I'm working on procedure profile for flushing pediatric cvad's(picc,port, hickman,etc) and I'm having trouble finding literature denoting specific flush strength and amounts for Heparin.
Any suggestion would be helpful or pass along your facilities policies on the above.
There are many controversies that exist about flushing protocols in the adult as well as the pediatric population. If you are looking for specific flush volumes from such places like the Infusion Nurses Society,you will not find it. What you will find is a general guidelines that you can apply to your clinical setting. You will not find a recommendation for Heparin strength either,since no consensus has been reached. ONS does suggest specific flushing protocols and Heparin strengths. Heparin strengths vary from 10 units per ml to 1000 units per ml. Here are the general recommendations you will find and then I will give you a sample protocol. As a general rule you should flush any CVC with a minimum of 2x the priming volume of that type or line plus the volume of any add on devices (such as a small extension set). Since,most nurses will find it annoying to memorize all the priming volumes most health care organizations select a volume sufficient to cover all the types of lines they are using and will often standardize the flush protocol for CVCs. If not standardized you will seen them make grids or charts as cheat sheets.
Here are the guidelines for flushing Of tunneled (non-valved),tunneled closed-tip valved) and ports and percutaneousely placed CVcs. Flush before and after intermittent medication administration,after blood infusion or withdrawal and maintenance flushing based on type of device.
In peds CVC volume less than 1 ml......Flush with 3 ml NS followed by 2-5 ml heparin (10-100 units per ml). After blood 5-10ml followed by 2-5 ml heparin (10-100 units per ml). Maintenance can vary greatly from as much as QD to weekly. IN CVCs greater than 1 ml it will be 5 ml for followed by 2-5 ml heparin (10-100 units per ml) and after a blood draw 5-10ml. On groshong PICCs and Chest lines Heparin is not necessary,but will not harm the catheter if your organization chooses to use it. For pediatric port....5 ml NS followed by Heparin 3-5ml (10-100 units per ml). After blood on the port 5-10 ml NS followed by 3-5 ml Heparin (10-100 units per ml). Again this should be done on locked ports before and after intermittent med administration (use NS only before) and after blood draws. When de-accessing port or the monthly flush use the 5 ml NS then the same Heparin 3-5 ml (10-100 units per ml.
If you need to stop a cont infusion to draw blood and when you are done will be resuming the cont infusion you do not need to use the Heparin. As you can see the suggested flush volumes are adequate to clearly deliver at least the 2x the priming volume. You will also notice that it is common practice to double the normal saline flush volume after a blood draw to clear the line well. All flushes should be performed in a pulsatile push pause fashion. Again this technique will clean and clear the line and diminish occlusion problems and potentially decrease infection risk by keeping blood out of the line and at the tip of the catheter. Also keep in mind that some hospitals are trying NS only flush policies. This is still a controversial practice b/c in a nutshell you lose all the benefits of heparin. Another peds issue is to make certain you are using PRESERVATIVE-FREE NS and HEPARIN FLUSHES. Neonates especially can have severe and sometimes fatal reactions to the benzyl alcohol used as a preservative. Also the use of Chorhexadine is contraindicated in neonates and infants less than 2 mos.
If you need references look at the 2006 INS guidelines for the general statements and the ONS guidelines and peds textbooks. If you want a list of current IV texts that have pediatric chapters that address these issues I can direct you to those. let me know and I hope this helps. Please remember that it is each health care institutions responsibility to select on and decide what guidelines they will use, though they should be reasonable and prudent and hopefully evidenced based.
Last edit by iluvivt on Oct 4, '08