Running head: CENTRAL LINE FLUSHING 1

Khetam Nadmi Al-Naamneh (159917)

Jordan University of science and Technology

Faculty of Nursing

Nursing Service Administration Practicum 1 (NUR704)

Evidence Based Practice Project

Central line flushing

Dr.Ibrahim Al-faouri

May 9, 2023
 CENTRAL LINE FLUSHING 2

Abstract

In the health care industries, central venous catheters (CVCs) are frequently utilized, mainly in

intensive care units. For the purpose of evaluating the central veins, a CVC is a device that is

temporarily implanted into patients. ” Lines” is another name for it. Central venous catheters can be

used for more than one reason such as hemodialysis CT, parental nourishment administration, blood

and blood products administration, medication or chemotherapy drugs administration, and

hemodynamic status monitoring.

There are four types of CVCs commonly used are tunneled (e.g. Hickman's Catheters, totally

implantable PORT-A Cath, and PERM dialysis), non-tunneled catheter, peripherally inserted central

catheters (PICC), and temporary central venous catheter (CVP).

CVCs are associated with complications can be mechanical complications and the occlusion is

one of this complications and could be complications related to thrombosis.

The procedures for flushing the catheter to keep a central venous catheter (CVC) patent differ

from institution to institution or practitioner to practitioner around the world. At this paper I will use

evidence based practice to identify or highlight the best criteria for central line flushing in order to

compare the effectiveness of heparin flush or normal saline flush in maintaining the patency of CVCs.

Background

Cancer patients often tacking aggressive treatment and receive supportive care requiring a long

term tunneled central venous catheter. Regular flushing promotes CVC patency when not in use (i.e.,

not connected). However, the CVCs flushing guidelines and the current practice of daily flushing are

not based on high quality evidence. Scarce studies have compared the effect of heparin flush or normal

saline flush on CVC patency.

 CENTRAL LINE FLUSHING 3

CVCs obstruction may lead to venous thrombosis or develop a fibrin sheath, accounts a critical

complication of catheter-related complications, it also a major causes for catheter dysfunctions.

Occlusion categorized as partial (good inflow and no backflow or good inflow and intermittent

backflow) and complete (occluded; no inflow and no backflow). The factors like condition of patient,

lumen size, the position of catheter, insertion site and technique, chemical composition and nature of

flushing solution, the uses of central line, and other many factors , which are associated with catheter-

related thrombosis. Catheter related thrombosis is an important causative factor for not only morbidity

and mortality but also that thrombus acts as good media for micro-organism growth. Another

complication which is associated with CVC-related upper limb DVT is pulmonary embolism, which is

a life threatening situation for the patients.

To prevent the risk of catheters occlusion and the catheter needed patent and functioning, proper

flushing of catheter is deemed necessary and considered as primary intervention. To prevent formation

of thrombus in central lines, the solutions used for flushing the catheter differ from institution to

another include heparin, 0.9% sodium chloride, alteplase (TPA), vitamin C, lepirudin, sodium citrate,

polygelin , or urokinase.

Heparin flushing most commonly performed procedure to avoid thrombosis in central lines.

Heparin flush is the standard guideline to maintain the lines patent. However, the effectiveness of this

standard practice is still unproven and associated with some complications such as heparin induced

thrombocytopenia (HIT), allergy, and risk of bleeding for post and pre operation patients, also for low

platelet patients.

The question and the search strategy

For patients with central lines; Heparin flush Vs. normal saline 0.9% flush to maintain the patency of

central venous catheter after lines disconnection?

 CENTRAL LINE FLUSHING 4

PICO question will be used to find the best evidence based practice for central lines flushing,

and this question was developed to direct the searching process:

Populations: Are all patients with central lines for all types and for any uses.

Intervention: Normal saline 0.9% flush.

Comparison: Between Normal saline 0.9% flush and heparin flush after disconnect the line or patient

discharge.

Outcome: the best evidence based criteria that used for central line flushing to reduce lines thrombosis

after discharge or disconnect the lines. Without major complication that affect patient outcomes.

Searching strategy depends on several databases such as Google scholar, PubMed, Cochrane

library and Science Direct, the searching was for systematic reviews studies from 2013 till 2023. Search

was in English language articles using the keywords (central line, central line flushing, heparin flushing

for central line, central line thrombosis)

Inclusion criteria: The researches that published from 2017 till 2023, that concerned central line

flushing to maintain line patent, and the study design that include systematic review studies, randomize

clinical trial, quasi-experimental, and meta-analysis or literature reviews if study founded, the search

was using the databases in English language.

Exclusion criteria: all researches that published and done before the year of 2017, any research that do

not have the keyword like “central line flushing to maintain line patent”, any research without full text

founded, case study or pilot studies.

At the end of searching strategy in the databases according to the key words I found that there is

8 researches regarding my concerns to compare the heparin Vs. normal saline effect 3 was excluded

because has not full text, so there are 5 researches met the inclusion criteria and related to the effect of
 CENTRAL LINE FLUSHING 5

normal saline flushing or heparin flushing for central line patency, as following (1.Systematic Review

and Meta-analysis, 2.Randomized controlled trials and prospective cohort studies, 3.Randomized

controlled trials and controlled clinical trials, 4.Systematic Review and Meta-analysis, 5.Randomized

controlled pilot study. All where included to discuss the best criteria for central line flushing to reduce

thrombosis after patient disconnection.

Critical appraisal for the evidence

A. Matrix

The matrix for the researches which are in the inclusion criteria will be in the (appendix).

B. State of the Science Summary

After analyses of the researches and the literature all articles that addressed the study question

were reviewed; to find the best evidence for central line flushing, there was a small variation between

the researches, but all has the same purpose to compare between heparin flush and normal saline 0.9%

flush to reduce lines occlusion, the data collection criteria was almost the same, used the followed the

guidelines of Cochrane library databases, and compare the effect of heparin flush compared to normal

saline 0.9% flush to reduce the central lines occlusion, the outcomes show a small variation but almost

reflect that Heparin is not superior to normal saline in reducing CVCs occlusion, and this finding is

from more than one report and findings. Also there is a study of (Klein et al. 2018) reflect that the

elimination of routinely heparin use for central line flush could positively affect the outcomes in this

patient population.

Bradford et al. (2020) the study was reported that the findings of their study were not enough

evidence to determine the effects of intermittent flushing with normal saline versus heparin to prevent
 CENTRAL LINE FLUSHING 6

occlusion in long‐term central venous catheters in infants and children. It remains unclear whether

heparin is necessary to prevent occlusion.

López-Briz et al. (2022) the results show that intermittent locking with heparin results in fewer

central venous catheter occlusions than intermittent locking with normal saline in adults. Low-certainty

evidence suggests that heparin may have little or no effect on catheter patency duration.

As the matrix of the researches we found that all researches have the level of evidence I which is

supporting the findings and the evidence

There were no side effects or harm or burden is associated with this intervention on the patients, so

it was safe, but the evidence picture sufficiently not complete and the knowledge about the benefits,

risks, or burden still unclear, and the evidences is not sufficient enough to support that normal saline

0.9% is better than Heparin or the opposite to decrease the occlusions or maintains the lines patent after

central lines disconnection, so the practice of flushing central lines with heparin flush still existed until

a new studies to be done and become a new evidence to change the practice.

As heparin is more expensive than normal saline, we are challenging its continued use in central

lines flushing outside of the context of clinical trials. So we need for more researches to support use or

discontinue use it in CVCs flushing.


Title of study Heparin flush vs. normal
saline flush to maintain the
patency of central venous
catheter among adult
patients: A systematic
review and meta-analysis
Name of authors Suresh K Sharma, Shiv K
and date Mudgal, Rakhi Gaur, Rakesh
Sharma, Maneesh Sharma,
Kalpana Thakur (Sep 2019)
Journal Journal of Family Medicine
and Primary Care
Design Systematic Review and Meta-
analysis
Hypothesis/ Evaluating the efficacy of
question/purpose heparin flush vs. normal
saline flush to maintain the
patency of CVC among adult
patients.
Level of Evidence Level I
Size of sample All resources which were
published from Jan. 2012 to
31 Dec. 2018 in English
language. Included only
randomized controlled trials
and nine studies were
included in this review. The
pooled standard mean
difference and relative risk
were calculated by using Rev
Man Review Manager 5.
Appendix (Matrix)
Heparin versus 0.9%
sodium chloride locking
for prevention of
occlusion in central
venous catheters in
adults
Eduardo López-
Briz, Vicente Ruiz
Garcia, Juan B
Cabello, Sylvia Bort-
Martí, Rafael Carbonell
Sanchis (Jul 2022)
Crossref
Randomized controlled
trials and prospective
cohort studies
To evaluate the benefits
and harms of intermittent
locking of CVCs with
heparin versus normal
saline in adults to prevent
occlusion.
Level II
Sample size was 185
catheters per group;
trialists stopped the study
early for 74 and 52
catheters in the heparin
and normal saline groups.
CENTRAL LINE FLUSHING 7
Normal saline (0.9% Normal saline versus Heparin Versus Normal
sodium chloride) versus heparin for patency of Saline Flushing
heparin intermittent central venous catheters effectiveness in
flushing for the in adult patients - a managing central
prevention of occlusion systematic review and venous catheters in
in long-term central meta-analysis patients undergoing
venous catheters in blood and marrow
transplantation.
infants and children
Natalie K Lei Zhong, Hai-Li John Klein,
Bradford, Rachel M Wang, Bo Xu, Yao Amelia Jepsen,
Edwards, Raymond J Yuan, Xin Wang, Ying- Amy Patterson,
Chan (Apr 2020) Ying Zhang, Li Ji, Zi-Mu ,Richard R. Reich (Apr
Pan, Zhan-Sheng Hu (Jan 2018)
2017)
Cochrane Database of Crossref Clinical Journal of
Systematic Reviews Oncology Nursing
Randomized controlled Systematic Review and Randomized, controlled
trials and controlled Meta-analysis pilot study
clinical trials
To assess the clinical Assess the efficacy of NS To determine if
effects (benefits and versus HS in the differences exist in CVC
harms) of intermittent maintenance of the patency, tissue
flushing of normal saline patency of CVCs in adult plasminogen activator
versus heparin to prevent patients. usage, and the incidence
occlusion in long-term of central line–
central venous catheters associated bloodstream
infections when flushing
in infants and children.
with normal saline only
versus heparin and
normal saline among
patients undergoing
BMT.
Level II Level I Level II
Was a small study with Searched in the Convenience samples of
only 14 participants da databases evaluating the 30 patients undergoing
Silva 2018 recruited only use of NS vs. HS to allogeneic or autologous
17 of a planned 100 maintain the transplantation with a
participants, of which 10 permeability of CVCs new non-port/non–
were children aged less among adult patients peripherally inserted
than 18 years. were included in our CVC (PICC) were
evaluated.
meta-analysis.
References of relevant
papers were reviewed
manually. No language
restriction was applied.
Non-human studies were
excluded. Pooled relative

Data Collection Followed the guidelines of
Instruments Cochrane handbook for
interventions and searched in
MEDLINE, Embase, Cochrane
library, Clinical trials
database, and reference list
of related articles
Statistical Consolidated results from
Results/Findings eight studies conveyed little
favorable effect to maintain
patency of CVC with heparin
when compared with normal
saline as evident by risk ratio
0.83, 95% CI 0.50 – 1.40; P =
0.13. We also carried out
analysis for secondary
outcomes, and there was no
evidence that heparin was
better than normal saline in
terms of safety except
heparin-induced
thrombocytopenia.
Used standard Cochrane
methods. Our primary
outcomes were occlusion
of CVCs and duration of
catheter patency.
results may show fewer
occlusions with heparin
compared to normal
saline but this is
uncertain (risk ratio (RR)
0.70, 95% confidence
interval (CI) 0.51 to 0.95;
10 studies; 1672
participants; low-
certainty evidence).
CENTRAL LINE FLUSHING 8
Two review authors
independently assessed
trial inclusion criteria,
trial quality and extracted
data. They assessed study
quality with the Cochrane
'Risk of bias' tool. For
dichotomous outcomes,
calculated the rate ratio
(RR) and corresponding
95% confidence interval
(CI). They pooled data
using a random‐effects
model; and we used
GRADE to assess the
overall certainty of the
evidence supporting the
outcomes assessed in this
review.
The estimated RR for CVC
occlusion per 1000
catheter days between
the normal saline and
heparin groups was 0.75
(95% CI 0.10 to 5.51; 2
studies, 229 participants;
very low certainty
evidence).
risk (RR) was calculated
using a Mantel-Haenszel
random-effects model.
We also performed
subgroup analysis
examining the effect of
the duration of catheter
placement on the
outcome. All statistical
tests were two-sided
using a significance level
of 0.05.
Searched PubMed, Patients were given a
Embase and the study recruitment flyer
Cochrane library by the transplantation
databases. Randomized nurse coordinator during
controlled trials (RCTs) the nurse visit
evaluating the use of NS appointment in the
vs. HS to maintain the BMT clinic prior to CVC
placement. Patients who
permeability of CVCs
wanted more information
among adult patients
about the study or who
were included in our were interested in
meta-analysis. participating in the study
contacted one of the
study co-investigators via
e-mail or telephone or
during a visit at the BMT
treatment center. A co-
investigator explained the
study and gave the
consent form to the
patient to read. If the
patient chose to
participate, he or she
signed the consent form,
and the patient was
systematically
randomized. Once the
group assignment was
made, the co-investigator
placed a corresponding
heparin or saline label on
the CVC dressing.
Ten RCTs involving 7875 The sample consisted of
subjects (with analysis at 10 women and 16 men
patient, catheter, lumen with a mean age of 54
and line access level) years. Among the 698
were included in this events, the rates of line
meta-analysis. Whether problems were similar
in terms of pooled or between flushing with
heparin and normal saline
local analysis (RR with
(8.8%) and with normal
95% confidence interval
saline (8.5%) (p = 0.88).
spans 1), NS can be These rates did not
equally, if not more change at the patient
effective, in keeping the level (p = 0.95). For
CVCs open. patients with line
problems, TPA was given
at similar rates for the
heparin flush (25%) and

Implications/ Heparin has little favorable
Conclusions effects to maintain patency of
catheter than normal saline
but not in secondary
outcomes. As the quality of
evidence was very low,
therefore, results should be
comprehended with care.
CENTRAL LINE FLUSHING 9
the normal saline flush
(27%) (chi-square = 0.02;
not significant) One
CLABSI occurred in the
normal saline only group.
Given the low-certainty There was not enough Based on the results of Elimination of routine
evidence, they are evidence to determine this meta-analysis, heparin use could
uncertain whether the effects of intermittent Heparin is not superior positively affect
intermittent locking with flushing with normal to normal saline in outcomes in this patient
heparin results in fewer saline versus heparin to reducing CVCs occlusion. population.
central venous catheter prevent occlusion in long‐
occlusions than term central venous
intermittent locking with catheters in infants and
normal saline in adults. children. It remains
Low-certainty evidence unclear whether heparin
suggests that heparin is necessary to prevent
may have little or no occlusion.
effect on catheter
patency duration.
 CENTRAL LINE FLUSHING 10

References

Mudgal, ShivK, et al. “Heparin Flush Vs. Normal Saline Flush to Maintain the Patency of Central
Venous Catheter Among Adult Patients: A Systematic Review and Meta-analysis.” Journal of Family
Medicine and Primary Care, vol. 8, no. 9, Medknow, 2019, p. 2779. Crossref,
https://doi.org/10.4103/jfmpc.jfmpc_669_19.

Adlard, Kathleen, et al. “Pilot Randomized Trial of a Three Times Weekly Heparin Flushing
Intervention in Children, Adolescents, and Young Adults With Cancer With Tunneled Central Venous
Catheters.” Journal of Pediatric Hematology/Oncology Nursing, vol. 40, no. 1, SAGE Publications,
May 2022, pp. 24–33. Crossref, https://doi.org/10.1177/27527530221090479.

Semerci, Remziye, et al. “Comparison of Heparin and Saline for Prevention of Central Venous Catheter
Occlusion in Pediatric Oncology: A Systematic Review and Meta-Analysis.” Seminars in Oncology
Nursing, Elsevier BV, May 2023, p. 151426. Crossref, https://doi.org/10.1016/j.soncn.2023.151426.

López-Briz, Eduardo, et al. “Heparin Versus 0.9% Sodium Chloride Locking for Prevention of
Occlusion in Central Venous Catheters in Adults.” Cochrane Database of Systematic Reviews, vol.
2022, no. 7, Wiley, July 2022. Crossref, https://doi.org/10.1002/14651858.cd008462.pub4.

Klein, John, et al. “Effectiveness of Heparin Versus Saline Flushing for Managing Central Venous
Catheters (CVCs) in the Blood and Marrow Transplant (BMT) Patients: A Pilot Study.” Biology of
Blood and Marrow Transplantation, vol. 23, no. 3, Elsevier BV, Mar. 2017, p. S390. Crossref,
https://doi.org/10.1016/j.bbmt.2016.12.608.

Conway, Margaret Anne, et al. “Central Venous Catheter Flushing Recommendations.” Journal of
Pediatric Oncology Nursing, vol. 31, no. 4, SAGE Publications, May 2014, pp. 185–90. Crossref,
https://doi.org/10.1177/1043454214532028.

Bradford, Natalie K., et al. “Normal Saline (0.9% Sodium Chloride) Versus Heparin Intermittent
Flushing for the Prevention of Occlusion in Long-term Central Venous Catheters in Infants and
Children.” Cochrane Database of Systematic Reviews, vol. 2020, no. 4, Wiley, Apr. 2020. Crossref,
https://doi.org/10.1002/14651858.cd010996.pub3.

Zhong, Lei, et al. “Normal Saline Versus Heparin for Patency of Central Venous Catheters in Adult
Patients - a Systematic Review and Meta-analysis.” Critical Care, vol. 21, no. 1, Springer Science and
Business Media LLC, Jan. 2017. Crossref, https://doi.org/10.1186/s13054-016-1585-x.
 CENTRAL LINE FLUSHING 11

BACKGROUND 5/ 5 points

THE QUESTION and THE SEARCH 4 / 5 points

CRITICALLY APPRAISE THE EVIDENCE (20 points)

 matrix 4. 5 / 5 points.
 State of the Science Summary 13.5/ 15 points

Total Score 27 / 30%