Clinical Decisions

This review provides many aspects of heparin use as a locking solution that require consideration; however, there are no concrete answers about the numerous issues associated with heparin. The goal among many healthcare professionals appears to be the elimination of heparin as a catheter locking solution, but this decision requires careful assessment of many factors. Based on the data presented, saline alone is not a reliable solution for ensuring catheter patency regardless of the type of needleless connector being used. To minimize complications, the data suggest that some form of anticoagulation is needed for central venous catheters. The alternative solutions will provide the added benefit of reducing CRBSI as well, but there are no commercially available alternative solutions on the US market. These solutions must be prepared in a compounding pharmacy.

While we wait for clearance by the FDA, we must make careful decisions about catheter lock solutions. Rapid elimination of heparin lock solutions may not be the best alternative. These decisions must be based on an assessment of many factors in each facility. All facilities currently using one of the technologies with instructions for heparin elimination should be documenting outcomes with the use of the catheter or needleless connector. These outcomes should include

• frequency of catheter lumen occlusion;
• quantity of thrombolytic agents and declotting procedures required in the patient population;
• rate of CRBSI in the facility with changes in this rate correlated to recent product change; and
• rate of heparin-induced complications in the patient population.

Patient safety is foremost in all healthcare practice settings today, followed closely by cost containment. The elimination of heparin lock solutions for central venous catheters requires a careful assessment of the evidence by a collaborative, multidisciplinary team of professionals. Does the risk of heparin elimination (eg, loss of catheter patency, diagnosis, treatment, and possible catheter replacement) outweigh the benefits derived from using saline only as a locking solution for central venous catheters? These and many other questions require careful evaluation. Heparin remains the recommended locking solution for intermittent central venous catheters.1 However, research on alternative solutions is ongoing and ideally will allow for practice changes in the future.