Change in Flush Practice May Reduce Toxicity for Adult Patients With Cancer

A reduction in adverse effects (AEs) and financial toxicity was observed after implementing an evidence-based practice (EBP) using saline in flushing peripherally-inserted central catheters (PICCs), ports, and central lines alone vs traditional heparin without significantly increasing occlusion rates among patients with cancer, according to findings from a presented at the 51st Annual Oncology Nursing Society (ONS) Congress.¹

Specifically, among hospitalized adult patients with cancer in the Bone Marrow Transplant, Solid Tumor, and Surgical Oncology units at University of Texas Southwestern (UT Southwestern), 103 alteplase doses were given prior to the EBP change during a period from July 2024 to December 2024 vs 203 doses given following the EBP change during a period from January 2025 to June 2025. The incidence rate of occlusions per 1000 central line days was 10.68 in the pre-EBP change cohort and 21.00 in the post-EBP change cohort, with percentages of 1.068% and 2.10%, respectively.

“Occlusion rates for central lines vary between [0% to 33%].² Post-EBP rates of alteplase usage increased from pre-EBP rates,” Linda Chan, MSN, RN, ONC, CMSRN, EBP-C, a nurse in the Surgical Oncology Unit at William P. Clements University Hospital and member of the Dallas Chapter Oncology Nursing Society, wrote in the presentation with study coinvstigators.¹ “Both pre- and post-EBP occlusion rates are low in relationship to anticipated occlusion percentage rates. [UT Southwestern] oncology units have dedicated unit nurse educators who can build educational interventions aimed at preventing central line occlusion.”

The study investigators conducted this research to institute a flush practice-related EBP change for patients with PICCs, ports, and central lines who use low dose heparin across UT Southwestern Oncology Units. Specifically, they aimed to increase patient safety, decrease organizational costs, and examine other outcomes, including occlusion rates.

The authors acknowledged prior research which suggested that central line flush practice may impact central line patency foregrounded by a requirement for central lines among patients with cancer for treatment purposes.^3,4 Moreover, they highlighted prior nurse-led UT Southwestern research which found comparable line patency using normal saline alone vs with heparin at 100 units/mL.⁵

Additionally, according to the investigators, the findings from the previous UT-led research were congruent with meta-analyses which showed a non-significant difference between the use of saline alone vs with heparin, with the latter conferring treatment-induced thrombocytopenia and hypersensitivity reactions. Additionally, they highlighted a reduction in financial toxicity, noting that saline is less expensive than heparin due to its reduction in organizational costs directly and indirectly, such as through nursing and pharmacy labor.

Of note, the investigators excluded all patients with lines that use heparin at 1000 units/mL and pediatric patients in the study protocol.

Following the EBP change, patients underwent pulsatile flushing with only normal saline starting in December 2024. Alteplase at 2 mg/mL was given to clear lines with either partial or full occlusions, the former of which entails a line flush with no blood return and the latter of which entails no line flush or blood return. The authors noted that alteplase dosing could be used a proxy measure for the number of line occlusions.

Moreover, the researchers noted that 2 methods could be employed to determine occlusion rates: cumulative percentage per line or incidence rate per 1000 central line days. They clarified that the incidence rate per 1000 days is the preferred method as it normalizes differences in patient groups and catheter dwell time.

“Data can be used by [UT Southwestern] oncology units in quality improvement projects aimed at decreasing occlusions,” Chan concluded with study coinvestigators. “On rare occasion, alteplase is used to clear pleural catheters. Continued work is needed to determine cost ramifications.”

Reference

1. Chan L Castillo R, Johns M, Riley C, Youssefi F, Mendoza C. Preliminary outcomes of an evidence-based practice change using normal saline to flush peripherally inserted central catheters, ports, and central lines to maintain line patency in hospitalized oncology patients. Presented at: 51st Annual Oncology Nursing Society (ONS) Congress; May 13-17, 2026; San Antonio, TX. Poster 86
2. Zhong L, Wang HL, Xu B, et al. Normal saline versus heparin for patency of central venous catheters in adult patients - a systematic review and meta-analysis. Crit Care. 2017;21(1):5. Published 2017 Jan 8. doi:10.1186/s13054-016-1585-x
3. Schiffer CA, Mangu PB, Wade JC, et al. Central venous catheter care for the patient with cancer: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol. 2013;31(10):1357-1370. doi:10.1200/JCO.2012.45.5733
4. Nickel B, Gorski L, Kleidon T, et al. Infusion therapy standards of practice, 9th edition. J Infus Nurs. 2024;47(1S Suppl 1):S1-S285. doi:10.1097/NAN.0000000000000532
5. Denke L, Allen M, Atem F, Nair K, Warkola R, Gonzales M. Heparin versus saline: a comparative study to support practice change within an organization. J Infus Nurs. 2025;48(1):11-16. doi:10.1097/NAN.0000000000000569