by the links you provided, that are experienceing tremendous success in regards to their blood stream infection rates and catheter occlusions. You only provided one small piece of the puzzle.

 Just to settle your little squabble with ksclafani, I included the definition of libel, which is a synonym of defamation, from Wikipedia. "In law, defamation (also called calumny, libel, slander, and vilification) is the communication of a statement that makes a false claim, expressly stated or implied to be factual, that may give an individual, business, product, group, government or nation a negative image."

So it can refer to an inanimate objet afterall.

Timothy Royer B...
"Nursing practice is key to

"Nursing practice is key to better patient care. Products and policies that enhance that practice do enhance outcomes."  These two sentences make the most sense to me. 

I would like everybody to consider a couple things here....if you can see inside the valve and visualized drug precipitate or blood residue would you be more or less apt to change the valve?  Would you be more or less apt to change how much, how often, and when you flush the line?  Would this be a visual cue for the nurse on the floor to flush this line?

Lynn is right here....there still is not any published studies of any kind about turbulent flushing scrubbing the catheter.  There is one study out there that shows that there is a connection between drug precipitates and clots being harder to break up inside the catheter.  I can't put my finger on it but I will look for it.

Shawn H.
I have a comment and a

I have a comment and a question.

Comment: The "Positive displacement, needle-free intravascular connector valves" in the below advisory refers to one specific device which the VA Hospitals converted to when they switched their pumps from one manufacturer to the other.

It it really frustrating that there is a continuation of generalization with all positive displacement connectors causing increased BSIs. As you know, the positive displacement valves all have their own designs (i.e. swabbing surface, internal mechanics, crevices, deadspace, etc).  With all these differences in valves currently out on the market, to actually think that ALL positive displacement valves are the same seems to be unjust.

Here's an anology - Let's say you got food poisoning eating spaghetti and meatballs at 3 different locations of a particular Italian Restaurant chain.  Is it logical to say that spaghetti and meatballs at ALL Italian Restaurants cause food poisoning?  It seems ludicrous but some of these posts and studies are continuously insinuating that!  

The fact of the matter is that all the "positive displacement devices" have their distinct features - internal and external, good or bad that separates one positive displacement valve from another.  Because of these vast differences, it's really not logical to group all the positive displacement devices as causing BSIs.  Sometimes I feel like we as people are so caught up on "studies" that we forget to use our basic common sense. I realize that everyone will have a difference of opinion on what is "common sense" but we as cognitive and educated people know what these are already.

It is imperative that nurses/institutions get things in writing from their reps as far as claims and find out for themselves if such claims are true or not either by having them demonstrate it first hand or the nurse performing the test themself.

Question to Lynn Hadaway re: Turbulent Flushing

Lynn, first of all thank you for continuous sharing of knowledge in the IV Therapy arena. You are certainly a wealth of infomation. I do have a question though.

You've been talking about the lack of studies and data regarding the turbulent flushing for quite some time now. I also understand your caution in the breaking up of the biofilm within the catheter lumen with the turbulent flushing.  I don't know about the rest of the country but in this region, majority of the hospitals are using the Power Injectable PICCs. If what you are saying is true about the turbulent flushing and how might possibly be "causing the bioflim to break off and float freely into the bloodstream which produces the BSI", what do you think is happening within a power injectable PICC when it's being injected with contrast @ 300psi's?  My common sense tells me that much more biofilm is being introduced into the patient than the actual turbulent flushing performed with a syringe.

Don't you think this is a bigger area of concern for the breakup of biofilm inside the catheter lumen during power injections? In the same light, what about Powerports?  Power injection is also performed with these ports which will have the same kind of biofilm growth in the lumen of the port as well as within the port itself under the septum.  Some hospitals are exclusively using PowerPICCs and power ports now. And I'm sure power injection is done on a regular basis throughout these hospitals.  However, with these facilities their CRBSI level is still extremely low.  If there is a relationship between turbulent flushing and BSI's wouldn't all these hospitals that are doing more power injections be noticing a increase in their BSi's.

Your insight is greatly appreciated.

You have raised some valid

You have raised some valid points. Regarding needleless connectors, there are numerous studies with multiple brands showing an increase in BSI with luer activated mechanical valves but they have lower (but not zero) rates of occlusion. Split septum devices are the opposite - lower rates of infection but higher rates of occlusion. There are many questions yet to be answered but I am referring to at least 7 published studies on this issue all included in the webinar series I did this spring now available at the INS website.

Regarding turbulent flushing technique and power injectable PICCs. There is a difference between laminar flow and turbulent flow. Power injection creates laminar flow while the stop-start manual flushing method is intended to cause turbulence inside the lumen. It is this turbulence that could cause the biofilm to break off. We definitely need more studies. Turbulent flushing technique is one of those nursing interventions started based on theory alone. It may increase the removal of whole blood that you have just aspirated into the catheter lumen, but there is no evidence that it will "clean the catheter walls" as I have heard many nurses say. And turbulence could cause biofilm to break off, but we do not have all the answers to these questions yet. We also need more information about outcomes with power injection. So I would urge more data collection and publication about outcomes to help answer these questions. 

Lynn Hadaway, M.Ed., RN, BC, CRNI

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

Shawn H.
Lynn, Thanks for your prompt


Thanks for your prompt response but I would like to point out a couple of things again.

1.  I agree that there is a difference between laminar and turbulent flow. I don't want to get into the boring scientific equations but did you know that as speed of the fluid increases, at some point the laminar flow transitions to turbulent flow? This is because fluid closest to the inner wall lumen flows slower than the fluid in the middle which eventually will create its own turbulence.  This has to do with drag arising from friction (fluid contact with the inner lumen wall).

Another point is that laminar flow is only possible at slow speeds AND if there is NO obstruction in the fluid path. If you're concerned that there is biofilm formation on the inner wall of the catheter lumen, you definitely know for sure that this "obstruction" along the wall will cause "eddies" to form as the fluid moves past the obstructions (if it doesn't get knocked off by the viscous contrast media first).  So your depiction of "laminar flows" with the power injection is only possible with the assumption that there is NO biofilm growth on the inner catheter lumen wall. I think we can all agree though that every indwelling catheter will form biofilm as soon as it enters the bloodstream. That's what the body does.

I'm sure you also know that contrast used for power injection is very viscous and dense.  This thicker viscosity being forced @ 300psi (in addition to the transitional turbulence caused by the speed/density of the fluid as described above as well as the turbulence formed by biofilm growth obstructions) will definitely cause more biofilm breakage than the average 20 psi pulsatile flushing performed with a 10cc saline syringe.

One more point on the "push pause" technique - that's how today's infusion pumps work with its periastalic (push pause) mechanism within the pump.  Infusion pumps exert pressures up to about 40 psi's and pumps the fluid through the tubing using the same principle as the push pause.  Depending on what fluids are being administered and at what rate, you're ALWAYS going to have that push pause action happening within the catheter because of the pumping mechanism.  What is the difference between this and the push pause technique that is manually performed with a syringe? Conceptually it's the same thing.  With 5lbs of force applied to a syringe plunger, the pressure being exerted by a 10cc syringe is less than 20psi's which is about the same as an infusion pump.  Why is the push pause only a concern during flushing when it's happening everywhere throughout the hospital where pumps are being used?

I feel that this "fear" that you're knocking off biofilm within the inner lumen of the catheter when using the push pause technique is NOT accurate at all. I agree with you that more studies need to be done on this subject but we know these studies are time consuming and very expensive.  I also feel like we can gather enough data from everyday practices and outcomes just by using some common sense.

I look forward to your comments, Lynn. Thank you again for sharing your expertise with a knucklehead like myself.


Marcia Ryder
Shawn, I concur with your

Shawn, I concur with your comments re the push pause/peristaltic flow pattern of pumps and the risks of shear force with power injection as risks of biofilm cell detachment and dispersion. Hemodialysis flow rates is another example of high shear flow. 

I would, however add some caution regarding the biofilm and flushing raised in these postings.
First, we need to be clear about what is attached to the inner lumen walls.  Conditioning films are formed when biomaterial surfaces are in contact with blood.  The conditioning film is composed of primarily platelets and plasma proteins (primarily fibrin(ogen) and fibronectin).  These films are tenaciously attached and are unlikely to be removed with physiologic and intravenous flow rates or flushing techniques.  Biofilm is formed when microorganisms attach/adhere to either the naked polymer or to the proteins or platelets in the conditioning film.  They may also incorporate the proteins are part of the biofilm matrix.  Biofilms on naked polymer are relatively thin (roughly 10 to 30 microns thick) and would unlikely cause turbulent flow where thick fibrin deposition may. The landscape of the internal lumen is undoubtedly highly variable from catheter to catheter.

The detachment of cells from a biofilm is a fundamental process in the biofilm life cycle that occurs naturally with starvation, liquid shear stress, cell-cell signaling, and microbial gene expression, and occurs readily in any flow system.  The detachment phenomenon is not yet well understood particularly in biological systems and implanted medical devices.
Only two studies (that I am currently aware of) have examined detachment (staph aureus and pseudomonas) to understand the potential for cell clump detachment from medical devices and the formation of microemboli that is hypothesized to lead to metastasis downstream.  (As an example, we have observed this phenomenon in clinical practice when TPN patients flush their catheters after locking over night and experience fever within a short time thereafter.)  These  studies were done in an in vitro glass flow cell with a constant flow rate of 1 ml per minute and with no conditioning films.  Indeed there was significant detection of both single cell and cell clumps in the effluent.  

Flushing catheters is an important procedure in maintaining catheter patency, drug clearance to avoid incompatibility, etc.  Power injection for diagnostics is also critical in diagnostics.  Blood clearance from catheters is also essential in that the presence of thrombus has been well documented as correlative to CRBSI.  Turbulent flushing is readily observed to clear blood from tubing compared to laminar flushing.  We have NO evidence at this point to direct us in any alteration of current practice of flushing techniques especially in relation to biofilm. To imply that turbulent flushing should be reconsidered due to biofilm detachment is making a huge leap and may lead to an increase of other risks associated with poor flushing.  Biofilm will themselves actively detach and disperse clumps and cells even in low shear. To that end, it is my opinion that our efforts are better directed at prevention of catheter occlusion and bacterial ingress to minimize biofilm formation with access site disinfection, antimicrobial locks and selection of minimal risk connectors until we better understand the relationships.

On that note, I also agree that we must caution against lumping connectors into the luer activated devices and split septums.  There are at least 7 luer activated connectors currently on the market in which the flow path is accessed via a split septum.   There is NO evidence to support the statements that there is an increase in BSI with all luer activated mechanical valves but they have lower (but not zero) rates of occlusion or that split septum devices are the opposite - lower rates of infection but higher rates of occlusion.
Marcia Ryder PhD RN

Research Coordinator, USC Center for Medical Biofilm Research

Marilyn Hanchett
Marcia Ryder's point about

Marcia Ryder's point about re-classiifying needleless connectors is important. The old way of categorizing these products, most often differentiated as split septum or mechnical valve, is no longer accurate. She and I have both used the older method, but have now abandoned it. In fact, we are sufficiently convinced that this out dated approach is adding to the on going confusion about the use of these types of products.

 As a result, Dr Ryder and I are currently developing a new tool and article that will address this issue specifically. It is not yet complete, but if you have interest/questions she and I will both be attending the upcoming AVA conference in Savannah and welcome the opportunity to discuss the need for and merits of a new clasiification model.

 Marilyn Hanchett RN

Westminster, Maryland

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