INS (Infusion Nurses Society) Standards emphasize a bundle of practices to prevent catheter occlusions, centered on proper flushing/locking technique, minimizing blood reflux, maintaining asepsis, and ensuring optimal device selection and stabilization.
Flushing to Maintain Patency
Flush before and after each medication, blood product, or intermittent infusion, and at established intervals for unused lumens, to assess and maintain patency.
Use preservative‑free 0.9% sodium chloride as the primary flushing solution; heparin may be used for locking central lines per organizational policy and device type, acknowledging limited evidence that heparin is superior to saline for routine patency maintenance.
Use a gentle pulsatile (“push‑pause”) technique to better clear fibrin and intraluminal debris while minimizing endothelial injury.
Locking Solutions and Technique
Lock all central venous access devices (CVADs) per manufacturer instructions and institutional policy after use, using saline or heparin as appropriate for the device.
Ensure the lock volume matches or slightly exceeds the internal volume of the catheter and any add‑on devices, as underfilling can allow blood reflux into the lumen.
For high‑risk patients or recurrent occlusions, INS Standards support considering evidence‑based adjuncts (e.g., innovative catheter materials or specific lock strategies) based on risk–benefit assessment.
Needleless Connectors and Blood Reflux
Recognize that all needleless connectors allow some fluid movement and blood reflux when connecting or disconnecting, which contributes to intraluminal occlusions.
Follow manufacturer‑specific instructions for flushing, clamping sequence, and disconnection (e.g., clamp‑before‑disconnect for positive pressure devices, or clamp‑after for neutral designs) to minimize reflux.
Use passive disinfection caps containing an alcohol‑based agent on needleless connectors to reduce intraluminal microbial contamination, which also lowers the risk of biofilm‑related occlusion.
Catheter Material and Device Selection
Choose catheter type, size, and material based on therapy characteristics, vein size, and patient risk factors to reduce phlebitis, thrombosis, and occlusion.
Newer hydrophilic catheter materials have been incorporated into INS standards as an option in populations with high rates of occlusion or thrombosis, as they may reduce thrombus accumulation and failure compared with traditional polyurethane.
Stabilization and Site Protection
Use engineered stabilization devices (ESDs) and appropriate dressings to minimize catheter movement, kinking, and mechanical irritation that can contribute to thrombotic occlusions.
Do not rely on dressings alone for stabilization; ensure dedicated securement to prevent dislodgement, micro‑movement, and line damage that can lead to flow issues and occlusion.
Protect the site during daily activities (bathing, dressing) and avoid pulling/tugging on the administration set to prevent mechanical complications.
Aseptic Technique and Infection Prevention
Maintain strict aseptic technique for all line accesses; microbial colonization and biofilm formation are major contributors to intraluminal occlusions and catheter‑related bloodstream infections.
Use chlorhexidine‑based skin antisepsis and consider CHG‑impregnated dressings for CVADs when infection risk is high, as reductions in infection also reduce occlusion events associated with thrombus and biofilm.
Assessment and Early Intervention
Assess for patency (flush and check for brisk blood return) before each infusion for central lines when within the clinician’s scope; lack of blood return or resistance warrants further evaluation.
Teach patients and caregivers to report resistance, pain with flushing, or swelling immediately rather than manipulating the catheter themselves (e.g., no routine self‑aspiration for blood return), to avoid worsening a partial occlusion.
Special Considerations for Occlusion Management
Differentiate between mechanical (kink, clamp, malposition), thrombotic (fibrin tail, intraluminal clot), and precipitate‑related occlusions, because management strategies differ.
For suspected thrombotic occlusions, follow organizational protocols and INS‑aligned guidance for use of catheter‑directed thrombolytic agents (e.g., alteplase) when indicated, after ruling out mechanical causes.
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References:
Nickel, B. et al., (2024, January/ February) Infusion Therapy Standards of Practice 9th edition. Journal of Infusion Nursing. https://www.ins1.org/publications/infusion-therapy-standards-of-practice/
Grady, N. et al., (2011, May 1) Guidelines for the Prevention of Intravascular Catheter-related Infections. National Library of Medicine https://pmc.ncbi.nlm.nih.gov/articles/PMC3106269/