heparin, saline, PICC capping, thrombocytopenia
Background: Heparin-induced thrombocytopenia (HIT) and HIT with thrombosis syndrome (HITTS) are serious conditions. Patients are at increased risk for developing HIT/HITTS with any exposure to heparin, even intravenous line flushes. Patients may be exposed to heparin multiple times each day when they have a peripherally inserted central catheter (PICC) that is flushed and capped with heparin. At Aurora Health Care, heparin is the standard capping solution for PICCs, but with a recent switch to positive pressurized caps, normal saline may be a capping option that reduces patient exposure to heparin.
Purpose: To reduce heparin exposure at a single hospital by replacing heparin with normal saline (0.9% sodium chloride) as the standard PICC capping solution.
Methods: We implemented an interdisciplinary pilot process change and evaluated whether normal saline was noninferior to heparin for maintaining PICC patency. Primary outcome measurements of patency include alteplase use due to occlusion. Secondary objectives were any change in invasive line infection rates and cost comparisons. The baseline patency rate for the hospital was derived from data extracted through a retrospective chart review from October 2013 through October 2014.
Results: Our baseline patency rate was 65.42% (N = 3,095); 33% of all PICC lines placed during the 12-month period were treated with alteplase. Patency rates during our pilot period were based on retrospective chart reviews of patients with PICC lines placed from February to May 2015. During this period, a total of 979 PICC lines were evaluated. Of these, 30.4% were treated with alteplase. This resulted in a pilot patency rate of 69.5%, which is 4.1% greater than our baseline patency rate. Given the prespecified noninferiority margin of 5%, our pilot demonstrates that normal saline is noninferior to heparin for maintaining PICC line patency when used with positive pressurized caps (α < 0.05). Although number of infections increased 16%, only 9% with line infections were part of our pilot. The estimated yearly cost of both capping solutions is equal, at approximately $3,960 per our baseline usage data. By potentially avoiding a diagnosis of HIT/HITT in these patients, the hospital would realize an annualized savings of over $86,000.
Conclusion: Normal saline has demonstrated historical noninferiority to heparin for maintaining PICC patency when used as the capping solution with positive pressurized caps. Similar results were found during our pilot.
Colella A, Bodager B, Spexarth F, McDonough N, Kastenholz D, Grebe P. An interdisciplinary process change: conversion of PICC line capping solution from heparin to normal saline. J Patient Cent Res Rev. 2016;3:239-40.