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Hello,
We are reviewing our central line management policies and we trying to find evidence related to the routine practice for aspiration of blood prior to accessing the central line (especially PICC).
Our ICU team states that this is routinely performed within oncology groups.I would be grateful for some specialist information.
Kind Regards
SonjaSonja Wegert | Infection Control Practitioner (ICP)
Infection Prevention and Control Unit | Central Australia Health Service
Northern Territory Government
Alice Springs Hospital, Gap Rd, Alice Springs
GPO Box 2234, Suburb, NT Postcode
p … 08 89517977
e … sonja.wegert@nt.gov.au http://www.nt.gov.au/healthMESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.
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Hi Sonja
I can’t say that I am an expert in this area, but in our PICC policy it states this:
If the PICC has not been accessed for 7 days access the PICC with an empty 10ml syringe. Remove 5mls of blood and discard. Then flush with Normal saline 10mls.
Not sure exactly why that is in there, as our PICC policy is based on The Queensland Health PICC guidelines (https://www.health.qld.gov.au/__data/assets/pdf_file/0028/444493/icare-pcvc-guideline.pdf) and I cannot see this statement in there.
Not sure if this helps or not!
Cheers
MichaelMichael Wishart, CICP-E
Infection Control CoordinatorA 627 Rode Road, Chermside QLD 4032
P (07) 3326 3068 | F (07) 3607 2226 | E michael.wishart@svha.org.au | W http://www.hsnph.org.au
[cid:image001.png@01D01926.61F1C2B0] [cid:image002.png@01D42997.357FB770]
P Please consider the environment before printing this emailHello,
We are reviewing our central line management policies and we trying to find evidence related to the routine practice for aspiration of blood prior to accessing the central line (especially PICC).
Our ICU team states that this is routinely performed within oncology groups.I would be grateful for some specialist information.
Kind Regards
SonjaSonja Wegert | Infection Control Practitioner (ICP)
Infection Prevention and Control Unit | Central Australia Health Service
Northern Territory Government
Alice Springs Hospital, Gap Rd, Alice Springs
GPO Box 2234, Suburb, NT Postcode
p … 08 89517977
e … sonja.wegert@nt.gov.au http://www.nt.gov.au/health______________________________________________________________________
This email and any attachments to it (the “Email”) is confidential and is for the use only of the intended recipient, and may not be duplicated or used by any other party without the express consent of the sender. If you are not the intended recipient of the Email, please notify the sender immediately by return https://clicktime.symantec.com/a/1/eICuiPwamVd0HdDhL54mwgyPwL5PbBdtnUw8ZSnbr9E?dH55wJZ44EgrBJUKutH8FokRhE9lhgYepMUofQb9yENyrJCvzyKojgW6vxaqIN6uqNLVwhqJzOvAzKhcW65QoNRPZevq9M3YSmHKUqaDHpt8ZTnXREj0wzj4AyUbCCSXyuk1BlbP_3Jc17L8e2soFFVROefIrlwITwVQL0v5G82PbcVNkUF3U9dXWcqnGoLKoRMHxaG_pOWDjX4yNS9mr42HYpDpLqs-o_43vPDvU2sjE_hFYvCNeLKXQ2hCoMMZR_jqZCRkGUzZ3iynRkipk20gwDbPub-l-MiltIAUVzOqbb_d6LBU5_ZCdUTM4qPwpRAPfNV5O0bG5VDMRizm1ewKBhLineMOfzLnhkdbwnRFiIEbTlau8SIqtT_lE6uPzR_JFedRhmAIgRBSEQYNDL1VCiu1KD2csRS-32323wYGzyR9fw0HWFCLtVrx06PowHtpQl72U0l4%3D&uemail%2C%20delete%20the%20Email%2C%20and%20do not copy, print, retransmit, store or act in reliance on the Email. St Vincent’s Health Australia (“SVHA”) does not guarantee that the Email is free from errors, viruses or interference. Emails to and from SVHA or its related entities may be scanned and filtered in locations outside Australia.
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______________________________________________________________________
This email and any attachments to it (the “Email”) is confidential and is for the use only of the intended recipient, and may not be duplicated or used by any other party without the express consent of the sender. If you are not the intended recipient of the Email, please notify the sender immediately by return email, delete the Email, and do not copy, print, retransmit, store or act in reliance on the Email. St Vincent’s Health Australia (“SVHA”) does not guarantee that the Email is free from errors, viruses or interference. Emails to and from SVHA or its related entities may be scanned and filtered in locations outside Australia.MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.
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Hi Both,
I am far from an expert in this area, but wouldn’t one expect that blood, if it stagnates for a while, will coagulate, and one wouldn’t want to push the blood clot back into the patient?
Best regards, Matthias.
—
Matthias Maiwald, MD, FRCPA
Senior Consultant in Microbiology
Head of Service, Microbiology
Adj. Assoc. Prof., Natl. Univ. Singapore
Department of Pathology and Laboratory Medicine
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Tel. +65 6394 8725 (Office)
Tel. +65 6394 1389 (Laboratory)
Fax +65 6394 1387Hi Sonja
I can’t say that I am an expert in this area, but in our PICC policy it states this:
If the PICC has not been accessed for 7 days access the PICC with an empty 10ml syringe. Remove 5mls of blood and discard. Then flush with Normal saline 10mls.
Not sure exactly why that is in there, as our PICC policy is based on The Queensland Health PICC guidelines (https://www.health.qld.gov.au/__data/assets/pdf_file/0028/444493/icare-pcvc-guideline.pdf) and I cannot see this statement in there.
Not sure if this helps or not!
Cheers
MichaelMichael Wishart, CICP-E
Infection Control CoordinatorA 627 Rode Road, Chermside QLD 4032
P (07) 3326 3068 | F (07) 3607 2226 | E michael.wishart@svha.org.au | W http://www.hsnph.org.au
[cid:image001.png@01D01926.61F1C2B0] [cid:image002.png@01D42997.357FB770]
P Please consider the environment before printing this emailHello,
We are reviewing our central line management policies and we trying to find evidence related to the routine practice for aspiration of blood prior to accessing the central line (especially PICC).
Our ICU team states that this is routinely performed within oncology groups.I would be grateful for some specialist information.
Kind Regards
SonjaSonja Wegert | Infection Control Practitioner (ICP)
Infection Prevention and Control Unit | Central Australia Health Service
Northern Territory Government
Alice Springs Hospital, Gap Rd, Alice Springs
GPO Box 2234, Suburb, NT Postcode
p … 08 89517977
e … sonja.wegert@nt.gov.au http://www.nt.gov.au/health______________________________________________________________________
This email and any attachments to it (the “Email”) is confidential and is for the use only of the intended recipient, and may not be duplicated or used by any other party without the express consent of the sender. If you are not the intended recipient of the Email, please notify the sender immediately by return https://clicktime.symantec.com/a/1/eICuiPwamVd0HdDhL54mwgyPwL5PbBdtnUw8ZSnbr9E?dH55wJZ44EgrBJUKutH8FokRhE9lhgYepMUofQb9yENyrJCvzyKojgW6vxaqIN6uqNLVwhqJzOvAzKhcW65QoNRPZevq9M3YSmHKUqaDHpt8ZTnXREj0wzj4AyUbCCSXyuk1BlbP_3Jc17L8e2soFFVROefIrlwITwVQL0v5G82PbcVNkUF3U9dXWcqnGoLKoRMHxaG_pOWDjX4yNS9mr42HYpDpLqs-o_43vPDvU2sjE_hFYvCNeLKXQ2hCoMMZR_jqZCRkGUzZ3iynRkipk20gwDbPub-l-MiltIAUVzOqbb_d6LBU5_ZCdUTM4qPwpRAPfNV5O0bG5VDMRizm1ewKBhLineMOfzLnhkdbwnRFiIEbTlau8SIqtT_lE6uPzR_JFedRhmAIgRBSEQYNDL1VCiu1KD2csRS-32323wYGzyR9fw0HWFCLtVrx06PowHtpQl72U0l4%3D&uemail%2C%20delete%20the%20Email%2C%20and%20do not copy, print, retransmit, store or act in reliance on the Email. St Vincent’s Health Australia (“SVHA”) does not guarantee that the Email is free from errors, viruses or interference. Emails to and from SVHA or its related entities may be scanned and filtered in locations outside Australia.
MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.The use of trade/product/commercial brand names through the list is discouraged by ACIPC. If you wish to discuss specific reference to products or services by brand or commercial names, please do this outside the list.
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______________________________________________________________________
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[cid:imaged6dc6e.GIF@6460fad3.468f2d3b]shstagl1
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Dear Sonja
The US INS Standards are world class and in Standard 40. Flushing and Locking the procedures are discussed in detail. See below.
I recall at a recent conference(s) dedicated to vascular access devices there was discussion and I believe a general consensus that blood should not be discarded. In paediatrics specifically repeated discards can lead to loss of blood volume and Hb.
Within hours I am sure Tim Spencer, Claire Rickard and perhaps even Tricia Kleidon may weigh in on this discussion. In the interim I will look for the references and hopefully it may help you.
Cath
Cathryn Murphy RN B. Photog MPH FSHEA FAPIC CIPC-E PhD CIC
Chief Executive Officer & Creative Director
Infection Control Plus Pty Ltd
Adjunct Assoc. Professor – Faculty of Health Services & Medicine
Bond University
QLD, AustraliaE: Cath@infectioncontrolplus.com.au
M: +61 428 154154
W:http://www.infectioncontrolplus.com.auStandard
40.1 Vascular access devices (VADs) are flushed and
aspirated for a blood return prior to each infusion to
assess catheter function and prevent complications.
40.2 VADs are flushed after each infusion to clear the
infused medication from the catheter lumen, thereby
reducing the risk of contact between incompatible
medications.
40.3 The VAD is locked after completion of the final
flush to decrease the risk of intraluminal occlusion and
catheter-related bloodstream infection (CR-BSI),
depending on the solution used.
Practice Criteria
A. Use single-dose systems (eg, single-dose vials or prefilled
labeled syringes) for all VAD flushing and
locking.
1. Commercially available prefilled syringes may
reduce the risk of CR-BSI and save staff time for
syringe preparation. 1-3 (IV)
2. If multiple-dose vials must be used, dedicate a
vial to a single patient (see Standard 49,
Infection ). 4 (V)
3. Do not use intravenous (IV) solution containers
(eg, bags or bottles) as a source for obtaining
flush solutions. 3-6 (IV)
4. Inform patients that disturbances in taste and
odor may occur with prefilled flush syringes and
may be related to several causes including systemic
conditions (eg, diabetes, Crohn’s disease),
medications (eg, antineoplastics), and radiation.
Leaching of substances from the plastic syringe
into the saline has been reported, although it is
not thought to be harmful to health. 7-9 (II)
B. Perform disinfection of connection surfaces (ie,
needleless connectors, injection ports) before flushing
and locking procedures (refer to Standard 34,
Needleless Connectors ).
C. Flush all VADs with preservative-free 0.9% sodium
chloride (USP).
1. Use a minimum volume equal to twice the internal
volume of the catheter system (eg, catheter
plus add-on devices). Larger volumes (eg, 5 mL
for peripheral VAD, 10 mL for central vascular
access devices [CVADs]) may remove more fibrin
deposits, drug precipitate, and other debris from
the lumen. Factors to consider when choosing
the flush volume include the type and size of
catheter, age of the patient, and type of infusion
therapy being given. Infusion of blood components,
parenteral nutrition, contrast media, and
other viscous solutions may require larger flush
volumes. 10 (IV)
2. If bacteriostatic 0.9% sodium chloride is used,
limit flush volume to no more than 30 mL in a
24-hour period to reduce the possible toxic
effects of the preservative, benzyl alcohol. 11 (V)
3. Use only preservative-free solutions for flushing
all VADs in neonates to prevent toxicity. 12 (V)
4. Use 5% dextrose in water followed by preservative-
free 0.9% sodium chloride (USP) when the
medication is incompatible with sodium chloride.
Do not allow dextrose to reside in the catheter
lumen as it provides nutrients for biofilm
growth. 13 (V)
5. Do not use sterile water for flushing VADs. 14 (V)
D. Assess VAD functionality by using a 10-mL syringe
or a syringe specifically designed to generate lower
injection pressure (ie, 10-mL-diameter syringe barrel),
taking note of any resistance.
1. During the initial flush, slowly aspirate the VAD
for blood return that is the color and consistency
of whole blood, which is an important
component of assessing catheter function prior
to administration of medications and solutions
(refer to Standard 48, Central Vascular Access
Device [CVAD] Occlusion ; Standard 53,
Central Vascular Access Device [CVAD]
Malposition ).
2. Do not forcibly flush any VAD with any syringe
size. If resistance is met and/or no blood return
noted, take further steps (eg, checking for closed
clamps or kinked sets, removing dressing, etc.) to
locate an external cause of the obstruction.
Internal causes may require diagnostic tests,
including, but not limited to, a chest radiograph
to confirm tip location and mechanical causes
(eg, pinch-off syndrome), color duplex ultrasound,
or fluoroscopy to identify thrombotic
causes (see Standard 52, Central Vascular Access
Device [CVAD]-Associated Venous Thrombosis ;
Standard 53, Central Vascular Access Device
[CVAD] Malposition ). 10 (IV)
3. After confirmation of patency by detecting no
resistance and the presence of a blood return, use
syringes appropriately sized for the medication
being injected. Do not transfer the medication to
a larger syringe. 3,15 (V)
4. Do not use prefilled flush syringes for dilution of
medications. Differences in gradation markings,
an unchangeable label on prefilled syringes,
partial loss of the drug dose, and possible contamination
increase the risk of serious medication
errors with syringe-to-syringe drug
transfer. 3,16 (V)
E. Following the administration of an IV push medication,
flush the VAD lumen with preservative-free
0.9% sodium chloride (USP) at the same rate of
injection as the medication. Use an amount of flush
solution to adequately clear the medication from the
lumen of the administration set and VAD. 3 (V)
F. Use positive-pressure techniques to minimize blood
reflux into the VAD lumen.
1. Prevent syringe-induced blood reflux by leaving
a small amount (eg, 0.5-1 mL) of flush solution
in a traditional syringe (ie, not a prefilled syringe)
to avoid compression of the plunger rod gasket
or by using a prefilled syringe designed to prevent
this type of reflux. 10,17 (IV)
2. Prevent disconnection reflux by using the appropriate
sequence for flushing, clamping, and disconnection
determined by the type of needleless
connector being used (refer to Standard 34,
Needleless Connectors ).
3. Consider using pulsatile flushing technique. In
vitro studies have shown that 10 short boluses
of 1 mL interrupted by brief pauses may be
more effective at removing solid deposits (eg,
fibrin, drug precipitate, intraluminal bacteria),
compared to continuous low-flow techniques.
Clinical studies are needed to provide more
clarity on the true effect of this technique. 10,18
(IV)
4. When feasible, consider orienting the bevel of an
implanted port access needle in the opposite
direction from the outflow channel where the
catheter is attached to the port body. In vitro testing
demonstrates a greater amount of protein is
removed when flushing with this bevel orientation.
19 (IV)
G. Lock short peripheral catheters immediately
following each use.
1. In adults, use preservative-free 0.9% sodium
chloride (USP) for locking. 10,20-24 (I)
2. In neonates and pediatrics, use heparin 0.5 units
to 10 units per mL or preservative-free 0.9%
sodium chloride (USP). Outcome data in these
patient populations are controversial. 25,26 (II)
3. For short peripheral catheters not being used for
intermittent infusion, consider locking once every
24 hours. 27 (III)
H. There is insufficient evidence to recommend the
solution for locking midline catheters.
I. Lock CVADs with either heparin 10 units per mL or
preservative-free 0.9% sodium chloride (USP),
according to the directions for use for the VAD and
needleless connector.
1. Establish a standardized lock solution for each
patient population, organization-wide. 28,29 (V)
2. Randomized controlled trials have shown equivalent
outcomes with heparin and sodium chloride
lock solutions for multiple-lumen nontunneled
CVADs, peripherally inserted central catheters
(PICCs), and implanted ports while accessed
and when the access needle is removed. There is
insufficient evidence to recommend one lock
solution over the other. 30-33 (I)
3. Use heparin or preservative-free 0.9% sodium
chloride (USP) for locking CVADs in children. 29
(II)
4. Consider using heparin 10 units per mL for locking
PICCs in home care patients. 34 (III)
5. Volume of the lock solution should equal the
internal volume of the VAD and add-on devices
plus 20%. Flow characteristics during injection
will cause overspill into the bloodstream. Lock
solution density is less than whole blood, allowing
leakage of lock solution and ingress of blood
into the catheter lumen when the CVAD tip location
is higher than the insertion site. 10,35-37 (IV)
6. Change to an alternative locking solution when
the heparin lock solution is thought to be the
cause of adverse drug reactions from heparin;
when heparin-induced thrombocytopenia and
thrombosis (HITT) develops; and when there are
spurious laboratory studies drawn from the
CVAD that has been locked with heparin. High
concentrations of heparin used in hemodialysis
catheters could lead to systemic anticoagulation.
Heparin-induced thrombocytopenia (HIT) has
been reported with the use of heparin lock solutions,
although the exact rates are unknown (see
Standard 43, Phlebotomy ). 11,38 (II)
7. Monitoring platelet counts for HIT is not recommended
in postoperative and medical patients
receiving only heparin in the form of a catheter
lock solution due to a very low incidence of HIT
of 1% or less (see Standard 52, Central Vascular
Access Device [CVAD] – Associated Venous
Thrombosis ). 38 (II)
8. Because of conflicts with religious beliefs, inform
patients when using heparin derived from animal
products (eg, porcine, bovine), and obtain consent.
Use preservative-free 0.9% sodium chloride
(USP) instead of heparin when possible. 39 (V)
J. Lock hemodialysis CVADs with heparin lock solution
1000 units/mL, 4% citrate, or antimicrobial
lock solutions. Use recombinant tissue plasminogen
activator to lock hemodialysis catheters once per
week as a strategy to reduce CR-BSI. 40-43 (I)
K. Lock apheresis CVADs with heparin 100 units/mL,
4% citrate, acid-citrate-dextrose Formula A, or
other antimicrobial lock solutions. 40-42,44,45 (IV)
L. Use solution containing heparin (eg, 1 unit per mL
of 0.9% sodium chloride [USP]) or preservative-free
0.9% sodium chloride (USP) as a continuous flow to
maintain patency of arterial catheters used for
hemodynamic monitoring. The decision to use preservative-
free 0.9% sodium chloride (USP) instead
of heparin infusion should be based on the clinical
risk of catheter occlusion, the anticipated length of
time the arterial catheter will be required, and
patient factors such as heparin sensitivities. 46-48 (II)
M. Apply the following recommendations for neonates
and pediatrics.
1. Use a continuous infusion of heparin 0.5 units
per kg for all CVADs in neonates.
2. Use continuous infusion of heparin 0.25 to 1 unit
per mL (total dose of heparin 25-200 units per kg
per day) for umbilical arterial catheters in neonates
to prevent arterial thrombosis.
3. Use heparin 5 units per mL, 1 mL per hour as a
continuous infusion for neonates and children
with peripheral arterial catheters (see Standard
30, Umbilical Catheters ). 29 (II)
N. Use antimicrobial locking solutions for therapeutic
and prophylactic purposes. Use in patients with
long-term CVADs, patients with a history of multiple
CR-BSIs, high-risk patient populations, and in
facilities with unacceptably high rates of central lineassociated
bloodstream infection (CLABSI), despite
application of other methods of CLABSI reduction.
42,49-52 (I)
1. Antibiotic lock solutions contain supratherapeutic
concentrations of antibiotics and may be
combined with heparin. Anticipate the chosen
antibiotic to be based on the specific infecting
organism or on prevalent organisms within the
organization when prophylaxis is the goal. For
therapeutic use, start the antibiotic lock solutions
within 48 to 72 hours of diagnosis; however, the
duration of use remains controversial. 53 (II)
2. Antiseptic locking solutions include ethanol,
taurolidine, citrate, 26% sodium chloride,
methylene blue, fusidic acid, and ethylenediaminetetra-
acetic acid (EDTA) used alone or in
numerous combinations. 51 (I)
3. Follow catheter manufacturers’ instructions for
intraluminal locking with ethanol. Changes in
CVADs made of polyurethane material, but not
silicone, have led to catheter rupture and splitting.
Monitor for thrombotic lumen occlusion as
ethanol has no anticoagulant activity, hemolysis,
and hepatic toxicity. Irreversible precipitation of
plasma proteins that could add to CVAD lumen
occlusion is associated with ethanol concentrations
greater than 28%. 37,54-56 (I)
4. Monitor sodium citrate, an anticoagulant with
antimicrobial effects, for systemic anticoagulation,
hypocalcemia that could produce cardiac
arrest, and protein precipitate formation with
concentrations greater than 12%. 36,43 (I)
5. Monitor taurolidine, an amino acid with antimicrobial
effects, for thrombotic lumen occlusion
and protein precipitation, which could cause
lumen occlusion. 30,51,57 (I)
6. Use standardized formulations and licensed independent
practitioner (LIP)-approved protocols
for all antimicrobial lock solutions to enhance
patient safety. Consult with pharmacy when
combinations of antimicrobial solutions are
planned so that correct information about compatibility
and stability of the solution are
addressed. 53,58 (II)
7. The length of time that antimicrobial lock solutions
should reside inside the CVAD lumen is
unclear; up to 12 hours per day may be required.
This will limit use in patients receiving continuous
or frequent intermittent infusions. 53 (II)
8. Aspirate all antimicrobial locking solutions from
the CVAD lumen at the end of the locking period.
Do not flush the lock solution into the
patient’s bloodstream, as this could increase
development of antibiotic resistance and other
adverse effects. Gentamicin-resistant bacteria
from gentamicin lock solution have been reported
to increase CLABSI rates. 42,58,59 (II)Hello,
We are reviewing our central line management policies and we trying to find evidence related to the routine practice for aspiration of blood prior to accessing the central line (especially PICC).
Our ICU team states that this is routinely performed within oncology groups.I would be grateful for some specialist information.
Kind Regards
SonjaSonja Wegert | Infection Control Practitioner (ICP)
Infection Prevention and Control Unit | Central Australia Health Service
Northern Territory Government
Alice Springs Hospital, Gap Rd, Alice Springs
GPO Box 2234, Suburb, NT Postcode
p … 08 89517977
e … sonja.wegert@nt.gov.au http://www.nt.gov.au/healthMESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.
The use of trade/product/commercial brand names through the list is discouraged by ACIPC. If you wish to discuss specific reference to products or services by brand or commercial names, please do this outside the list.
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