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Bri Brief resume of the intended work
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6.1. Need for the study
Patients are admitted to ICU for various ailments and all these clients require
parental infusions for medication as well as nutrition. Peripheral intracathline are
frequently required for the critically ill patients. Proficiency in safe and effective
catheterization includes not only possession of good skills acquired during supervised
practice, but also knowledge of indications, contraindications, advantages, disadvantages,
complications, measures to prevent complications, and specific techniques.1
Peripheral intracathlines in India are used very frequently in critically ill patients like
cardiac arrest, shock, respiratory arrest, CVA and burns etc, for Intravenous infusion,
administration of medication, maintenance of fluid and electrolyte balance etc, and they
need to be kept patent for more than a day or so. But with venous/peripheral cannulation,
the incidence of positive catheter culture and associated bacteraemia increases markedly
after 2 to 3 days with irritation, pain and discomfort leading to following problems like
thrombosis at Intravenous site, infiltration, thrombophlebitis etc.2
While caring for clients with peripheral intracathline thrombosis is a very common
occurrence in the ICU leading to Phlebitis which occurs more commonly when veins of
lower extremity are used.3 Also, the type and size of the catheter, the duration of
cannulation and the infusion of hypertonic fluids or various drugs influence the occurrence
of phlebitis.4 The incidence of thrombosis has been shown to range from 0.3 – 71%.
5
Thrombosis can be prevented by many ways by flushing the intracathline with: Heparin or
Normal saline or Sterile water.
Heparin prevents blood clotting by its antithrombin activity so it is widely used as an
anticoagulant in clinical practice. Heparin directly acts on thrombin by suppressing its
activity. Heparin also combines with antithrombin III and it removes thrombin from
circulation and it inactivates the active form of other clotting factors like IX, X, XI and
XII. With the administration of heparin, clients are at risk for impaired comfort such as
irritation, pain, or redness at the insertion site and unusual hair loss, allergic reactions,
thrombocytopenia, osteoporosis with long term therapy. 6
Normal saline is a sterile solution of sodium chloride in purified water containing 0.9
gram of sodium chloride in 100 ml.
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After the medication has been administered, the
catheter is flushed with an inert isotonic solution such as normal saline. This is done to
minimise potential incompatibility problems like occlusion due to the corrosive and
irritating drugs administered through the catheter and preventing stagnation of drugs.
In spite of benefits, complications were also associated with heparin flush and
normal saline flush. Through this study the investigator is evaluating the effectiveness of
normal saline flush for maintaining the patency of intracath line and to arrive at a definitive
line of management for thrombosis of the intravenous site with more benefits and less
complications.
6.2. Review of literature
A study conducted to compare effects of Heparinised solution versus Nonheparinised
solution for the maintenance of patency of peripheral intracath line among the patients
admitted in the medical and surgical wards of Bharati Hospital, Pune. The data collected
from 60 medical & surgical patients admitted in the hospital showed that there is highly
significant association between doses of drug ranged 500-1000 mg in heparinised solution
at 72 hrs and resistance [p=0.002], dilution of drug 5ml and resistance [p=0.035] in
heparinised solution, dilution of drug 10 ml and resistance [p=0.000] in nonheparinised
solution and frequency of drug 6 hourly and resistance [p=0.000] in peripheral intracath
line at 72 hrs in both solutions. And it was concluded that “Both the solutions were
effective in maintaining the patency of peripheral intracath line and the duration of patency
maintained by both solutions was 72 hours. This indicates that both solutions have equal
effectiveness in maintaining the patency of peripheral intracath line and there is highly
significant association between resistance and age, weight, dose, dilution, frequency and
diagnosis, at 72 hrs for the both solutions”. 7
A study conducted in a large academic medical centre in Midwest on the effect of
Heparin versus Normal saline for maintenance of peripheral intravenous locks in 73
pregnant women of which 35 in normal saline group and 38 in heparin group between 2442 weeks of gestation, hospitalized in the obstetric units. Groups were similar for maternal
age, gravidity and parity. The original intent of the study was to measure and compare the
outcomes in the two groups within 12, 24, 48 and 72 hrs. However, assessments of iv lock
status were rare beyond 12 hrs, generally because of the initiation of fluid infusion.
Because there were insufficient data to make comparisons in the 24, 48 and 72 hr groups,
only the assessments within 12 hrs for patency are reported. The result showed that of the
35 iv locks flushed with saline, 68.6% had no obstruction within 12 hrs, as compared to no
obstruction within 12 hrs in 76.3% of the iv locks flushed with heparin (n=38). This
difference in patency was not significant as shown by p=0.459. And it was concluded that
there were no statistically significant differences in IV lock patency nor in phlebitis
between heparin or normal saline flushes.8
A study was conducted to compare the effect of heparin versus normal saline flush
solutions on the duration of patency of peripheral IV catheters of neonates in University of
Missouri Columbia Children’s Hospital’s NICU. A quasi experimental design compared
the outcomes in 87 infants who were 32 weeks or greater gestation at birth. Thirty three
received heparin and 54 received normal saline. In the analysis of all IVC starts, the size of
catheter was excluded as a predictor variable because of the low number of 22 gauge
catheters used in the sample. The predictor variables of gestational age, site of insertion,
type of catheter and additional solution administration (Ampicillin and Gentamicin) were
included in analysis, along with the solution used
(heparin and normal saline). The
findings showed that the mean duration of patency for all IVC starts was 44.4 hours
(S.D=29.3). The majority of IVCs were started in the scalp (57%), followed by the hand
(18%), arm (13%), foot (9%) and leg (3%).
The result shows that no statistically
significant difference in duration of patency between IVCs locked with heparin versus
normal saline groups. The duration was significantly longer for insertion in scalp, arm or
hand than for the leg or foot. 9
A study conducted on heparin verses normal saline as a peripheral line flush in
maintenance of intermittent intravenous lines in obstetric patients. Researcher
hypothesised that in pregnancy use of heparin flushes would improve intermittent IV lock
patency, compared with normal saline flushes. Fourty four pregnant women who were
between 26 and 34 weeks gestation were included and compared heparin sodium (100
U/ml) with normal saline for use in maintenance of IV locks. Catheter sites were examined
and flushed with the study solution at least once every 6 hrs. Partial thromboplastin times
were also measured at catheter insertion and 48 hrs later. Although no difference were
found in partial thromboplastin times, there was a significant increase in catheter patency
rate at 48 and 72 hrs in the heparin group (84% Vs 52% and 68% Vs 27%, respectively;
p<0.01). There was also a significantly lower rate of catheter complications in heparin
group (13% Vs 31%, p<0.01). 10
A study on efficacy of normal saline solution verses heparin solution for maintaining
patency of peripheral intravenous catheters in children at the children’s hospital, Denver,
Colorado, USA. The study consisted of 150 emergency department patients with mean age
of 5.5 years requiring IV heparin lock placement were included in the sample. Patients
were randomised to the control group (n=77) to receive 3 ml of a 10 units heparin/ml
normal saline solution IV flush, or to the treatment group (n=73) to receive 3 ml of normal
saline solution only for IV flush. For the heparin lock placement in the emergency
department the study had a mean and median duration of 2.89 (range: 0.5 – 24 hrs) and 2.5
hrs, respectively. The result suggested that normal saline solution (p<0.01) may be an
effective alternative to heparin flush in maintenance of patency in peripheral intermittent
IV access devices in the paediatric emergency department. 11
6.3. Statement of the problem
The effectiveness of normal saline flush for maintenance of patency of peripheral
intracath line among the patients admitted to ICU of a selected hospital of Mangalore
6.4.Objectives of the study

To determine the patency of peripheral intracath line of patients on heparin flush.

To determine the patency of peripheral intracathline of patients on normal saline
flush.

To compare the patency of peripheral intracath line between patients on heparin
flush and normal saline flush.

To determine the association between the selected variables with the patency of
peripheral intracath line.
6.5.Operational Definition
Effectiveness: Effectiveness refers to a change produced by an action or a cause, a result
or an out come (Oxford dictionary).12
Effectiveness in this study refers to the extent to which normal saline flush is effective in
maintaining patency of intracath line as that of heparin.
Normal saline flush: Normal saline flush is injecting 1-2ml of a sterile solution of 0.9%
sodium chloride. It is also known as isotonic sodium chloride solution; normal salt
solution; physiological saline; physiological salt solution; physiological sodium chloride
solution; sodium chloride solution.6
In this study the normal saline flush indicates injecting 2 ml of normal saline flush into the
peripheral intracathline every 12 hrs.
Heparin flush: Heparin flush prevents blood clotting by its antithrombin activity so it is
widely used as an anticoagulant in clinical practice.6
In this study heparin flush indicates injecting 10 U/ml into the peripheral intracath line
every 12 hrs to maintain patency of intracath line.
Patency: Patency means unobstructed or open (oxford dictionary).12
In this study patency of intracath line means unobstructed or open passage way of the
inthracath line as measured by observation check list and Poiseuillie’s law.
6.6. Assumption

Patients who are on prolonged intracath line need maintenance of patency of
intracath line to prevent occlusion of catheter or vein.

Patency of intracathline can be objectively measured.
6.7.Delimitation

The study is delimited to patients who are admitted to ICU.

Patients who are on intracath line for at least 72 hrs.
6.8.Hypothesis
H1: There will be a significant difference in patency scores of peripheral intracath line
of patients on heparin flush and normal saline flush.
H2:
There is significant association between selected demographic variables and
patency scores of peripheral intracath line.
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Material and methods
7.1. Source of data
Patients who are admitted in ICU of selected hospital Mangalore.
7.1.1.Research design
Quasi experimental design ( post test only control group design)
E
X
O1
O2
O3
C
---
O4
O5
O6
E = Experimental group
C = Control group( conventional heparin flush)
X = Treatment with Normal saline flush
O1, O2 and O3 = Post test of the experimental group at 24, 48 and 72 hours.
O4, O5 and O6= Post test of control group at 24, 48 and 72 hours respectively from the
time of insertion of intracath line.
7.1.2. Setting
The study will be conducted in the ICU of a selected hospital Mangalore.
7.1.3. Population
Patients who are admitted in the ICU and with intracathline of selected hospital
Mangalore.
7.2 Method of data collection
7.2.1 Sampling procedure
Sample for the present study will be selected by purposive sampling technique. Then
the sample will be randomly assigned into experimental and control group.
7.2.2 Sample size
Forty patients who are admitted in the ICU.
7.2.3 Inclusion criteria
- Patients who require intracath line for at least 72 hours.
-
Patients willing to participate.
7.2.4 Exclusion criteria
1. Patients who are sensitive to heparin.
2. Patients who are on anticoagulant therapy including aspirin.
7.2.5. Instruments intended to be used

Observation check list to assess the patency of intracath line.

Poiseuille’s law for laminar flow through tubes.
7.2.6. Data collection method

Prior to data collection permission will be obtained from the hospital authority
concerned for conducting the study.

Subjects will be selected according to the selection criteria of the study.

Patients in the experimental group is treated with normal saline flush every 12 hrs
from the time of insertion of the intracath line.

Post tests on the experimental group (O1, O2, and O3) and control group (O4, O5
and O6) will be done to assess for patency after 24, 48 and 72 hours respectively.

The patency will assessed according to the observation checklist for measuring the
patency of intracath line and poiseuille’s law for laminar flow through tubes.
7.2.7. Data analysis plan
Data would be analysed using the descriptive and inferential statistics.
7.3. Does the study require any investigations or intervention to be conducted on
patients or other humans or animals?
Yes, Normal saline flush will be used in the experimental group.
7.4. Has ethical clearance been obtained from your institution in case of 7.3?
Yes, ethical clearance will be obtained from the concerned authority.
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List of references
1. Kaye W. Intravenous techniques in text book of advanced cardiac life support.
American heart association, Dallas; chapter 12; 1981.
2. Maki DG, Goldman DA, Rhame FS. Infection control in intravenous therapy; Annals
of internal medicine 1973; 79; 867.
3. Thomas F, Burke JP, Parker J, et al .The risk of infection related to radial verses
femoral sites for arterial catheterization Critical care medicine 1983; 11: 807-812.
4. Charles LS, Ake G. Clinics in critical care medicine. Invasive procedures in critical
care; IST edition; 1-48.
5. Alexander.
J.
A
new
and
improved
guide
to
IV
therapy.
www.arrowint/.com/documents/pdf/education-n91201
6. Mckenry, Salevno. Mosby’s Pharmacology in Nursing; 21st edition ; Mosby’s
Publication; 622-627.
7. Pramod Sucheta. A comparative study of heparinised solution versus nonheparinised
solution for the maintenance of patency of peripheral intracath line among the patients
admitted in the medical and surgical wards of Bharati hospital Pune. Journal of
Nightingale Nursing times 2006; Page no 28-30.
8. Kathryn M. Niesen, Denise Y. Harris, Linda S. Parkin, Lynn T. Henn. The effect of
heparin verses normal saline for maintenance of peripheral intravenous locks in
pregnant women. JOGNN clinical research July August 2003; vol 32; page no 503-308.
9. Marilyn Krueger Paislely, Nancy Brown, Maura Stamper, Carry H Ganong, Julie
Brown. The use of heparin and normal saline flushes in neonatal intravenous catheters.
Paediatric nursing September- October 1997; vol 23; no 5; page no 521-527
10. Meyer BA, Little CJ, Thorp AJ, Cohen GR, Yeaster JD. Heparin verses normal saline
as a peripheral line flush in maintenance of intermittent intravenous lines in obstetric
patients. Obstetric and Gynaecology 1995; 85; 433-436.
11. Leduc K. Efficacy of normal saline solution versus heparin solution for maintaining
patency of peripheral intravenous catheters in children; Journal of emergency nursing
1997; 23(4); 306-309.
12. The concise Oxford Dictionary. Edited by Judy Pearsall; 10th edition; 456, 1044.