I am 1 of 2 FTE's for an outpatient infusion therapy clinic, and also a PICC RN for both inpatient and outpatient. My facility is approx 160 beds, and we place approx 60 to 75 PICC's monthly. We have a CLABSI committee that has decided, based on evidence based research suggesting that Heparin administration via central lines increases the risk of thrombocytopenia, that we will no longer flush central lines (other than ports and dialysis catheters) with Heparin. The PICC's we place are non-Groshong and we are looking @ placing positive pressure caps on them rather than the negative pressure caps that are currently in use. I was wondering if anyone has faced this issue and how the outcomes have been, ie, has the use of Cath-Flo increased as a result of the absence of Heparin, and will using positive pressure caps help?
First, the type of needleless connector you are talking about is not a "pressure cap" and its funtion does not involve any pressure whatsoever. These devices merely displace fluid. See this article for more details:
1. Hadaway L, Richardson D. Needleless Connectors: A Primer on Terminology. Journal of Infusion Nursing. 2010;33(1):22.
These devices are totally dependent upon when the device is clamped and it is exactly the opposite from ones with negative displacement - lots of staff education if you change.
Second, I am giving a presentation at AVA on alternative locking solutions to heparin. I know there are issues with heparin but there is virtually no data about the incidence of HIT with heparin lock solutions. So I am not sure what they are looking at that has caused them to believe otherwise. Can you share their references?
When the Standards of Practice committee from INS looked at the literature, we decided that heparin 10 units per mL should remain the standard for locking CVADs based on the evidence we found. See that standard for more information and the list of references we used.
I have also heard lots of anecdotal information about use of alteplase increasing when saline has been used for locking CVAD. A well-done RCT from Italy showed twice the complications with saline locking and the positive displacement NC when compared to saline and heparin lock in newly inserted tunneled cuffed catheters on peds hem-onc patients.
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
Thank you Lynn for your response. Unfortunately, although we have asked for the reference information regarding their decision, neither my director or myself have received as requested. We currently use 100 u per ml Heparin for CVAD's. I will look on the INS website for the references you mentioned. That committee is meeting again tomorrow, and I would like to have this info to present to them, as I feel we are going to cause more problems by deleting Heparin than we will solutions.
On the INS website, you will find information about how to order the document, but the contents are not available directly from the site. You can download the content electronically but it is not free. If you get their information, please share what they are referring to. I just went through a huge stack of articles on alternatives for cath locking. HIT information associated with hep lock solution is extremely limited and the whole issue of the incidence of all HIT may be lower than some earlier studies reported. I gave a similar talk last year at WoCoVA. In the room was Dr. Ted Warkenton when had give his talk on HIT immediately before mine on alternative lock solutions. Afterwards, he said he had never thought about HIT in association with hep locks. If the leading expert in the world had not thought about this, then what level of a problem do we really have? Is the abandoment of hep lock for the sake of reducing HIT appropriate if increased CVAD complications occur? Interesting questions and no real concrete answers that I can find. 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