pulsatile flushing - lippincott nursingcenter.com

Copyright © 2019 Infusion Nurses Society. Unauthorized reproduction of this article is prohibited.

VOLUME 42 | NUMBER 1 | JANUARY/FEBRUARY 2019 journalofinfusionnursing.com 37

The Art and Science of Infusion Nursing

In the United States, more than 5 million central vascular access devices (CVADs) are inserted each year.1 CVADs are used to deliver lifesaving medications and critical treatment in both intensive care and specialty care units.

In outpatient settings, CVADs are also used for patients undergoing long-term therapies, such as chemotherapy. A major complication with these types of devices are central line-associated bloodstream infections (CLABSIs), which can have a significant impact on patient outcomes as they are associated with longer hospital stays, increased risk of mor-bidity and mortality, and increased medical costs.2

In an effort to lower CLABSI rates, hospitals have focused on evidence-based prevention efforts, including hand hygiene, chlorhexidine (CHG) skin preparation, full barrier precautions during insertion, avoiding the femoral site, and the removal of unnecessary catheters.2 From 2008 to 2011, CLABSI rates declined by 50%.3 Despite these prevention efforts, the Centers for Disease Control and Prevention esti-mates that there were 71 900 CLABSIs in 2011.3 In addition to the prevention efforts described previously, catheter maintenance measures, such as daily CHG bathing and the use of port protectors, are often now being used.4 Routine

care and maintenance of CVADs include hand hygiene; sterile dressing changes; cleaning catheter hubs before each access; and changing caps, intravenous (IV) fluids, and tubings as recommended.5 CVAD occlusion is a major concern because it not only interferes with normal use of the CVAD but also is strongly associated with subsequent bloodstream infection.6 It is estimated that 36% of patients with a CVAD are affected by an occlusion.6 Occlusions can be partial, meaning the catheter can be flushed but blood cannot be aspirated, or complete—that is, neither flushing nor aspiration is possible.7 Flushing is an essential strategy in maintaining catheter patency.7 Unfortunately, there is no practice standard related to flushing techniques.

According to the Infusion Nurses Society (INS), CVADs should be flushed with 0.9% sodium chloride before and after medication administration.8(S77) In the past, pulsatile flushing, a technique that uses 10 brief boluses of 1 mL interrupted by a short pause, has been cited as helping to remove built-up residue, medications, and fibrin from the walls of the catheter.9 However, it was recommended solely on the principles of fluid dynamics and is, therefore, not a universal practice. The Infusion Therapy Standards of Practice8 suggests considering the use of pulsatile flushing, as in vitro studies demonstrated pulsatile flushing to be more effective at removing solid deposits and, therefore, may be more effective at preventing occlusions. The most recent Access Device Standards of Practice for Oncology Nursing10 from the Oncology Nursing Society (ONS) also recommends pulsatile flushing for CVADs.

EVIDENCE SEARCH

The purpose of this review is to evaluate and synthesize the literature for the clinical question: In adult patients

ABSTRACTFlushing is an essential strategy in maintaining patency of a central vascular access device. However, there is no standard practice regarding flushing techniques. Pulsatile flushing has been discussed in the past based on the principles of fluid dynamics. Recently, in vitro studies regarding pulsatile flushing have shed light on the usefulness of this technique. A critique of the current literature regarding pulsatile flushing compared with standard continuous flushing is presented here.Key words: central vascular access devices, CLABSIs, flushing techniques, occlusions, pulsatile flushing, push-pause-push flushing, vascular access device

Author Affiliation: University of Maryland Medical Center, Baltimore, Maryland.

Christina Boord, BSN, RN, OCN®, is a clinical practice and educa-tion specialist at the University of Maryland Medical Center, where she sits on several hospital- and system-wide committees, working to improve patient-centered care. She is passionate about support-ing staff in both education and process improvement initiatives.

The author of this article has no conflicts of interest to disclose.

Corresponding Author: Christina Boord, BSN, RN, OCN®, University of Maryland Medical Center, Greenbaum Comprehensive Cancer Center, 22 South Greene Street, Baltimore, MD 21201 ([email protected]).

Pulsatile FlushingA Review of the Literature

Christina Boord, BSN, RN, OCN®

DOI: 10.1097/NAN.0000000000000311


38 Copyright © 2019 Infusion Nurses Society Journal of Infusion Nursing

with CVADs, does pulsatile flushing, compared with stan-dard continuous flushing, decrease the number of catheter occlusions? Keywords used for the search included pulsatile, push-pause flush, turbulent, puls*, flushing, central venous catheter, central venous access, central catheter, and cen-tral line. The search included the databases Cumulative Index to Nursing and Allied Health Literature (CINAHL) and MEDLINE. The search tool OneSearch was used to broaden the search to additional databases. Articles published in the past 5 years that evaluated pulsatile flushing were included in the review. Articles on interventions and outcomes that focused on patients younger than 18 years of age, and arti-cles that were not written in English or peer reviewed, were excluded from review. In all, 323 articles were retrieved. After duplicates were removed, 252 titles and abstracts were reviewed and screened for inclusion and exclusion criteria; of these, 6 articles were identified and read in full to determine appropriateness for inclusion. A hand search identified 1 additional article from the reference list pro-vided in the Journal of Infusion Nursing regarding pulsatile flushing. A total of 7 articles were included in the final review (Figure 1).

EVIDENCE REVIEW AND APPRAISAL

Each article was critically appraised and rated by level of evidence, according to Melnyk and Fineout-Overholt.11 Each study also was assigned a quality rating based on Newhouse’s12 quality rating scheme. Summaries of each article are included with information regarding strengths and weaknesses (Table 1).13-19

Ogston-Tuck18 states that IV therapy is a routine, but sig-nificant, part of nursing practice, requiring nurses to have

sound knowledge and skill. The article aims to address key issues for safe practice. Pulsatile flushing is recommend-ed based on guidelines by the Infusion Nursing Network and the Royal College of Nursing. It is further stated that pulsatile flushing has been shown to have more effective clearing action compared with passive injection. However, no details are provided to support this claim. The article is written as an expert opinion and is therefore rated VII for the level of evidence, and because the support for the opinion is based on guidelines written by 2 different orga-nizations, it was given a quality rating of B.

Royon et al15 conducted an in vitro study to present data regarding the efficacy of pulsatile flushing compared with a single bolus for clearing catheters. Each test consisted of 12 catheters, 16 cm long, in which known amounts of fibronec-tin and albumin were fixed on the wall of the catheter. The catheters were then flushed with 10 mL of 0.9% sodium chloride, using either a single bolus or successive boluses of 1 mL, with a brief pause between each bolus. The efficacy of clearing the line was determined based on the amount of albumin recovered from the clearing solution, which was measured using a UV spectrophotometer. The first part of the study looked at the efficacy of continuous flushing using 4 clearing durations ranging from 2.5 to 10 seconds. The second part of the study looked at the efficacy of pulsatile flushing using 0.5 and 0.7 seconds as the push sequence and varying durations of the pause sequence.

The results of this research are 2-fold. First, the study showed that a single bolus becomes less effective as the administration time of the bolus increases, and second, that a pulsatile flush is most effective when the push sequence is administered over 0.5 seconds and the pause between boluses is 0.4 seconds. As a rigorous experiment, no threats to internal validity were identified, and several

Figure 1 PRISMA flow diagram. Abbreviations: CINAHL, Cumulative Index of Nursing and Allied Health Literature; PICO(T), patient population, intervention, comparison, outcome, and time; PRISMA, transparent reporting of systematic reviews and meta-analyses.



TABLE 1

Evidence Review TableAuthor(s), Year Sample (n)

Intervention/Outcomes Studied Results

Strengths and Weaknesses

Level/Quality Rating

Guiffant et al,13 2012

12 catheters for each test

Group AA single 10-mL bolus adminis-

tered over 6 different times: 2.5 s, 5 s, 10 s, 20 s, 40 s, and 60 s

Group B24-h continuous infusion at

0.35 mL/minGroup C10 successive boluses of 1 mL

each administered over 0.5 s with 6 different timed pauses: 0.1 s, 0.2 s, 0.4 s, 0.5 s, 0.6 s, and 0.8 s

Cleaning efficacy measured by the amount of albumin recovered and measured by UV spectrophotometer at 280 nm

Group AA single 10-mL bolus admin-

istered over 2.5 s or 5 s was found to be statisti-cally more efficient. Bolus administered over 2.5 s was more effective com-pared with 5 s.

Group BUninterrupted 24-h flush

almost as effective as 2.5-s single bolus

Group CPulsatile flush most effi-

cient when 1-mL boluses administered over 0.5 s with a 0.4-s pause between pulses

StrengthsCatheter size and length

chosen based on wide use

Blood protein contaminants used

Tested various flushing scenarios

WeaknessesIn vitro studySmall sample size

(12 catheters/trial)No power analysis

IIIA

Ferroni et al,14 2014

4 catheters for each test

10 successive 1-mL 0.9% sodium chloride bolus over 0.1 s with a delay of 0.9 s between each bolus

Amount of Staphylococcus aureus collected from the catheters was measured by collecting residual liquid in the catheter into 1-mL saline buffer.

The liquid then was vortexed for 30 s and 100 μL was added to a blood agar medium, which was incubated for 24 h at 35°C, and then the number of colonies was counted in colony-forming units/mL.

Residual liquid from pul-satile flushing resulted in fewer colony-forming units compared with con-tinuous flushing.

StrengthsLarge sample sizeContaminate bacteria

frequently recovered in CLABSIs

Blood protein contaminants used

WeaknessesIn vitro studyCatheters tested were only

4.5 cmUsed only 1 type of

bacteria

IIIB

Royon et al,15 2012

12 catheters for each test condition

10 successive flow impulses lasting 0.5 s and 0.7 s sepa-rated by different flow inter-ruption durations

Cleaning efficacy was mea-sured by the amount of albumin recovered and measured by UV spectro-photometer at 280 nm.

The efficacy of continuous flushing decreases as the duration of the flush increases.

Pulsatile flushing most effective using 10 succes-sive boluses lasting 0.5 s with 0.4-s pause between pulses

StrengthsTested various flushing

scenariosDeveloped protocol for

reproducible contami-nation close to in vivo deposits

Catheter length approxi-mated in vivo lengths

Pulsatile flushing timing intervals based on hospi-tal practices

WeaknessesIn vitro studySmall sample size

(12 catheters/trial)No power analysis

IIIA

Chong et al,16 2013

29 nurses Education regarding correct pulsatile flushing technique and use of saline for locking

Compliance of correct pulsa-tile flushing technique and saline lock use

Compliance of pulsatile flushing increased from 25% to 93%.

Compliance of using a saline lock increased from 68% to 100%.

StrengthRNs practiced daily until

skill was mastered, reducing variability between nurses.

VIB

(continues)



TABLE 1

Evidence Review Table (Continued)Author(s), Year Sample (n)

Intervention/Outcomes Studied Results

Strengths and Weaknesses

Level/Quality Rating

In addition, the number of catheter occlusions decreased by 50% during a 6-month period from January to June 2011 compared with January to June 2012.

WeaknessesNo randomizationSmall sample sizeDoes not describe pulsatile

flushing technique usedNo power analysis; conve-

nience sample

Goossens,17 2015

2 trials; sam-ple size of each trial is not described

Vigier and colleague in vitro trial compared the remov-al of solid deposits with unsteady flow and laminar flow. No other details pro-vided. Trial outcomes not described.

Guiffant and colleagues stud-ied catheter flushing under laminar and pulsed flow conditions and investigat-ed various times between boluses. Measured amount of albumin recovered from the lumen in a laboratory setting. No other details provided.

No RCTs foundDiscussion of 2 in vitro stud-

ies. Vigier and colleagues demonstrated that flushing with successive boluses had a significant reduction of time scale for the removal of solid deposits and confirmed the promoted practice of pulsatile flushing.

Guiffant and colleagues found that not only flow type but also the time between boluses is criti-cal for efficient flushing. Ten successive boluses of 1 mL each with 0.4 s between boluses is most efficient at flushing the catheter.

StrengthsCites research supporting

pulsatile flushingWeaknessesNo search strategy includedNo analysis of studies

included

VIIB

Ogston-Tuck,18 2012

N/A N/A Pulsatile flushing technique recommended to create turbulence to clear the internal catheter, and has been shown to be more effective than passive injection

StrengthsRecommendation based

on standards by Infusion Nursing Network and Royal College of Nursing

WeaknessDoes not provide informa-

tion on recommendation

VIIB

Pittiruti et al,19 2016

N/A N/A Pulsatile flushing appears to be more effective compared with contin-uous infusion flush at clearing catheter lumen. Technique is both widely recommended in the literature, as well as in most international guidelines.

StrengthsTechnique used in most

international guidelinesNo side effect found relat-

ed to using techniqueWeaknessesLimited evidence of efficacy

of techniqueDoes not describe pulsatile

flushing technique that should be used

VIIA

Abbreviations: CLABSI, central line-associated bloodstream infection; h, hour; N/A, not applicable; nm, nanometer; RCT, randomized controlled trial; RN, registered nurse; s, second; UV, ultraviolet.

strengths decrease the threat to external validity: devel-oping a protocol that produces a reproducible amount of protein within the catheter lumens, choosing proteins that are representative of in vivo deposits, using a catheter length that could be seen in practice, and choosing time intervals for pulsatile flushing that are used in hospital practice. However, the size of the experiment of 12 cathe-ters increases the threat to external validity, as well as the in vitro nature of the experiment. Because the experiment

was well designed with a sufficient sample, the level of evi-dence is rated as III with an A quality rating.

Guiffant et al13 performed an in vitro study to compare the efficacy of single-bolus flushing, successive bolus flush-ing, and continuous flushing. Each test consisted of 12 cath-eters, 16 cm long, in which known amounts of fibronectin and albumin were fixed on the wall of the catheter. Clearing efficacy was determined based on the amount of albumin recovered from the clearing solution measured using an



ultraviolet spectrophotometer. All flushing was carried out using 0.9% sodium chloride. The 3 flushing methods were tested using the following parameters: 1) a single 10-mL bolus flushed using 6 different flushing times rang-ing from 2.5 to 60 seconds, 2) a continuous flow infusion of 500 mL over 24 hours, and 3) 10 successive boluses of 1 mL administered over 0.5 seconds with 6 different pause timings between each bolus. The single 10-mL bolus was found to be most effective if the bolus was administered over 2.5 or 5.0 seconds. The continuous flow infusion showed that efficacy increased with time but would need to infuse for a minimum of 18 hours to approach the effi-cacy demonstrated by the 5-second single bolus. Pulsatile flushing was found to be the most efficient of the 3 flushing methods when using a 0.4-second pause between each bolus. Several strengths decrease the threat to external validity: developing a protocol that produces a reproducible amount of protein within the catheter lumens, choosing proteins that are representative of in vivo deposits, using a catheter size that mimics what is seen in short- and medium- length IV therapy in adults, and experimental models that mimic nursing practice. Although the experiment was well designed, external validity is threatened by the in vitro study design and small number of catheters (12) in each test. Because the experiment was well designed and built on the findings of Royon and collegues,15 it is rated level III with an A quality rating.

Chong et al16 implemented a quality improvement project in an ambulatory oncology setting, focusing on nurse education regarding the proper technique for pulsa-tile flushing. The project was conducted in 3 phases over 5 months. It consisted of a baseline audit, an education phase, and a postimplementation audit. Pulsatile flushing compliance was found to increase from 25% preimple-mentation to 93% postimplementation. Ongoing audits showed that compliance rates continued to improve in the 6 months following the intervention. Although the pri-mary outcome for the project was compliance, the center saw a 50% decrease in the number of catheter occlusions during the 6-month sustainment period. The sample size is relatively small, 29 nurses, but the project included all the nurses in the ambulatory center, which allowed the project team to consider the impact of pulsatile flushing on CVAD occlusions in the center. However, neither the pulsatile flushing timing sequence nor how the technique was taught is described in the article; this omission pre-vents other organizations from reproducing the education strategy used. Results from this project support the con-clusion that pulsatile flushing is efficient at removing solid deposits, as demonstrated by both Royon and colleagues15 and Guiffant and colleagues.13 The article was rated level VI with a B quality rating.

Ferroni et al14 performed an in vitro study to determine the effectiveness of pulsatile flushing on catheters contami-nated with the fibronectin and albumin supplemented with Staphylococcus aureus. Four catheters were used for each

test: 1 to serve as a positive control, 1 to serve as a negative control, 1 flushed using pulsatile flushing, and the other using a single 10-mL bolus. Clearing efficiency was mea-sured by the number of colony-forming units per milliliter. A total of 576 catheters were used, each 45 mm long. The research found that pulsatile flushing was at least twice as effective as continuous flushing at reducing the number of bacteria in the catheter. The strengths of this study include the use of S aureus to contaminate the catheters, since it is one of the most frequently isolated species recovered in CLABSIs; the use of fibronectin and albumin for catheter contamination, as both are blood proteins; a large sample size; and the use of both positive and negative controls. A significant threat to validity is the 45-mm catheter length used for the trials, which is significantly shorter than what is seen in central catheters. Despite the short catheter length, the authors state that the results can be extrapolat-ed because flushing efficacy is dependent on the technique used. Because the experiment was a well-designed in vitro study, the article was rated level III. The study received a B quality rating because of the significantly shorter catheter length used compared with previous studies.

Goossens17 wrote a review article on both the flush-ing and locking of CVADs to prevent catheter occlusions. With regard to pulsatile flushing, the review cited the in vitro study by Vigier and colleagues20 as confirmation that pulsatile flushing enhances the clearing of the catheter, but Goossens’ review17 provides no details concerning the experiment. The time between boluses was recognized as a significant factor in efficient flushing, and the author cited the research by Guiffant and colleagues13 as support. The review does not describe the search strategy that was used to find evidence for the support of pulsatile flush-ing. Although the article reviewed the groundwork study by Vigier and colleagues20 and the study by Guiffant and colleagues,13 the author neglected to include the work of Royon and colleagues.15 For this reason, the article was rated level VII with a B quality rating.

Pittiruti et al19 aimed to develop an evidence-based consensus on the most appropriate lock solution for CVADs. The group specifically examined whether there was any evidence regarding the most appropriate flushing method. The panel of experts, all of whom are from Europe, found pulsatile flushing widely recommended in the literature and in most international guidelines, yet no in vitro studies have been conducted outside of Europe. In vitro studies were cited as evidence supporting pulsatile flushing in prevent-ing catheter occlusions. Based on the potential advantages and lack of side effects using the technique, the expert panel recommends pulsatile flushing for all CVADs. The arti-cle describes both how the panel of experts were selected and how the search strategy was used. For these reasons, and considering that the article is a consensus document from a group expert opinion and not a clinical guideline, the article is rated VII for the level of evidence with an A quality rating.



OVERALL EVIDENCE SYNTHESIS

In all, 7 articles were appraised to answer the clinical ques-tion: In adult patients with CVADs, does pulsatile flushing compared with standard continuous flushing decrease the number of catheter occlusions? Although no randomized controlled trials have explored the effect of pulsatile flush-ing on catheter occlusions, several in vitro studies provide evidence that pulsatile flushing is more effective at remov-ing solid deposits from catheters than standard continuous flushing. Pulsatile flushing with a 0.5-second push sequence followed by a 0.4-second pause between each bolus has been found to be most effective in removing solid depos-its.13,15 In addition, Ferroni et al14 found that pulsatile flush-ing was effective at removing adhered bacteria from the catheter. However, successive boluses were administered over 0.1 seconds with a 0.9-second pause between each bolus, rather than the optimal timing sequence previously described. As of this review, the only in vivo support for pul-satile flushing is the quality improvement project by Chong et al,16 which observed a decrease in the number of catheter occlusions as compliance with pulsatile flushing improved.

Because the efficacy of pulsatile flushing is dependent on the timing of both the push and pause aspects of the flushing sequence, it is vital for staff to be trained on the proper mechanics of pulsatile flushing. No information is available, however, regarding how to train nurses to use this very precise flushing sequence. Education and encour-agement on the use of pulsatile flushing by staff have been shown to reduce the number of catheter occlusions for patients seen in an ambulatory cancer center setting.16 Additional research is needed to verify whether the prac-tice of pulsatile flushing would have the same effects in an inpatient setting, and if the practice were extended to all patients with CVADs. There is no research regarding the use of pulsatile flushing to affect CLABSI rates.

RECOMMENDATION FOR PRACTICE

Flushing catheters before and after use is a routine nursing practice used to prevent catheter occlusions. The practice of pulsatile flushing with 0.9% sodium chloride appears more efficient than current practice in preventing occlu-sions and is relatively inexpensive because it requires no additional supplies. In addition, the practice of pulsatile flushing presents no risks to the patient because routine flushing is part of current practice to maintain patency of CVADs. Excessive force during flushing, regardless of technique, should be avoided because this creates high pressure within the catheter, leading to potential damage of the catheter.21

Until recently, there were no studies demonstrating the efficacy of pulsatile flushing over a continuous 10-mL bolus. The practice was supported based on the dynamics of fluid flow—namely, wall shear stress.15 Recent in vitro studies

have demonstrated that pulsatile flushing is more efficient at clearing catheters of solid deposits compared with flushing the catheter with a single 10-mL bolus.13-15 Royon and colleagues,15 as well as Guiffant and colleagues,13 demonstrated that a 0.4-second pause between successive boluses optimizes the flushing sequence. However, shorter or longer pauses between boluses also have been shown to be more effective compared with a single 10-mL bolus administered over a range of flushing times.13 Furthermore, Ferroni and colleagues14 demonstrated that pulsatile flush-ing is at least twice as effective in reducing the number of colony-forming units per mL compared with a single 10-mL bolus. According to the methodology used by the US Preventive Task Force,22 the recommendation for the use of pulsatile flushing in clearing CVADs is given a B, meaning “there is a high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.”22 In addition, a review of the literature sup-ports both INS and ONS recommendations regarding pul-satile flushing. Potential barriers to implementation would be designing a reliable training method for staff to learn the mechanics of correct technique and the necessity of random audits to help ensure that staff are using pulsatile flushing and carrying out the technique correctly.

REFERENCES

1. Kornmbau C, Lee KC, Hughes GD, Firstenberg MS. Central line com-plications. Int J Crit Illn Inj Sci. 2015;5(3):170-178. doi:10.4103/2229-5151.164940.

2. Agency for Healthcare Research and Quality. Tools for reducing central line-associated blood stream infections. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum- tools/clabsitools/clabsitools.pdf. Published January 2013. Accessed September 28, 2018.

3. Centers for Disease Prevention and Control. Healthcare-associated infections. https://www.cdc.gov/hai/surveillance. Published October 5, 2016. Accessed January 30, 2017.

4. Marschall J, Mermel L, Fakih M, et al; Society for Healthcare Epidemiology of America. Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(7):753-771.

5. The Joint Commission. Preventing central line-associated blood-stream infections: useful tools, an international perspective. http://www.jointcommission.org/CLABSIToolkit. Published November 20, 2013. Accessed September 28, 2018.

6. Wolf J, Tang L, Rubnitz JE, et al. Monitoring central venous cath-eter resistance to predict imminent occlusion: a prospective pilot study. PLoS One. 2015;10(8):e0135904. Published August 31, 2015. Accessed September 28, 2018. doi:10.1371/journal.pone.0135904.

7. Bolton D. Preventing occlusion and restoring patency to central venous catheters. Br J Community Nurs. 2013;18(11):539-544.

8. Gorski L, Hadaway L, Hagle M, McGoldrick M, Orr M, Doellman D. Infusion therapy standards of practice. J Infus Nurs. 2016;39(suppl 1): S1-S159.

9. Molin A, Rasero L, Guerretta L, Perfetti E, Clerico M. The late compli-cations of totally implantable central venous access ports: the results from an Italian multicenter prospective observation study. Eur J Oncol Nurs. 2010;15(5):377-381.

10. Camp-Sorrell D, Matey L, eds. Access Device Standards of Practice for Oncology Nursing. Pittsburgh, PA: Oncology Nurses Society; 2017.

https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/clabsitools/clabsitools.pdf



11. Melnyk B, Fineout-Overholt E. Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice. 3rd ed. Philadelphia, PA: Wolters Kluwer Health; 2015.

12. Newhouse RP. Examining the support for evidence-based nursing practice. J Nurs Adm. 2006;36(7-8):337-340.

13. Guiffant G, Durussel J, Merckx J, Flaud P, Vigier J, Mousset P. Flushing of intravascular access devices (IVADs)—efficacy of pulsed and continuous infusions. J Vasc Access. 2012;13(1):75-78. doi:10.5301/JVA.2011.8487.

14. Ferroni A, Gaudin F, Guiffant G, et al. Pulsatile flushing as a strategy to prevent bacterial of vascular access devices. Med Devices (Auckl). 2014;7:379-383. doi:10.2147/MDER.S71217.

15. Royon L, Durussel JJ, Merckx J, Flaud P, Vigier J, Guiffant G. The fouling and cleaning of venous catheters: a possible optimization of the process using intermittent flushing. Chem Eng Res Design. 2012;90(6):803-807. doi:10.1016/j.cherd.2011.10.004.

16. Chong LM, Chow YL, Kong SS, Ang E. Maintenance of patency of central venous access devices by registered nurses in an acute ambu-latory setting: an evidence utilisation project. Int J Evid Based Healthc. 2013;11(1):20-25. doi:10.1111/j.1744-1609.2012.00303.x.

17. Goossens G. Flushing and locking of venous catheters: available evidence and evidence deficit. Nurs Res Pract. 2015;2015:985686. doi:10.1155/2015/985686.

18. Ogston-Tuck S. Intravenous therapy: guidance on devices, manage-ment and care. Br J Community Nurs. 2012;17(10):474, 476-479, 482-484.

19. Pittiruti M, Bertoglio S, Scoppettuolo G, et al. Evidence-based crite-ria for the choice and the clinical use of the most appropriate lock solutions for central venous catheters (excluding dialysis catheters): a GAVeCeLT consensus. J Vasc Access. 2016;17(6):453-464.

20. Vigier J, Merckx J, Coquin J, Flaud P, Guiffant G. The use of a hydro-dynamic bench for the experimental simulation of flushing venous catheters: impact on the technique. ITBM-RBM. 2005;26(2):147-149. doi:10.1016/j.rbmret.2005.03.001.

21. Macklin D. Catheter management. Semin Oncol Nurs. 2010;26(2): 113-120.

22. US Preventive Services. US Preventive Services Task Force rat-ings. http://www.uspreventiveservicestaskforce.org/Page/Name/us-preventive-services-task-force-ratings. Published December 2013. Updated June 2007. Accessed September 28, 2018.

FUNDED THROUGHA GRANT BY

INS podcasts are on-demand audio recordings of infusion-related topics.

VISIT WWW.LEARNINGCENTER.INS1.ORG/PODCASTS AND LISTEN TODAY!

pulsatile flushing - lippincott nursingcenter.com

Documents