Normal saline versus heparin for patency of central venous catheters in adult patients - a systematic review and meta-analysis

Lei Zhong, Hai-Li Wang, Bo Xu, Yao Yuan, Xin Wang, Ying-Ying Zhang, Li Ji, Zi-Mu Pan, Zhan-Sheng Hu, Lei Zhong, Hai-Li Wang, Bo Xu, Yao Yuan, Xin Wang, Ying-Ying Zhang, Li Ji, Zi-Mu Pan, Zhan-Sheng Hu

Abstract

Background: Heparin saline (HS) is theoretically superior to normal saline (NS) for maintaining the patency of central venous catheters (CVCs), but the comparative efficacy of them remains controversial. The aim of this systematic review and meta-analysis was to assess the efficacy of NS versus HS in the maintenance of the patency of CVCs in adult patients.

Methods: We searched PubMed, Embase and the Cochrane library databases. Randomized controlled trials (RCTs) evaluating the use of NS vs. HS to maintain the permeability of CVCs among adult patients were included in our meta-analysis. References of relevant papers were reviewed manually. No language restriction was applied. Non-human studies were excluded. Pooled relative risk (RR) was calculated using a Mantel-Haenszel random-effects model. We also performed subgroup analysis examining the effect of the duration of catheter placement on the outcome. All statistical tests were two-sided using a significance level of 0.05.

Results: Ten RCTs involving 7875 subjects (with analysis at patient, catheter, lumen and line access level) were included in this meta-analysis. Whether in terms of pooled or local analysis (RR with 95% confidence interval spans 1), NS can be equally, if not more effective, in keeping the CVCs open. Of studies reporting secondary outcomes (maneuver needed, heparin-induced thrombocytopenia, haemorrhage, central venous thrombosis and catheter-related bloodstream infection), heparinised saline was shown not to be superior to non-heparinised solution. Subgroup analysis in patients with short vs long term CVC placement was consistent with the main outcome partly and in particular for maintenance of catheter patency in patients with a long-term placement i.e. >30 days, the RR was 0.97 (n = 6589; 95% CI = 0.76 to 1.23; P = 0.796). However, for patients in whom the catheter was in place for <30 days, the RR was 1.52 (n = 1286; 95% CI = 1.02 to 2.27; P = 0.041).

Conclusions: Based on the results of this meta-analysis, HS is not superior to NS in reducing CVCs occlusion. But in the short term, the use of HS is slightly superior to NS for flushing catheters from a statistical point of view.

Keywords: Central venous catheters; Heparin; Normal saline; Occlusion.

Figures

Fig. 1
Fig. 1
Flow chart of article selection procedure
Fig. 2
Fig. 2
Risk of bias assessment. a Risks of bias graph. b Risks of bias summary
Fig. 3
Fig. 3
Funnel plot was generally asymmetrical. The black dots and dotted line indicate individual studies and 95% confidence intervals, respectively
Fig. 4
Fig. 4
Forest plot of association between use of normal saline (NS) vs heparin saline (HS) and the incidence of catheter occlusion. RR relative risk, CI confidence interval, NS normal saline, HS heparin saline
Fig. 5
Fig. 5
Forest plot of association between use of NS vs HS and the incidence of complications. RR relative risk, CI confidence interval, NS normal saline, HS heparin saline
Fig. 6
Fig. 6
Subgroup analysis based on the duration of catheter placement. RR relative risk, CI confidence interval, NS normal saline, HS heparin saline

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