What is the recommended nightly flushing protocol for a Peripherally Inserted Central Catheter (PICC) line using saline and heparin?

From the Guidelines

The recommended nightly flushing protocol for a Peripherally Inserted Central Catheter (PICC) line involves flushing with saline solution when not in use, and heparinized solutions may be used as a lock after flushing with saline, when recommended by the manufacturer, in the case of implanted ports or opened-ended catheter lumens which are scheduled to remain closed for more than 8 h 1.

Key Considerations

• The use of saline solution for flushing is recommended for most central venous access devices, including PICC lines, as it is effective in maintaining catheter patency and preventing occlusion 1.
• Heparinized solutions may be used in addition to saline, but only when recommended by the manufacturer, and typically for implanted ports or opened-ended catheter lumens that will remain closed for an extended period 1.
• The frequency of flushing and locking with saline or heparin solution depends on the type of catheter and the manufacturer's recommendations, but typically ranges from daily to weekly 1.

Flushing Protocol

• Flush the PICC line with 10 mL of 0.9% normal saline using a push-pause technique to remove any residue from the catheter walls.
• If recommended by the manufacturer, administer 5 mL of heparin solution (usually 10 units/mL concentration) after the saline flush to prevent blood clot formation within the catheter lumen.
• Always use a clean technique when accessing the PICC line, including hand hygiene and disinfecting the hub with alcohol for 15 seconds before connecting syringes.

Important Notes

• For patients with heparin allergies or certain conditions, a saline-only protocol may be prescribed, but this should be specifically directed by the healthcare provider managing the PICC line.
• The use of heparinized solutions should be carefully considered, as they may facilitate the precipitation of lipids, and saline flushing is mandatory during parenteral nutrition with lipids before any flushing with heparin 1.

From the Research

Flushing Protocols for PICC Lines

The recommended nightly flushing protocol for a Peripherally Inserted Central Catheter (PICC) line using saline and heparin is not universally agreed upon, but several studies provide insight into the effectiveness of different flushing protocols.

• A study published in 2018 2 compared the traditional flushing method with a novel flushing method, known as the Venous Arterial Blood Management Protection (VAMP) system, and found that the VAMP-system flushing method was simple to use and may be more beneficial for patients with a PICC, as it lowered the risk of catheter-associated bloodstream infections (CABSIs).
• A 2014 study 3 compared three commonly used flushing protocols in home infusion patients with PICCs and found that the data provided some evidence to support the elimination of heparin flushing in home care patients with PICCs, although the saline-only group experienced a higher incidence of complications.
• A 1992 study 4 hypothesized that 10 units of heparin would maintain the patency of the PICC line as effectively as 100 units and found that there appears to be evidence to support this hypothesis, although a controlled, blinded study was recommended to test the hypothesis statistically.
• A 2022 study 5 analyzed the effect of different doses of heparin sodium injection on the incidence rate of PICC-related venous thrombosis in non-small cell lung carcinoma (NSCLC) patients during postoperative chemotherapy and found that heparin sodium injection could significantly lower the incidence rate of PICC-related venous thrombosis.
• A 2012 study 6 compared intermittent flushing with heparin versus saline for maintenance of peripheral intravenous catheters and found that heparin 100 U/mL was more effective than saline solution in reducing the number of catheter-related phlebitis/occlusions and the number of catheters per patient.

Key Findings

• The use of heparin in flushing protocols may help to reduce the risk of catheter-related complications, such as venous thrombosis and catheter-associated bloodstream infections.
• The optimal dose of heparin for flushing PICC lines is not universally agreed upon, with studies recommending doses ranging from 10 units/mL to 100 units/mL.
• Saline-only flushing protocols may be associated with a higher incidence of complications, such as catheter occlusion and phlebitis.