What is the standard of care for flushing a Peripherally Inserted Central Catheter (PICC) line?

From the Guidelines

The standard of care for flushing a Peripherally Inserted Central Catheter (PICC) line involves using normal saline rather than heparin to maintain catheter patency and prevent lumen occlusion, as reflected in recent recommendations 1, 2.

Key Points for Flushing a PICC Line

• Use of normal saline is preferred over heparin for maintaining catheter patency, as stated in the Michigan Appropriateness Guide for Intravenous Catheters 1.
• The push-pause technique should be used during flushing to create turbulence that helps remove debris from the catheter wall.
• Always use a 10 mL syringe or larger to avoid excessive pressure that could damage the catheter.
• Before flushing, disinfect the hub with alcohol or chlorhexidine for at least 15 seconds and allow it to dry completely.
• After flushing, maintain positive pressure by clamping the catheter while still injecting the last 0.5-1 mL of solution to prevent blood reflux into the line.

Maintenance Flushing

• For maintenance flushing when the line is not in use, the PICC should be flushed every 12-24 hours with 10 mL of normal saline, as suggested by guidelines for central venous access in oncology 3, 4.
• Routine flushing with saline after the completion of any infusion or blood sampling is recommended to maintain patency 3.

Prevention of Complications

• Intraluminal obstruction of the central venous access can be prevented by appropriate nursing protocols in maintenance of the line, including the use of nutritional pumps 5.
• Catheter-related central venous thrombosis can be avoided by the use of insertion techniques designed to limit damage to the vein, including ultrasound guidance at insertion, choice of a catheter with the smallest caliber compatible with the infusion therapy needed, and position of the tip of the catheter at or near to the atrio-caval junction 6.

From the Research

Standard of Care for Flushing a Peripherally Inserted Central Catheter (PICC) Line

The standard of care for flushing a PICC line is a crucial aspect of maintaining catheter patency and preventing complications. According to the available evidence:

• Flushing with saline solution is a common practice, and studies have shown that it can be effective in maintaining catheter patency 7, 8, 9, 10.
• The frequency of flushing is also an important consideration, with some studies suggesting that daily flushing may be sufficient to maintain patency 10.
• The use of heparin flushing has been debated, with some studies suggesting that it may not be more effective than saline flushing in preventing occlusion or bloodstream infections 8, 9.
• Other factors that may affect catheter function, such as patient age, gender, diagnosis, therapy type, frequency of catheter use, catheter brand/size/number of lumens, concomitant use of anticoagulant medications, and whether PICCs are used for routine lab testing, have been analyzed, but no statistical significance was determined 8.

Flushing Protocols

Different flushing protocols have been compared in various studies, including:

• A novel flushing method using the VAMP-system, which was found to be simple to use and may be more beneficial for patients with a PICC, with a lower risk of catheter-associated bloodstream infections (CABSIs) 7.
• A comparison of three commonly used flushing protocols in home infusion patients with PICCs, which found that the data provide some evidence to support the elimination of heparin flushing in home care patients with PICCs 8.
• A study comparing pulsatile flushing (PF) and continuous flushing (CF) on time and type of peripheral intravenous catheters patency, which found no difference between the two techniques regarding the time and type of catheter patency 11.

Recommendations

Based on the available evidence, it can be recommended that:

• Saline flushing be used as a standard practice for maintaining PICC line patency 7, 8, 9, 10.
• Daily flushing may be sufficient to maintain patency, but the frequency of flushing should be individualized based on patient needs and catheter type 10.
• The use of heparin flushing should be carefully considered, and alternative flushing protocols should be explored 8, 9.