Central Venous Access Device Care and Management
Elizabeth Smith
N408
Lakeview College of Nursing
October 27, 2011

	 Central Venous Access Device Care and Management
	Provena USMC has a policy in place regarding the central venous access devices. This policy is set in place to provide a uniform set of standards for central venous access devices. The policy is called “Central Venous Access Device (CVAD) Care and Maintenance”. In this paper, there will be 5 nursing research articles analyzed to prove the fact that Provena USMC is practicing evidence based protocols. The purpose of this paper is to prove that Provena USMC is adhering to the evidence based practice of flushing a central venous catheter with normal saline.
	The CVAD policy’s purpose is to provide guidelines for safe use, management, and maintenance of Central Venous Access Devices. The significance of the CVAD policy is that it provides written instruction on the purpose, procedure of insertion, documentation, maintenance, catheter flushing, cap change, central venous pressure, dressing changes, obtaining blood specimens, restoring blood in partial occlusion, restoring blood in complete occlusion, and discontinuing a central venous access device. The individuals who follow this policy include anyone who has to manage the care for the CVAD at any given time during their hospital stay, this includes the physicians who insert the CVAD and nurses. The CVAD policy goes into detail about assessment guidelines, definitions of devices, and procedures involved with central venous access devices. One in particular, catheter flushing, is of particular importance in this paper. Provena USMC’s policy states that each lumen should be flushed with 10 ml 0.9% normal saline before and after each use, as well as every twelve hours when the CVAD is not in use. 
	The first article depicted the ongoing evidence that there is a lack of standardized flushing protocols for CVAD’s among health care institutions. This leads to confusion and care that is not standardized. The information was gathered from studies of corporate and individual in-services to help educate and receive better understanding of evidence-based practice related to flushing CVAD’s (Mathers, 2011).  Some important facts about heparin were included in the synopsis of this study. Adverse outcomes of heparin include bleeding, heparin-induced thrombocytopenia, clotting disorders, potential to cause erroneous lab results when blood is drawn from a catheter flushed with heparin, and higher costs when compared with normal saline use. The conclusion of this study is that continuing education and reinforcement of proper flushing techniques of CVAD’s is essential in providing evidence based practice protocols. This study concluded that the use of normal saline is the best flushing solution to be used for CVAD’s.
	In the second article, a questionnaire was sent out to 22 national, tertiary pediatric surgical centers and neonatal units regarding the types of access devices and dressings used, cleansing agents, solutions to flush the devices, and sizes of the syringes used to access the devices (Douglas, 2009). The results that were gleaned from this study included a considerable variation in the range of flushes. This study felt that the variation in the recommended flushes was dependent upon the manufacturer of that CVAD. It was noticed that there is a lack of national and regional consensus regarding all aspects of flushing CVAD’s and that this has resulted in confusion among healthcare professionals. According to Linda Douglas, the most common flush was 0.9% sodium chloride (normal saline) and the second most common was Hepsal (Douglas, 2009). It was also noted that most heparin solutions contain preservatives and is evidenced with being related to bleeding disorders and other complications.
	The third article depicted a large-scale study that analyzed complications of CVADs used for outpatient home infusion therapy in 50,000 patients. The most common complications associated with CVAD placement in this study was loss of patency (either thrombolytic or nonthrombolytic) and infection. The results of this study concluded that prior to complications, a CVAD should be actively flushed with 0.9% normal saline and post-complications, a CVAD should be flushed with a thrombolytic agent (Cummings-Winfield & Mushani-Kanji, 2008). 
	In the fourth article, a study was done over 2 years. It was depicted from this study that there were 3 cases of heparin induced thrombocytopenia that each patient acquired through heparin flushes given at least daily in their central venous access devices. This information was acknowledged by both clinical and laboratory evidence of heparin induced thrombocytopenia (HIT) due to heparin flushes (Kadidal, Mayo & Horne, 1999). 
	The last article gave the synopsis of a systematic review of primary studies of protocols for central venous access devices. There were 6 practice guidelines, one pooled analysis, and forty-one clinical studies reviewed. Methods used were meta-analysis of randomized controlled trials, review of published meta-analysis, and systematic review with evidence tables ("Managing central venous," 2006). The conclusion of this review was that the use of either saline or heparin in the central venous access devices are usually based on the manufacturer’s recommendations. The difference of catheters directly indicates which flush to use. For example, in closed ended catheters that have no blood backflow into the lumen, saline should be used. To prevent thrombus development if blood enters the lumen in open ended catheters, Heparin should be used. It was concluded that though there is not a standardized guideline for practice of flushes for central venous access devices, individual institution’s own protocols are sufficient enough.
	After giving a synopsis of all 5 articles, the evidence shows that the flush that should be used when flushing central venous access devices should be 0.9% normal saline. The evidence points to adverse effects and outcomes associated with sole heparin usage to flush CVAD’s; including heparin induced thrombocytopenia. The most common flushing agent used in all the studies was 0.9% normal saline with heparin agents being indicated only after there were complications with the CVAD. Although there was an enormous amount of evidence depicting 0.9% normal saline as the proper flushing agent, it was still noted that flushes should be consistent with what the manufacturer of that specific CVAD recommends. Further studies are needed to indicate that normal saline is the proper and evidence based practice for flushing central venous access devices. 

	

References
(2006). Managing central venous access devices in cancer patients: A clinical practice 

	guideline. U.S. Department of Health & Human Resources, 1-39. Retrieved from 

	http://www.guideline.gov/content.aspx?id=10160

Cummings-Winfield, C., & Mushani-Kanji, T. (2008). Restoring patency to central 

	venous access devices. Clinical Journal of Oncology Medicine, 12(6), 925-934. 

	doi: 10.1188/08.CJON.925-934

Douglas, L. (2009). Central venous access devices: Review of practice. Pediatric 

	Nursing, 21(5), 19-22. Retrieved from 

	http://web.ebscohost.com.ezproxy.lakeviewcol.edu:2048/ehost/pdfviewer?vid=6&

	hid=110&sid=907fcc98

Mathers, D. (2011). Evidence-based practice: Improving outcomes for patients with a 

	central venous access device. Journal of the Associatin for Vascular Access, 

	16(2), 64-72. doi: 10.2309/java.16-2-3

Kadidal, V., Mayo, D., & Horne, M. (1999). Heparin-induced thrombocytopenia (hit) due 

	to heparin flushes: A report of three cases. Journal of Internal Medicine, 325-329. 

	Retrieved from 

	http://web.ebscohost.com.ezproxy.lakeviewcol.edu:2048/ehost/pdfviewer/pdfview