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Saline-only flushing of CVC's and INS standards

We have been trialing saline-only flushing of CVC's at our hospital since April...with mixed results.  The biggest arguments I've been receiving are from our local college nursing school instructors who point to INS standard 50, Flushing, Practice Criteria:  F.  Flushing with a heparin flush solution to ensure and maintain patency of an intermittently used central vascular access device should be performed at established intervals.

  These instructors say that even if our policy and procedure state to flush with saline only, it would be indefensible in court since INS standards say to use heparin solution.  What do you experts out there say?

Ann Briggs
I'm concerned about going

I'm concerned about going outside not only INS standards but also the manufacturers Directions for use.   I know some reps are telling clinicians that saline only is fine with a certian end caps but the evidence I've seen is anecdotal.  I've seen it work work well with the Boston Scientific valve but am concerned that the market is trying to jump ahead of evidence.  Without protections that research would provide it seems premature to not use heparin for flushes.   

I'll be very interested to see the INS working group will develop on this question. 

 Ann E. Briggs, RN, BSBA, CRNI

Quality Improvement Coordinator

Largo Medical Center

Ann E. Briggs, RN, BSBA, CRNI

Quality Improvement Coordinator

Largo Medical Center

Largo, FL

lynncrni
Saline as the catheter
Saline as the catheter -locking solution is acceptable when the manufacturer of a product has written instructions for use indicating this. These include catheters with integral valves and add-on needleless devices. As I have stated numerous times, we must think of this as a system - flush solution container, flush solution, syringe used for flushing, needleless device and catheter. Changing one component of the system may not change the clinical outcome. For instance on the positive displacement devices, is the volume of fluid held in reserve enough to offset the reflux caused by syringe and disconnection? I also think there is language in the 2006 edition of the standards about saline-only flushes with these devices. Don't have them on my desk right now to check. Lynn

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

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

kokotis
Heparin is 100 years old

Heparin is 100 years old and the FDA did not exist when it was invented.  Heprain was grandfathered in.  It was not used on patients until the 50's.  It is made of pig or cattle lung tissue.  The half life is less than one hour.  There are studies over the years to question its effectiveness to reduce clotting.  Not sure if it ever worked.  By the way it is not fibrin specific and all it does it attempt to reduce clot formation to add on to an existing clot.  I am doing lots of heparin research lately. 

 

Will the use of heparin or saline only make a difference for CVC's.  At this point there is no confirmed opinion on open ended lines as there is no large prospective, randomized blinded studies.  I would not expect to see anyone do this research as heparin cost pennies to administer as well as saline.  I think the bigger question we will have over the next three years is should we even use heparin or is it an outdated drug.  With the growing awareness of HIT and the new JACHO guideliens for 2008 on usage of heparin for DVT prophylaxis as a NO I think we will see changes in heparin use.  New recommendations indicate to use LMWH instead as it lowers the risk of HIT.  ASHP published a paper on getting rid of heparin in all peripherals.  It is a matter of time a few years that we see the elimination in central lines as well and go saline only. 

To add this thought if you utilized a product that has been approved by the FDA for saline only such as a valved catheter, port, or needle-less system than you can stop using heparin and stop exposing the patient needlessly to a drug that may or may not work.  No studies to indicate it works in the last decade at least.  there are at least 3-4 needle-less systems that have this indication.

 The future holds no heparin - therefore no HIT risk 

Kathy Kokotis

 

 

 

 

 

 

 

 

Kathy Kokotis

Bard Access Systems

Kathy Kokotis

Bard Access Systems

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