1. Maintaining Arterial Catheters with Normal Saline Catherine Williams MSN student

2. A research based protocol The Stetler model was used for this protocol Phase I: Introduction Phase II: Validation Phase III: Comparative Evaluation/Decision making Phase IV: Translation/Application Phase V: Evaluation

3. Abstract Arterial catheters are used in critical care units to continuously monitor blood pressures and to obtain blood samples without performing multiple venipunctures. For decades arterial catheters have been maintained with a pressurized heparinised 0.9% normal saline to prevent thrombus formation. The use of heparin for its pharmacological properties as an anticoagulant. Research evidence indicates that short term arterial lines may be maintained effectively and at a reduced cost by using normal saline instead of heparinised saline.

4. Phase : I Introduction The risks associated with the routine use of heparin are abnormal coagulation studies, bleeding, heparin induced thrombocytopenia or HIT, embolic events and death. In the critical care setting 23-41% of patients will have an incidence of thrombocytopenia. Mortality rates related to thrombocytopenia in the ICU are between 38-54%( Napolitano,L.M.,2006).

5. Phase II: Validation Five studies found that examine this subject. Hook and colleagues’(1987) study using quasi- experimental design, patency [dependent variable], type of solution [independent variable] N=50. Two groups one group with catheters maintained with ringers lactate the other with heparinised saline. Nurses were instructed to flush the non- heparinised catheters every hour even though both groups lines were under continuous pressure via pressure bag at 300mmHG. Results concluded that arterial catheters can be maintained with out the use of heparin in short term catheters.

6. Literature Review Heparin as a continuous flush at 3units/hr does not improve function of arterial lines compared with continuous flushing with normal saline( Hall,K.,et al,2006). Prospective double blind study compared the effects of heparinised and 0.9% normal saline both administered via continuous flush device to an arterial catheter, N=65. Comparison using central limit theorem showed means were not different at the 95% confidence interval(Hall,K.,et al,2006).

7. Phase:III Feasability: Potential risks of occlusion of catheters. Investigation of current practices at UVA, MCV and Duke University all confirm the use of 0.9% normal saline without the use of heparin for all pressure lines to include arterial, CVP, and Swan Ganz catheters. Largest study done in 1993 The AACN Thunder Project promotes the use of heparin in all pressure lines. Presentation of findings to Critical Care committee. Recommendation : 0.9% normal saline to be used in all pressure lines, no trial recommended.

8. Phase: IV Translation/Application Phase: V Evaluation Presented to policy and procedure committee. Nursing policy 11.06 [normal saline used in all pressure lines at Centra Health]. Annual cost savings $25,174.80 Evaluation will be ongoing staff instructed to notify Mary Ann Tate CNS for any problems related to catheters.

9. Conclusion Applying research and related evidence to nursing practice to promote better patient outcomes, save money and to avoid the use of additional sometimes harmful medications.