Standard Operating Procedure
Hem/Onc High-Risk CLABSI Maintenance
Ethanol Lock Protocol
Catheter Type
Silicone
Lock Solution
Ethanol
Lock Schedule
Monday-Wednesday-Friday
Vancomycin
Cipromycin
Tuesday
Thursday
Standard Broviac – single or
double lumen
Polyurethane
All other catheters – single or
double lumen
 All catheters are treated with 1x Ethanol Lock if possible contamination is
expected or suspected due to line disconnection or line break
 Catheter breaks should be repaired asap by Surgical Fellow
Follow these procedural elements in compliance with bundle:
 Following lock, catheter must be off infusion for 4 hours
 Locks must be ordered standard prn for each lumen (if double) so RN can
lock patient in conjunction with work flow. If RN cannot incorporate lock
into workflow, prn lock order is not pulled to eMAR
 Try to lock both lumens of a double-lumen catheter on the same day. If
unable, document date that lumen (white or red) was locked. Check
eMAR when last locked and proceed accordingly (see above schedule)