Replacing heparin with saline to prevent complications in long term central venous catheters in children

Background

A central venous catheter (CVC) is a long, thin, flexible tube which is inserted into a large central vein. This enables access to the blood stream for people with serious medical conditions to receive medications and fluids, as well as the collection of blood specimens. Long term central venous catheters are used to access the blood system in children with complex medical conditions like cancer. To stop the catheter from becoming blocked it is usual to use heparin, a drug that prevents clots forming, to flush the catheter. However, some studies have shown that heparin is not necessary, and that normal saline (a sterile salt water solution) can be safely used instead. Heparin may be associated with complications, such as bleeding and infection, along with higher costs for health care providers. While the complications such as infections and occlusions are uncommon, practices vary around the world and there are many inconsistencies regarding the best flush solution to use to prevent complications in long term catheters.

Study characteristics and key results

This review included randomised controlled trials, (clinical studies where people were randomly assigned into one of two or more treatment groups), that compared the use of saline and heparin to prevent blockage, and other complications related to long term catheters. The evidence is current to April 2015. Two review authors independently reviewed the studies. Three studies with a total of 245 participants were included in the review. The three trials directly compared the use of saline and heparin, however, between studies, all were very different in the way they compared saline and heparin, with different concentrations of heparin and different frequency of flushes reported. We were able to combine the results of two studies; the analysis showed imprecise results for the blocking of catheters and blood stream infections between normal saline and heparin. One study reported the duration of catheter placement to be similar between the two study arms.

Quality of the evidence

The overall quality of the evidence ranged from low to very low. There was high risk of bias for blinding, there were differences between the studies methods and interventions, inconsistent results between the studies, and not all studies reported all outcomes of interest. We found there was not enough evidence to determine which solution, heparin or saline, is more effective for reducing complications. Further research is required and is likely to have an important impact in this area.

Authors' conclusions: 

The review found that there was not enough evidence to determine the effects of intermittent flushing of heparin versus normal saline to prevent occlusion in long term central venous catheters in infants and children. Ultimately, if this evidence were available, the development of evidenced-based clinical practice guidelines and consistency of practice would be facilitated.

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Background: 

Guidelines and clinical practice for the prevention of complications associated with central venous catheters (CVC) around the world vary greatly. Most institutions recommend the use of heparin to prevent occlusion, however there is debate regarding the need for heparin and evidence to suggest 0.9% sodium chloride (normal saline) may be as effective. The use of heparin is not without risk, may be unnecessary and is also associated with increased cost.

Objectives: 

To assess the clinical effects (benefits and harms) of intermittent flushing of heparin versus normal saline to prevent occlusion in long term central venous catheters in infants and children.

Search strategy: 

The Cochrane Vascular Trials Search Co-ordinator searched the Specialised Register (last searched April 2015) and the Cochrane Register of Studies (Issue 3, 2015). We also searched the reference lists of retrieved trials.

Selection criteria: 

Randomised controlled trials that compared the efficacy of normal saline with heparin to prevent occlusion of long term CVCs in infants and children aged up to 18 years of age were included. We excluded temporary CVCs and peripherally inserted central catheters (PICC).

Data collection and analysis: 

Two review authors independently assessed trial inclusion criteria, trial quality and extracted data. Rate ratios were calculated for two outcome measures - occlusion of the CVC and central line-associated blood stream infection. Other outcome measures included duration of catheter placement, inability to withdraw blood from the catheter, use of urokinase or recombinant tissue plasminogen, incidence of removal or re-insertion of the catheter, or both, and other CVC-related complications such as dislocation of CVCs, other CVC site infections and thrombosis.

Main results: 

Three trials with a total of 245 participants were included in this review. The three trials directly compared the use of normal saline and heparin, however, between studies, all used different protocols for the standard and experimental arms with different concentrations of heparin and different frequency of flushes reported. In addition, not all studies reported on all outcomes. The quality of the evidence ranged from low to very low because there was no blinding, heterogeneity and inconsistency between studies was high and the confidence intervals were wide. CVC occlusion was assessed in all three trials (243 participants). We were able to pool the results of two trials for the outcomes of CVC occlusion and CVC-associated blood stream infection. The estimated rate ratio for CVC occlusion per 1000 catheter days between the normal saline and heparin group was 0.75 (95% CI 0.10 to 5.51, two studies, 229 participants, very low quality evidence). The estimated rate ratio for CVC-associated blood stream infection was 1.48 (95% CI 0.24 to 9.37, two studies, 231 participants; low quality evidence). The duration of catheter placement was reported to be similar between the two study arms, in one study (203 participants).

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