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The Art and Science of Infusion Nursing
Pulsatile Flushing
A Review of the Literature
Christina Boord, BSN, RN, OCN®
ABSTRACT
Flushing 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
I
n the United States, more than 5 million central vascular care and maintenance of CVADs include hand hygiene;
access devices (CVADs) are inserted each year.1 CVADs sterile dressing changes; cleaning catheter hubs before
are used to deliver lifesaving medications and critical each access; and changing caps, intravenous (IV) fluids,
treatment in both intensive care and specialty care units. and tubings as recommended.5 CVAD occlusion is a major
In outpatient settings, CVADs are also used for patients concern because it not only interferes with normal use of
undergoing long-term therapies, such as chemotherapy. A the CVAD but also is strongly associated with subsequent
major complication with these types of devices are central bloodstream infection.6 It is estimated that 36% of patients
line-associated bloodstream infections (CLABSIs), which can with a CVAD are affected by an occlusion.6 Occlusions can
have a significant impact on patient outcomes as they are be partial, meaning the catheter can be flushed but blood
associated with longer hospital stays, increased risk of mor- cannot be aspirated, or complete—that is, neither flushing
bidity and mortality, and increased medical costs.2 nor aspiration is possible.7 Flushing is an essential strategy
In an effort to lower CLABSI rates, hospitals have focused in maintaining catheter patency.7 Unfortunately, there is no
on evidence-based prevention efforts, including hand practice standard related to flushing techniques.
hygiene, chlorhexidine (CHG) skin preparation, full barrier According to the Infusion Nurses Society (INS), CVADs
precautions during insertion, avoiding the femoral site, and should be flushed with 0.9% sodium chloride before and
the removal of unnecessary catheters.2 From 2008 to 2011, after medication administration.8(S77) In the past, pulsatile
CLABSI rates declined by 50%.3 Despite these prevention flushing, a technique that uses 10 brief boluses of 1 mL
efforts, the Centers for Disease Control and Prevention esti- interrupted by a short pause, has been cited as helping
mates that there were 71 900 CLABSIs in 2011.3 In addition to remove built-up residue, medications, and fibrin from
to the prevention efforts described previously, catheter the walls of the catheter.9 However, it was recommended
maintenance measures, such as daily CHG bathing and the solely on the principles of fluid dynamics and is, therefore,
use of port protectors, are often now being used.4 Routine 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
Author Affiliation: University of Maryland Medical Center,
Baltimore, Maryland. more effective at removing solid deposits and, therefore,
Christina Boord, BSN, RN, OCN®, is a clinical practice and educa- may be more effective at preventing occlusions. The most
tion specialist at the University of Maryland Medical Center, where recent Access Device Standards of Practice for Oncology
she sits on several hospital- and system-wide committees, working Nursing10 from the Oncology Nursing Society (ONS) also
to improve patient-centered care. She is passionate about support-
ing staff in both education and process improvement initiatives. recommends pulsatile flushing for CVADs.
The author of this article has no conflicts of interest to disclose.
Corresponding Author: Christina Boord, BSN, RN, OCN®, EVIDENCE SEARCH
University of Maryland Medical Center, Greenbaum Comprehensive
Cancer Center, 22 South Greene Street, Baltimore, MD 21201
(cboord@umm.edu). The purpose of this review is to evaluate and synthesize
DOI: 10.1097/NAN.0000000000000311 the literature for the clinical question: In adult patients
VOLUME 42 | N U M B E R 1 | JANUARY/FEBRUARY 2019 j o u rn a l o f i n f u s i o n n u rs i n g. c o m 37
Copyright © 2019 Infusion Nurses Society. Unauthorized reproduction of this article is prohibited.with CVADs, does pulsatile flushing, compared with stan- sound knowledge and skill. The article aims to address key
dard continuous flushing, decrease the number of catheter issues for safe practice. Pulsatile flushing is recommend-
occlusions? Keywords used for the search included pulsatile, ed based on guidelines by the Infusion Nursing Network
push-pause flush, turbulent, puls*, flushing, central venous and the Royal College of Nursing. It is further stated that
catheter, central venous access, central catheter, and cen- pulsatile flushing has been shown to have more effective
tral line. The search included the databases Cumulative clearing action compared with passive injection. However,
Index to Nursing and Allied Health Literature (CINAHL) and no details are provided to support this claim. The article
MEDLINE. The search tool OneSearch was used to broaden is written as an expert opinion and is therefore rated VII
the search to additional databases. Articles published in the for the level of evidence, and because the support for the
past 5 years that evaluated pulsatile flushing were included opinion is based on guidelines written by 2 different orga-
in the review. Articles on interventions and outcomes that nizations, it was given a quality rating of B.
focused on patients younger than 18 years of age, and arti- Royon et al15 conducted an in vitro study to present data
cles that were not written in English or peer reviewed, were regarding the efficacy of pulsatile flushing compared with a
excluded from review. In all, 323 articles were retrieved. single bolus for clearing catheters. Each test consisted of 12
After duplicates were removed, 252 titles and abstracts catheters, 16 cm long, in which known amounts of fibronec-
were reviewed and screened for inclusion and exclusion tin and albumin were fixed on the wall of the catheter. The
criteria; of these, 6 articles were identified and read in full catheters were then flushed with 10 mL of 0.9% sodium
to determine appropriateness for inclusion. A hand search chloride, using either a single bolus or successive boluses of
identified 1 additional article from the reference list pro- 1 mL, with a brief pause between each bolus. The efficacy
vided in the Journal of Infusion Nursing regarding pulsatile of clearing the line was determined based on the amount
flushing. A total of 7 articles were included in the final of albumin recovered from the clearing solution, which was
review (Figure 1). 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
EVIDENCE REVIEW AND APPRAISAL second part of the study looked at the efficacy of pulsatile
flushing using 0.5 and 0.7 seconds as the push sequence
Each article was critically appraised and rated by level of and varying durations of the pause sequence.
evidence, according to Melnyk and Fineout-Overholt.11 The results of this research are 2-fold. First, the study
Each study also was assigned a quality rating based on showed that a single bolus becomes less effective as the
Newhouse’s12 quality rating scheme. Summaries of each administration time of the bolus increases, and second,
article are included with information regarding strengths that a pulsatile flush is most effective when the push
and weaknesses (Table 1).13-19 sequence is administered over 0.5 seconds and the pause
Ogston-Tuck18 states that IV therapy is a routine, but sig- between boluses is 0.4 seconds. As a rigorous experiment,
nificant, part of nursing practice, requiring nurses to have 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.
38 Copyright © 2019 Infusion Nurses Society Journal of Infusion Nursing
Copyright © 2019 Infusion Nurses Society. Unauthorized reproduction of this article is prohibited.TABLE 1
Evidence Review Table
Author(s), Intervention/Outcomes Strengths and Level/Quality
Year Sample (n) Studied Results Weaknesses Rating
Guiffant 12 catheters Group A Group A Strengths IIIA
et al,13 2012 for each A single 10-mL bolus adminis- A single 10-mL bolus admin- Catheter size and length
test tered over 6 different times: istered over 2.5 s or 5 s chosen based on wide
2.5 s, 5 s, 10 s, 20 s, 40 s, was found to be statisti- use
and 60 s cally more efficient. Bolus Blood protein contaminants
Group B administered over 2.5 s used
24-h continuous infusion at was more effective com- Tested various flushing
0.35 mL/min pared with 5 s. scenarios
Group C Group B Weaknesses
10 successive boluses of 1 mL Uninterrupted 24-h flush In vitro study
each administered over almost as effective as Small sample size
0.5 s with 6 different timed 2.5-s single bolus (12 catheters/trial)
pauses: 0.1 s, 0.2 s, 0.4 s, Group C No power analysis
0.5 s, 0.6 s, and 0.8 s Pulsatile flush most effi-
Cleaning efficacy measured cient when 1-mL boluses
by the amount of albumin administered over
recovered and measured by 0.5 s with a 0.4-s pause
UV spectrophotometer at between pulses
280 nm
Ferroni et al,14 4 catheters 10 successive 1-mL 0.9% Residual liquid from pul- Strengths IIIB
2014 for each sodium chloride bolus over satile flushing resulted Large sample size
test 0.1 s with a delay of 0.9 s in fewer colony-forming Contaminate bacteria
between each bolus units compared with con- frequently recovered in
Amount of Staphylococcus tinuous flushing. CLABSIs
aureus collected from the Blood protein contaminants
catheters was measured used
by collecting residual liquid Weaknesses
in the catheter into 1-mL In vitro study
saline buffer. Catheters tested were only
The liquid then was vortexed 4.5 cm
for 30 s and 100 μL was Used only 1 type of
added to a blood agar bacteria
medium, which was
incubated for 24 h at 35°C,
and then the number of
colonies was counted in
colony-forming units/mL.
Royon et al,15 12 catheters 10 successive flow impulses The efficacy of continuous Strengths IIIA
2012 for each lasting 0.5 s and 0.7 s sepa- flushing decreases as Tested various flushing
test rated by different flow inter- the duration of the flush scenarios
condition ruption durations increases. Developed protocol for
Cleaning efficacy was mea- Pulsatile flushing most reproducible contami-
sured by the amount of effective using 10 succes- nation close to in vivo
albumin recovered and sive boluses lasting 0.5 s deposits
measured by UV spectro- with 0.4-s pause between Catheter length approxi-
photometer at 280 nm. pulses mated in vivo lengths
Pulsatile flushing timing
intervals based on hospi-
tal practices
Weaknesses
In vitro study
Small sample size
(12 catheters/trial)
No power analysis
Chong et al,16 29 nurses Education regarding correct Compliance of pulsatile Strength VIB
2013 pulsatile flushing technique flushing increased from RNs practiced daily until
and use of saline for locking 25% to 93%. skill was mastered,
Compliance of correct pulsa- Compliance of using a saline reducing variability
tile flushing technique and lock increased from 68% between nurses.
saline lock use to 100%.
(continues)
VOLUME 42 | NUMBER 1 | JANUARY/FEBRUARY 2019 journalofinfusionnursing.com 39
Copyright © 2019 Infusion Nurses Society. Unauthorized reproduction of this article is prohibited.TABLE 1
Evidence Review Table (Continued)
Author(s), Intervention/Outcomes Strengths and Level/Quality
Year Sample (n) Studied Results Weaknesses Rating
In addition, the number Weaknesses
of catheter occlusions No randomization
decreased by 50% during Small sample size
a 6-month period from Does not describe pulsatile
January to June 2011 flushing technique used
compared with January No power analysis; conve-
to June 2012. nience sample
Goossens,17 2 trials; sam- Vigier and colleague in vitro No RCTs found Strengths VIIB
2015 ple size trial compared the remov- Discussion of 2 in vitro stud- Cites research supporting
of each al of solid deposits with ies. Vigier and colleagues pulsatile flushing
trial is not unsteady flow and laminar demonstrated that Weaknesses
described flow. No other details pro- flushing with successive No search strategy included
vided. Trial outcomes not boluses had a significant No analysis of studies
described. reduction of time scale included
Guiffant and colleagues stud- for the removal of solid
ied catheter flushing under deposits and confirmed
laminar and pulsed flow the promoted practice of
conditions and investigat- pulsatile flushing.
ed various times between Guiffant and colleagues
boluses. Measured amount found that not only flow
of albumin recovered from type but also the time
the lumen in a laboratory between boluses is criti-
setting. No other details cal for efficient flushing.
provided. Ten successive boluses
of 1 mL each with 0.4 s
between boluses is most
efficient at flushing the
catheter.
Ogston-Tuck,18 N/A N/A Pulsatile flushing technique Strengths VIIB
2012 recommended to create Recommendation based
turbulence to clear the on standards by Infusion
internal catheter, and has Nursing Network and
been shown to be more Royal College of Nursing
effective than passive Weakness
injection Does not provide informa-
tion on recommendation
Pittiruti et al,19 N/A N/A Pulsatile flushing appears Strengths VIIA
2016 to be more effective Technique used in most
compared with contin- international guidelines
uous infusion flush at No side effect found relat-
clearing catheter lumen. ed to using technique
Technique is both widely Weaknesses
recommended in the Limited evidence of efficacy
literature, as well as in of technique
most international Does not describe pulsatile
guidelines. flushing technique that
should be used
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- was well designed with a sufficient sample, the level of evi-
oping a protocol that produces a reproducible amount of dence is rated as III with an A quality rating.
protein within the catheter lumens, choosing proteins that Guiffant et al13 performed an in vitro study to compare
are representative of in vivo deposits, using a catheter the efficacy of single-bolus flushing, successive bolus flush-
length that could be seen in practice, and choosing time ing, and continuous flushing. Each test consisted of 12 cath-
intervals for pulsatile flushing that are used in hospital eters, 16 cm long, in which known amounts of fibronectin
practice. However, the size of the experiment of 12 cathe- and albumin were fixed on the wall of the catheter. Clearing
ters increases the threat to external validity, as well as the efficacy was determined based on the amount of albumin
in vitro nature of the experiment. Because the experiment recovered from the clearing solution measured using an
40 Copyright © 2019 Infusion Nurses Society Journal of Infusion Nursing
Copyright © 2019 Infusion Nurses Society. Unauthorized reproduction of this article is prohibited.ultraviolet spectrophotometer. All flushing was carried test: 1 to serve as a positive control, 1 to serve as a negative
out using 0.9% sodium chloride. The 3 flushing methods control, 1 flushed using pulsatile flushing, and the other
were tested using the following parameters: 1) a single using a single 10-mL bolus. Clearing efficiency was mea-
10-mL bolus flushed using 6 different flushing times rang- sured by the number of colony-forming units per milliliter.
ing from 2.5 to 60 seconds, 2) a continuous flow infusion A total of 576 catheters were used, each 45 mm long. The
of 500 mL over 24 hours, and 3) 10 successive boluses of research found that pulsatile flushing was at least twice as
1 mL administered over 0.5 seconds with 6 different pause effective as continuous flushing at reducing the number of
timings between each bolus. The single 10-mL bolus was bacteria in the catheter. The strengths of this study include
found to be most effective if the bolus was administered the use of S aureus to contaminate the catheters, since it
over 2.5 or 5.0 seconds. The continuous flow infusion is one of the most frequently isolated species recovered in
showed that efficacy increased with time but would need CLABSIs; the use of fibronectin and albumin for catheter
to infuse for a minimum of 18 hours to approach the effi- contamination, as both are blood proteins; a large sample
cacy demonstrated by the 5-second single bolus. Pulsatile size; and the use of both positive and negative controls. A
flushing was found to be the most efficient of the 3 flushing significant threat to validity is the 45-mm catheter length
methods when using a 0.4-second pause between each used for the trials, which is significantly shorter than what
bolus. Several strengths decrease the threat to external is seen in central catheters. Despite the short catheter
validity: developing a protocol that produces a reproducible length, the authors state that the results can be extrapolat-
amount of protein within the catheter lumens, choosing ed because flushing efficacy is dependent on the technique
proteins that are representative of in vivo deposits, using a used. Because the experiment was a well-designed in vitro
catheter size that mimics what is seen in short- and medium- study, the article was rated level III. The study received a B
length IV therapy in adults, and experimental models that quality rating because of the significantly shorter catheter
mimic nursing practice. Although the experiment was well length used compared with previous studies.
designed, external validity is threatened by the in vitro Goossens17 wrote a review article on both the flush-
study design and small number of catheters (12) in each ing and locking of CVADs to prevent catheter occlusions.
test. Because the experiment was well designed and built With regard to pulsatile flushing, the review cited the in
on the findings of Royon and collegues,15 it is rated level III vitro study by Vigier and colleagues20 as confirmation that
with an A quality rating. pulsatile flushing enhances the clearing of the catheter,
Chong et al16 implemented a quality improvement but Goossens’ review17 provides no details concerning the
project in an ambulatory oncology setting, focusing on experiment. The time between boluses was recognized
nurse education regarding the proper technique for pulsa- as a significant factor in efficient flushing, and the author
tile flushing. The project was conducted in 3 phases over cited the research by Guiffant and colleagues13 as support.
5 months. It consisted of a baseline audit, an education The review does not describe the search strategy that was
phase, and a postimplementation audit. Pulsatile flushing used to find evidence for the support of pulsatile flush-
compliance was found to increase from 25% preimple- ing. Although the article reviewed the groundwork study
mentation to 93% postimplementation. Ongoing audits by Vigier and colleagues20 and the study by Guiffant and
showed that compliance rates continued to improve in colleagues,13 the author neglected to include the work of
the 6 months following the intervention. Although the pri- Royon and colleagues.15 For this reason, the article was
mary outcome for the project was compliance, the center rated level VII with a B quality rating.
saw a 50% decrease in the number of catheter occlusions Pittiruti et al19 aimed to develop an evidence-based
during the 6-month sustainment period. The sample size consensus on the most appropriate lock solution for CVADs.
is relatively small, 29 nurses, but the project included all The group specifically examined whether there was any
the nurses in the ambulatory center, which allowed the evidence regarding the most appropriate flushing method.
project team to consider the impact of pulsatile flushing The panel of experts, all of whom are from Europe, found
on CVAD occlusions in the center. However, neither the pulsatile flushing widely recommended in the literature and
pulsatile flushing timing sequence nor how the technique in most international guidelines, yet no in vitro studies have
was taught is described in the article; this omission pre- been conducted outside of Europe. In vitro studies were
vents other organizations from reproducing the education cited as evidence supporting pulsatile flushing in prevent-
strategy used. Results from this project support the con- ing catheter occlusions. Based on the potential advantages
clusion that pulsatile flushing is efficient at removing solid and lack of side effects using the technique, the expert
deposits, as demonstrated by both Royon and colleagues15 panel recommends pulsatile flushing for all CVADs. The arti-
and Guiffant and colleagues.13 The article was rated level VI cle describes both how the panel of experts were selected
with a B quality rating. and how the search strategy was used. For these reasons,
Ferroni et al14 performed an in vitro study to determine and considering that the article is a consensus document
the effectiveness of pulsatile flushing on catheters contami- from a group expert opinion and not a clinical guideline,
nated with the fibronectin and albumin supplemented with the article is rated VII for the level of evidence with an A
Staphylococcus aureus. Four catheters were used for each quality rating.
VOLUME 42 | NUMBER 1 | JANUARY/FEBRUARY 2019 journalofinfusionnursing.com 41
Copyright © 2019 Infusion Nurses Society. Unauthorized reproduction of this article is prohibited.OVERALL EVIDENCE SYNTHESIS have demonstrated that pulsatile flushing is more efficient
at clearing catheters of solid deposits compared with
In all, 7 articles were appraised to answer the clinical ques- flushing the catheter with a single 10-mL bolus.13-15 Royon
tion: In adult patients with CVADs, does pulsatile flushing and colleagues,15 as well as Guiffant and colleagues,13
compared with standard continuous flushing decrease the demonstrated that a 0.4-second pause between successive
number of catheter occlusions? Although no randomized boluses optimizes the flushing sequence. However, shorter
controlled trials have explored the effect of pulsatile flush- or longer pauses between boluses also have been shown
ing on catheter occlusions, several in vitro studies provide to be more effective compared with a single 10-mL bolus
evidence that pulsatile flushing is more effective at remov- administered over a range of flushing times.13 Furthermore,
ing solid deposits from catheters than standard continuous Ferroni and colleagues14 demonstrated that pulsatile flush-
flushing. Pulsatile flushing with a 0.5-second push sequence ing is at least twice as effective in reducing the number
followed by a 0.4-second pause between each bolus has of colony-forming units per mL compared with a single
been found to be most effective in removing solid depos- 10-mL bolus. According to the methodology used by the US
its.13,15 In addition, Ferroni et al14 found that pulsatile flush- Preventive Task Force,22 the recommendation for the use
ing was effective at removing adhered bacteria from the of pulsatile flushing in clearing CVADs is given a B, meaning
catheter. However, successive boluses were administered “there is a high certainty that the net benefit is moderate or
over 0.1 seconds with a 0.9-second pause between each there is moderate certainty that the net benefit is moderate
bolus, rather than the optimal timing sequence previously to substantial.”22 In addition, a review of the literature sup-
described. As of this review, the only in vivo support for pul- ports both INS and ONS recommendations regarding pul-
satile flushing is the quality improvement project by Chong satile flushing. Potential barriers to implementation would
et al,16 which observed a decrease in the number of catheter be designing a reliable training method for staff to learn
occlusions as compliance with pulsatile flushing improved. the mechanics of correct technique and the necessity of
Because the efficacy of pulsatile flushing is dependent random audits to help ensure that staff are using pulsatile
on the timing of both the push and pause aspects of the flushing and carrying out the technique correctly.
flushing sequence, it is vital for staff to be trained on the
proper mechanics of pulsatile flushing. No information is REFERENCES
available, however, regarding how to train nurses to use 1. Kornmbau C, Lee KC, Hughes GD, Firstenberg MS. Central line com-
this very precise flushing sequence. Education and encour- plications. Int J Crit Illn Inj Sci. 2015;5(3):170-178. doi:10.4103/2229-
agement on the use of pulsatile flushing by staff have been 5151.164940.
shown to reduce the number of catheter occlusions for 2. Agency for Healthcare Research and Quality. Tools for reducing
patients seen in an ambulatory cancer center setting.16 central line-associated blood stream infections. https://www.ahrq.
gov/sites/default/files/wysiwyg/professionals/education/curriculum-
Additional research is needed to verify whether the prac- tools/clabsitools/clabsitools.pdf. Published January 2013. Accessed
tice of pulsatile flushing would have the same effects in an September 28, 2018.
inpatient setting, and if the practice were extended to all 3. Centers for Disease Prevention and Control. Healthcare-associated
patients with CVADs. There is no research regarding the use infections. https://www.cdc.gov/hai/surveillance. Published October
of pulsatile flushing to affect CLABSI rates. 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
RECOMMENDATION FOR PRACTICE Control Hosp Epidemiol. 2014;35(7):753-771.
5. The Joint Commission. Preventing central line-associated blood-
Flushing catheters before and after use is a routine nursing stream infections: useful tools, an international perspective. http://
practice used to prevent catheter occlusions. The practice www.jointcommission.org/CLABSIToolkit. Published November 20,
2013. Accessed September 28, 2018.
of pulsatile flushing with 0.9% sodium chloride appears
6. Wolf J, Tang L, Rubnitz JE, et al. Monitoring central venous cath-
more efficient than current practice in preventing occlu-
eter resistance to predict imminent occlusion: a prospective pilot
sions and is relatively inexpensive because it requires no study. PLoS One. 2015;10(8):e0135904. Published August 31, 2015.
additional supplies. In addition, the practice of pulsatile Accessed September 28, 2018. doi:10.1371/journal.pone.0135904.
flushing presents no risks to the patient because routine 7. Bolton D. Preventing occlusion and restoring patency to central
flushing is part of current practice to maintain patency venous catheters. Br J Community Nurs. 2013;18(11):539-544.
of CVADs. Excessive force during flushing, regardless of 8. Gorski L, Hadaway L, Hagle M, McGoldrick M, Orr M, Doellman D.
technique, should be avoided because this creates high Infusion therapy standards of practice. J Infus Nurs. 2016;39(suppl 1):
S1-S159.
pressure within the catheter, leading to potential damage
9. Molin A, Rasero L, Guerretta L, Perfetti E, Clerico M. The late compli-
of the catheter.21
cations of totally implantable central venous access ports: the results
Until recently, there were no studies demonstrating the from an Italian multicenter prospective observation study. Eur J Oncol
efficacy of pulsatile flushing over a continuous 10-mL bolus. Nurs. 2010;15(5):377-381.
The practice was supported based on the dynamics of fluid 10. Camp-Sorrell D, Matey L, eds. Access Device Standards of Practice for
flow—namely, wall shear stress.15 Recent in vitro studies Oncology Nursing. Pittsburgh, PA: Oncology Nurses Society; 2017.
42 Copyright © 2019 Infusion Nurses Society Journal of Infusion Nursing
Copyright © 2019 Infusion Nurses Society. Unauthorized reproduction of this article is prohibited.11. Melnyk B, Fineout-Overholt E. Evidence-Based Practice in Nursing & 17. Goossens G. Flushing and locking of venous catheters: available
Healthcare: A Guide to Best Practice. 3rd ed. Philadelphia, PA: Wolters evidence and evidence deficit. Nurs Res Pract. 2015;2015:985686.
Kluwer Health; 2015. doi:10.1155/2015/985686.
12. Newhouse RP. Examining the support for evidence-based nursing 18. Ogston-Tuck S. Intravenous therapy: guidance on devices, manage-
practice. J Nurs Adm. 2006;36(7-8):337-340. ment and care. Br J Community Nurs. 2012;17(10):474, 476-479, 482-
13. Guiffant G, Durussel J, Merckx J, Flaud P, Vigier J, Mousset P. Flushing 484.
of intravascular access devices (IVADs)—efficacy of pulsed and 19. Pittiruti M, Bertoglio S, Scoppettuolo G, et al. Evidence-based crite-
continuous infusions. J Vasc Access. 2012;13(1):75-78. doi:10.5301/ ria for the choice and the clinical use of the most appropriate lock
JVA.2011.8487. solutions for central venous catheters (excluding dialysis catheters): a
14. Ferroni A, Gaudin F, Guiffant G, et al. Pulsatile flushing as a strategy GAVeCeLT consensus. J Vasc Access. 2016;17(6):453-464.
to prevent bacterial of vascular access devices. Med Devices (Auckl). 20. Vigier J, Merckx J, Coquin J, Flaud P, Guiffant G. The use of a hydro-
2014;7:379-383. doi:10.2147/MDER.S71217. dynamic bench for the experimental simulation of flushing venous
15. Royon L, Durussel JJ, Merckx J, Flaud P, Vigier J, Guiffant G. The catheters: impact on the technique. ITBM-RBM. 2005;26(2):147-149.
fouling and cleaning of venous catheters: a possible optimization doi:10.1016/j.rbmret.2005.03.001.
of the process using intermittent flushing. Chem Eng Res Design. 21. Macklin D. Catheter management. Semin Oncol Nurs. 2010;26(2):
2012;90(6):803-807. doi:10.1016/j.cherd.2011.10.004. 113-120.
16. Chong LM, Chow YL, Kong SS, Ang E. Maintenance of patency of 22. US Preventive Services. US Preventive Services Task Force rat-
central venous access devices by registered nurses in an acute ambu- ings. http://www.uspreventiveservicestaskforce.org/Page/Name/
latory setting: an evidence utilisation project. Int J Evid Based Healthc. us-preventive-services-task-force-ratings. Published December 2013.
2013;11(1):20-25. doi:10.1111/j.1744-1609.2012.00303.x. Updated June 2007. Accessed September 28, 2018.
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