Heparin Flush Solution Research Articles

Comparison of normal saline versus heparin flush solutions for maintaining patency of central venous catheter in cancer patients.

6501 Background: Published guidelines recommend normal saline (NS) flushes for maintaining patency of central venous catheters (CVCs) in cancer patients. The practice at a large oncology ambulatory facility was modified to use NS flushes instead of heparin for CVC maintenance (centrally inserted catheters and peripherally inserted central catheters, excluding implanted ports). The number of catheter occlusion events, pre- and post-implementation, was utilized to determine the effectiveness and safety of this practice change. Methods: Retrospective data of patients aged 18 years and older who presented to the ambulatory centers were collected from the electronic health record (EHR). The number of alteplase instillations was used as a surrogate measure for occlusion events. Ambulatory line-days, defined as patients arriving for an appointment and with either an active CVC or a CVC placement, was the denominator. The numerator was the number of ambulatory line-days with a catheter line and alteplase dose(s) given. The pre-intervention CVC maintenance period using heparin flushes was March 2016 - April 2017. The post-intervention CVC maintenance period using NS flushes was May 2017 - September 2018. Results: 95,089 line-days and 4,452 unique patients were analyzed pre-intervention and compared to 115,194 line-days and 5,575 unique patients post-intervention. The baseline incidence rate of occlusion was 0.91%, compared to the post-intervention incidence rate was 2.67% ( p < 0.01). The increase started immediately within the first month of the practice change (2.26%) and continued throughout the post-implementation observation time. Conclusions: In an ambulatory oncology-practice setting with a high volume of CVC utilization, an increase in line occlusions rate was observed after implementing the practice change of flushing CVCs from heparin to NS. This raises concerns regarding safety and additional burdens to patients and caregivers, and additional analyses are ongoing to evaluate the further impact of this evaluation.

Role of Heparin in Arterial Line Flushing Solution on Platelet Count and Indwelling Arterial Catheter Patency after Cardiac Valvular Surgery

Background: Heparin can cause thrombocytopenia but what is it’s effect on platelet when used in solution for flushing indwelling arterial catheter is not clear. This study was designed to find out any effect of heparin on platelet count and to see the efficacy of normal solution as flushing solution.Method:This was a prospective randomized comparative clinical trial in the Department of Cardiovascular Surgery of National Institute of Cardiovascular Diseases Hospital, Sher - e - Banglanagar, Dhaka,Bangladesh during the period from july 2016 to june 2017. Total sixty patients who underwent single valve replacement surgery were divided into two groups and were evaluated for heparin effect and compared for arterial catheter patency rate.Results: Platelet count on third postoperative day is 226517+- 60185/ml and 245957+-52826/ml in heparinized flush solution and normal saline flush solution group respectively. The difference of mean is not significant with p value 0.188. Arterial catheter patency rate was 50.0% in heparinized flush solution group and 43.3% in normal saline flush solution group on third postoperative day which signifies no difference between the groups with p value 0.607.Conclusion: The use of heparin in normal saline in continuous flushing devices for an arterial catheter does not significantly reduce platelet counts in cardiac valve surgery patients in comparison to normal saline. It seems that there is no difference in the use of heparinized and normal saline solutions to maintain indwelling arterial catheter patent.Bangladesh Heart Journal 2018; 33(1) : 61-66

Description of outbreaks of health-care-associated infections related to compounding pharmacies, 2000–12

Outbreaks of health-care-associated infections related to compounding pharmacies from 2000 through 2012 are described. PubMed and the websites for the Centers for Disease Control and Prevention and the Food and Drug Administration were searched to identify infectious outbreaks associated with compounding pharmacies outside the hospital setting between January 2000 and November 2012. Between January 2000 and before the 2012 fungal meningitis outbreak, 11 outbreaks were identified, involving 207 infected patients and 17 deaths after exposure to contaminated compounded drugs. The 2012 meningitis outbreak had a similar mortality rate but increased these totals almost fivefold. Half of the outbreaks involved patients in more than one state. Three outbreaks involved ophthalmic drugs. The remaining outbreaks involved corticosteroids, heparin flush solutions, cardioplegia solution, i.v. magnesium sulfate, total parenteral nutrition, and fentanyl. The outbreaks were caused by pathogens commonly associated with health-care-associated infections, common skin commensals, and organisms that rarely cause infection. Morbidity was substantial, including vision loss. Half the outbreaks resulted in recall of all sterile drugs from the pharmacy due to systemic problems with sterile procedures. Before the nationwide 2012 fungal meningitis outbreak, drugs produced by compounding pharmacies were associated with 11 other smaller, but equally serious, outbreaks that occurred sporadically over the past 12 years. Lapses in sterile compounding procedures led to contamination of compounded drugs, exposure to patients, and a threat to public health in these outbreaks. Recognition and subsequent public health investigation were usually triggered by the occurrence of illness among multiple patients in a single health care setting.

Efficacy of Normal Saline in the Maintenance of the Arterial Lines in Comparison to Heparin Flush: A Comprehensive Review of the Literature

The aim of this study is to examine the efficacy of normal saline (0.9% sodium chloride) as a flush solution on patency of arterial lines in comparison to heparin flush. Data have been examined in various categories of specialty (medical, surgical, cardiac, burns, gynecology), frequency of flushes, strength and volume of flushes, continuous versus bolus, duration of each flush and patency incidence (range, ≤ 24 to ≥ 96 hours). The secondary aim focused on the incidences of reported heparin-induced thrombocytopenia (HIT type I and II). A comprehensive review of the literature from 1951 to 2012. An electronic search of OVID, Medline, Embase, Cochrane, Scopus and CINAHL database in English language was conducted. The search was limited to adult subjects only. The following keywords were used: heparin flush, saline flush, 0.9% sodium chloride flush, arterial line and indwelling vascular line. A total of ten papers (n=10) were found eligible. The evidence suggests patency is feasible with both solutions but if longer duration of use (arterial line) is advocated, heparin is superior in the long term. Furthermore, heparin flush effects are dose dependent and require fewer numbers of flushes. In addition, no adverse effects were found with heparin flush solution. There is level 1 evidence to support heparin as a flush solution once the time frame exceeds 48 hours. In addition, there is level 1 evidence to suggest that heparin at higher doses and in continuous infusion has better patency incidence with no reports of HIT type II or I.

Vancomycin flush solution for prevention of catheter-related infections in oncology patients with PICC: a systematic review of the effectiveness

Objective To assess the efficacy of vancomycin flush solution for prevention of catheter-related infections in oncology patients. Methods Randomized controlled trials(RCTs) were searched and identified from Cochrane library, PubMed, EMBASE, CBM, CNKI and related journals were also scanned. In accordance with inclusion and exclusion criteria, we evaluated the quality of the included studies by Jadad scale and analyzed the data of catheter- related sepsis, catheter colonization, exit- site infection by RevMan 5.0. Results We included 5 randomized controlled trials (400 patients). Meta analysis showed that there were statistical differences between vancomycin- heparin mixture and heparin solution on the incidence of catheter-related sepsis, catheter colonization, but no difference was found on the incidence of exit-site infection. Conclusions The current evidences show that contrast with heparin flush solution, van comycin - heparin flush solution can significantly reduce the incidence, of catheter - related sepsis and catheter colonization. But vancomycin-heparin flush solution was more effective, and the results should be further confirmed in prevention of Gram-positive bacterial and fungal catheter-related infections or in non- neutropenic patients. Before draw the conclusions, further high-quality, large scale, double-blind randomized controlled trials are still needed. Key words: Vancomycin; Prophylaxis; CVCs; Infection; Systematic review

Epidemiologic Investigation of a 2007 Outbreak of Serratia marcescens Bloodstream Infection in Texas Caused by Contamination of Syringes Prefilled With Heparin and Saline

This retrospective cohort study found that syringes prefilled with heparin flush solution caused an outbreak of Serratia marcescens bloodstream infection at an outpatient treatment center in Texas in 2007. The epidemiologic study supported this conclusion, despite the lack of microbiologic evidence of contamination from environmental and product testing. This report underscores the crucial contributions that epidemiologic studies can make to investigations of outbreaks that are possibly product related.

Type II Heparin-Induced Thrombocytopenia: Toward Developing a Strategy to Determine the Role of Routine Vascular Access Device Heparinization

Abstract Immunologic Heparin-induced Thrombocytopenia (HIT Type II) results from heparin exposure in any form, and can result in major intravascular thrombotic events, ischemia, and death. Type II HIT occurs in approximately 1 to 3% of patients receiving heparin and can occur at any dose or via any route of administration, making it a potentially serious complication of routine central venous access device (CVAD) maintenance with heparin flush locking techniques. A review of the clinical literature reveals largely anecdotal information implicating the role of heparin flush solutions in its development. Further study is needed to more specifically identify the likelihood of developing HIT from vascular access device related causes.

Type II Heparin-Induced Thrombocytopenia: Toward Developing a Strategy to Determine the Role of Routine Vascular Access Device Heparinization

Immunologic Heparin-induced Thrombocytopenia (HIT Type II) results from heparin exposure in any form, and can result in major intravascular thrombotic events, ischemia, and death. Type II HIT occurs in approximately 1 to 3% of patients receiving heparin and can occur at any dose or via any route of administration, making it a potentially serious complication of routine central venous access device (CVAD) maintenance with heparin flush locking techniques. A review of the clinical literature reveals largely anecdotal information implicating the role of heparin flush solutions in its development. Further study is needed to more specifically identify the likelihood of developing HIT from vascular access device related causes.

Significant increase of activated partial thromboplastin time by heparinization of the radial artery catheter flush solution with a closed arterial catheter system.

Evaluate whether the use of a heparinized flush for an arterial catheter with a closed-loop blood sampling system leads to erroneous coagulation studies. Prospective study. Twenty-two-bed surgical adult intensive care unit in a university hospital. Sixty patients, 30 in each phase of the study. Phase 1: coagulation studies on a blood sample from a venous puncture and an arterial blood sample from an arterial catheter with heparinized flush. Phase 2: the same protocol but the arterial catheter was flushed with saline. Activated partial thromboplastin time, fibrinogen, percentage of prothrombin time, and international normalized ratio of prothrombin time on the venous and arterial samples. Activated partial thromboplastin time in the arterial blood samples taken from an arterial catheter with heparinized flush was significantly prolonged compared with the venous controls. This was not the case in blood samples from an arterial catheter with saline flush. The magnitude of this difference found by the Bland and Altman analysis was clinically significant. In 23.3% of the patients in phase 1, there was a difference of >50% between the arterial and venous sampled activated partial thromboplastin time, compared with 0% of the patients in phase 2 (p =.018). There was no difference between the venous and the arterial blood samples for the non-heparin-sensitive coagulation studies in both phases of the study. An explanation for these findings could be that there was release of heparin bound to the arterial catheter into the blood sample. A heparinized flush solution for the arterial catheter, when used together with a closed-loop blood sampling system, leads to erroneous results of heparin-sensitive coagulation studies. Heparin-sensitive coagulation studies, therefore, should not be analyzed on blood samples from such a system if a heparinized flush solution is used.

ヘパリン生食液の適正注入量・濃度に関する物理化学的検討

The purpose of this study is to investigate in vitro the effects of the flush volumes and concentrations of heparin-saline solutions in maintaining indwelling intermittent (“heparin lock”) injection sites.Samples from simulated heparin locks to maintain the patency of established intravenous pathways were collected under selected flushing conditions. The Hagen-Poiseuille equation for the flow of a fluid through a tube was used to assess the effects of the concentration of the flush solution, flush speed, tube type and catheter conditions when replacing a pre-existing solution in the tube.It was found that the observed fluidity of the flush solution in the tube was similar to that predicted by the Hagen-Poiseuille equation, if a small difference between the density of the pre-existing solution and that of the flush solution existed. Comparisons of the results for the replacing ratios of the pre-existing solution by the flush solution revealed the ratio in a coiled tube to be lower than that in a straight tube at the initial phase. Under each of the conditions tested, the flush procedure with the double volumes of a add-on device (two-fold V0) demonstrated a more than 90% replacing ratio. The remaining percentages of heparin concentration in the small diameter and large-diameter catheters were 10.9% and 14.6% after drawing the catheter volume (V0) of the blood backflow into the catheter. However, the percentages were not detectable and 2% after drawing twofold V0, respectively.Our results indicate that. the Hagen-Poiseuille equation can determine the necessary volume of the heparinized flush solution, based on several factors, including the diameter of the tube or catheter and the V0. To precisely maintain the patency of the heparin locks while minimizing the influx of flush solution to the blood, the use of a small-diameter tube and a large-diameter catheter, and two-fold V0 of 10units JP14 sodium heparin per milliliter of normal saline solution is suggested when there is no flush of the heparin lock with normal saline.

Vancomycin Heparin Flush Solution to Prevent Line Infection in the PICU 192

Introduction: Infections associated with percutaneously placed central venous lines continue to be a problem in pediatric intensive care units. Bacteremias associated with these lines is reported in approximately 1-2% of children in intensive care units. Various strategies are suggested to reduce the incidence of these infections. Vancomycin has been successfully used through central lines in the NICU to reduce the risk of infection from coagulase negative staphylococcus. We compared heparin-vancomycin flushes to standard heparin in lines that were not otherwise infusing fluid or medication. This technique has previously only been used in children with surgically placed lines for chemotherapy.

Efficacy of normal saline solution versus heparin solution for maintaining patency of peripheral intravenous catheters in children

Objectives Literature reports support the use of normal saline solution for maintaining patency of peripheral intermittent intravenous infusion devices (PIID) in the adult population; however, there are limited data regarding this policy in the pediatric population. The purpose of this study was to establish the effects of heparin flush and saline solution flush solutions in maintaining patency of infusion devices in the pediatric population, and to establish cost-saving implications related to both procedures. The specific aims of the study included the following: (1) to determine the efficacy of normal saline solution flush for peripheral IV access devices for the pediatric population, and (2) to establish cost-saving implications related to normal saline solution versus heparin flush for PIIDs in terms of pharmacy costs and costs related to nursing time. Methods The study was a prospective, randomized, doubleblind controlled trial of flushing solutions. The control group ( n = 77) received 3 ml of a 10 units heparin/ml normal saline solution IV flush. The experimental group ( n = 73) received 3 ml of normal saline solution only for the IV flush. Routine hospital procedure for flushing was followed during the study period. Results Descriptive and correlation statistics were used to analyze the data; ξ 2, t test, and analysis of variance were calculated. There were no significant differences between the two groups for demographics or complications. Annual cost savings were computed for both procedures with an estimated annual savings of nursing time and unit cost of solutions equaling $27,594. The savings per procedure was estimated at $9.45. Discussion This study provided support for the efficacy of normal saline solution as an alternative to heparin solutions for the maintenance of peripheral IV devices. Implications include elimination of risks associated with heparin (drug incompatibilities, thrombosis syndrome, hypersensitivity reactions, local tissue damage, and iatrogenic hemorrhage); decreased potential for infection associated with breaks in the integrity of the IV system; substantial money savings as a result of the change to normal saline solution realized by the patient and the institution; and decreased nursing time. By simplifying the procedure, nurses have more time to provide aspects of nursing care to patients.

Neuromuscular Blocking Agents

O nene afternoon at her 150bed community hospital, Marcia Czabo, RN, a new nurse manager for the intensive care unit, was conducting a quality improvement survey of stock medications in the medication room. She quickly made two alarming discoveries: She found pancuronium located in the stock box where heparin flush solutions should have been, and succinylcholine vials were stocked in the drawer marked for bacteriostatic water.

Outbreak of Pseudomonas cepacia bacteremia in oncology patients.

In 1991, an outbreak of Pseudomonas cepacia bacteremia (PCB) occurred among patients at an oncology clinic in Alabama. A case-patient was defined as any patient at Alabama Oncology Hematology Associates (AOHA) who had at least one blood culture positive for P. cepacia from 7 August through 31 October. Fourteen case-patients were identified; all required hospitalization (median duration, 17 days), but none died of PCB. A cohort study assessing risk factors for PCB focused on all patients who had been treated on the 8 days when case-patients had last visited AOHA during the period 7-21 August. Only patients with central venous catheters developed PCB (P < .001). Among patients with central venous catheters, PCB occurred only after visits to AOHA at which the catheters were flushed with heparin solution in the AOHA laboratory rather than in the treatment area (P < .001). P. cepacia was cultured from the only intravenous fluid bag used to prepare heparin flush solution in the laboratory during the interval 7-21 August. All outbreak-associated isolates of P. cepacia had an identical DNA ribotype pattern. These findings emphasize the importance of avoiding multiple use of single-use solutions, especially for high-risk patients with long-term indwelling central venous catheters.

A Meta-Analysis of Effects of Heparin Flush and Saline Flush

The purpose of this meta-analysis was to estimate the effects of heparin flush and saline flush solutions on maintaining patency, preventing phlebitis, and increasing duration in peripheral heparin locks. The average effect size (d value) across 15 studies with a total sample size of 3,490 was .0573 for patency (clotting). The 95% credibility interval ranged from -.2267 to .3413. The average effect size across 13 studies with a total sample size of 2,356 was -.0757 for phlebitis. The 95% credibility interval ranged from -.2497 to .0983. The average effect size for duration across six samples with a total sample size of 1,960 was -.0550. The 95% credibility interval ranged from -.2424 to .1324. It can be concluded that saline is as effective as heparin in maintaining patency, preventing phlebitis, and increasing duration in peripheral intravenous locks. Quality of care can be enhanced by using saline as the flush solution, thereby eliminating problems associated with anticoagulant effects and drug incompatibilities. In addition, an estimated yearly savings of $109,100,000 to $218,200,000 U.S. health care dollars could be attained.

Is Heparin Really Necessary in the Lock and, If So, How Much?

The literature on the issue of whether heparin is necessary in an intermittent peripheral venous access device (lock) is critically reviewed. Issues explored include loss of patency, development of phlebitis, duration of lock placement, type of cannula material, sample size, risk of toxicity with heparin flush solutions, risk of clot embolism, and physical or chemical incompatibilities. Available studies indicate that heparin is not necessary to maintain fluoroethylenepropylene (FEP-Teflon) peripheral venous access devices unless the lock is used to obtain blood specimens. Considering the benefit-to-risk ratio for the use of heparin, it is advisable to maintain FEP-Teflon locks with normal saline alone. When locks are used to obtain blood specimens, as in a pharmacokinetic study, then a dilute heparin flush solution should be used. Whether heparin is necessary for the maintenance of locks composed of other materials is uncertain. Newer, less thrombogenic materials such as ethylene tetrafluoroethylene may also obviate the need for heparin, but comparative trials in a larger number of patients are needed for confirmation. When heparin is used, an effort should be made to avoid systemic toxicities by using the lowest known effective concentration (10 units/mL) pending further studies.

A common-source outbreak of fulminant hepatitis B in a hospital.

A nosocomial outbreak of fulminant hepatitis B infection at a medical center in Haifa, Israel, between 7 and 26 June 1986, involved five patients who had been hospitalized previously in the medical ward in late April and early May (first generation). This outbreak had an unusual clinical course, with fulminant hepatic failure associated with acute renal failure from acute glomerulonephritis, leading to death within a few days. The onset dates of hepatitis were tightly clustered temporally and incubation periods were short. Extensive laboratory and epidemiologic evaluation showed that the probable common-source vehicle of transmission was a multiple-dose vial of heparin and normal saline flush solution that may have been contaminated by blood of a known HBsAg carrier, who was positive for anti-HBe, hospitalized at the same time. A sixth patient died in August 1986 (second generation), after his initial admission in June that coincided with the terminal hospitalizations of three first-generation patients. Those patients had marked coagulopathies, and transmission to the sixth patient most probably occurred through environmental contamination by patients or through cross-contamination between patients through staff. The unusually high mortality rate (5 of 6) in this outbreak has not been definitely explained.

Infection potential of nondisposable pressure transducers prepared prior to use.

This study was designed to examine whether pressure transducer systems prepared hours or days before actual use represent an infection potential. Twenty-one nondisposable transducers assembled with sterile plastic disposable domes and extension tubing were utilized. The systems were prefilled with heparinized flush solution (2 U sodium heparin per ml normal saline). Flush solution samples were cultured from the distal end of the equipment immediately after set-up (time 0) and 24, 48, and 72 h after set-up in all 21 transducers. In 11 of 21 transducers, cultures were also taken at 168 h (1 wk) and 336 h (2 wk) after set-up. Out of the total 106 cultures, only two showed growth, both of which proved to be external skin or mouth contaminants. Binomial distribution testing indicated that if a .05 probability level was used, the chance was 1.3% that one or more transducers in 100 could become contaminated by 72 h. Using the same statistical analyses for the 66 cultures involving the 11 transducers cultured for 2 wk, the chance of contamination in 100 cultures is 2.7% at 2 wk. We conclude from these data that nondisposable transducer systems, when preassembled using standard aseptic precautions and sterile disposable plastics, show no evidence of significant contamination when allowed to stand in readiness after assembly but not connected to a patient. We feel it is safe to preassemble transducers for at least a 72-h period before use. Longer intervals from set-up to use may also be justified.