We are trying to revamp our flushing protocol for our PICC lines. This has been prompted because our rates for no blood return within the first week or two have been 80-100%.  We use Interventional Radiology for PICC line insertions.  For the last 1.5 years they have been placing Bard Power Ports on everyone.  I personally do not like the power ports for multiple reasons. There is only a small percentage of patients who actually need power injectable piccs.  So. we are going to place BS Vaxcil PASV.  I have used several brands of PICCS and so far BS has the best product.  The flushing protocol for the V. PASV will be NS only with a clave injection cap.  But, we are still planning to place some power piccs for certain patients.  I have read many studies, resources,  and opinions and we cannot decide strength or amount of heparin to use.  Any suggestions.

Thanks

Karen

Melinda, how about

Melinda, how about considering 10u/mL conc.? As well, look to the literature related to heparin-induced thrombocytopenia to support your position. Another reference is the RNAO Best Practice Guideline: Care & Maintenance to Reduce Vascular Access Complications, accessed at   www.rnao.org/Storage/11/570_BPG_Reduce_Vascular_Access_Complications.pdf

   "...heparin should be used with caution because it poses the risk of serious complications even in small doses. Heparin has been associated with iatrogenic hemorrhage (a lifethreatening reaction to heparin), heparin induced thrombocytopenia (HIT), drug nteractions and inaccurate blood results (Dougherty, 1997; EPIC 2001b; Hadaway, 2001). Therefore, it should be used only when necessary in order to reduce heparin-related complications." (page 30)

Unfortunately, I don't have the reference for Kelli Rosenthall's article on HIT. A few other references:

Hadaway L. Heparin Locking for Central Venous Catheters. Accessed at http://www.hadawayassociates.com/  (in the Clinical Articles tab)
Swanson, J. Heparin-induced thrombocytopenia: A general review. Journal of Infusion Nursing. 2007;30(4):232-?
Kadidal C et al. Heparin-induced thrombocytopenia (HIT) due to thrombocytopenia: a report of 3 cases. Journal of Internal Medicine 1999; 246: 325±
Warkentin TE, Greinacher A. Heparin-induced thrombocytopenia: Recognition, treatment, and prevention. The Seventh ACCP  Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004; 126:311S-337S.

Daphne Broadhurst
Desjardins Pharmacy
Ottawa, Canada

Help Guys-I am looking to

Help Guys-I am looking to the experts-We are revamping our flush protocol.  We are using 100 units/ml heparin after a saline flush on our lines:  Midline-2 ml heparin bid; Power PICC-3 ml heparin bid; Triple lumen CVC-3ml heparin bid; Hickman, Broviac, Hohn-3ml heparin bid; Power port-5 ml heparin bid if accessed but not in use or monthly if not accessed;  Where can I safely either decrease the amount of heparin we are using or safely get rid of it all together and can you steer me toward that documentation--Very much appreciate your help-Missy

Why do you feel that

Why do you feel that 100units/ml is to much?  Just curious.  Is there documentation in journals that state this or just a person opinion?  I am just trying to revamp our hospital again.  They are not flushing with heparin at ALL.  They are supposed to flush all devices every 4 or 8 hours with NS only.  I am not comfortable with this and many times the central lines become occluded.

What has changed in your

What has changed in your environment to bring about the increase in clotted and withdrawal occlusions.? Is there a turn over in staff and a gap in education? I find in our setting it is usually a change in staffing with pooreducational support OR more often...... Staff nurses getsloppy with their care as they get busier and flushes get missed. blood draws through lines are not done correctly etc.... We seem to see a number of times that the staff nurse cannot get blood from a line and we simply change the cap andstart over and it works..... They do not change caps in our organization.....Sad but true. IV team does that and dressings and primary tubings. Just call us the tubing Naxis! It's alright though we do perform other more hihgly skilled procedures as well.

Jose Delp RN BSNClinical coordinator IV Team

Upper Chesapeake Health

Jose Delp RN BSN

CliClinical Nurse Manager IV Team

Upper Chesapeake Health

To answer your question of

To answer your question of how much Heparin to use. At our facility they have been flushing with 100u/cc Heparin. I have not been able to convince them that this is too much. We do not use needleless caps. Our incidence of occlussions is not that high. What is the recommended amount of Heparin to use? I thought it was 10u/cc after each use or 100u/cc  a day if line not in use.

I would want to do more

I would want to do more investigation into why you have suddenly noticed this occlusion problem. I have serious doubts that it is all related to the use of power injectable PICCs. There are numerous other factors in catheter flushing - syringe-induced reflux, the correct flushing technique for the type of needleless connector being used, etc. I think this problem will not be solved by simply changing the brand of PICC being used. 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

i would go with a positive

i would go with a positive or neutral displacement caps and forget about using heparin. I would also use those caps on the vaxcel PASV catheters as they still can clot even with the valve.

Sorry, I meant Bard power

Sorry, I meant Bard power piccs.

Karen