How often should saline locked central lines (not in use) be checked for a blood return? for example - triple lumen PICC, only one port needed for blood draws or infusion of medications, what do you do with the other ports? Check once every 24 hours hours, every shift?
The standard remains heparin lock solution 10 units per mL, not saline only for CVCs. See the INS standard on Flushing and Locking. There is no research to support the frequency of catheter flushing and locking when a lumen is not in use. It depends upon the setting. Hospitalized inpatients usually receive this flushing and locking every 8 or 12 hours while home care patients may go 24 hours. Ambualtory patients may even go several days such as over the weekend before the lumen is flushed and locked again. CDC states that the device with minimum number of lumens for the required therapy should be chosen. So a CVC with any extra lumens as you describe would fall below that set of guidelines and add risk of complications such as CRBSI. 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
Our physicians will not budge on locking with Heparin due to HIT issues. With the exception of Hemo cath, all our lines are flushed/'locked' with saline - hence our problems with clotting. This is why I wondered the best way to handle these lines. I want to manage these line as carefully as possible to prevent problems so wasn't sure if a blood return should be confirmed every shift or daily? One issue brought up was if we check for a blood return more frequently than 24 huors we may be putting our patient more at risk for infection by frequent accessing of line.
Our lines are often dual or triple lumens as they are often placed in the ICU setting when multiple ports are initally necessary and remain inplace until the patient is discharged to home.
Will you be at AVA in October? If so, I am giving a presentation on Catheter Locking Solutions: Alternatives to Heparin. 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
Unfortunately I will not be attending. I would be thrilled if you would share your powerpoint notes after the conference!
Lynn,
I would love some information as well, I have been using TKO-4s with the Clave Needless connector. In theory a saline lock is all that is needed however have been having issues with clotting, although I know nursing needs further education on proper flushing technique and that is scheduled. Wondering if anyone else has had similar issues, also using Navalyst catheters on some patients as well and wonder if people are still using hepain lock with them or strictly saline lock?
Thank You
BJ Sherman, RN
Vascular Access coordinator
Jasper Indiana
We recently had a patient with a port a cath in our hospital that was receiving 2-3 different IV push meds at all different hours. The nurses were flushing with saline after the meds but not locking the port off with heparin. Our policy states to flush with NS and then 500 units of heparin after administering medications unless there is a continuous IV going. The patient was ambulatory and did not want to be hooked to an IV pole. It would seem to be that flushing with Heparin after each medication administration would have been such a high risk for HIT syndrome. I was just wondering if flushing with just saline was most appropriate action to take with this situation.
Thanks,
Kim Springer
The dose of heparin has no influence over the development of HIT. This problem does not develope with high or low doses. It can develop with extremely low doses if the patient is going to develope it at all. However low doses are preferred. The Infusion Nursing Standard of Practice states to lock all CVADs with heparin 10 units per mL and the volume should be the internal volume of the catheter + add-on devices X 2 after each infusion or injection. Use SASH - saline, administer the meds, saline, and heparin. 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
Central Venous Catheter Care for the Patient With Cancer:
American Society of Clinical Oncology Clinical Practice
Guideline
Charles A. Schiffer, Pamela B. Mangu, James C. Wade, Dawn Camp-Sorrell, Diane G. Cope, Bassel F. El-Rayes,
Mark Gorman, Jennifer Ligibel, Paul Mansfield, and Mark Levine
See accompanying article in J Oncol Pract doi:10.1200/JOP.2012.000780
Charles A. Schiffer, Karmanos Cancer
Institute, Wayne State University
School of Medicine, Detroit, MI;
Pamela B. Mangu, American Society of
Clinical Oncology, Alexandria, VA;
James C. Wade, Geisinger Cancer Institute,
Danville, PA; Dawn Camp-Sorrell,
University of Alabama, Birmingham, AL;
Diane G. Cope, Florida Cancer Specialists
and Research Institute, Fort Myers,
FL; Bassel F. El-Rayes, Emory University,
Atlanta, GA; Mark Gorman, Patient
Representative, Silver Spring, MD;
Jennifer Ligibel, Dana-Farber Cancer
Institute, Boston, MA; Paul Mansfield,
University of Texas MD Anderson Cancer
Center, Houston, TX; and Mark Levine,
Henderson Hospital, Hamilton, Ontario,
Canada.
Published online ahead of print at
www.jco.org on March 4, 2013.
Clinical Practice Guideline Committee
Approved: September 5, 2012.
Editor’s note: This is a summary of the
literature that was used to inform the
American Society of Clinical Oncology
Clinical Practice Guideline for Central
Venous Catheter Care for the Patient
With Cancer and provides recommendations
with brief discussions of the
relevant literature for each. Evidence
tables with details about the studies
and meta-analyses cited are provided in
Data Supplements 1 and 2 at www.asco.
org/guidelines/cvc.
Authors’ disclosures of potential conflicts
of interest and author contributions
are found at the end of this
article.
Corresponding author: American Society
of Clinical Oncology, 2318 Mill Rd,
Suite 800, Alexandria, VA 22314;
e-mail: [email protected].
© 2013 by American Society of Clinical
Oncology
0732-183X/13/3199-1/$20.00
DOI: 10.1200/JCO.2012.45.5733
A B S T R A C T
Purpose
To develop an evidence-based guideline on central venous catheter (CVC) care for patients with
cancer that addresses catheter type, insertion site, and placement as well as prophylaxis and
management of both catheter-related infection and thrombosis.
Methods
A systematic search of MEDLINE and the Cochrane Library (1980 to July 2012) identified relevant
articles published in English.
Results
The overall quality of the randomized controlled trial evidence was rated as good. There is
consistency among meta-analyses and guidelines compiled by other groups as well.
Recommendations
There is insufficient evidence to recommend one CVC type or insertion site; femoral catheterization should
be avoided. CVC should be placed by well-trained providers, and the use of a CVC clinical care bundle is
recommended. The use of antimicrobial/antiseptic-impregnated and/or heparin-impregnated CVCs is
recommended to decrease the risk of catheter-related infections for short-term CVCs, particularly in
high-risk groups; more research is needed. The prophylactic use of systemic antibiotics is not recommended
before insertion. Data are not sufficient to recommend for or against routine use of antibiotic
flush/lock therapy; more research is needed. Before starting antibiotic therapy, cultures should be obtained.
Some life-threatening infections require immediate catheter removal, but most can be treated with
antimicrobial therapy while the CVC remains in place. Routine flushing with saline is recommended.
Prophylactic use of warfarin or low–molecular weight heparin is not recommended, although a
tissue plasminogen activator (t-PA) is recommended to restore patency to occluded catheters.
CVC removal is recommended when the catheter is no longer needed or if there is a
radiologically confirmed thrombosis that worsens despite anticoagulation therapy.
J Clin Oncol 31. © 2013 by American Society of Clinical Oncology