The aim of this systematic review was to assess the efficacy of heparin flushing in the lock of central venous catheters.
Methods
We searched MEDLINE and CINAHL databases. Eligible studies were randomized controlled trials evaluating the use of heparin versus normal saline or other solution in the flushing of central catheter among adult patients. No language restrictions were applied. Two reviewers independently screened titles and abstracts in order to identify relevant publications. The same two reviewers retrieved and evaluated full texts. Parameter estimates regarding catheter occlusion were pooled using network meta-analysis with Bayesian hierarchical modeling.
Results
We identified 462 references. Eight studies were included. There was no evidence that heparin was more effective than normal saline in reducing occlusions. It was unclear whether urokinase and lepirudin were more effective than heparin in reducing occlusions. Vitamin C solution does not appear to prolong catheter patency.
Conclusions
There is no evidence of a different effectiveness between heparin flushing and normal saline or other solutions in reducing catheter occlusions. Due to the little and inconclusive evidence available in this field, further studies might be necessary.
Gillanders L, Angstmann K, Ball P, et al; Australasian Society of Parenteral and Enteral Nutrition.AuSPEN clinical practice guideline for home parenteral nutrition patients in Australia and New Zealand. Nutrition.2008; 24(10): 998–1012.
2.
INS Standards—Intravenous Nurses Society.Infusion nursing standard of practice. Journal of Intravenous Nursing.2011; 34(1S): S96.
3.
GallieniM., PittirutiM., BiffiR.Vascular access in oncology patients. CA Cancer J Clin.2008; 58(6): 323–346.
4.
VesciaS., BaumgärtnerA.K., JacobsV.R.Management of venous port systems in oncology: a review of current evidence. Ann Oncol.2008; 19(1): 9–15.
5.
KuoY.S., SchwartzB., SantiagoJ., AndersonP.S., FieldsA.L., GoldbergG.L.How often should a port-A-cath be flushed?Cancer Invest.2005; 23(7): 582–585.
6.
Dal MolinA., RaseroL., GuerrettaL., PerfettiE., ClericoM.The late complications of totally implantable central venous access ports: the results from an Italian multicenter prospective observation study. Eur J Oncol Nurs.2011; 15(5): 377–381.
7.
KefeliU., DaneF., YumukP.F.Prolonged interval in prophylactic heparin flushing for maintenance of subcutaneous implanted port care in patients with cancer. Eur J Cancer Care (Engl).2009; 18(2): 191–194.
8.
IgnatovA., IgnatovT., TaranA., SmithB., CostaS.D., BischoffJ.Interval between port catheter flushing can be extended to four months. Gynecol Obstet Invest.2010; 70(2): 91–94.
9.
RCN Standards—Royal College of Nurses.Standards for infusion therapy, 2010.
10.
PrattR.J., PelloweC.M., WilsonJ.A.epic2: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect.2007; 65(Suppl 1): S1–S64.
11.
ClemenceM.A., WalkerD., FarrB.M.Central venous catheter practices: results of a survey. Am J Infect Control.1995; 23(1): 5–12.
12.
SonaC., PrenticeD., SchallomL.National survey of central venous catheter flushing in the intensive care unit. Crit Care Nurs.2012; 32(1): e12–e19.
13.
PassannanteA., MacikB.G.The heparin flush syndrome: a cause of iatrogenic hemorrhage. Am J Med Sci.1988; 296(1): 71–73.
14.
GarajováI., NepotiG., ParagonaM., BrandiG., BiascoG.Port-a-Cath-related complications in 252 patients with solid tissue tumours and the first report of heparin-induced delayed hypersensitivity after Port-a-Cath heparinisation. Eur J Cancer Care (Engl).2013; 22(1): 125–132.
15.
MilaniA.Positive pressure and normal saline instead of heparinized solution when washing indwelling ports in patients with cancer. Presented at the 2005 ECCO Congress, Paris.
16.
Da RosL., PonzoC., StortoS., CiuffredaL.Assessment of the use of heparinated solution for clamping medium/long term CVC after 8 hours. Ann Oncol.2008; 19(Supp 9): x112–ix117.
17.
SchallomM.E., PrenticeD., SonaC., MicekS.T., SkrupkyL.P.Heparin or 0.9% sodium chloride to maintain central venous catheter patency: a randomized trial. Crit Care Med.2012; 40(6): 1820–1826.
18.
RandolphA.G., CookD.J., GonzalesC.A., AndrewM.Benefit of heparin in peripheral venous and arterial catheters: systematic review and meta-analysis of randomised controlled trials. BMJ.1998; 28(316): 969–975.
19.
GoodeC.J., TitlerM., RakelB.A meta-analysis of effects of heparin flush and saline flush: quality and cost implications. Nurs Res.1991; 40(6): 324–330.
20.
PetersonF.Y., KirchhoffK.T.Analysis of the research about heparinized versus nonheparinized intravascular lines. Heart Lung.1991; 20(6): 631–640.
21.
RichardsonW.S., WilsonM.C., NishikawaJ., HaywardR.S.The well-built clinical question: a key to evidence-based decisions. ACP J Club.1995; 123(3): A12–A13.
22.
AltmanD.G.Practical Statistics for Medical Research.London: Chapman & Hall; 1992.
23.
GuyattG.H., SackettD.L., CookD.J.Users' guides to the medical literature. II. How to use an article about therapy or prevention. JAMA.1993; 270: 2598–2601 and 1994; 271(1): 59-63.
HigginsJ.P.T., JacksonD., BarrettJ.K., LuG., AdesA.E., WhiteI.T.Consistency and inconsistency in network meta-analysis: concepts and models for multi-arm studies. Res Synth Method.2012; 3(2): 98–110.
WhiteI.Multivariate random-effects meta-analysis. Stata J.2009; 9: 40–56.
28.
PumarolaC.F., MercaderR.C., PlanaM.C.Comparative study of maintenance of patency of triple-lumen central venous catheter. Enferm Intensiva.2007; 1(18): 25–35.
29.
BowersL., SperoniK.G., JonesL., AthertonM.Comparison of occlusion rates by flushing solutions for peripherally inserted central catheters with positive pressure Luer-activated devices. J Infus Nurs.2008; 31(1): 22–27.
30.
GoossensG.A., JérômeM., JanssensC.Comparing normal saline versus diluted heparin to lock non-valved totally implantable venous access devices in cancer patients: a randomised, non-inferiority, open trial. Ann Oncol.2013; 24(7): 1892–1899.
31.
RayC.E.Jr., ShenoyS.S., McCarthyP.L., BroderickK.A., KaufmanJ.A.Weekly prophylactic urokinase instillation in tunneled central venous access devices. J Vasc Interv Radiol.1999; 10(10): 1330–1334.
32.
SolomonB., MooreJ., ArthurC., PrinceH.M.Lack of efficacy of twice-weekly urokinase in the prevention of complications associated with Hickman catheters: a multicentre randomised comparison of urokinase versus heparin. Eur J Cancer.2001; 37(18): 2379–2384.
33.
HorneMKIII, McCloskeyD.J., CalisK., WesleyR., ChildsR., Kasten-SportesC.Use of heparin versus lepirudin flushes to prevent withdrawal occlusion of central venous access devices. Pharmacotherapy.2006; 26(9): 1262–1267.
34.
RabeC., GramannT., SonsX.Keeping central venous lines open: a prospective comparison of heparin, vitamin C and sodium chloride sealing solutions in medical patients. Intensive Care Med.2002; 28(8): 1172–1176.
35.
Dal MolinA., Di MassimoD.S., BraggionC.Totally implantable central venous access ports in patients with cystic fibrosis: a multicenter prospective cohort study. J Vasc Access.2012; 13(3): 290–295.
36.
Registered Nurses Association of Ontario (RNAO).Care and maintenance to reduce vascular access complication. Nursing Best Practice Guideline.2008.
37.
MitchellM.D., AndersonB.J., WilliamsK., UmscheidC.A.Heparin flushing and other interventions to maintain patency of central venous catheters: a systematic review. J Adv Nurs.2009; 65(10): 2007–2021.
38.
López-BrizE., Ruiz-GarcíaV.[Effectiveness of heparin versus NaCl 0.9% in central venous catheter flushing. A systematic review]. Farm Hosp.2005; 29(4): 258–264.
39.
BertoglioS., SolariN., MeszarosP.Efficacy of normal saline versus heparinized saline solution for locking catheters of totally implantable long-term central vascular access devices in adult cancer patients. Cancer Nurs.2012; 35(4): E35–E42.
