Central venous catheters (CVCs) are increasingly used in the medical management of chronic diseases and are essential in administering treatments.1, 2, 3 CVCs offer convenient intravenous access for blood sampling, the administration of chemotherapy drugs, and supportive treatments such as antibiotics and blood products/components.4, 5, 6 The widespread use of CVCs has facilitated the implementation of treatments, leading to shorter hospital stays, increased safety, and reduced hospital costs.1,5 With the advantages of long-term use, CVCs have become standard tools in providing care for pediatric patients with cancer.6, 7, 8

There are many advantages to the use of CVCs, such as convenient access for medical treatments, but there are also many potential complications (eg, occlusion, infection, and dislocation) that can arise if proper care is not taken.2,9,10 Obstruction of CVCs is a common problem, occurring in approximately 36% of children with cancer.6,8 Although CVCs offer many benefits, studies have reported a 14% to 36% incidence of mechanical, infectious, or thrombotic complications after 2 years of implantation in patients.7,11,12 CVC occlusions can lead to treatment delays, hospital readmissions, an increased risk of inflammation, life-threatening events, and the need for CVC removal or replacement.5,7

The most effective approaches to managing CVC occlusions are implementing flushing and locking protocols, which are more cost-effective and efficient and less invasive than removing or replacing the CVCs.5,7 Currently, nurses routinely flush CVCs to maintain open lumens. Flushing occluded catheters with appropriate agents has become the first treatment option to avoid the risks and costs associated with removing and reimplanting CVCs. The solutions commonly used for catheter flushing include normal saline and heparin.5 Although heparin is commonly used as the standard method to flush the CVCs, it can be unsafe for patients and costly for health institutions. Heparin use increases the risk of thrombocytopenia in patients, and up to 30% of patients experience allergic reactions to it.1 Because the focus of health care institutions is on providing good-quality care to patients, it is preferable to use normal saline instead of heparin to flush the CVCs. Normal saline is safer than heparin and has been shown to be just as effective in preventing CVC occlusion.1

The management of CVC occlusion presents a significant clinical problem that disrupts antineoplastic treatment. However, the methods used for prevention and the associated risks and costs of diagnosis and treatment vary. As a result, the management of CVC occlusion remains a gap in evidence-based guidelines. Although prospective randomized controlled trials indicate no significant advantage of heparinized solutions over normal saline in reducing catheter dysfunction due to thrombosis,3 the strength of evidence from these studies is limited.12,13 A previous study performed by Bradford et al12 as a Cochrane review compared the efficacy of heparin and normal saline in preventing CVC occlusion by including general pediatric patients. Because one in three CVCs in pediatric oncology patients is thought to be infected, thrombosed, or occluded during treatment13,14 and CVC care is important for this population, a meta-analysis study is needed to compare the efficacy of heparin and normal saline to prevent obstruction. Therefore, this systematic review and meta-analysis aimed to compare the effectiveness of heparin and normal saline flushing in preventing CVC occlusion in pediatric cancer patients.

Hypothesis 1

Heparin flushing will be more effective than normal saline flushing in reducing CVC occlusion in pediatric cancer patients.

Hypothesis 2

Normal saline flushing will be more effective than heparin flushing in reducing CVC occlusion in pediatric cancer patients.

Hypothesis 3

Heparin flushing and normal saline flushing will have the same effect on reducing CVC occlusion in pediatric cancer patients.