Article

Pilot Randomized Trial of a Three Times Weekly Heparin Flushing Intervention in Children, Adolescents, and Young Adults With Cancer With Tunneled Central Venous Catheters

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Abstract

Background: Children and adolescents with cancer often undergo aggressive treatment and receive supportive care requiring a long-term tunneled central venous catheter (TCVC). Regular flushing promotes TCVC patency when not in use (i.e., noninfusing). However, TCVC flushing guidelines and the current practice of daily flushing are not based on high-quality evidence. Few studies have compared the effect of less frequent flushing on TCVC patency. The purpose of this study was to evaluate the feasibility of a three times weekly heparin flushing intervention, as compared to daily heparin flushing, in children and adolescents and young adults (AYAs) with noninfusing TCVCs. Methods: Twenty children and AYAs were randomized to one of two groups, standard of care (SOC) (i.e., daily heparin flushing) or intervention (three times weekly heparin flushing) for 8 weeks. Feasibility data (recruitment, retention, acceptability, TCVC patency, and complications) were analyzed descriptively. Results: Twenty of 22 eligible patients were enrolled in the study (90% recruitment rate). Four participants discontinued the study early due to TCVC removal (20% attrition rate). One participant in each group had their TCVC removed due to a central line-associated bloodstream infection, one SOC group participant had their TCVC removed due to damage, and one intervention group participant had their TCVC removed due to discontinuation of treatment. No participants were withdrawn for safety concerns or because they did not find the protocol acceptable. Conclusions: It is feasible to conduct a large-scale randomized controlled trial to investigate a three times weekly heparin flushing intervention in children and AYAs with TCVCs.

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PurposeTo apply evidence-based practice when flushing central venous access devices (CVADs).Background/IntroductionThere is a lack of standardized flushing protocols for CVADs among health care institutions. Identifying best practice and assuring skillful implementation of evidence-based practice protocols is essential to maintaining catheter patency.Review of Relevant LiteratureEvidence supports the use of nonheparinized saline flush, positive-pressure valve caps, and proper flushing technique to maintain CVAD patency (Bowers, Speroni, Jones, & Atherton, 2008; Hadaway, 2006; & Jasinsky & Wurster, 2009). Reinforcement of proper flushing techniques has demonstrated improved patency rates of CVADs (Feehery, Allen, & Bey, 2003).Methods Corporate and individual in-services were conducted to improve nurses’ skill and knowledge of evidencebased practice related to flushing CVADs. Outcomes were measured by comparing baseline data with data collected in the same manner post-education. Data was obtained by means of a questionnaire and direct observation of nurses’ flushing technique.OutcomesThe evidence-based practice project demonstrated a significant improvement (p <0.05) in both the nurses’ knowledge and skill in flushing CVADs.Conclusion Continuing education and reinforcement of proper flushing technique is an appropriate strategy to increase knowledge of and compliance with evidence-based practice protocols.Implications for practiceProviding continuing education and periodic reinforcement of nursing skills can lead to improved patient outcomes. These strategies, along with changing flushing protocols to non-heparinized saline, can also reduce health care costs. Future studies are needed to determine the appropriate frequency of in-service education.
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Flushing central venous access devices with heparin to maintain patency is considered standard practice in healthcare. However, the use of heparin in pediatric and neonatal populations is associated with significant risks. This article outlines the evidence-based practice process used to develop and implement venous access device flushing guidelines.
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This paper is a report of a review to assess clinical studies comparing the effectiveness of different means of maintaining central venous catheter patency. Flushing with heparin is a routine part of central venous catheter maintenance, but it presents risks, including heparin-induced thrombocytopenia. Other techniques used to prevent occlusion of catheters include saline flushes, heparin-bonded catheters and pressure caps. A search was conducted using the MEDLINE, CINAHL, EMBASE, Cochrane, National Guideline Clearinghouse and University Healthsystem Consortium databases. A systematic review of effectiveness was conducted, using GRADE criteria to assess the strength of evidence for each intervention. The review period covered 1982 or earlier to January 2008. There is weak evidence that heparin flushing reduces occlusion of catheters, but no evidence that it reduces bloodstream infections. Results from clinical trials of pressure caps are inconsistent regarding their ability to maintain catheter patency, but provide moderate evidence that at least some varieties of caps are associated with increased bloodstream infections. The evidence base on heparin flushing and other interventions to prevent catheter occlusion is small, and published studies are of low quality. There is insufficient evidence on which to conclude that flushing catheters with heparin is more effective than flushing with saline solution.
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The use of indwelling central venous catheters for the ambulatory management of children with cancer has been well described. There remains uncertainty as to the best method for maintaining the patency of these catheters. The standard approach at our institution is to flush the catheter twice daily with a solution containing heparin. This is both costly and inconvenient for most families. We describe a randomized cross-over study designed to compare the standard approach to a less intense program using an isotonic saline flush once a week. Evaluation continued for approximately 1,515 days in each study arm. The catheters were monitored for blockage, clot formation, and infection. One catheter blocked in a patient receiving the experimental method of care. Two episodes of thrombus formation were demonstrated at the end of the study (one in each of the study arms). The incidence of infection, while in keeping with our overall experience, was higher in the experimental arm. This led to a subsequent study, reported separately in this symposium. The results indicate that there is no significant difference, in the incidence of blocked catheters or other complications, between the two forms of care.
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