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Cogitare Enferm. 2022, v27:e88205
Effectiveness aof ascorbic acid and saline solution in pedriatric central venous access: randomized clinical trial.
Giacomozzi LM, Silva RPVC, Danski MTR, Carreiro JE, Silva RF da, Giacomozzi CM, et al.
ORIGINAL ARTICLE
EFFECTIVENESS OF ASCORBIC ACID AND SALINE
SOLUTION IN PEDIATRIC CENTRAL VENOUS ACCESS:
RANDOMIZED CLINICAL TRIAL
HOW TO REFERENCE THIS ARTICLE:
Giacomozzi LM, Silva RPVC, Danski MTR, Carreiro JE, Silva RF da, Giacomozzi CM, et al. Effectiveness aof ascorbic
acid and saline solution in pedriatric central venous access: randomized clinical trial. Cogitare Enferm. [Internet].
2022. [accessed “insert day, month and year”]; 27. Available on: http://dx.doi.org/10.5380/ce.v27i0.83942.88205.
ABSTRACT
Objective: to compare the effectiveness between the use of ascorbic acid and 0.9% saline
solution in the prevention of pediatric central venous catheter obstruction. Method:
randomized clinical trial conducted in a public hospital in Paraná, between the months of
June 2018 to October 2019 with 152 participants, of which, 73 in the experimental group
and 79, control group) who underwent central venous catheter insertion and randomized
to receive the ush intervention with ascorbic acid or 0.9% saline solution. Results: Catheter
obstruction occurred in 17 cases (11.2%), nine (11.4%) in the control group and eight (10.9%)
in the experimental group. Thrombotic obstruction occurred in 15 cases, in a similar way,
in both groups (p=0.88). Catheter removal occurred in 82 cases for elective reasons and
in 63 cases for complications. Conclusion: the use of ascorbic acid is as efcient as 0.9%
saline solution in preventing central venous catheter obstruction. The study expands the
possibilities of interventions within the theme.
DESCRIPTORS: Catheters; Permeability; Ascorbic Acid; Saline Solution; Nursing.
dx.doi.org/10.5380/ce.v27i0.88205
Letícia Morgana Giacomozzi1
Regina Paula Vieira Cavalcante Silva1
Mitzy Tannia Reichembach Danski2
José Eduardo Carreiro1
Rodrigo Figueira da Silva3
Clélia Mozara Giacomozzi4
Thaline dos Reis Wosnes5
1Universidade Federal do Paraná, Programa de Pós Graduação em Saúde da Criança e do Adolescente, Curitiba, PR, Brasil
2Universidade Federal do Paraná, Programa de Pós Graduação em Enfermagem, Curitiba, PR, Brasil
3Universidade Federal do Paraná, Curitiba, PR, Brasil
4Universidade Federal do Paraná, Complexo Hospital de Clínicas, Curitiba, PR, Brasil
5Universidade Federal do Paraná, Programa de Residência Multidisciplinar em Saúde da Criança e do Adolescente, Curitiba, PR, Brasil.
Cogitare Enferm. 2022, v27:e88205
Effectiveness aof ascorbic acid and saline solution in pedriatric central venous access: randomized clinical trial.
Giacomozzi LM, Silva RPVC, Danski MTR, Carreiro JE, Silva RF da, Giacomozzi CM, et al.
INTRODUCTION
The use of central venous catheters (CVC) is common in pediatrics, with the purpose
of ensuring a safe and permanent access route for infusion of uids, total parenteral
nutrition (TPN), drugs and blood products for patients in outpatient or inpatient treatment,
when there is need for intravenous therapy for more than a week1. Short-term CVCs are
polyurethane devices with 4 to 8 French caliber, single or multiple lumens, for continuous
use exclusively in hospitals. They are inserted into deep vessels by direct percutaneous
puncture with a tip positioned in the superior vena cava2,3,4.
According to the protocols of the related entities, the CVC should be kept patent by
performing a ush - a procedure that consists in washing the catheter lumen before and
after the administration of any substance, with an infusion of 0.5 ml of 0.9% saline solution
(0.9% saline solution) and with a ushing technique, applying light pressure and using a 10
ml syringe5.
Thanks to its safety, low complication rate, ease of implantation, and effectiveness,
CVC has been considered an important tool in the treatment of critically ill children and
in the outpatient management of pediatric oncologic diseases. Although its use has been
encouraged as a safe option, some adverse events may be observed, such as catheter-
associated infection (16.4 to 28.8%), venous thrombosis (13-91%), and mechanical
complications like migration, obstruction, and fracture (35 to 48%)1,6. In the pediatric
population, the complication rate is usually lower, ranging from 1.11 to 19.3/1,000 catheter
days, and its patency, as well as the incidence of complications, also vary according to the
child’s clinical and immunocompetence conditions, as well as the routine of insertion and
maintenance procedures1.
Among the main complications, the occurrence of obstructions, which may be total
or partial7, thrombotic or no thrombotic, is more frequent in pediatric practice due to the
smaller caliber (French) of venous catheters used8. Thrombotic events are characterized
by clot formation or brin accumulation in the lumen, thrombi formed by the backow of
blood into the catheter or by platelet and residue accumulation after hemotransfusion9.
Non-thrombotic events are associated with residual drug deposits or due to drug
incompatibilities, or even mechanical causes such as kinking and contact with the vessel
wall, which, for the most part, can be solved by repositioning the catheter10,11.
The obstruction can still be partial whose signs include absence of reux, resistance
to uid infusion, or slow infusion, while signs of complete obstruction include absence of
ow and reux and leakage at the insertion site, both with insistent alarms by the infusion
pumps12.
This is a problem that is a constant concern for the professionals involved in this
activity, because the loss of the catheter due to failure in its maintenance implies relevant
damage to the patient.
Recognizing the importance of the ush technique to be performed primarily in
CVC maintenance, the solutions used are being studied to reduce obstruction, which is
totally preventable. Although 0.9% saline solution is indicated for catheter permeability
maintenance5, other substances have been studied to prevent and reverse obstruction,
such as citrate, urokinase, alteplase, and streptokinase14,15,16.
The use of heparin was, for a long time, the focus of several studies conducted
with high potential for adverse events when compared to saline solution. The results of
comparisons between heparin and saline solution 0.9% vary, some pointing to benets
and others not1. In addition to the lack of consensus and variety of studies on the use of
heparin for CVC maintenance, there is also variation in concentrations and intervals, and
associated risks1.
Cogitare Enferm. 2022, v27:e88205
Effectiveness aof ascorbic acid and saline solution in pedriatric central venous access: randomized clinical trial.
Giacomozzi LM, Silva RPVC, Danski MTR, Carreiro JE, Silva RF da, Giacomozzi CM, et al.
METHOD
A randomized controlled, parallel, open-label, controlled clinical trial (RCT) was
conducted at a Federal Public University Hospital with participants in the pediatric age
group (between 29 days and under 14 years) who had short-stay CVC insertion, admitted
to the Pediatric Intensive Care Unit (PICU) with inpatient follow-up in the Hematology,
Pediatric Clinic, Pediatric Surgery, and Pediatric Emergency Units of the Institution in the
period from June 2018 to October 2019. All infants, children and/or adolescents admitted
to the Units during the RCT period were considered for participation in the study. The 178
participants were recruited by the researcher, soon after the insertion of the CVC with the
approach of parents and/or guardians for signing the ICF and allocated with allocation rate
of 1:1 to constitute the control group (CG) and the experimental group (EG) according to
randomization generated by Random.org20.
After allocation to the groups, the participant was identied, and their CVC was
maintained according to the research protocol. The sample was generated by convenience,
and during the study period, 465 infants, children and/or adolescents were admitted to
the PICU, and the eligible population for this period was 179 infants, children and/or
adolescents.
The non-eligibility criteria were kidney failure; coagulation disorders (hemophilia and
thrombocytopenia); and parents or guardians under the age of 18.
While the exclusion criteria for participants in the research were: prescription of
incompatible drugs in the AA group (etomidate, propofol, thiopental, amikacin, and
vancomycin), two or more consecutive tests with thrombocytopenia (below 150,000/
mm6), evolution with acute renal failure requiring dialysis, transfer from hospital or to
non-participating sectors, and signs suggestive of AA intoxication (nausea, vomiting, and
diarrhea).
Following the search for a solution that may offer more adequate maintenance for
catheter patency with low costs and related risks, the use of Ascorbic Acid (AA) has been
considered16. The Interdisciplinary Committee on Catheters of the National Cancer Institute
(INCA) has recommended the use of 2 mL of AA in maneuvers of catheter clearance that
do not respond to the use of 0.9% saline solution17. The use of AA is also recommended
for CVC clearance by another Brazilian health institute, which recommends its use after an
attempt to restore the catheter permeability through the negative pressure technique with
a three-way device in the dilution of 0.5 ml of AA and 4.5 ml of total solution19.
When used in vitro, AA acts on blood thrombi, especially in the clot pre-formation
stage, changing its structure from the periphery to the central region, promoting lysis,
reducing, and inhibiting the increase in size of the pre-formed clot and the generation of new
clots, thus facilitating the reestablishment of local ow in catheters18. The recommended
concentration dose is 50mg/mL17.
Empirically, AA is used in CVC clearance, and it is believed that, due to its
pharmacological characteristics and low associated risk, it may be an alternative solution
for maintaining their permeability, preventing obstruction by clots, and undoing possible
blood adhesions in the lumen. This could prolong the life of the CVC as well as reduce the
adherence of blood components that favor bacterial adhesion and growth. However, there
are few studies involving the use of this solution.
Therefore, this study proposes to compare the effectiveness between the use of
ascorbic acid and 0.9% saline solution in preventing pediatric central venous catheter
obstruction.
Cogitare Enferm. 2022, v27:e88205
Effectiveness aof ascorbic acid and saline solution in pedriatric central venous access: randomized clinical trial.
Giacomozzi LM, Silva RPVC, Danski MTR, Carreiro JE, Silva RF da, Giacomozzi CM, et al.
Renal failure or coagulation disorders were considered as exclusion criteria. In the
CG, ten cases were lost, ve due to intra-hospital transfer and ve due to platelet count
changes, with a nal sample of 79 cases in the hospital environment and ve due to platelet
count changes, with a nal sample of 79 cases. In the EG, there were 16 cases lost, four
due to dialysis, eight due to use of incompatible medications, three due to loss of medical
records and, consequently, of data, and one due to intra-hospital transfer.
The intervention, performed in both groups by the nursing team (after training,
orientation, and clarications made by the researcher about the research protocol, under
the supervision of the researcher), consisted in the administration of 2mL of the solution in
each CVC route, differing exclusively by its type according to the experimental group. In the
intermittent drug and/or solution infusion routes, the catheter ush was performed every six
hours, while in the continuous drug and/or solution infusion routes it was performed every
12 hours, respecting the hospital CVC maintenance protocol. The volume used corresponds
to the minimum volume of twice the priming (internal volume) of the catheters21.
The maintenance protocol contemplates the same volume and interval adopted by
the researcher (ush with 2mL of solution in each pathway every six hours in the intermittent
infusion pathways and every twelve hours in the continuous infusion pathways). The
intervention in the EG consisted in the administration of 2mL of AA solution at 25mg/mL
in the CVC according to the type of infusion, continuous or intermittent. The preparation
of the solution was performed with aspiration of 0.5mL of the 100mg/mL AA ampoule
(Farmace®) and lling of the syringe up to the 2mL mark with 0.9% SS, obtaining the nal
concentration of 25mg/mL. After the use of the required dose, the ampoule was discarded,
and no stability was considered.
The control group intervention consisted in the administration of 2 mL of 0.9% saline
solution into the CVC according to the type of infusion, continuous or intermittent. The
solution for ush was aspirated from 0.9% SS acons of the brand and lot available in the
institution during the study period, containing 10mL, and the remainder was discarded.
The preparation of the two solutions for the EG and CG was performed immediately
before use, by the professional responsible for their administration through prescription
and checking, and the solution was administered in 10mL syringes employing the ush
technique.
The AA ampoules and 0.9% saline solution acons were available and unrestricted
for the team responsible for CVC maintenance during the entire data collection period and
in all services involved in the study. The choice of AA dose concentration was based on the
values of its tolerable intake in children19 with a limit of more than 400 mg/day in children
aged one to three years. Thus, we considered the maximum use value, in other words, four
ushes/day/CVC route that, according to the catheter, can total eight ushes/day, each of
25mg/mL with 2mL, corresponding to 50 mg per ush.
Blinding was not performed for the participants, team, and researcher due to the
ease of recognition of the uids by their coloration at the time of infusion in the transparent
material CVCs. Furthermore, the researcher started to collect data daily, and there was
identication in each bed with the solution to be infused.
Participants were followed until the primary endpoint (total obstruction) or termination
of participation in the study (removal of the CVC). For the purposes of data analysis, drug
obstructions were considered those that occurred during or immediately after the infusion
of intermittent medications. The remaining obstructions were classied as thrombotic
obstructions.
Other variables studied included: CVC dwell time, signs of AA intoxication, CVC
type, CVC gauge, blood product administration, total parenteral nutrition administration,
number of ushes, continuous infusion volume, use and days of associated peripheral
venous access, and days of CVC resistance. The mono-lumen (ML) CVCs used were PICC
Cogitare Enferm. 2022, v27:e88205
Effectiveness aof ascorbic acid and saline solution in pedriatric central venous access: randomized clinical trial.
Giacomozzi LM, Silva RPVC, Danski MTR, Carreiro JE, Silva RF da, Giacomozzi CM, et al.
French 2.0, PICC 3.0, PICC 4.0, and PICC 5.0. The double lumen (DL) CVCs used were PICC
French 2.0 (each lumen with 1.0 French), 4.0 and 7.0.
In the statistical analysis, the Kolmogorov-Smirnov and Shapiro-Wilks tests for
normality and Pearson’s Chi-square, Fisher’s Test, and Mann-Whitney test were applied
to compare the primary outcome and secondary outcomes between the groups, and
univariate logistic regression (R Program for Data Science).
The research was approved by the Research Ethics Committee of the institution
where it was conducted under number 65887416.3.0000.0096 and is registered in the
Brazilian Registry of Clinical Trials under number RBR-4tg72t.
RESULTS
According to the characteristics of the participants, we observed homogeneity of the
sample between the groups (Table 1).
Table 1 - Characteristics of the participants included in the sample. Curitiba, PR, Brazil,
2021
Variable CG n = 79
(%)
EG n = 73
(%) p
Gender
Male 56 (70.9) 47 (64.4) 0.31
Female 23 (29.1) 26 (35.6)
Age group
< 1 year old 47 (59.5) 38 (52)
0.27≥ 1 and< 5 14 (17.7) 21 (28.8)
≥ 5 18 (22.8) 14 (19.2)
Main Diagnosis
Surgical 18 (22.8) 10 (13.7) 0.22
Clinical 61 (77.2) 63 (86.3)
CVC type
Mono-lumen 16 (20.3) 16 (21.9) 0.96
Double lumen 63 (79.7) 57 (78.1)
Insertion site (vein)
Axillary 1 (1.3) 2 (2.7)
-
Cephalic Region 3 (3.8) 1 (1.4)
Femoral 6 (7.6) 3 (4.1)
Jugular 64 (81) 59 (80.8)
MMSS 3 (3.8) 3 (4.1)
Subclavian 2 (2.5) 5 (6.9)
Note: Pearson’s Chi-square test
Cogitare Enferm. 2022, v27:e88205
Effectiveness aof ascorbic acid and saline solution in pedriatric central venous access: randomized clinical trial.
Giacomozzi LM, Silva RPVC, Danski MTR, Carreiro JE, Silva RF da, Giacomozzi CM, et al.
Legend: CVC - Central Venous Catheter - MMSS - upper limbs; CG - Control Group; EG - Experimental Group.
Source: The authors (2021).
Considering all participants, CVC obstruction was observed in 17 cases (11.2%),
nine in the CG (11.4%) and eight in the EG (10.9%) (p = 0.94). Thrombotic obstruction
occurred in seven cases in the CG (8.9%) and eight cases in the EG (10.9%) (p = 0.88); and
drug obstruction occurred in two cases in each group (2.5% versus 2.7%, p = 0.66) (Table
2). Drug obstructions occurred during infusion of furosemide (one case), phenytoin (two
cases), and linezolid (one case).
Infusion resistance was reported in nine cases in the CG (16.1%) and six cases in the
EG (12.8%) (p = 0.76), however, the number of days of resistance was lower in the EG [11
(1.1%) versus 32 (2.8%), p = 0.01]. In 86.6% of the thrombotic obstructions (13 cases) no
previous and/or last 24 hours resistance was reported. In two cases (13.3%) resistance was
reported on the day of obstruction. CVC removal due to complications was observed in 33
cases in the CG (50.6%) and 30 (41.1%) in the EG (p = 0.96). Elective removal occurred in
40 cases in the CG (50.6%) and in 42 (57.5%) in the EG (p = 0.56). One patient died in the
EG (1.4%) and six in the CG (7.6%) (p = 0.19) (Table 2).
Table 2 - Outcomes of the participants included in the sample. Curitiba, PR, Brazil, 2021
Final outcome of the CVC CG (n = 79) EG (n = 73) p
Obstruction 9 (11.4) 8 (10.9) 0.94
Thrombotic Obstruction 7 (8.9) 6 (10.9) 0.88
Medication 2 (2.5) 2 (2.7) 0.66
Number of catheters with reported resistance 9 (16.1) 6 (12.8) 0.76
Days of reported resistance 32 (2.8) 11 (1.1) 0.01*
Elective Removal - Discharge 40 (50.6) 42 (57.5) 0.56
Non-Elective Removal - Complications 33 (41.8) 30 (41.1) 0.96
Death 6 (7.6) 1 (1.4) 0.19
Notes: Pearson’s chi-square test
Legend: CVC - Central Venous Catheter MMSS - upper limbs CG - Control Group GE - Experimental Group.
Source: The authors (2021).
The distribution of obstruction cases according to the type of catheter is shown in Table 3.
Obstructions occurred in two PICC 2.0 (CG) and 11 DL 4.0 (ve in the CG and six in the EG).
Table 3 - Distribution of obstructions by type of central venous catheters. Curitiba, PR,
Brazil, 2021
Cogitare Enferm. 2022, v27:e88205
Effectiveness aof ascorbic acid and saline solution in pedriatric central venous access: randomized clinical trial.
Giacomozzi LM, Silva RPVC, Danski MTR, Carreiro JE, Silva RF da, Giacomozzi CM, et al.
Type of CVC
CG (n = 9) EG (n = 8) General
Total
Type of Obstruction Type of Obstruction
Medication Thrombotic Medication Thrombotic
DL 4,0 0 5 1 6 12
DL 7,0 1 0 0 0 1
PICC 2,0 0 2 1 0 3
PICC 3,0 1 0 0 0 1
General Total 2 7 2 6 17
Note: CVC - Central Venous Catheter DL - Double lumen; CVC - Central Venous Catheter; CG - Control Group; EG - Experimental
Group.
Source: The authors (2021).
In the catheters in which thrombotic obstruction occurred, the length of stay ranged
from 30 to 51 days in the CG, with a median of 10, and from two to 67, with a median of
six days in the EG (p = 0.51). The median continuous infusion volume in the distal port of
the obstructed DL 4,0 catheters was signicantly lower (p < 0.001) in the CG (6.4 mL/h)
when compared to the EG (23 mL/h), a fact not observed in the proximal port (p = 0.67).
The median number of intermittent infusions in both routes was signicantly lower in the
CG compared to the EG (p < 0.001).
The data referring to continuous infusion and intermittent infusion in LD CVCs are
presented in Table 4. Only greater volume was observed in the proximal pathway with
continuous infusion in the CG (p < 0.001). No difference was observed in ushes between
the two groups.
Table 4 - Continuous infusion and intermittent infusion in double lumen catheters. Curitiba,
PR, Brazil, 2021
Type of CVC Variables CG (n = 79) EG (n = 73) p
Double
Lumen
CI volume via distal (ml/h) 9.0 (0.2-110) 10.0 (0.2-115.9) 0.49
CI volume proximal port (mL/h) 13.0 (0.1-143) 5.5 (0.3-188) < 0.001
Number II distal access 5.0 (1-27) 5.0 (1-30) 0.80
Number II proximal access 5.0 (1-19) 5.0 (1-20) 0.79
Mono Lumen CI volume via (mL/h) 3.5 (0.3-50.7) 3.5 (0.2-76.0) 0.82
Number II access 6.0 (1-9) 4.0 (1-16) 0.10
Note: Mann Whitney test. Values presented in median (minimum-maximum)
Legend: CVC - Central Venous Catheter CI - Continuous infusion II - Intermittent infusion CG - Control Group EG - Experimental
Group.
Source: The authors (2021).
The performance of ushes in DL CVCs in the CG had a mean of 1.2 ± 0.8 and 1.3
± 0.7mL for continuous infusion pathways, and 2.3 ± 1.6 and 2.3 ± 1.5mL for distal and
proximal intermittent infusion pathways, respectively. In the EG, this mean was 1.4 ± 2.1
and 1.4 ± 0.6mL for continuous infusion pathways and 2.1 ± 1.5 and 2.2 ± 1.4mL for distal
and proximal intermittent infusion pathways, respectively (Table 5).
Cogitare Enferm. 2022, v27:e88205
Effectiveness aof ascorbic acid and saline solution in pedriatric central venous access: randomized clinical trial.
Giacomozzi LM, Silva RPVC, Danski MTR, Carreiro JE, Silva RF da, Giacomozzi CM, et al.
Table 5 - Number of ushes performed per day according to type of catheter and infusion.
Curitiba, PR, Brazil, 2021
Type of catheter Infusion Pathway Flushes
number CG (n=79) EG (n=73) p
Double Lumen Continuous
(mL/h)
Distal Mean ± SD 1.40 ±0.77 1.49 ±0.70 0.05
Proximal Mean ± SD 1.45 ±0.77 1.52 ±0.68 0.11
Mono Lumen Continuous
(mL/h) Mean ± SD 1.39 ±0.84 1.42±0.80 0.74
Double Lumen Intermittent Distal Mean ± SD 2.52 ±1.48 2.61 ±1.43 0.41
Proximal Mean ± SD 2.47 ±1.52 2.46/1.51 0.97
Mono Lumen Intermittent Mean ± SD 2.14 ±1.34 2.55 ±1.24 0.09
Note: Student’s t test
Legend: CG - Control Group EG - Experimental Group.
Source: The authors (2021).
The report of resistance by days of catheter stay prior to obstruction occurred on 14
(87.5%) days of CVC stay in the CG and two days (12.5%) in the EG (p < 0.01). The median
time of CVC stay in both groups was one day, ranging from one to 80 days in the CG and
two to 78 days in the EG.
The use of another concomitant venous access corresponded to 37.0% of the CVC
duration of stay in the CG and 32.8% in the EG. Peripheral venous access was the most
frequent (35.3%), corresponding to 15.8% of the CVC duration of stay in the CG and 19.5%
in the EG (p < 0.01), while the use of another CVC was higher in the CG (20.8% versus
13.1%, p < 0.01).
To identify whether the variables continuous infusion, intermittent infusion and
days of resistance reported interfered with the rates of thrombotic obstruction, univariate
logistic regression analysis was applied to assess the impact of days of resistance on the
occurrence of this complication, and for each day that resistance was reported, the chance
of occurrence of thrombotic obstruction in CVCs increased by 45.1%.
No participant showed signs of intoxication, and the dose used was considered safe
for patients in the age range of the research, even for those who remained with the CVC
for a prolonged time.
DISCUSSION
Although CVC occlusion is a common problem in the daily practice of pediatric
patient care, management varies widely in different institutions due to the lack of consistent
evidence in the literature regarding best practices for its prevention. In a recent systematic
review conducted in Australia and published in the Cochrane database in 2020, only
four studies (255 participants) were selected for the review, all evaluating the benet of
intermittent ushing with 0.9% saline versus heparin for the prevention of occlusion in
long-term catheters in infants and children. Still, these are studies with low to moderate
evidence, unblinded, heterogeneous, inconsistent, and with wide condence intervals1.
Studies on the effectiveness of AA in CVC clearance are still rare. Only Rabe et al.
(2002) evaluated the rates of CVC obstruction in adults, comparing the use of 0.9% saline,
heparin 5000 IU/mL and AA 200 mg/mL. Of the 99 CVCs evaluated, the lowest incidence
Cogitare Enferm. 2022, v27:e88205
Effectiveness aof ascorbic acid and saline solution in pedriatric central venous access: randomized clinical trial.
Giacomozzi LM, Silva RPVC, Danski MTR, Carreiro JE, Silva RF da, Giacomozzi CM, et al.
of obstruction was observed in the group receiving heparin, while in the groups receiving
0.9% SS and AA there was no statistically signicant difference.
In this study, the obstruction rate observed in the EG, conducted with the use of
AA (10.9%) was like that of the CG, maintained with 0.9% SS (11.4%), indicating equal
effectiveness of the two procedures in preventing this adverse event. Considering only
the thrombotic obstructions, the same result was observed (10.9% versus 8.9%) and, in
general, the obstruction rate of 11.2%, considering the total sample, is consistent with that
described in the literature, which ranges from 6.9 to 25%24,25.
However, it was observed that CVCs maintained with AA had lower rates of resistance
on infusion (1.1%) compared to those maintained with 0.9% SS (2.8%), and 86.6% of
thrombotic obstructions had no reports of previous resistance and/or in the last 24 hours.
In two of the CVCs (15.4%) there was resistance reported on the day of obstruction, which
may suggest previous partial obstruction.
Although it is known that ushing is the best practice to avoid catheter obstruction,13
the performance of ushes in this sample did not correspond to what was proposed, both
in routes with continuous infusion and in those with intermittent infusion, and, although it
did not interfere with the result, it shows the difculty in compliance with care protocols by
the teams, even after training and elucidation of the established routines.
The infusion of blood products is also known to be a risk factor for CVC obstruction,
observed in 18 cases in the sample, of which one culminated in thrombotic obstruction.
The recommendation for the infusion of blood products is the use of catheters with more
than 3 FR and procedures such as evaluation of permeability before blood infusion, use of
infusion pump and performance of ush after the end of infusion12,26,27.
The most used CVC was the DL (78.9%), given the characteristics of the sample
participants (intensive care patients), who usually require multiple therapies. The number
of catheter lumens can be considered a risk factor for non-elective removal due to the
increased risk of obstruction, because the presence of the second lumen implies the
reduction of the routes’ calibers, as it is difcult to increase their total caliber for insertion
in the venous network of children28.
Another controlled variable was the use of another associated catheter, considering
35.1% of the 2,111 catheter days followed, and the frequency of CVC with another
associated central venous access was 25.7%, lower than the association with another
peripheral venous access (69.7%). However, when comparing this frequency in the length
of stay by days, it was noted that the use of another central venous access corresponded to
17.0% of the days, and the peripheral one, to 17.1%. And nally, the difculty of blinding,
related to the coloration of the solutions used and the transparency of the catheters.
Obstruction is a preventable and manageable event, in which the nursing team
plays a key role, because the technical expertise (proper infusion and lavage practices and
meticulous assessment) determines the outcome. Thus, continuous staff training, adoption
of updated policies, and periodic evaluations are measures that modify care practice and
CVAcomplication rates1,5,10-13,18,23,24. These interventions show modication in the results of
obstruction rates within three months after the beginning of educational activities29.
The diversity of protocols and professional conducts, the relevance of the topic
within the concepts of quality of hospital care, the high costs related to the use of venous
accesses for institutions, among other aspects, highlight the importance of the need to
form an intravenous therapy team, with the purpose of reducing complications related to
the intravascular device, and its main attribution is to guide professionals and monitor the
results of standardizations (material and conduct) adopted1,6,10,18,23,24.
Moreover, despite the number of existing studies on CVC maintenance, the study
expands the possibilities of interventions to reduce the problem in care practice, since
Cogitare Enferm. 2022, v27:e88205
Effectiveness aof ascorbic acid and saline solution in pedriatric central venous access: randomized clinical trial.
Giacomozzi LM, Silva RPVC, Danski MTR, Carreiro JE, Silva RF da, Giacomozzi CM, et al.
it was applied in a population that has been scarcely studied (pediatrics). It assesses the
various interfaces that culminate in the loss of a CVC due to obstruction, sometimes not
explored in other studies and that translate the dimension of the problem, within which the
solution is a bias in an extensive set of factors.
The use of AA seems to be as efcient as the use of 0.9% saline solution in preventing
CVC obstruction (rejecting the hypothesis of the study). However, the evidence of lower
frequency of partial obstruction in the group receiving AA, justied by the lower frequency
of resistance to uid infusion, points to the fact that further research should be conducted
to elucidate the problem and standardize the best conduct for a procedure that constitutes
the daily practice of caring for critically ill patients.
CONCLUSION
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Received: 16/02/2022
Approved: 27/07/2022
Associate editor: Dra. Claudia Palombo
Corresponding author:
Letícia Morgana Giacomozzi
Universidade Federal do Paraná
Rua Frederico Maurer, nº 540, Hauer, Curitiba, PR, Brasil. CEP.: 81630-020
E-mail: leticia.giacomozzi@hc.ufpr.br
Role of Authors:
Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for
the work - Giacomozzi LM, Silva RPVC, Danski MTR, Carreiro JE, Silva RF da, Giacomozzi CM; Drafting the work or revising it
critically for important intellectual content - Giacomozzi LM, Silva RPVC, Danski MTR, Carreiro JE, Giacomozzi CM, Wosnes, T
dos R; Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity
of any part of the work are appropriately investigated and resolved - Giacomozzi LM, Silva RPVC, Danski MTR, Carreiro JE,
Giacomozzi CM. All authors approved the nal version of the text.
*Article extracted from the master’s/PhD thesis “Ensaio clínico randomizado do uso de ácido ascórbico intermitente na
prevenção de obstrução de cateter venoso central pediátrico”, Universidade Federal do Paraná, Curitiba, PR, Brasil, 2021.
This work is licensed under a Creative Commons Attribution 4.0 International License.
ISSN 2176-9133
