From the Guidelines
If a central line is not bleeding back, you should not routinely flush it without first assessing the situation and considering the potential risks and benefits, as gentle flushing with saline may be attempted but forcing a flush against resistance is contraindicated 1. When a central line is not bleeding back, it is essential to assess the situation carefully before taking any action. The absence of blood return may indicate catheter occlusion, malposition, or thrombosis.
- Contacting the healthcare provider or following the institution's protocol is crucial before proceeding with any intervention.
- In some cases, gentle flushing with 5-10 mL of normal saline using a 10 mL syringe may be attempted after confirming the line is not kinked, clamped, or positioned improperly 1.
- However, forcing a flush against resistance is contraindicated as it could dislodge a clot, damage the catheter, or cause complications.
- Changing the patient's position, having them cough, or raising their arm might help restore patency.
- If gentle flushing is unsuccessful, thrombolytic agents like alteplase (2 mg/2 mL) may be needed to clear the occlusion, as suggested by the most recent guidelines 1.
- Documentation of all interventions and the patient's response is essential.
- The inability to withdraw blood but ability to flush (known as "one-way occlusion") requires careful evaluation as it may indicate the catheter tip is against a vessel wall or a fibrin sheath has formed. It is also important to note that the use of heparinized solutions for flushing and locking central venous catheters is not universally recommended and should be based on the manufacturer's instructions and the specific clinical situation 1.
From the Research
Central Line Management
- The provided studies do not directly address the question of flushing a central line if it isn't bleeding back 2, 3, 4, 5, 6.
- However, studies have investigated the use of thrombolytics such as alteplase and urokinase to restore blood flow through occluded central venous catheters 3, 4, 6.
- These studies suggest that alteplase and urokinase can be effective in restoring catheter patency, but do not provide guidance on flushing a central line that is not bleeding back 3, 4, 6.
- One study emphasizes the importance of proper maintenance and care of central vascular access devices, including hand hygiene, dressing management, and access of intravenous infusion sets, to prevent central line-associated bloodstream infections 5.
- There is no direct evidence to support or refute the practice of flushing a central line if it isn't bleeding back, and further research may be needed to address this specific question 2, 3, 4, 5, 6.
Thrombolytic Agents
- Alteplase and urokinase have been compared in several studies for their effectiveness in restoring blood flow through occluded central venous catheters 3, 4, 6.
- These studies suggest that both agents can be effective, but may have slightly different success rates and complication profiles 3, 4, 6.
- The choice of thrombolytic agent may depend on various factors, including the specific clinical situation and patient characteristics 3, 4, 6.
Central Line Care
- Proper care and maintenance of central vascular access devices are crucial to prevent central line-associated bloodstream infections 5.
- This includes following evidence-based guidelines for hand hygiene, dressing management, and access of intravenous infusion sets 5.
- Nurses play a critical role in ensuring proper care and maintenance of central lines, and can significantly reduce the risk of complications with evidence-based practice 5.