Practice Based Learning: Ethanol lock – Is it safe to flush?

Amy Cheng, MD

Presented by Amy Cheng, MD PGY-1

Clinical questions:

  • What is ethanol lock?
  • Is it safe to flush it into a central line?

Ethanol Lock:

  • A technique used for treatment or prophylaxis of central venous catheter infections
  • 70 – 74% of Ethanol is instilled into a catheter and allowed to dwell in the lumen
  • Acts as nonspecific protein denaturant that can degrade biofilms and kill bacteria and fungi
  • Known to dissolve intraluminal obstruction caused by waxy lipid deposits associated with administration of TPN
  • Prevents unnecessary use of antibiotics
  • Inexpensive and universally available

Dannenberg, et al. (2003):

  • 74% ethanol, 2.3 ml flushed + systemic antibiotics vs systemic antibiotics alone
  • 18 (age 2-14 yr), 24 events, in the study group , 28 or 39 events, in the control group (age 2-18 yr)
  • 67% of patient in the study group had no infectious relapse vs. 47% in the controlled group
  • Side effects
    • Tiredness, headaches, dizziness, nausea
    • No cases of seizures, loss of consciousness, or delirium
  • Elevated AST/ALT/GGT: 12 in study group, 6 in controlled group
  • Returned to normal within days

McGrath, et al. (2011):

  • 70% ethanol (mean 0.5 mL, range 0.3 – 1.0 ml) + systemic antibiotics
  • 59 patients (2 mo – 19 years), 80 episodes
  • 86% of CLABSI were cleared after 1 ELT + systemic antibiotics vs 50% recorded in other pediatric studies
  • 12 recorded episodes of AST/ALT elevation that was reversible

Slobbe, et al. (2010):

  • 70% ethanol, 3 ml flushed vs. 0.9% NaCl
  • 226 events in the study group vs 222 in placebo group
  • Insignificant results in prevention of the CRBSI
  • Mild side effects
    • Discomfort, flushing, drowsiness, taste of alcohol
    • Discomfort were significant enough to discontinue lock therapy or continued with a frequency-adjusted regimen
  • 1 patient had syncope shortly after flushing the first lock, but did not have further side effect with subsequent flushing
  • No significant differences in AST/ALT/GGT levels when compared to baseline

Valentine (2011):

  • Retrospective chart review
  • 70% ethanol (1 – 3 mL), flushed + systemic antibiotics
  • 20 patients (77 days – 20 years)
  • 92 % of CABSI were cleared
  • Mild elevation of AST and ALT in 2 patients in the study group, but not different from their baseline levels

Other literature reviewed:

  • Further review of other smaller studies also showed similar adverse effects
  • However, transient rise in AST/ALT were also seen in the studies that would aspirate the ethanol locks
  • Several studies showed catheter occlusion, more in the locks that were aspirated
  • One study compares heparin versus ethanol lock, aspirated at the end of dwell time, showed significant thrombotic events requiring tPA, line repair, or removal in the ethanol lock group
  • Other small studies that used aspiration of ethanol lock also resulted similar thrombotic events

Conclusions:

  • Ethanol lock is safe to flush
  • Mild adverse effects include tiredness, headaches, dizziness, nausea, and taste of alcohol
  • Elevated AST/ALT seem to be transient
  • No cardiac arrhythmia observed

Further questions/recommendations:

  • Is ethanol lock the best thing compared to antimicrobial or heparin locks?
  • If we were to use ethanol locks, we should try to flush the lines or incorporate some kind of heparin lock therapy to avoid risks of thrombotic events that may lead to line replacement

References:

Dannenberg C, Bierbach U, Rothe A, Beer J, Körholz D. Ethanol-lock technique
in the treatment of bloodstream infections in pediatric oncology patients with
broviac catheter. J Pediatr Hematol Oncol. 2003 Aug;25(8):616-21.

Kayton ML, Garmey EG, Ishill NM, et al. Preliminary results of a phase I trial of prophylactic ethanol-lock administration to prevent mediport catheter-related bloodstream infections. J Pediatr Surg. 2010 Oct;45(10):1961-6.

McGrath EJ, Salloum R, Chen X, Jiang Y, Boldt-MacDonald K, Becker C, Chu R,
Ang JY. Short-dwell ethanol lock therapy in children is associated with increased
clearance of central line-associated bloodstream infections. Clin Pediatr
(Phila). 2011 Oct;50(10):943-51.

Mermel LA, Alang N. Adverse effects associated with ethanol catheter lock
solutions: a systematic review. J Antimicrob Chemother. 2014 Jun 2. pii: dku182.

Slobbe L, Doorduijn JK, Lugtenburg PJ, et al. Prevention of catheter-related bacteremia with a daily ethanol lock in patients with tunnelled catheters: a randomized, placebo-controlled trial. PLoS One. 2010 May 26;5(5):e10840.

Valentine KM. Ethanol lock therapy for catheter-associated blood stream infections in a pediatric intensive care unit. Pediatr Crit Care Med. 2011 Nov;12(6):e292-6.

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