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JVA
ISSN 1129-7298
J Vasc Access 2016; 00 (00): 000-000
© 2016 Wichg Publishing
REVIEW
Introducon
There is a wide consensus that a central venous line – if
us iscnnuusl shul b iicll ush ih
nl slin s cs h iusl inus
sluns ls s h lin is cls i shul b ll ih
lc slun hich h ncguln cn n
n nbcil cn s in h cs nl slin
n scic cn ll
10010006
Evidence-based criteria for the choice and the clinical
use of the most appropriate lock soluons for central
venous catheters (excluding dialysis catheters):
a GAVeCeLT consensus
Mauro Piru1, Sergio Bertoglio2, Giancarlo Scoppeuolo1, Roberto Bi3, Massimo Lamper4, Alberto Dal Molin5,
Nicola Panocchia1, Nicola Petrosillo6, Mario Vendi7, Carla Rigo8, Enrico DeLuo
1 nin Pliclinic nisii lli l
2 i cin hiugich nisi gli ui n l
su u i nclgi iln l
4 lln linic sil bu hbi ni b is
nisi l Pin inl ill l
6 su inl l n llnni l
nisi in l
8 in sli nisii ggi ll i l
ABSTRACT
Background: h s i lc slun cnl nus ccss ics is sll b n
h lin gu nus ccss ics hs l cnsnsus n h incbs
cii h chic n h clinicl us h s i lc slun cnl nus chs
cluing ilsis chs
Method: h cnsun nl s ssc cllcn n i h liu hs bn
cusing n clinicl suis ling ih lc sluns us nn cclusin hin ci
uins cbinn ssu lsingn c P nl slin nn incn
ci hnl uliin hlniincc ci nccin linli n h nbi
ics in bh uls n in iic ns uis n cnl lins us ilsis hsis n ihl
nus lins n n il lins clu his nlsis uis n lc sluns us n
bsucn incn n cnsi h cnsnsus hs bn ci u ccing h lhi
h
Results: h nl hs cnclu h h is n inc sung h hin lc b h nn
cclusin is bs n h ushing n lcing chniu ih nl slin c h s i lc
slun incn nn shul inclu ci n uliin hich h bh nbcil n
nbil ci ih ngligibl unsi cs i c nbics h n ulns s
lil bn ciuliin lc b n
Conclusions: h cul lu hinin nnilsis chs shul b cnsi ls h us
lc ih subsncs ih nbcil n nbil ci such s ci uliin shul b n
in cnsin in slc ulns ns
Keywords: nl nus chs i lushing in c slun uliin
Accepted: 2016
Published online:
Corresponding author:
Mauro Piru, MD
Università Caolica del Sacro Cuore
Fondazione Policlinico Universitario ‘A. Gemelli’
Largo Francesco Vito 1
00168 Roma, Italy
mauro.piru@policlinicogemelli.it
nsnsus n lc sluns cnl nus chs
2
© 2016 Wichg Publishing
cnns bu ushing n lcing h nus
ccss ic in h inl bn inusins inclu in
ll sn ngn licis s ln issu in
nng clicns b unsning h
ils such cus cl nin h s ush
n lc is cull in s c h
s ush n lc ss uull chng
n biguusl n in guilins n liu hus
ling cnusin n isunsning h ush in n
inscul ch is n s h nul incn
slun gnll nl slin ih h us cln
ing h inn lun h ch ing nns
inus subsncs n inining is nc h lc is
gnll n s h inluinl incn lii l
u ui h ch ush in h inls
hn h ch is n in us ih h us n
ing lun cclusin n bcil clnin 1 h
sl hlgis ushing n lcing bu nn
h is unisll cc s sn cc
Whil n gs h h ush n nus c
css ic is n is us n h such ush
shul b n ih nl slin h l lc h
nus ccss is sll lgl cnsil ning n h
nus ccss n n is us h in incs
bing l bn ihl nus ccss
ics Ps n cnl nus ccss ics s b
n cnl nus chs ininl us bl
chng cus such s ilsis hsis ilsis
cnl nus ccss n cnl nus lins us
n ilsis hsis bu innus ug inusin
nl nuin chh bl sling h
nic niing nnilsis cnl nus ccss
h is sng scinc inc h shul b
lc ih n ncguln slun s n h is
lun cclusin u cls his is u n ilsis ch
ih nnunnl cuunnl ih ins
in h cichcic innl ugul in inni
n in c in h gin l in h lc slu
ns icll us his us cnin ih hin
siu ci hil s cnsis sll is bu h
l cncnn ncguln nging 00
000 unis in h cs hin n 0
ci i lc is cunl us in n un hsi
ls s n c sg nng lun cclusin
ilsis chs s ll s nng h is incn
u inluinl cninn h lin in c ci hs
ln nbil n nbcil cs hich hin
hs n ls ilsis chs ss lc ih
cbin sluns incluing bh ci n uliin
nh ug ih nbcil ci
n h h hn h inc sung h us
ncguln n nbcil lc sluns is scc in
h h is n cnincing inc h s
cic lc sluns igh h clinicl ng slin in
nng lun cclusin sh iu
lng cnl nus ccss ics such s nnunnl
cnll ins cnl chs ihll ins
cnl chs P ll ins cnl chs
ll ilnbl nus ics lng
cuunnl cnl chs hugh s guilins 2
h cn h us hin lc iu n
lng nus ccss ics P s cuunnl
chs hich n in us such cnns
n bs n cnincing clinicl inc ls s s
cic lc sluns ci uliin hnl nbics
c h bn s n nng lun cclusin
bu ucing h is chclnin ch
l bl s incn hugh biusl
nn incn is inl bs n bunls innns
hich shul b uing cnl lin insn n u
ing h c h i si 1 2 sll i is bli h s
in nbcil lc igh b c in ucing h is
inluinl bcil cninn h ic cu
ll in highis ns h ilbl h liu
sll n cnclusi n n cnn is b
s guilins
h i his cnsnsus is i sscll h
inc h chic n clinicl us h s i
lc sluns cnl nus chs n us
ilsis hsis s i n incbs s
cnns h cun clinicl cc s ll s
uu sch in his l
Methods
h sl guilins n sns ssing
h issu h s i lc slun nni
lsis cnl nus ccss bu s h
bs n uli inc sinc nl ni
clinicl ils ilbl in his n h h hn
sc n sc suis is n
nlss cus n his sc clinicl cc h l
cnsil cnclusins s sul cls lc
h ui ign n n bs n
snl nc hisicl in
nsiing h nu h bl n h scci
sng inc high uli scinc suis cnsn
sus s cnsi h s i l iing
cnns in his
his cnsnsus s l b h l
in u ng nus ccss ics nl
s s chsn cnsisng igh ng nliss n
innn chisn ih s in cnsnsus h
lg n n nnng bs Pnliss
slc hi s in cnl nus ccss
ics n s uhs ln s ublish n
his ic h ng s n sns icl ini
cl b n ccil cn bu clusil su
b s cnuc in sgs bh ih
l n bbs ngs h uln h
sns b iscuss b h nl liu sch
s ih h ssisnc h hlgis n
ll nglish lngug cls 1 201 in
Pub bs n i using scic s n
hings s cnl nus ch lc hbsis
incn nbic clicn ncguln
nl slin clicns n n hs nl hu
n clinicl suis n lc sluns cnsi
glss h nins nn cclusin
Piu l
© 2016 Wichg Publishing
n nn incn h suis in uls n in
iic ns inclu Ps n lc sluns
ihl nus ccss ics Ps n cnl nus
ccss chs ilsis n cnsi
ls suis n lc sluns n cclusin n
incn clu b h nlsis h cus bing
clusil n nn
h cnsnsus css s ci u ccing h
l nisi lini s ngls
inss hlg s sg cnsnsus
css h h is icn h lhi h
sucu css cllcng n cnnsing nlg
gu s hugh sis usnnis
h h s iginll us ssis in
ining h l igh bns n s icl
gss bu hs ls bn us l h i
cl guilins n cnns 6 lis issus
n sns s n n ll cins s
innnl sc hs sns using in
i scl n scl nging 1 sngl isg
sngl g his inil ssssn uing l
cc ng h hl nl iscuss h suls
s usnni scn usnni s l
incluing n issus in uing h s un
h suls h scn usnni cusi n
sn h nl nl l gn lls
isg uncin g ch sn clcu
l s h in nl sc in 1 inic
isgn ih h sn 6 uncin n
gn h ll cnsnsus ch sn in
nl sc in s clcul b h nPcnl
ng us P h n P
sc 0 inics cnsnsus ng h gu ih high
scs inicng sng cnsnsus ll nl sns
ching gn isgn inclu in hs
cnns h cnnc h cn
ns n su h cnsnsus s cicul h
nl i n nl l
h suls sn s sns sing
h lling sn in usns iscuss b h nl
1 s h l nicguln lc in h ng
n nnilsis cnl nus ccss s
h nin lun cclusin
2 Which ug hin ci uins cbinn
issu lsingn ci P c h
i l in his in lc
s h inc h lc ih nl slin igh b
s i s n nicguln lc in s
nin lun cclusin
s h n inc bu h s i lush
ing h ih slin b n in lc
s h l niicbil gns in h lc
s h nin ch clniin
chl bl s incin
6 Which niicbil gns nibiics ci u
liin hnl hlniincic ci
c h i l in his g
s h n nicgulnniicbil ssciin h
h l h lc
Results
Q1 – Is there a role for ancoagulant lock in the manage-
ment of non-dialysis central venous access (NDCVA), as a
method for prevenon of lumen occlusion?
un cclusin is sius cncn ih n in
cnl nus ccss ic i sns n h
un s ns ling ilu Phlcc
sgis n his clicn inl bs n
h us sni cls ushing n lcing
in h inl bn inusins h us ncguln
lc n cclusin hs inll bn
us in h s n h bsis lgi susicin
cnss i s inill scib bc in h 10s ih
lil n inc inl in b h inc ih
inc hn n in lcing cls h bn
scib ih h us hgnus i hin
cncnns
h css in i ch cclusin is cl n
ulcil n sil bs n bl clng n
si bl ins bl clls in c h inluinl
cclusin is n scn h siulnus si
nns huc sluns ug ciis cns
i bli ucs liis nl nuin
c incng ih bcii bil n bcil
bis hus n h hcl in i h
chncs h hin lc b ll c s
i ul c nl n h bli n h
il sn insi h lun uh i ul sul b
inc hn cnsisn bl u ccus in h ss
his lin h bsnc inc cc
hin slun in nng lun cclusin in s
s b h cun liu ls h is n inc
h h cc h hin lc igh b s cn
cnn nn n h h hn h n
hin h ncguln ugs incs h is
unsi si cs n s ignic clic
ns 1 h is cclusin is cunl cnsi
b l ini licis ushing n in
i us h lin s ll bl u in h
ic icll ini us nl cnncs
s guilins cn h us nl cnnc
s ih nul si islcn n n
u sg inc siulnus inusin inc
bl ugs n i ushing ih slin b n
ch inusin s bl hil h is n inc
h l uc h is cclusin 1 16
In the last two decades, several studies have shown that
nl slin is s n c ln n h
in lc in ihl scul ccss ics P n in
us iic ns 120 iil suls h
bn iu n lng in uls
21 n cul cn ni cnll il su
s h cnclusin h nl slin is h bs chic s
lcing slun s i cbin ih sic hnc
cl ic insn n innnc 22
h ncguln lc sluns isiu ci
in cncnns hbin inhibis binlc
ugs n lsin cs h bn h
nsnsus n lc sluns cnl nus chs
4
© 2016 Wichg Publishing
0 n 2000 h cn gins us high
cncnn ci 6 s ch ncguln
u cs n h inc ci
c s ssibl scn hclci lling
ullsngh incn in nl lc hilsis
ch inl sius s cs ssci ih
high cncnns ci lc sluns cnnu b
li n h cunl cns
ci cncnns n hn us s ch
lc h P ls cns ci slun
hich is ssci ih bl bnis i
c high cncnns ci sluns
high cncnn b inic us in hsis
cus
hs clinicl ngs ci in h
s n incsing ins ci us ls in
scill cnsiing h siulnus cc n h
innnc nc n nl ucn
Whil h incsing nn ng schs n is
us s is us h in bl s
blnc h cc n s h in sluns
cunl ilbl
nsl h is scn liu inc n h us
binlcs n P in nng ch cclusin
Whn s ncguln lc in h
lss c hn hin ci bing l
nsi n lil b ssci ih unsi
cs hhgic clicns in hs lii
ns in h cs hi clinicl us shul b li
i h n cclusin n n is nn
1 h ill b biusl inic nl h n
cclusin scn bl cls sinc cclusins u
ug ciis cns iu lii gggs
ill n b c b binlcs ging uins
s s l ih is us in ng cll l
uncn scill in hilsis ns hn
lc n clng cn b n ih highs
ls bu n cnsnsus iss n h u
s bin hblsis 2 gin h s i
ilbl inc cs h clinicl sng
n suis n cli h cs c
nss hblc gns in nng ch clng
n chl bci in h cn
guilins suggs h us P lc nc
s sg uc 1
inll h scc clinicl ging h us
in ch lcs inl s n l bu h
liin suls ising n uh insgns
ssing his ic ui cnsiing h scic
cn gins bil
Panel recommendaon
Heparin lock and citrate lock both guarantee an eecve
ancoagulant acon, which is proven to be useful in DCVA
rather than in NDCVA.
Thrombolyc/brinolyc drugs, as currently available, are
neither safe nor cost eecve for prevenon of occlusion of
NDCVA, while they have a denite role in the treatment of
lumen occlusion due to blood clots.
siil cc in nng cclusin c hin
in 2 2 lhugh h h n bn c
nl slin n cul n su hs s h
cc ci sus slin in h nn lun c
clusin uch suis igh b cull si
bl in slc cgis ns ih high
is incn cnsiing h nl l ci in
csing inluinl bcil cninn
Panel recommendaon
The role of ancoagulant lock is only marginally impor-
tant in the management of NDCVA, in terms of prevenon of
lumen occlusion.
Future assessment of the role of citrate lock in NDCVA is
desirable and considered to be of increasing importance. The
benet of citrate might be more focused on its acon against
biolm and against bacteria rather than on its ancoagulant
eect.
Q2 – Which drug (heparin, citrate, urokinase, rTPA, etc.)
may have a primary role in this kind of lock?
i in ncguln gns cnsi h
in uins isiu ci P
h ln clinicl suis su h nc
guln cc hin ci lcing uss
scicll in h guilins h nusin using
ci in h cnl ublish 2016 in c
n lc ll ih hin 1000 unis in
ilsis 100 unis in hsis ci
1 s suggs b h icn ci ignsc n
nnnl hlg 2 h us ci
lc s b s ln 1000 unis
hin lc in cn nlsis 1 n
i cnll ils suggs h ci lcs sui
hin lcs in nng in ns ih
is 0 0001 26 i lcs ls
ssci ih signicnl l is bling ns
c hin lcs in his n uln
0 0002 hil ucs ging ch nc
cbl n 2010 sin sn n h n
gn h un nl s Pcc P
su ci n 2 n in
is ncguln s ci hs h ng n
icbil ci n ucn bil n 2
ilbl sluns ci h cncnns nging
6 h cc n nng lun cclusin
s b s l s high cncnns il
b suls h cs ci scn is cl
ciuchlng s hich ccuns bh h n
icbil n h ncguln c h cs is
bling ns is lil b scn h i
blis ci in h bls his l
is in in h n h cicnining lc bing
innl ush in h ssic ciculn
hlss ci ulns h s cn
cns igh ci cncnns us b us cuusl
bcus nl s c such s ihl
shsi llic s n n sius hhis 2
Piu l
© 2016 Wichg Publishing
Q3 – Is there evidence that lock with normal saline might
be as appropriate as an ancoagulant lock, in terms of
prevenon of lumen occlusion?
Whn using hin lc sl hclgicl n
clinicl issus us b n in ccun in b isl is
n hblc subsnc n i s n cl cus
h lsis h inluinl bl cl i l ns
h gssin h bsucn b inhibing uh cl
n n lling h cn nul cl lsis
hin hs sh hlli 60
0 inus n h is n inc h sisnc is
cc insi h ch lng s
in hs ls ln si cs i b ssci
ug hsnsii ug incbilis n
cus hininuc hbcni scill in i
lsis n cnc n h sius lihning
clicns ccu s in h sg in h cn
cnn b ssci ih ignic hhgs
suggsng h uni lbling hin ils s high
l icn 1 n in iss u
cninn hini slun h bn
scill hn h hin slun is n l
niul
h ssibili using slin lc h hn h
in lc hs bn nsil insg sinc h 10s in
cul iic ns P n sh i
u h i hs s il sh
suii hin hn c slin in nng
ch luncn ilu cclusi ns
h un us nl slin lc s n shn
incs h incinc inc clicns 120
his s n c ning cnsiing h hin
hs n nbcil ci
inc hn ch lc ih nl slin i s
0 siu chli hs bn us n s
iu n lng cn ils h ns
h nninii slin sus hin n is cc in
nng cclusin in s n Ps 21 22 6
h cn sns ls b 1 cnclu h
sinc ni cnll ils h shn uiln
ucs ih hin n slin lc sluns s
Ps n s h is insucin inc cn
n lc slun h h h s guilins c
n slin lc ihl in uls bu n
sng cnns in nns n chiln cnsi
ing h inc n h nc slin sus hin
ihl s is cnsil in hs n ul
ns 1 nsngl h 2016 guilins cn
h h lu slin ushing shul b ls ic
h innl lu h ss ch lus n
ics hil h lu slin lc shul b ls h
innl lu lus 20
n cnclusin h is i cngnc s h lc
ih nl slin slun is s i s lc ih n
cgulns in s nn lun cclusin in
h nl cnsi his sn b li n
sh s n s Ps cu
unnl chs s in ll uln ns bh
uls n iics
Panel recommendaon
Saline lock is as appropriate as ancoagulant lock in
prevenon of occlusion of NDCVA
Q4 – Is there any evidence about the most appropriate
ushing method with saline before any kind of lock?
lushing is i inc chi cc in
luinl clnsing in n ihl nus ccss P
s ll s in n unnl n nnunnl s
Ps s c h is n incsing nn c
us n chnlg lns cncning his nu
ln issus ing slun lus
ssu n chniu ushing
s innnl cnns s h ushing
shul b b n h inisn
n in innus inusin scll sunc
i lininisnlin n b n bl
sling ushing uss nl slin 0 l is
h cn slun n in ic in sn
clinicl cc lu 10 is gnll cnsi
b sucin h i ul ns ih
s gun h l s inluinl sis
ug ciis 21 lus high hn 10
icll 20 nl slin shul b ush in ul
ns h inusin iscus sluns ilgic cn
s i bl ucs liibs nl nuin
lhugh h is lc clinicl suis sung h
cc his ch n iic ns
l lus us sn ushing n 10
cl iscus sluns n ul ns l ushing
P is usull cn h cnl ublish
ns cn h h ushing lu shul n
b ini h ubl h iing lu h lin
b ush i ls incluing ssibl nsins 1
h chniu ushing is gnll cnsi b
ln bin cc clnsing h ch lun
lushing shul b ci u b hn sing
sinc gi inusins uin inusins n
c in his g Whn ushing silicn chs n
nnincbl ics 10 lu sings
cn s n ssu g h ch
0 nnuus hn inusin 10
slin s b lss c hn nic ulsl in
usin h scll ush n us s n s
h s h l cs ubulnc insi h ch
such nu is il cn in h liu n
in s innnl guilins 22 1 n i
suis n h nic ush cc h iscnnuus
inusin ns is suii in nng h
inluinl si subsncs i c cnnuus
lin inusin 2 n h liu suis n
ushing hnics h bn i n h
is lii inc h nicbil cc h uls
l ushing chniu chs bs n
h nl ngs nic ush n h bsnc
si cs h chniu is us is il cn
ll ushing cus n in cul n in
is in h h us hs uing h ush
nsnsus n lc sluns cnl nus chs
6
© 2016 Wichg Publishing
n us nu shul n b ssci ih n c
cinl bl u u bc n h isn
h sing
lng s h n in us h s u
l inl ing ushing is 2 s unnlcu
s 6 s ll ilnbl s
inl hs bn suggs Ps
h is scn inc in liu bu h il inl in
s cc in inining nc n i is ui lil
h lng inls b s cn b
P guilins sc chniu uing
ushing is n in sc bunl sg n
h s liu incs n h cc
h us ll sings sus null ll sings
uc niulns n hus h is incn
6 h cnl ublish ns 1 cn
using singls sss g singls ils ll
lbl sings ll ushing n lcing n i
n s ll slin sings scill sign
gun h innnc si ssu h
n h inusin hus nng bc bl in
h ch uh clinicl ils isbl su
is us hs sings hich l n i
n l in innnc lic ng nu
sg
Panel recommendaon
A pulsale posive “push and pause” (“start and stop”)
technique is the most appropriate methodology of ushing.
Q5 – Is there a role for anmicrobial agents in the lock of
NDCVA, as a method for prevenon of catheter colonizaon
or catheter-related blood stream infecon?
lnin scul ch is h s s
incn hs inl clni i h
luinl b h inluinl u sh
s n un 10 s h sin un h ch
insn si is h s cn suc ic
gniss sin igs lng h nl
si h ch in h subcunus c s cll
luinl clnin iu n lng
cnin ch hubs h s cn
suc nnc icgniss b ign i h
innl suc h ch inluinl clni
n 0 1
ci n ungi clni P n in clus
cng gggs clls bil icbil bi
l is sucu cnsu icbil clls suun
b sluc l i 2 n in
bci n ungi h bil i ls inclus c
nns h hs bin lls iunglbulins
c ils cn b n licbil 2
il chnic incns sinc i shils bc
i h su nbic ugs n h hss
nbis n chgs s h h incn sis
si u nbic h n si h hss
ns chniss nbic ilu uing ns
is n u sisnc gs insi h bil n such
css ch l is cnsi h bs chic
n 6
n s css ch slg cul b highl si
bl n cull in ns ih lii ilbili
ins n nus ccsss n ih high is inc
n such s nchlgicl ns ns ci
ing nl nuin
If Staphylococcus aureus or Candida spp inl s
lgic gns ch l is h s n hil
cns n b hn is u
h icgniss such s cgulsng hl
ccci n ng bcilli Whn ing s
h ic h bs n is h cbinn ssic n
bics lus nicbil lc h
h nbic lc chniu s s scib ls 0
s g h n chl ssis ihu
unnl i si incn n ihu sc cli
cns in unnl chs in h nl nuin
ns nbic lc chniu cnsiss in inis
ng n nbic slun in h hub n in h lun
h is n in us s chi high cncn
n high hn h inil inhibi cncnn
h bci inl 2 60 h nbic slun us
in in h lun lng i hus
s uch sg is n c scill i h
nbic slun ss insi h lun lng i
b i h gs u 100 succss
ng u succss n c i h lc is ssci
ih h ssic inisn nbics sic
nbic inisn ihu lc is uch lss c
in 1 n ils ling ih slg lng chs
b inisn sn nl h nl h
n succss in ng s 6 his bbl
cs h inbili s nbics chi hu
c cncnns hn icgniss clus insi
h bil 6166 h nicbil lc chniu is c
n b cun guilins s ngn
chl incns in ll n cicu
sncs n clic nnsc incns hn
h slg ch is highl ui 6
n h h hn h us nicbil lc sluns
s hlis incn is uch cnsil
h s s sl ni ils h ss his
issu ih ncuging suls 6 6 cncns
sll is bu h ssibl gnc nicbil
sisn bci 6 n bu h is nninc
clicns 0 ls s suis h suggs h
nicbil lc hlis h lil n ng
s i c sn nn sgis such s
i innnc bunls 1 h nicbil
lc hlis is n cn s un chniu
n chl incns 2 2
ns iss nl n Pnn gui
lins cn nicbil lc sluns n
nl in scil cicusncs ns ih lng
ns ih his ull in
si hnc sic sc chnius 2
ccing h guilins nic
bil lc sluns shul n b us unl n
Piu l
© 2016 Wichg Publishing
chl bls incns in s
l sns bcus h i h suis n his
issu h bn cnuc in hilsis ns n
h cnn b gnli b bcus h scinc
inc h cnss h un us nbi
cbs lc sluns is n c bcus h
cncn h h us such sluns incs h n
icbil sisnc 2
s c cnsiing h is nicbil
sisnc h guilins suggs us n
bic lc sluns s n sg nl in siu
ns ns ih lng hilsis chs b
ns ih lii nus ccss n his cun
cnl linssci bl s incn c
ns h highn is s sul
g n ih cnl iln inscul
ics such s shc h l c g siil
cnclusin is b h cn guilins 1 hich
suggs h us nicbil lcing sluns incn
nn in ns ih lng s in ns
ih his ull in highis n ul
ns n in cilis ih unccbl high s
si licn h hs incn nn
n h s cun n ssibl nicbil sluns
n in cnsin such s nbic lc sluns
cnin suhuc cncnns nbics n
sc lcing sluns hnl uliin ci 26
siu chli hln blu usiic ci 1
ccing h cnclusins cn nlsis
ni cnll ils n nicbil lc slu
ns s h n us nicbil lc
sluns is n c nn sg uc h is
incns lhugh h lii nub sc
ni suis in iic n hlg ns
clu n iinn chng in lic in hs subgus b
lg ils isng inc in ns
ciing hilsis suggss h ilnn n
icbil lc hlis shul b cnsi
uh i is ssibl h h us nicbil
lc sluns hich n cnin nbics lii
n h is nicbil sisnc n n l in h
uu clinicl cc
Panel recommendaon
While anbacterial lock (specically with anbiocs)
has a clear role in clinical pracce as a treatment of some
selected CRBSIs, the use of anbacterial lock for the purpose
of prevenon of catheter colonizaon and/or infecon is a
new eld which demands further research, as it may prove
to have an important clinical role in some selected popula-
ons of high-risk paents where the standard bundles of
infecon prevenon appear to be ineecve or insucient.
Q6 – Is there a role for anmicrobial agents in the lock of
NDCVA, as a method for prevenon of catheter colonizaon
or catheter-related blood stream infecon?
his usn s inl ss in
s nbcil gns nbics uliin ci
hnl nsiing h is llg cns n
h nl gnc bcil sisnc nbcil
lc ih nbic ugs n b g s n ins
ing ln in h uu hil h us nn
nbic lc sluns ill c ins
h l ci lc hs bn iscuss b usn
2 h nl h nnnbic lc sluns inclu u
liin hnl n chlng gns siu ci
uliin i h in ci uin is n
nicbil gn ih b scu ci gins
bci n ungi h hl is inc ih bc
il cll ll cusing n isibl inu sisnc
uliin hs n bn his
l suis n h c uliin in nng
h bn ublish nlsis n s
hs suis un h h us uliin s s
sci ih uc c h cnl
lc sluns ls in highis ns s l
nn sisnc uliin is nl bsn
bbl bcus his ug cs s bici n n s n
nbic his is ll n in issu h lls
cing h cncn nl nicbil sisnc
inuc b nbic lc sluns h usul cncnns
uliin 12 ls 10 s high h
0 h i si n ng
icgniss ihu signicn incs bn h
0
n s cs h bn
ih h us uliin his suis n
cli h i inicn uliin n ssi
bl inicn bing l cun iss
in ns n h nl nuin si g
hnc hn shing sc chniu c n is cs
cnss 0
hnl lc sluns cn ls uc h is
s n sl in iic ns n in h sng
nl nuin cn n l 1 lu
1 hnl lc hlis suis n 61 ns ll
suis cs s incn n ch
l h s c hnl cncnn s 0
n h s nin suis hnl n
ls lu hnl lc s cull c ls s
n ih 0 cu n lin slg
hn ssci ih ssic inisn nbics
ll h s cncns bu s hnl bu
li l 2 un ucn incn bu ls
ng c hnl n ch ingi l n
lng un h h us hnl lc b ss
ci ih sucul chngs in chs sl sn
luhn bu ls silicn n cbhn chs
n ih incs is ch cclusin n ssic
ici g bnlis li uncn s uh
suis n cli h nl ng cs
hnl n ns n scul ics
hlng gns siu ci ls ising
s nnnbic nicbil lc sluns n
ln ih h subsncs g uliin su
is suggs hi cnss h igh h s n
gs nbic lcs n bcil sisnc
l inusil css bili n ch cclusin
nsnsus n lc sluns cnl nus chs
8
© 2016 Wichg Publishing
Panel recommendaon
Non-anbioc anbacterial lock will have a major future
role for prevenon of catheter colonizaon and infecon.
While ethanol lock is highly eecve, due to concerns about
its safety, the drugs most likely to be used as anbacterial lock
are taurolidine and citrate, which have opmal characteris-
cs in terms of safety, ecacy and cost eecveness.
Q7 – Is there any ancoagulant/anmicrobial associaon
that may have a role for the lock of NDCVA?
ng h nicbilncguln sscins h
b usul h lc bbl h s
c n ising is uliinci
hs bn shn h his cbinn is c n
c hn hin ln hn h cbinn
uliinhin in nng bh n ch
cclusin in ns ih cnc n in nl nuin
s ll s in hilsis
inc 2002 hh l h high ci
uliinci lc gins lnnic icbs ln
nicbil ci in ch l n signicn
icn bil in l 6 in singlcn
sc iic nh ch su c ns
ciing chh in 200200 hin lc n in
200200 uliinci lc n h l gu h
us uliinci signicnl uc n
uln iic ns ih hlgicl lignncis
uliinci hs bn shn b sui hin
2 nlsis iu l 0 sh h u
liinci is c in nng lhugh h is
ch cclusin ls b incs n his l
nlsis h suis inling 26 ns ih l
ch s inclu h us uliin
ci signicnl uc h is 0
020 n ng bcil incn h
s n signicn inc in si incns n
isi incns
n h uu uh suis n in h
s i cncnns uliin cull
12 n ci cull n bh inc
n n cclusin
Panel recommendaon
The associaon that is most promising as anbacte-
rial/ancoagulant lock, in NDCVA as in DCVA, is taurolidine-
citrate.
Further studies should clarify which populaons of pa-
ents might benet from this associaon, and which concen-
traons of taurolidine and of citrate might be associated with
the best outcome in terms of safety and ecacy.
Conclusions and call for further research
The role of lock in prevenng occlusion of NDCVA
his nl hs sss h lii lu ilbl
inc sung h us hin s lcing gn
in lhugh hin lc hs bn us s
in scill in ll ilnbl nus ccss
ics i is n in h i is n sui slin
lc h nn lun cclusin n ch
clnin n chl bl s inc
ns
h innnc h nc s
b inl bs n h cs such s n i
ushing lic incluing h nul ulsl ush ch
niu h n nl cnncs ih si
nul islcn nu sg hich
inclu nu sings n clsu h ss
inining n inn si ssu n ls bu n
ls n i ucn h s cing h
cnl lin
biusl uh sch is n s singl n
i cnll il n ll nlsis
n ni cnclusins n s ublicns ih
cscnl ch suis hich c h uli
h inc i h i sll b icul
i highuli cnns schul n
unc slin lc in h in s ics n in
in clinicl sngs
ll h un us hin lc in shul b
sngl usn cnsiing h lc inc
cc n is nl css n iss s c ih s
lin hich is bslul s
uh his nl hs sss h n ig
usl sign highuli ni cnll i
ls n bilgicl suis ssing h gns such s
ci n h nins nicbil c s
i ni n cis inc cc
nsln clinicl cc i hs bn s
b h nliss s ising gn b insg
in h n uu bsing his sin inl n n
ings
Pnl hs g h h is sucin inc su
h us nl slin s lcing gn nng
lun cclusin in sh s ll s in i n lng
chs n us ilsis hsis uu
sch shul b cus n inisn schul n
unc nl slin lc n n ssibl icng
cs such s in ushing hs
lushing chniu is ug un inc
Pushus ss h is h s c
n scill ih P n lng h sig
nicn inls bn ch us ccu
Pnliss h sngl suggs h suis
n hnics ushing chnius shul b c
i u s ushing is cicl ing
ins clls n bis h lun h ch
inll us ll sings n cis nin
inls h bn cn s h issus uu
sch
The role of lock in prevenng infecon of NDCVA
h nl cnsi his in issu cliing
uh insgn Whil ll s h
cs in h ls 101 s h in subsnl
Piu l
© 2016 Wichg Publishing
suc bii n li in n hlhc ss
uilins h ns iss nl n Pn
n 2 cn nicbil lc s hl
is ns ih lng chs n his ull
si il s ll sc chnius
h c chniss nbic sisnc ihin bil
in uncl cn hhsis is subhuc
su bil clls nbics s nbics is
sll cicl issu s lll su nbics
nll incs h is bcil sisnc ilbili
n c n s ugs igh chng his sc
ni in h n uu cliing cc n csc
nss inc
hciscs h il nicbil lc slun
bing ch h inclu bili n
isu bil i scu ci lng sbil
i l is ici n s ns l nl
bcil sisnc s ll s cs cnss ccing
cn ssc i n nlsis h
nl uliin n s nbics cin gc
clin b h bs cun ns s nbcil
lc ng hs inc nbcil
lc incn nn is sll scc
nnbic nscs such s hnl uliin
n ci h bn us in lc slun h n
n ih inc cc lhugh ll hs
gns ui uh sch in n hi
s n cs cnss in in ulns ih
ccing h nl ci n uliin h
s ising gns b insg in h n uu
u hi bili n bil n c gins
is clls
h nl unsc h sscin uliin
ci lc slun s h in sscin b uh
insg
Pnl cnns in bl
Disclosures
inncil su gns uning h bn ci l
his su
nic ins n h uhs hs nncil ins
l his su iscls
References
1 si gl l nusin h sn
s cc nus us 2016111
2 P ln uns l lhc ncn
nl Pccs is i uilins h
nn inscul chl incns nc
nl 2011ul 11
ugh bil ls cls n
ns inusin h h h u
hi in nu 2010 l llg using
ilbl hbbunicunsui
linsh ccss 1 2016
ich nsin guil l h
inss h uss nul n nic
n 2001 ilbl hsngcn
nnubsnghs2011126
ccss 1 2016
hll P P hn P bg n
sin nsii n scici h
inss h in h us n unus
cn sculin n hsc lin iil
2001101001010
TABLE I - Pnl cnns
The role of lock in prevenng occlusion of NDCVA
The role of ancoagulant lock is only marginally important in the management of NDCVA, in terms of prevenon of lumen occlusion.
Future assessment of the role of citrate lock in NDCVA is desirable and considered of increasing importance. The benet of citrate might
be more focused on its acon against biolm and against bacteria rather than on its ancoagulant eect.
Heparin lock and citrate lock both guarantee an eec ve ancoagulant acon, which is proven to be useful in DCVA rather than in NDCVA.
Trombolyc/brinolyc drugs, as currently available, are neither safe nor cost-eecve for prevenon of occlusion of NDCVA, while they
have a denite role in the treatment of lumen occlusion due to blood clots.
Saline lock is as appropriate as ancoagulant lock in prevenon of occlusion of NDCVA.
A pulsale posive “push and pause” (“start and stop”) technique is the most appropriate methodology of ushing.
The role of lock in prevenng infecon of NDCVA
While anbacterial lock (specically with anbiocs) has a clear role in clinical pracce as a treatment of some selected catheter-related
blood stream infecon, the use of anbacterial lock for the purpose of prevenon of catheter colonizaon and/or infecon is a new eld
which demands further research, as it may prove to have an important clinical role in some selected populaons of high risk paents where
the standard bundles of infecon prevenon appear to be ineecve or insucient.
Non-anbioc anbacterial lock will have a major future role for prevenon of catheter colonizaon and infecon. While ethanol lock is
highly eecve, due to concerns about its safety, the drugs most likely to be used as anbacterial lock are taurolidine and citrate, which have
opmal characteriscs in terms of safety, ecacy and cost-eecveness.
The associaon that is most promising as anbacterial/ancoagulant lock, in NDCVA as in DC VA, is taurolidine/citrate. Further studies should
clarify which populaons of paents might benet of this associaon, and which concentraons of taurolidine and of citrate might be as-
sociated with the best outcome in terms of safety and ecacy.
nsnsus n lc sluns cnl nus chs
10
© 2016 Wichg Publishing
6 il nsn il l Piis sch in
gnc icl sics chiln suls cnsn
sus cnnc nn g 12206210
il il 1 uilins iic uin n
sulis gnc ns i n Piic
uin n ulis gnc ns nl
gnc icl ics hiln suc llinc
Pi g 111626
Pssnnn ci h hin ush sn cus
ignic hhg ci 12611
P l P W l nn sil
sis ncguln u hin lin lcs il n
200110
10 Wnn ininuc hbcni l
ncl lin h 2002160
11 g nc hn Wl h hin
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cns ncguln ugs ignsis n ngn
ns llg 200661121210
1 h ngs hin ushs Psg
201061012666
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in nsnsus u ncn hin cus n
highl ug Phch 2002 P 2161
1 hnsn ni s l un
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i su sc ccss 2012 cc 121
16 Piu li P P ch nglis c
ul sc ni cisn h
in s l n nnl ihll ins
cnl chs sc ccss 2011612
1 il l l nlsis cs
hin ush n slin ush uli n cs ilicns
us s 110620
1 Psn ichh nlsis h sch bu h
ini sus nnhini inscul lins ung
112066160
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in slin ush sluns sch ulin l
ilnn g us 110612
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lun inining nc ihl innus ch
s in chiln g us 12060
21 gli li ss P l cc nl slin
sus hini slin slun lcing chs
ll ilnbl lng cnl scul ccss ics in
ul cnc ns nc us 20122
22 ssns nssns l ing nl
slin sus ilu hin lc nnl ll iln
bl nus ccss ics in cnc ns nis
nninii n il nn ncl 2012121
2 n cls lis Wsl hils sn
s s hin sus liuin ushs n
ihl cclusin cnl nus ccss ics Ph
ch 2006261262126
2 illn PW ns gnllb ucl Win
s hilns nclg u Phlcc ui
ns in h ngn lng nus ccss ics
in chiln hilns nclg u su lin ncl
2002212122
2 n sh linicl Pcc i cing
sluns hilsis chs hin n ci
sin b in il 2002102
26 h i hng l i sus hin lc h
ilsis chs ssc i n nlsis n
i cnll ils in is 20160
2 nhl nu luc l ignsis nn
n n hilsis chl bls
incns sin sn un nl
s Pcc P Plus 2010226
2 s W ig Pbs P Wi ucn
bil isn cclusin s b ushing sluns
ih isiu ci in hilsis chs n
i cnll il hl il nsln 20102
121121
2 Wi n n l n n P l
u u ni clinicl il cisn
isiu ci 0 n hin s chlcing slu
n in hilsis ns c hl 20016
262
0 Plschgg nn iss l ch lcing
sluns cnining cncn ci hl il ns
ln 20011226260
1 lgn is l Pnn il
sis h un cclusin ih P sus in u
u Pnn ilsis ch luncn ih c
binn ssu lsingn c ngl 20116
012
2 hi ischi Plsin n li igh s u
ins sn nc cclu nn cnl
nus chs in hilsis ns lin hl 2010
202
u is b sc l lg lng
cnl nus chs uing n ub Psu
ns u n nhns lhili incns
ssci ih cnin hin chlc slun
nc nl s iil 200221210
iu hng P ung l ub cs
cns incn u cninn ulls il
hinslin slun us ush nus chs
ihl cs s nc 20112116
il l l nlsis cs
hin ush n slin ush uli n cs ilicns
us s 110620
6 ns Phln ni cnll cisn
ushing cls in h c ns ih ihll in
s cnl chs nus us 2012021
chi ngu P W l nl nus ch
c h n ih cnc icn ci linicl
nclg clinicl cc guilin lin ncl 201110
110
unsln linicl uilin nus hbblis
hlis in gnnc n h uiu 201 b ui
lin n 11 ilbl hshlh
lgucgcunsg ccss 1 2016
Pnl u lisn s P nnh
is cs l chl incns in cnc
ns nc 2001101612
0 ln nusin h sns cc
nus us 2011 nb11110 ilbl
hngghigighgicsnl
cunilshcunil220c21
62c16 ccss 1 2016
1 uin uussl c lu P igi P uss
P lushing inscul ccss ics s cc
uls n cnnuus inusins sc ccss 201211
2 igi P c uin lu P uin h us
hnic bnch inl siuln ushing
Piu l 11
© 2016 Wichg Publishing
nus chs ic n h chniu u unn
chnlgi iicl 2002611
uin uussl c lu P igi P uss
P lushing inscul ccss ics s cc
uls n cnnuus inusins sc ccss 201211
ni uin uin l Puls ushing s
sg n bcil clnin scul ccss
ics ics ucl 201
gli l l Pll nl slin
sings uc ll ilnbl nus ccss ic
ssci bls incn singl insun il
su s nc 2011
6 gh sh iggins is ic n
n su ihl nus ch ushing cc
using null n ll ush sings nus
us 20126101
uich scil bls incns n scn
gnn scul chs n Wnl P i Pn
n n cnl nscil incns h l
iinc Willis Wilins 200
ui icl l in sus hub culus
ic clnin n incn cnl nus ch in
innsi c ns ncn 1221
i bb n hi ing lgsn
n chbl silign cu nn in
cn ih cnl nus chs sc n
i ulcn il 101
0 ln snbg hi isi P ubin
sc su h ch hub s h l n
icgniss cusing chl ssis in nns
nc is 11620
1 ln ubin lnc h ch hub s
l icgniss cusing chl bls
incns uin 11ul11
2 lll l P hu l s igns
c guilins bilssci incns unl
icbil 201262121
g bsn Willis ngh in nubs
nungl sgis gins ungl bils n nicb
gns 201211120
bu huhn nuls l in i in
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nshl iu lin is ib ling
insighs bil bilg ug ln cn n
ch b l ug isc 2011210
10
6 l lln u l linicl cc guilins
h ignsis n ngn inscul ch
l incn 200 b h ncus isss ci
ic lin nc is 20011
unlls nnilg g l c
nss nbiclc h lng chl
bci u ng bcilli sc bs
nl su lin nc is 20111212
sh lsn h cun scu incn in cn
c ns ih chh l nuni nc
n 201211
ssing Pihn bu lih ni n
biclc chniu n ch l h
chl ssis in hnl nuin ns
P Pn nl u 112211
60 il ninc lcs
n cnl linssci bls incn ss
c i n nlsis hl 2011
122
61 ill lin P l nnnl n nn
cnnnl s nccin inisn cn
taminate the internal surface of catheters colonized with
cgulsng shlccci P Pn nl
u 1016
62 in in nbcil ci iclnin n
nccin in cbinn ih iicin usiic ci s
cin gins shlccci n in chs cn nc
is ul 102sul11
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in i c nbics n chs clni b shl
ccci u lin icbil nc is 121101
6 i lln Pscul nn P
ci igh nbcil gns n hlcccus i
iis ch n chs icbil 1
01
6 c ubn Wushn schn n i c
i nccin n iclnin gins hlcccus uus
n hlcccus iiis clniing chs u lin
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66 Pscul i lln n n P
c luhn chs n bcil bils n
h ini ci nicbils gins hlcccus
iiis s nc 1221121
6 s nl nlli nns c lgn
lb in iss nlsis nbics
hlis gins hilsis chl incns
nn nn 2001660
6 h n i i li ib ici
Pul nicbil lc sluns h nn in
cns ssci ih inscul chs in ns
unging hilsis ssc i n nl
sis ni cnll ils lin nc is 200
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u in hl ns 201226666
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cn in ns n hilsis hl 2011
226
2 chi ngu P W l nl nus ch
c h n ih cnc icn ci linicl
nclg clinicl cc guilin lin ncl 201110
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ls 201 u nc nl s iil 201
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l lnis nicbil lc sluns s h
n cnl linssci bls incns
nlsis ni cnll ils lin nc is
20112111
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ci nl ch lc slun nicb gns
hh 2002661616
6 in nn Wisnis lischhc
sun uliinci lc slun uc sig
nicnl ucs ssci gsi incns in
iic cnc ns nc is 2001102
l hill ish il n hilsis
chlcing gn ucs incns in hilsis
ns n 200116120
nsnsus n lc sluns cnl nus chs
12
© 2016 Wichg Publishing
issling Wills slin W nis isss
Wnn uliin lc is highl c in nng
chl bls incns in ns n h
nl nuin hincnll sc il
lin u 2010266
ln hsbugh bh l ni u
blblin cnll il uliinci ch lcs
h nn bci in ns ih h
ilsis in is 201061060106
0 iliuls inns us l chs
lng h us uncu hilsis chs suls
ni il hl 201126026
1 hu P in ill ignicn ucn in cnl
nus chl bls incns in chiln n
P sng n ih uliin lin lc Pi
snl u 201200
2 ichn g l ni cnll
il uliin ci sus hin s ch lc slu
n in iic ns ih hlgicl lignncis
s nc 2012000
ln hsbugh hg l bsnl
su n hblc h n incinc bc
i using uliincihin uliinci n
hin ch lcs in ns ih hilsis
in il 20122222
u u Pli l uliin lc slu
n in h scn nn cnl nus ch
ssci bls incn in h nl nuin
ns lin u 2012160
nu ll ch nl nus chs
n ch lcs in chiln ih cnc sc n
i il uliin sus hin Pi l n
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il in ilsis Pns h 201622
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nuin sc ccss 201 cc12
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