Power PICC Flushing Protocols
We are seeing an increased use of double & triple-lumen Power PICC lines in some local hospitals. When these patients come home for line maintenance, there seems to be confusion as to what the proper flushing protocol is. The manufacturer recommends 1 ml of "heparinized saline" (no conc. given) every 12 hours daily to each lumen. However, one local hospital uses a protocol of 10 ml of saline daily to each lumen. Thus, two questions for the board: (1) Is there a standardized conc. for "heparinized saline" as I have seen both 2 units/ml and 100 units/ml reported in the literature? (2) What is the flushing protocol you use in the home for the Power PICC? (3) Doesn't it seem odd if not dangerous for the manufacturer not to state the conc. of "heparinized saline" or have I missed the boat & EVERYONE knows what this means?
Submitted by: Gerry McKeegan, RPh, Ross Park Home Infusion
Response Summary
The responses were indicative of local area standards of practice plus an offering from the Infusion Nurses Society (INS).
Grace P. Sierchio, Director of Quality & Regulatory Activities, Vital Care, Inc. wrote:
Hope this information is helpful. It’s based on what we typically see in our area. Power PICCs are named thus because they withstand high force injectors, but otherwise they are treated the same as far as site maintenance and flushing protocols. The standard rule of thumb in our practice is that any catheter must be flushed with a minimum of twice the internal dwell volume. Therefore, PICCs would require at least 2 ML. However our community standard has been five, figuring a little more can't hurt and you have less chance of leaving residual drug or blood.
As far as heparin, we typically use 1 ml because that more than fills a standard PICC internal dwell space. It would be less for a pediatric catheter due to shorter length. For concentration we generally use 100 u/ml unless the patient is pediatric, or has a need to limit heparin due to predisposition to bleeding, white clot syndrome, etc...
Kelli Krutsinger RN,BSN,CRNI; Nurse Manager, University of Iowa Community HomeCare wrote:
The Infusion Nursing Society Standards of Practice states:
A. "Solution and frequency of flushing a vascular access catheter should be established in organizational policies and procedures and should be in accordance with the manufacturer's labeled use and directions."
B. "The minimum volume of the flush solution should be equal to at least twice the capacity of the catheter and add on devices"
C. "The concentration of heparin should not be in amounts that cause systemic anticoagulation. The concentration of heparin should be the lowest possible to maintain patency."
You will also need to take into account if you are using valves, because they also have manufacturer guidelines for flushing.
The majority of our patients have Bard Power PICCS and we flush with 10cc NS and follow with 3cc 10U heparin. If we are drawing blood from the line we flush with 20cc of saline following the blood draw to ensure the catheter is cleared. The INS and AVA conferences I have attended the last 2 years have both recommended the 10cc saline flushes. The last I have heard on heparin is that the patient should receive less than 400U of heparin a day or the risk of HIT (heparin induced thrombocytopenia) is significantly increased.
Rock-Pond Analysis
The Infusion Nursing Society Standards of Practice, as stated above, are directed towards patient safety but also allows for flexibility within a local clinical setting. To address Gerry’s third question: Doesn't it seem odd if not dangerous for the manufacturer not to state the conc. of "heparinized saline" or have I missed the boat & EVERYONE knows what this means? A manufacturer of catheters will not offer an absolute concentration of Heparinized Saline, but will reference standards of practice. The manufacturer must minimize their legal liability unless there is strong evidence from clinical trials that supports the recommendation of heparinized saline concentrations. Both NHIA and INS work closely together to assure patient safety and positive patient outcomes.