Adults
There is insufficient evidence for or against the choice of a particular protocol in the adult cancer population. Recommendations by the panel regarding the schedule of solutions, volumes, concentrations, and frequencies are based on a consensus of the expert clinical opinion and the experience of the Central Venous Access Device (CVAD) Panel in their practices and the best available evidence. These recommendations are framed as a consensus schedule and are presented in the Table below.
The purpose of the consensus schedule is to provide clinical institutions and other organizations with a framework on which to build their own institutional protocols, and to encourage standardization of protocols across institutions. While there is dearth of evidence to drive institutional change, standardization of protocols is of value in and of itself as it can increase patient confidence in nursing care, improve the patient experience, and simplify nursing education. Other important considerations include:
- The impact on patients, families, and staff of inconsistent practice, at a time of transition of care between centres.
- The cost to patients and families in both quality of life and dollars of potentially unnecessary increase in frequency of hospital visits for CVAD management that are required by some hospitals.
- The cost to the health care system associated with more frequent flushing with more costly solutions that may not be justified.
Table. Consensus Recommendations for Locking Central Venous Access Devices in Adult Cancer Patients
| CVAD |
Lock solution |
VolumeA |
Concentration |
Frequency |
| Implanted device (e.g., Port-A-Cath™) |
Heparin |
5 mL |
100 units/mL |
After each use or four weeks if not in use |
| Closed end Tunnelled catheter (e.g., Groshong™) |
Sterile Saline |
10 mL |
0.9% |
After each use or weekly if not in use |
| Open ended Tunnelled catheter (e.g., Hickman™) |
Heparin |
3 mL |
100 units/mL |
After each use or weekly if not in use |
| Closed ended peripherally inserted central line (PICC) (e.g., Groshong™) |
Sterile Saline |
10 mL |
0.9% |
After each use or weekly if not in use |
| Open ended PICC (e.g., Cook™, Vaxcel™) |
Heparin |
3 mL |
100 units/mL |
After each use or weekly if not in use |
A Rationale for volumes was based on dead space volume of the catheter plus sufficient volume to ensure positive pressure. The volume of solution should be altered if the volume of the catheter being used is non-standard or unique. The weight of patient is not a consideration when determining the volume of solution; the volume of the catheter is the key parameter.
- Guidelines published by the Oncology Nursing Society (ONS) in 2004 were used as a framework for the consensus schedule.
- Heparin use would be contraindicated in patients with heparin-induced thrombocytopenia (HIT).
- All lines should be flushed with a minimum of 10 mL of normal saline prior to locking to prevent solution incompatibilities.
- Positive pressure apparatus are not included in the recommendations because there is no evidence pertaining to whether they provide a benefit or not.
Pediatric
There is insufficient evidence for or against the choice of a particular protocol in the pediatric population to justify a change in current institutional practices. Although the pediatric representatives on the panel recognized the value of standardized guidelines and practice, a pediatric consensus could not be achieved.
Indicators
There is insufficient evidence to determine specific indicators that may have an impact on the decision to insert a CVAD or for catheter-related intraluminal thrombosis among adults and pediatric cancer patients.
