Intravascular Therapy: Peripheral Lock and Flush
CLINICAL GUIDELINES
A healthcare prescriber must order saline or heparin for peripheral locks and flushes. Follow institutional policies and standards of care for ordering and administering, stocking and distributing flushes for individual patient care use.
A physician, registered nurse (RN), or licensed practical nurse (LPN) may administer saline or heparin flushes per state practice acts.
Children who do not require continuous intravenous (IV) infusion may still require IV access for intermittent intravascular medication administration and are considered candidates for a saline or heparin lock.
The efficacy of saline flushes to maintain the patency of an intermittent IV access site has been demonstrated to be safe for children of all ages, including neonates, using catheters 24 gauge and larger. Despite a growing body of evidence supporting saline locks, heparin continues to be preferred by some healthcare prescribers as a peripheral lock or flush solution, therefore parameters for using heparin are provided in this chapter.
The minimum volume of saline flush used depends on the type and size of catheter, age of the child, fluid restrictions, and type of infusion therapy that will be given (if any) following the flush. A minimum of twice the internal volume of the catheter system is recommended. A larger volume may be needed for blood sampling or blood transfusion procedures (Infusion Nurses Society [INS], 2011).
Peripheral intravascular locks shall be flushed
prior to each IV infusion to assess catheter patency,
after each IV infusion to clear the infused medication from the catheter lumen and to prevent contact between incompatible medications or fluids,
after completion of medication or IV infusion to decrease risk of occlusion,
or a minimum of every 8 to 12 hours to maintain patency on a catheter not being regularly used for medication or IV fluid infusion purposes.
See Chapters 55, 56, and 57 for recommendations regarding flushing of other types of infusion access devices.
EQUIPMENT
Nonsterile gloves
Antiseptic wipes: alcoholic chlorhexidine-based preparation is preferred, tincture of iodine, an iodophor (e.g., povidone-iodine), or 70% alcohol can be used
caREminder
The evidence is mixed regarding safety of the use of chlorhexidine (CHG) in infants under 2 months of age. The Centers for Disease Control and Prevention (CDC) makes no recommendation for the use of CHG (O’Grady, Alexander, Burns, et al., 2011) and the INS (2011) does not recommend the use of CHG in this population. The Association for Women’s Health, Obstetric and Neonatal Nurses (AWHONN) neonatal skin care guidelines recommend either 2% CHG without alcohol in aqueous solution or povidone-iodine (let dry and wipe off with sterile normal saline) (Association for Women’s Health, Obstetric and Neonatal Nurses [AWHONN], 2013).
Needleless male adapter (injection cap) (if converting an IV continuous infusion to a lock)
For saline lock/flush: preservative-free normal saline (0.9% NaCl) commercially available prefilled syringe or vial of preservative-free 0.9% NaCl solution
For heparin lock/flush: heparin commercially available prefilled 10 unit/mL syringe with injection cartridge or vial of heparin solution, 10 unit/mL
1-or 3-mL needleless syringe
Use preservative-free saline and heparin for neonates because neonates are not able to metabolize preservatives well. This inability may result in the accumulation of toxic amounts, a condition called gray baby syndrome or gasping syndrome that presents as metabolic acidosis, lethargy, and hypotension. The most common preservative is benzyl alcohol, an antibacterial agent that is used in many medications.CHILD AND FAMILY ASSESSMENT AND PREPARATION
Assess the cognitive level, readiness, and ability to process information of the child and family. The readiness to learn and process information may be impaired as a result of age, stress, or anxiety.
Reinforce the need and identify and discuss the risks and benefits of saline lock placement, as appropriate, to both the child and the family. Explain the signs and symptoms that may indicate the need for IV catheter site change should the saline lock become infiltrated or clotted.
KidKare Teach the family to “Touch-Look-Compare” (TLC) the child’s IV access site. This is an effective acronym to teach and remind the family that they are an active participant in monitoring the child’s IV site (Cincinnati Children’s, 2012).
Explain the procedure, as appropriate, to both the child and family. Use therapeutic play as indicated.
KidKare Be honest; never say “It won’t hurt.” When a heparin solution is used, it may “sting” when flushing the peripheral access device.
Assess the IV site every hour for signs of infiltration, irritation, phlebitis, or extravasation (see Chapter 53).
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