title: Heparin versus 0.9% sodium chloride intermittent flushing for the prevention of occlusion in long term central venous catheters in infants and children: A systematic review.
abstract: BACKGROUND
  Around the world, guidelines and clinical practice for the prevention of complications associated with central venous catheters (CVC) vary greatly. To prevent occlusion, most institutions recommend the use of heparin when the CVC is not in use. However, there is debate regarding the need for heparin and evidence to suggest normal saline may be as effective. The use of heparin is not without risk, may be unnecessary and is also associated with increased costs.
  
  
  OBJECTIVE
  To assess the clinical effects (benefits and harms) of heparin versus normal saline to prevent occlusion in long-term central venous catheters in infants, children and adolescents.
  
  
  METHODS
  A Cochrane systematic review of randomised controlled trials was undertaken.
  
  
  METHODS
  The Cochrane Vascular Group Specialised Register (including MEDLINE, CINAHL, EMBASE and AMED) and the Cochrane Register of Studies were searched. Hand searching of relevant journals and reference lists of retrieved articles was also undertaken.
  
  
  METHODS
  Data were extracted and appraisal undertaken. We included studies that compared the efficacy of normal saline with heparin to prevent occlusion. We excluded temporary CVCs and peripherally inserted central catheters. Rate ratios per 1000 catheter days were calculated for two outcomes, occlusion of the CVC, and CVC-associated blood stream infection.
  
  
  RESULTS
  Three trials with a total of 245 participants were included in this review. The three trials directly compared the use of normal saline and heparin. However, between studies, all used different protocols with various concentrations of heparin and frequency of flushes. The quality of the evidence ranged from low to very low. The estimated rate ratio for CVC occlusion per 1000 catheter days between the normal saline and heparin group was 0.75 (95% CI 0.10 to 5.51, two studies, 229 participants, very low quality evidence). The estimated rate ratio for CVC-associated blood stream infection was 1.48 (95% CI 0.24 to 9.37, two studies, 231 participants; low quality evidence).
  
  
  CONCLUSIONS
  It remains unclear whether heparin is necessary for CVC maintenance. More well-designed studies are required to understand this relatively simple, but clinically important question. Ultimately, if this evidence were available, the development of evidenced-based clinical practice guidelines and consistency of practice would be facilitated.
authors.affiliation: The Centre for Online Health, School of Medicine, The University of Queensland, Brisbane, Australia; Queensland Youth Cancer Service, The Lady Cilento Children's Hospital, Brisbane, Australia. Electronic address: Natalie.bradford@health.qld.gov.au.
authors.forename: Natalie K
authors.initials: NK
authors.lastname: Bradford
authors.affiliation: Queensland Children's Cancer Institute, The Lady Cilento Children's Hospital, Brisbane, Australia.
authors.forename: Rachel M
authors.initials: RM
authors.lastname: Edwards
authors.affiliation: Institute of Health and Biomedical Innovation and School of Nursing, Queensland University of Technology, Brisbane, Australia; Cancer Nursing Professorial Precinct, Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Brisbane, Australia.
authors.forename: Raymond J
authors.initials: RJ
authors.lastname: Chan
mesh_terms: D062905:Central Venous Catheters / Q000009:adverse effects; D002675:Child, Preschool; D006493:Heparin / Q000008:administration & dosage*; D006801:Humans; D007223:Infant; D016032:Randomized Controlled Trials as Topic; D012965:Sodium Chloride / Q000008:administration & dosage*
chemical_list: D012965:Sodium Chloride; D006493:Heparin
keywords: Cancer care; Central venous line; Evidence based care; Occlusion; Systematic Review