Care and Maintenance to Reduce Vascular Access Complications

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Care and Maintenance to Reduce Vascular Access ComplicationsThe Four Elements of Flushing and LockingFlushing and locking interventions involve four elements that need to be described in client specific ordersand/or in established medical directives. It is important that flushing/locking interventions are based onstandards of practice, evidence-based practice guidelines and current research (EPIC, 2001b; INS, 2000; RCN 2003).These four elements include:■■■■Type of solution;Concentration of solution;Volume of solution; andFrequency of administration.1. Type of solutionFlushing: The nurse should choose normal saline or other compatible solutions to flush the VAD in orderto prevent incompatibilities between two infusates.Locking: Locking solutions used with positive pressure technique maintain catheter patency by preventingblood reflux and by reducing the risk of blood clotting in the device lumen when blood reflux occurs.Locking solutions include:■■Normal saline; andHeparin.Positive Pressure Saline LockingThere is a significant amount of literature which supports normal saline locking to maintainpatency of CVADs when using valved CVADs (e.g. PASV ® or Groshong ® ) and/or when using positivepressure caps (EPIC, 2001b; INS, 2000; RCN 2003).Positive Pressure Heparin LockingWhen open-ended devices are used without positive pressure technology (i.e., positive pressurecaps), blood can reflux into the device lumen. To reduce the incidence of the refluxed blood clottingheparin can be used to lock the device. Concentrations of heparin reported for use in CVADs rangefrom 10-1000 IU/mL of which the most commonly reported heparin concentration is 100 IU/mL.A meta-analysis of randomized controlled trials focusing on CVADs (CDC, 2002) concluded thatheparin significantly reduced bacterial colonization and showed a strong but non-significant trendtowards reductions of catheter-related bacteremia. Because thrombi and fibrin deposits on cathetersmight serve as a nidus for microbial colonization of intravascular catheters the use of anticoagulantsmight have a role to play in the prevention of catheter related blood stream infections (CRBSI) (CDC,2002). Despite this benefit, heparin should be used with caution because it poses the risk of seriouscomplications even in small doses. Heparin has been associated with iatrogenic hemorrhage (a lifethreateningreaction to heparin), heparin induced thrombocytopenia (HIT), drug interactions andinaccurate blood results (Dougherty, 1997; EPIC 2001b; Hadaway, 2001). Therefore, it should be used onlywhen necessary in order to reduce heparin-related complications.30
Nursing Best Practice GuidelineCritical ThinkingRemember to heparinize the device not the client. Some clients that require a significantvolume or concentration of Heparin locking solutions may experience complications. Considerwithdrawal of the heparin lock prior to flushing to reduce the amount of heparin a client receives.While this is practiced in some settings, there is no scientific evidence to support this recommendation.The panel offers this as an option that could be considered based on the risks and benefits for someclients at high risk of device occlusion.2. Concentration of SolutionThe concentration of the flushing or locking solution relates to the use of heparin. The heparin used shouldbe the lowest therapeutic concentration (e.g., 10 IU/mL) and have the smallest volume that will maintainpatency relative to the internal volume of the device (DH, 2001b; INS, 2000; RCN, 2003).3. Volume of SolutionFlushing: Nurses will use sufficient volumes of flush solutions to clean the internal lumen of the device(3-5 mL for PVAD and 10-20 mL for CVAD). The volume after blood withdrawal and medicationadministration should be at least 20 mL for all VADs. Macklin (1997) concludes that problems may occurwith too little flush solution but not with too much.Locking: The volume should be at least twice the volume capacity of the catheter lumen (usually between3-10 mL for all devices (Macklin, 1997)) plus the priming volume of all add-on devices of the infusion system(e.g., extension tubing) (INS, 2000).4. Frequency of AdministrationGenerally, flushing shall be performed:■ After blood sampling;■ When converting from continuous to intermittent therapies;■ Before and after medication administration;■ Before and after administration of blood components;■ Before and after intermittent therapy; and■ For maintenance of a dormant device (INS, 2000; RCN, 2003).Frequency of device use often determines the frequency of flushing and locking. Devices usedintermittently are flushed before administration and are flushed and locked at a minimum after everyinfusion or medication administration. The schedule of catheter flushes varies among practice settings andamong indwelling devices (Ray, 1999). Despite this, VADs should be flushed and locked at establishedintervals to maintain patency and to prevent occlusion.Table 2 summarizes the recommended flushing and locking interventions related to VAD tip position andtechnology.31
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Care and Maintenance to Reduce Vascular Access Complications

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