Impact of flushing with aseptic non-touch technique using pre-filled flush or manually prepared syringes on central venous catheter occlusion and bloodstream infections in pediatric hemato-oncology patients: A randomized controlled study

Published:February 09, 2018DOI:


      • Standardized flushing method with ANTT was effective to prevent CLABSI and catheter occlusion.
      • Standardized flushing method with ANTT using single-use pre-filled flush syringes can be used in PHO patients.
      • Flushing is very important for maintaining the CVC safety.
      • The pulsatile technique, use of 10-mL syringe size with 0.9% NaCl, flushing once a day is the gold standard for CVCs.



      To compare standardized flushing methods with aseptic non-touch technique; (1) Manually prepared syringes (2) Single-use prefilled flush syringes.


      Forty-eight PHO patients with Hickman or Port catheters were recruited to participate in a prospective, randomized study. Standardized flushing methods with aseptic non-touch technique (ANTT) using single-use pre-filled flush syringes (intervention group) or manually prepared syringes (control group) also included the pulsatile technique, use of 10-mL syringe size with 0.9% NaCl for flushing, flushing once a day, flushing training of the nurses. The effects of standardized flushing methods on occlusion and CLABSI evaluated.


      Of the patients in the intervention group, 8.7% (n: 2) had catheter occlusion, while this rate was 20.0% (n: 5) in the control group. Of the patients in the intervention group, 8.7% (n: 2) had CLABSI, while this rate was 36.0% (n: 9) in the control group. While there was no difference in occlusion, there was a difference between the groups in terms of CLABSI development. In the intervention group, CLABSI rate was 1.9/1000 per catheter-days, in the control group CLABSI rate was 10.1/1000 per catheter-days. In the intervention group, occlusion rate was 1.9/1000 per catheter-days, in the control group, occlusion rate was 5.6/1000 per catheter-days.


      Standardized flushing and single-use prefilled flush syringes are effective in reducing CLABSI rates in PHO patients.


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        • Arora R.S.
        • Roberts R.
        • Eden T.O.
        • Pizer B.
        Interventions other than anticoagulants and systemic antibiotics for prevention of central venous catheter-related infections in children with cancer.
        Cochrane Database Syst. Rev. 2010; 12CD007785
        • Bradford N.K.
        • Edwards R.M.
        • Chan R.J.
        Heparin versus 0.9% sodium chloride intermittent flushing for the prevention of occlusion in long term central venous catheters in infants and children.
        Cochrane Database Syst. Rev. 2015; 11CD010996
        • Bradford N.K.
        • Edwards R.M.
        • Chan R.J.
        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.
        Int. J. Nurs. Stud. 2016; 59: 51-59
        • Bundy D.G.
        • Gaur A.H.
        • Billett A.L.
        • He B.
        • Colantuoni E.A.
        • Miller M.R.
        • Children’s Hospital Association Hematology/Oncology CLABSI Collaborative
        Preventing CLABSIs among pediatric hematology/oncology inpatients: national collaborative results.
        Pediatrics. 2014; 134: e1678-e1685
        • CDC
        Bloodstream Infection Event (Central Line-Associated Bloodstream Infection and Non-Central Line-Associated Bloodstream Infection).
        2017 (Retrieved from)
        • Cesaro S.
        • Tridello G.
        • Cavaliere M.
        • Magagna L.
        • Gavin P.
        • Cusinato R.
        • Carli M.
        Prospective, randomized trial of two different modalities of flushing central venous catheters in pediatric patients with cancer.
        J. Clin. Oncol. 2009; 27: 2059-2065
        • Choi S.W.
        • Chang L.
        • Hanauer D.A.
        • Shaffer-Hartman J.
        • Teitelbaum D.
        • Lewis I.
        • Niedner M.F.
        Rapid reduction of central line infections in hospitalized pediatric oncology patients through simple quality improvement methods.
        Pediatr. Blood Canc. 2013; 60: 262-269
        • Conley S.
        Central line–associated bloodstream infection prevention: standardizing practice focused on evidence-based guidelines.
        Clin. J. Oncol. Nurs. 2016; 20: 23-26
        • Conway M.A.
        • McCollom C.
        • Bannon C.
        Central venous catheter flushing recommendations: a systematic evidence-based practice review.
        J. Pediatr. Oncol. Nurs. 2014; 31: 185-190
        • Dal Molin A.
        • Clerico M.
        • Baccini M.
        • Guerretta L.
        • Sartorello B.
        • Rasero L.
        Normal saline versus heparin solution to lock totally implanted venous access devices: results from a multicenter randomized trial.
        Eur. J. Oncol. Nurs. 2015; 19: 638-643
        • Devrim İ.
        • Yaşar N.
        • İşgüder R.
        • Ceylan G.
        • Bayram N.
        • Özdamar N.
        • Ağın H.
        Clinical impact and cost-effectiveness of a central line bundle including split-septum and single-use prefilled flushing devices on central line–associated bloodstream infection rates in a pediatric intensive care unit.
        Am. J. Infect. Control. 2016; 44 (e125–e128)
        • Duffy E.A.
        • Rodgers C.C.
        • Shever L.L.
        • Hockenberry M.J.
        Implementing a daily maintenance care bundle to prevent central line–associated bloodstream infections in pediatric oncology patients.
        J. Pediatr. Oncol. Nurs. 2015; 32: 394-400
        • Ferroni A.
        • Gaudin F.
        • Guiffant G.
        • Flaud P.
        • Descamps P.
        • Berche P.
        • Durussel J.-J.
        Pulsative flushing as a strategy to prevent bacterial colonization of vascular access devices.
        Med. Dev. (Auckl). 2014; 7: 379-383
        • Furtwängler R.
        • Laux C.
        • Graf N.
        • Simon A.
        Impact of a modified Broviac maintenance care bundle on bloodstream infections in paediatric cancer patients.
        GMS Hygiene Infect. Control. 2015; 10: 1-10
        • Gerçeker G.Ö.
        • Yardımcı F.
        • Aydınok Y.
        Randomized controlled trial of care bundles with chlorhexidine dressing and advanced dressings to prevent catheter-related bloodstream infections in pediatric hematology-oncology patients.
        Eur. J. Oncol. Nurs. 2017; 28: 14-20
        • Giordano P.
        • Saracco P.
        • Grassi M.
        • Luciani M.
        • Banov L.
        • Carraro F.
        • Italian Association of Pediatric Hematology and Oncology (AIEOP)
        Recommendations for the use of long-term central venous catheter (CVC) in children with hemato-oncological disorders: management of CVC-related occlusion and CVC-related thrombosis. On behalf of the coagulation defects working group and the supportive therapy working group of the Italian Association of Pediatric Hematology and Oncology (AIEOP).
        Ann. Hematol. 2015; 94: 1765-1776
        • Gonzalez G.
        • Davidoff A.M.
        • Howard S.C.
        • Pui C.-H.
        • Rao B.N.
        • Shenep J.L.
        • Shochat S.J.
        Safety of central venous catheter placement at diagnosis of acute lymphoblastic leukemia in children.
        Pediatr. Blood Cancer. 2012; 58: 498-502
        • Goossens G.A.
        Flushing and locking of venous catheters: available evidence and evidence deficit.
        Nursing Res. Pract. 2015; : 1-12
        • Heidari Gorji M.A.
        • Rezaei F.
        • Jafari H.
        • Yazdani Cherati J.
        Comparison of the effects of heparin and 0.9% sodium chloride solutions in maintenance of patency of central venous catheters.
        Anesthesiol. Pain Med. 2015; 5e22595
        • Hadaway L.
        Technology of flushing vascular access devices.
        J. Infusion Nurs. 2006; 29 (Retrieved from): 137-145
        • Hentrich M.
        • Schalk E.
        • Schmidt-Hieber M.
        • Chaberny I.
        • Mousset S.
        • Buchheidt D.
        • Karthaus M.
        Central venous catheter-related infections in hematology and oncology: 2012 updated guidelines on diagnosis, management and prevention by the Infectious Diseases Working Party of the German Society of Hematology and Medical Oncology.
        Ann. Oncol. 2014; 25: 936-947
        • Hill J.
        • Al E.
        Occlusion management guideline for central venous access devices (CVADs).
        Vasc. Access. 2013; 7 (Retrieved from): 1-36
        • Infusion Nurses Society
        Infusion therapy standards of practice.
        J. Infusion Nurs. 2016; 39 (Retrieved from): S1-S159
        • Journeycake J.M.
        • Buchanan G.R.
        Catheter-related deep venous thrombosis and other catheter complications in children with cancer.
        J. Clin. Oncol. 2006; 24: 4575-4580
        • Keogh S.
        • Marsh N.
        • Higgins N.
        • Davies K.
        • Rickard C.
        A time and motion study of peripheral venous catheter flushing practice using manually prepared and prefilled flush syringes.
        J. Infusion Nurs. 2014; 37: 96-101
        • Keogh S.
        • Flynn J.
        • Marsh N.
        • Higgins N.
        • Davies K.
        • Rickard C.M.
        Nursing and midwifery practice for maintenance of vascular access device patency. A cross-sectional survey.
        Int. J. Nurs. Stud. 2015; 52: 1678-1685
        • Linder L.A.
        • Gerdy C.
        • Abouzelof R.
        • Wilson A.
        Using practice-based evidence to improve supportive care practices to reduce central line–associated bloodstream infections in a pediatric oncology unit.
        J. Pediatr. Oncol. Nurs. 2017; 34: 185-195
        • McKnight S.
        Nurse's guide to understanding and treating thrombotic occlusion of central venous access devices.
        Medsurg Nurs. 2004; 13: 377-382
        • Milani A.
        • Mazzocco K.
        • Gandini S.
        • Pravettoni G.
        • Libutti L.
        • Zencovich C.
        • Saiani L.
        Incidence and determinants of port occlusions in cancer outpatients.
        Cancer. Nurs. 2017; 40: 102-107
        • Miliaraki M.
        • Katzilakis N.
        • Chranioti I.
        • Stratigaki M.
        • Koutsaki M.
        • Psarrou M.
        • Stiakaki E.
        Central line-associated bloodstream infections in childhood malignancies. Single-center experience.
        Pediatr. Int. 2017; 59: 769-775
        • Mutalib M.
        • Evans V.
        • Hughes A.
        • Hill S.
        Aseptic non-touch technique and catheter-related bloodstream infection in children receiving parenteral nutrition at home.
        United Eur. Gastroenterol. J. 2015; 3: 393-398
        • O'Grady N.P.
        • Alexander M.
        • Burns L.A.
        • Dellinger E.P.
        • Garland J.
        • Heard S.O.
        • Saint S.
        Guidelines for the prevention of intravascular catheter-related infections.
        Am. J. Infect. Control. 2011; 39: S1-S34
        • Palese A.
        • Baldassar D.
        • Rupil A.
        • Bonanni G.
        • Capellari Maria T.
        • Contessi D.
        • Zanini A.
        Maintaining patency in totally implantable venous access devices (TIVAD): a time-to-event analysis of different lock irrigation intervals.
        Eur. J. Oncol. Nurs. 2014; 18: 66-71
        • Revel-Vilk S.
        • Yacobovich J.
        • Tamary H.
        • Goldstein G.
        • Nemet S.
        • Weintraub M.
        • Kenet G.
        Risk factors for central venous catheter thrombotic complications in children and adolescents with cancer.
        Cancer. 2010; 116: 4197-4205
        • Rinke M.L.
        • Chen A.R.
        • Bundy D.G.
        • Colantuoni E.
        • Fratino L.
        • Drucis K.M.
        • Miller M.R.
        Implementation of a central line maintenance care bundle in hospitalized pediatric oncology patients.
        Pediatrics. 2012; 130: e996-e1004
        • Rosenthal V.D.
        • Udwadia F.E.
        • Kumar S.
        • Poojary A.
        • Sankar R.
        • Orellano P.W.
        • Patil P.
        Clinical impact and cost-effectiveness of split-septum and single-use prefilled flushing device vs 3-way stopcock on central line–associated bloodstream infection rates in India: a randomized clinical trial conducted by the International Nosocomial Infection Control Consortium (INICC).
        Am. J. Infect. Control. 2015; 43: 1040-1045
        • Rowley S.
        • Clare S.
        • Macqueen S.
        • Molyneux R.
        ANTT v2: an updated practice framework for aseptic technique.
        Br. J. Nurs. 2010; 19: S5-S11
        • Schallom M.E.
        • Prentice D.
        • Sona C.
        • Micek S.T.
        • Skrupky L.P.
        Heparin or 0.9% sodium chloride to maintain central venous catheter patency: a randomized trial.
        Crit. Care Med. 2012; 40: 1820-1826
        • Schreiber S.
        • Zanchi C.
        • Ronfani L.
        • Delise A.
        • Corbelli A.
        • Bortoluzzi R.
        • Barbi E.
        Normal saline flushes performed once daily maintain peripheral intravenous catheter patency: a randomised controlled trial.
        Arch. Dis. Child. 2015; 100: 700-703
        • Schulz K.F.
        • Altman D.G.
        • Moher D.
        • the CONSORT Group
        CONSORT 2010 statement: updated guidelines for reporting parallel group randomized trials.
        Obstet. Gynecol. 2010; 115: 1063-1070
        • Shah P.S.
        • Shah V.S.
        Continuous heparin infusion to prevent thrombosis and catheter occlusion in neonates with peripherally placed percutaneous central venous catheters.
        Cochrane Database Syst. Rev. 2008; 2CD002772
        • Viana Taveira M.R.
        • Lima L.S.
        • de Araújo C.C.
        • de Mello M.J.G.
        Risk factors for central line-associated bloodstream infection in pediatric oncology patients with a totally implantable venous access port: a cohort study.
        Pediatr. Blood Cancer. 2017; 64: 336-342
        • Tsai H.-C.
        • Huang L.-M.
        • Chang L.-Y.
        • Lee P.-I.
        • Chen J.-M.
        • Shao P.-L.
        • Lu C.-Y.
        Central venous catheter-associated bloodstream infections in pediatric hematology-oncology patients and effectiveness of antimicrobial lock therapy.
        J. Microbiol. Immunol. Infect. 2015; 48: 639-646
        • Wiersma P.
        • Schillie S.
        • Keyserling H.
        • Watson J.R.
        • De A.
        • Banerjee S.N.
        • Srinivasan A.
        Catheter-related polymicrobial bloodstream infections among pediatric bone marrow transplant outpatients—atlanta, Georgia, 2007.
        Infect. Control Hosp. Epidemiol. 2010; 31: 522-527
        • Worth L.J.
        • Seymour J.F.
        • Slavin M.A.
        Infective and thrombotic complications of central venous catheters in patients with hematological malignancy: prospective evaluation of nontunneled devices.
        Support. Care Cancer. 2009; 17: 811-818