Thrombotic Occlusions

Report
Central Venous Catheter
Occlusion Management
Learning Module
September 2013
adapted from Calgary Zone Alberta Health
Services Education
Table of Contents
Introduction
3
Qualification
6
Objectives
7
Target Audience
8
Required Reading
9
Types of Occlusion
10
Non-Thrombotic Occlusions
13
Thrombotic Occlusions
26
Assessment of Occlusion
37
Catheter Clearance Agents
44
Calculating Catheter Lumen Volume
72
Instillation of Catheter Clearance Agents
77
Education and Documentation
85
Learning Resources and Activities
91
Frequently Asked Questions
97
Post-Test
104
Skills Checklist
112
Introduction
• Occlusion is one of the most common complications
associated with central venous catheters
• It is a significant complication because it can result in:
–
–
–
–
–
Infusion therapy being disrupted
Thrombosis of the blood vessel
Infection
Infiltration and extravasation
Need for catheter removal or replacement
Whenever possible…
• “Salvaging the
dysfunctional catheter, as
opposed to removal and
insertion of a replacement,
is the preferred approach”
(Haire, WD., & Herbst, SF.,
2000)
If catheter patency is not
restored…
• “…catheter removal should be
considered ...” (INS, 2011,
p.S77).
• “…microbiological studies
have shown that the proteins
within a clot, such as
fibrinogen and fibronectin,
attract staphylococcal species
and enhance their adherence
to the catheter surface,
thereby increasing the risk of
catheter infection” (Baskin, JI,
Pui, Ch and Reiss, U et al,
2009, 164)
Qualification
• Management of occluded central venous catheters (CVCs) is a
specialized clinical competency which is defined as any
procedure that requires the nurse to have additional cognitive and
psychomotor skill and qualification prior to performing the
procedure.
• Qualification is achieved by successfully completing the
educational program which includes the following components:
– Covenant Health policies, procedures and protocols
– Learning module
– Qualification examination - Obtain 85% prior to demonstration of
skills
– Skill demonstration as per checklist
Objectives
On completion of the learning module, the learner will be able to:
• Identify the different types of central venous catheter occlusions
• Describe assessment of an occluded catheter
• Describe methods to restore catheter patency
• Differentiate the various types of catheter clearance agents
• Describe how to calculate catheter clearance volume
• Distinguish between the various methods of catheter clearance
instillation
• Describe required patient and staff education
• Describe required documentation
• Successfully demonstrate occlusion management procedures as
per checklist
Target Audience
• Nurses who will be a Unit resource
• Nurses in specialized areas where this skill
is deemed necessary
• Prior to undertaking this module, the nurse
must be qualified in:
– CVC - General Care and Maintenance
– CVC - Removal.
Required Reading
• Covenant Health- Central Venous Catheter Occlusion Management
Procedure –
– Appendix A Medical Protocol for Occlusion Management
– Appendix B Priming Volumes and Catheter Composition
• Covenant Health Latex Allergy Precautions – Care of the Patient/
Client/Resident, Corporate Policy #VII-B-105
Types of Occlusions
Types of Occlusions
•
It is estimated that 25% of catheters will become occluded
•
Signs that may indicate a catheter occlusion include:
– Unable to flush or aspirate - complete occlusion
– Able to flush but unable to aspirate - withdrawal
occlusion
– Increased resistance to flushing - sluggish catheter
Types of Occlusions
• Types of occlusions include:
– Thrombotic
– Non-thrombotic
• While the majority of occlusions are
thrombotic, the literature states
42% are nonthrombotic
• Occlusions may have more than
one cause
Genentech Inc.
Non-Thrombotic Occlusions
Non-thrombotic Occlusions
There are 4 types of non-thrombotic occlusions
including:
1.
2.
3.
4.
Mechanical
Malpositioned tip
Drug or mineral precipitate
Lipid residue
Mechanical Occlusions
•
Mechanical occlusions are caused by an external factor that prevents
flushing or aspiration
•
Examples of mechanical occlusions include:
– Closed clamps
– Tight sutures around catheter
– Kinked catheter or tubing
– Clogged injection cap
– Catheter collapsing with forceful aspiration
– Incorrect placement of non-core needle in implanted port
– Incorrect length of non-coring needle in implanted port
– Pinch-off syndrome
Mechanical Occlusions
• When a catheter appears to be occluded, the first step is to rule out
a mechanical obstruction
Mechanical Occlusions
Incorrect Placement of Non-Core Needle
•
Remember, if unable to flush or
aspirate blood with an implanted port the first step is to re-access to rule out
needle malposition
Mechanical Occlusions
Pinch-Off Syndrome
•
Catheters inserted into the subclavian
vein may be “pinched off” between the
clavicle and first rib
•
Signs and Symptoms:
– inability to infuse and/or withdraw
that is resolved when changing
the patient’s position (raising
arms or rolling shoulders forward)
•
Chest X-ray must be taken to confirm
pinch-off syndrome
•
If pinch-off syndrome confirmed on
CXR – catheter must be removed due
to risk of catheter rupture or fracture
Catheter Tip Malposition
•
Ideal CVC tip placement is in the
lower 1/3 of the SVC
•
Incidence of malposition has been
reported to be as high as 29% for
CVCs inserted in the subclavian vein
and up to 55% for PICCs
•
Factors that may increase the
incidence of malposition include:
– Initial tip placement not in the
lower 1/3 of SVC
– Increased intrathoracic pressure coughing and vomiting
– Vigorous movements of upper
extremities
– Inadequate catheter securement
Catheter Tip Malposition
• In addition to the inability to infuse and/or withdraw, there
may be additional signs and symptoms of catheter tip
malposition including:
– Change in length of external portion of catheter
– Arm or shoulder discomfort
– Arrhythmias
– Feeling a sensation in neck or hearing a gurgling
sound during infusion
Catheter Tip Malposition
• If any of the additional signs
and symptoms of catheter tip
malposition exist, radiographic
studies must be undertaken
prior to instilling a catheter
clearance agent
• Possible interventions to
assist with tip reposition
include:
– repositioning patient
– coughing
– vigorous flushing of
catheter, if appropriate
Drug or Mineral Precipitates
•
Causes of drug or mineral precipitates
include:
– Drug crystallization
– Drug-drug incompatibility
– Drug-solution incompatibility
•
Drugs that are notorious causes of
precipitate include:
– Phenytoin
– Heparin (given after a drug
without first flushing with normal
saline)
– Calcium and phosphate
safeinfusiontherapy.com
Drug or Mineral Precipitates
Understanding drug precipitate is simple chemistry.
•
Acidic drugs (low pH) are more soluble in an
acidic environment. They will have a tendency
to precipitate when mixed with a basic drug
(high pH).
•
Basic drugs (high pH) are more soluble in a
basic environment. They will have a tendency
to precipitate when mixed with an acidic drug
(low pH).
Lipid Residue
• Lipid residue
– Drugs with lipid-containing
vehicles (eg. Propofol)
– Total nutrient admixtures
(3-in-1)
• The exact cause of the waxy
lipid build-up is unknown;
however, formation of a lipid
protein complex has been
suggested
Lipid Residue
• It is often difficult to distinguish between lipid
and thrombotic occlusions.
• Typically with a lipid occlusion, increasing
resistance to flushing will be noted for several
days prior to the catheter completely
occluding with lipid sludge.
• In some cases, a waxy like substance may
be visualized in the hub of the catheter when
the cap is removed.
Thrombotic Occlusions
Thrombotic Occlusions
• Thrombotic occlusions involve the formation
of fibrin or thrombus within/around the CVC
or in the surrounding vessel.
• 4 types of thrombotic occlusions include:
–
–
–
–
Intraluminal thrombus
Fibrin tail
Fibrin sheath or sleeve
Mural thrombus
Thrombotic Occlusions
• Thrombotic occlusions involve the formation
of fibrin or thrombus within/around the CVC
or in the surrounding vessel.
• 4 types of thrombotic occlusions include:
–
–
–
–
Intraluminal thrombus
Fibrin tail
Fibrin sheath or sleeve
Mural thrombus
Four Types of Thrombotic Occlusions
• Forms inside
catheter lumen
• May cause partial
or complete
occlusion
• Fibrin extends
from the end of
the catheter
• Can act as a oneway valve
causing a partial
occlusion
Images courtesy of Genentech, Inc. used with permission.
• Fibrin from vessel
wall injury binds
to fibrin on
catheter surface
• May cause venous
thrombus as well
as catheter
obstruction
• Forms when fibrin
adheres to the
external catheter
surface, encasing it
like a sock, covering
the opening of the
catheter tip
Haire WD. J Vasc Access Devices. 2000; Wingerter. L. Clin J Oncol Nurs. 2003; 7:435
Intraluminal Thrombus
•
Internal lumen of catheter is
obstructed either by clotted blood
or the accumulation of fibrin.
•
Coagulation and clot formation
results from inadequate flushing
or reflux of blood due to negative
pressure within the catheter (i.e.
coughing, valsalva maneuver,
failure to use positive pressure).
Genentech Inc.
Fibrin Tail
•
Platelet aggregation and fibrin
accumulation can cause a “tail” of
fibrin that extends off the end of
the catheter tip.
•
The tail may not interfere with
infusion but may occlude the
catheter during aspiration, if it is
drawn up against the tip. This
type of occlusion is called a
withdrawal occlusion.
Genentech Inc.
Fibrin Sleeve or Sheath
•
Platelet aggregation and fibrin
deposit encase the external
surface of the catheter and form a
sac around the distal end.
•
The sleeve or sheath may cause
retrograde flow of infusate back
up the length of the catheter.
•
If the sleeve or sheath extend to
the vein insertion site, the infusate
may even be observed on the
skin, or in subcutaneous pocket.
Genentech Inc.
Genentech Inc.
Mural Thrombus
•
Endothelial damage to the blood
vessel results in fibrin deposition
at the point of cellular damage.
•
If the thrombus occurs only along
the wall of the vein, it is called a
mural thrombus.
•
If thrombus completely occludes
the vein, it is called a venous
thrombus.
Genentech Inc.
•
If mural or venous thrombosis
involves the tip of the catheter,
obstruction may occur.
Assessment for Occlusion
Management
Risk vs. Benefit
• Although occlusion management has many benefits, it
may also be associated with some risks including:
– Releasing bacteria into the venous system that may
have been embedded in the clot, biofilm, fibrin, or
precipitate
– Adverse reactions to catheter clearance agent
– Catheter damage
– Embolization of clot, precipitate or catheter
Risk vs. Benefit
When assessing risk vs. benefit, the following questions may assist in
determining if the occlusion should be managed or the catheter
removed:
• Is the CVC still required? If so, for how long?
• Are there any other venous access options? Would alternate
appropriate venous access be easily obtained?
• Is there a suspected or confirmed catheter related infection?
• Are there any contraindications to using a specific unblocking
agent?
The main question that must be answered is: Does the need to
salvage this catheter outweigh the risks associated with treating
the occlusion?
Assessment
• Prior to initiating occlusion management the qualified
nurse must confirm:
– The type of catheter
– That an occlusion exits and the most likely cause
• The qualified nurse must also review the patient’s
physical status, allergies and any other contraindications
to using the catheter clearance agent
Assessing Type of Catheter
Tunneled CVCs,
PICCs and
Implanted Ports
Unblocking procedures
may be used if
deemed appropriate
Direct
Percutaneous
CVCs and Midlines
Blocked lumens should
be labeled as blocked
and consideration
given to removing
catheter as soon as
possible. If catheter is
not removed, manage
the occlusion.
Apheresis or
Dialysis Catheters
Blocked lumens must
be managed by
qualified staff in those
specialty areas
Assessing the Cause
•
•
•
•
•
•
•
Does patient have a history of
hypercoagulation?
Have mechanical causes of
occlusion been ruled out?
Are there any indications that the
tip may be malpositioned?
What was the last medication
infused?
Is the patient receiving
incompatible medications?
Has the catheter been flushed
with saline between
infusions/medications?
Is the catheter locked with
heparin?
Assessing the Cause
• Are drugs with lipid containing
vehicles or TNA being
infused?
• Did the occlusion develop
suddenly or over several
days?
• Has the catheter been used
for blood sampling?
• Are push/pause flushing and
positive pressure being used?
• Are blood or lipids visible in
the catheter?
Catheter Clearance Agents
Catheter Clearance Agents
Indication
Clearance Agent
Thrombotic Occlusions
Alteplase (Cathflo)
Lipid Occlusions
Ethyl Alcohol
Precipitates of low pH (acidic) drugs or
calcium phosphorus precipitates
Hydrochloric Acid
Precipitates of high pH (alkaline) drugs
Sodium Bicarbonate
i.e. gancyclovir, acyclovir, ampicillin, phenytoin, septra
The most common type of occlusion is thrombotic. If an occlusion is caused by precipitate or lipid,
contact site resource for assistance with occlusion management.
Note...
• The majority of catheter
occlusions are thrombotic,
therefore, if unable to
determine the cause of the
occlusion, and there are no
contraindications, a
thrombolytic should be tried
first.
Genentech Inc.
pH of common drugs
Medication
Alkaline
Acidic
pH
Unblocking Agent
Ampicillin
8 - 10
Sodium Bicarbonate
Dilantin
10 - 12
Acyclovir
10 - 12
Gancyclovir
11
Vancomycin
2.5 – 4.5
Ciprofloxacin
3.5 – 4.6
Dopamine
3.3 – 3.6
Gentamicin
3.0 – 5.5
Morphine
2.5 – 6.5
Amikacin
3.5 – 5.5
Piperacillin/Tazobatam
4.5 – 6.9
Hydrochloric Acid
Note: Information regarding pH of medications is located in Micromedix – Trissel’s IV Compatibility
Note: Some medications have a tendency to precipitate which is not related to pH. The use of sodium bicarbonate or
hydrochloric acid is unlikely to be effective. Some examples include: cloxacillin, heparin, diazepam
Cathflo
Description
• Converts plasminogen to plasmin which
initiates local fibrinolysis.
Indications and Usage
• Cathflo is indicated for restoration of
function to CVCs - as assessed by the
ability to withdraw blood.
Genentech Inc.
Cathflo Breaks Down the Clot
Genentech Inc.
See How Cathflo Works
• http://www.cathflo.com/moa/index.jsp
Cathflo
Efficacy
• Efficacy has been shown in 2 major studies – COOL-1 and
COOL-2
Concentration
•
Cathflo
2mg vial – 1 mg/mL
Preparation
•
•
•
•
•
•
Add 2.2 mL of sterile water for injection (nonbacteriostatic)
Do not shake vial – swirl and/or invert gently
to mix
Attach a 5 micron filter needle to 10mL
syringe
Withdraw 2mL (2mg) of solution from the
reconstituted vial
Remove the filter needle from syringe
Note: For patients with a latex allergy,
prepare medication according Covenant
Health Policy & Procedure.
Stability
•
•
Reconstituted vial may be stored for 8 hours
when stored between 2 - 30° C
Unreconstituted vials must be refrigerated
Genentech Inc.
Cathflo
Instillation Volume
• 2 mL or equal to volume of
catheter lumen, if indicated
Dwell Time
• 30 -120 minutes
• May be left in catheter overnight if
required
• Aspirate 4-5mLs and discard
•
May repeat dose x 1
Genentech Inc.
Monitoring
• Baseline BP, pulse, respirations
and temperature
Cathflo
Genentech Inc.
Cathflo
Contraindications
•
Cathflo should not be administered to patients with known
hypersensitivity to Alteplase or any component of the
formulation.
Precautions
•
Caution with patients who have active internal bleeding or
who have had any of the following within 48 hours:
– Surgery
– Obstetrical delivery
– Percutaneous biopsy of viscera or deep tissues or
puncture of non-compressible vessels
•
Caution with patients who have thrombocytopenia, other
hemostatic defects or any condition for which bleeding is a
significant risk or would be difficult to manage because of its
location or who are at high risk for embolic complications
(venous thrombosis in the region of the catheter)
•
Use in pregnancy only if potential benefit justifies the potential
risk to the fetus
•
Caution in the presence of known or suspected infection in
the catheter
Genentech Inc.
Reconstituting Cathflo
See Resource List for video
Ethyl Alcohol
Description
•
Acts as a solvent to dissolve the lipid residue
Indications and Usage
•
Lipid occlusions in central venous catheters
Efficacy
•
In a study by Werlin (1995), 58% of catheters thought to be occluded with
lipid were cleared with ethyl alcohol.
Ethyl Alcohol
Concentration
•
70% ethyl alcohol for injection
Preparation
•
•
Prepared by pharmacy
Supplied in vial
Stability
•
May be stored for 24 hours at room temperature
Instillation Volume
• Equal to volume of catheter lumen
Ethyl Alcohol
Dwell Time
•
•
•
60 minutes
Aspirate 3mLs and discard
May repeat dose x 1
Monitoring
•
Baseline BP, pulse, respirations and temperature
Ethyl Alcohol
Adverse Reactions
•
•
•
•
•
Sepsis
Tiredness
Headaches
Dizziness
Nausea
Contraindications
•
•
Hypersensitivity to ethanol
DO NOT use with polyurethane catheters
Precautions
•
•
Patients should be advised not to drive following instillation of ethanol
Caution in the presence of known or suspected infection in the catheter
Hydrochloric Acid
Description
• Dissolves drug precipitate by altering the pH in the catheter. Acidic
drugs become more soluble in an acidic environment
Indications and Usage
•
Calcium phosphorus precipitates or precipitates of low pH drugs in CVCs
i.e. amikacin, piperacillin, vancomycin, heparin, morphine, adriamycin,
ciprofloxacin
Efficacy
•
In a study by Duffy, et al (1989), 58% of occlusions attributed to mineral
precipitate cleared with HCl
Hydrochloric Acid
Concentration
•
0.1 N (molar)
Preparation
•
•
Prepared by pharmacy
Supplied in vial
Stability
•
May be stored for 24 hours at room temperature
Instillation Volume
•
Equal to volume of catheter lumen
Hydrochloric Acid
Dwell Time
•
•
•
20-60 minutes
Aspirate 3mL and discard
May repeat dose x 3
Monitoring
•
Baseline BP, pulse, respirations and temperature
Hydrochloric Acid
Adverse Reactions
•
•
•
Febrile reaction
Sepsis
Otherwise, minimal risk of adverse reactions when used for occlusion
management
Contraindications
•
None
Precautions
•
•
DO NOT use hydrochloric acid (HCL) after sodium bicarbonate (or vice
versa) – even in final effort to clear a catheter. The combination could
generate heat and damage the catheter material.
Measures must be taken to protect the patient and the nurse from a
potential splash to eyes or exposed skin
Sodium Bicarbonate
Description
•
Dissolves drug precipitate by altering the pH in the catheter. Alkaline drugs
become more soluble in an alkaline environment
Indications and Usage
•
Precipitates of high pH drugs in CVCs i.e. gancyclovir, acylovir, ampicillin,
phenytoin, septra
Efficacy
•
Although literature describes the use of sodium bicarbonate, there are no
reported statistics on the efficacy
Sodium Bicarbonate
Concentration
•
8.4% NaHCO3
Preparation
•
•
Prepared by pharmacy
Supplied in vial
Stability
•
May be stored for 24 hours at room temperature
Instillation Volume
•
Equal to volume of the catheter lumen
Sodium Bicarbonate
Dwell Time
•
•
•
20-60 minutes
Aspirate 3mLs and discard
May repeat dose x 1
Monitoring
•
Baseline BP, pulse, respirations and temperature
Sodium Bicarbonate
Adverse Reactions
•
•
•
Febrile reactions
Sepsis
Otherwise, minimal risk of adverse reactions when used for occlusion
management
Contraindications
•
None
Precautions
•
DO NOT use sodium bicarbonate after hydrochloric acid (or vice versa) –
even in final effort to clear a catheter. The combination could generate
heat and damage the catheter material.
Calculating Lumen Volume
Calculating Lumen Volume
•
•
•
Calculating lumen volume may
rarely be required when instilling
catheter clearance agents
If catheter has been trimmed on
insertion you will need to
calculate volume after trimming
To calculate lumen volume refer
to:
– catheter insertion record
– Appendix 2 – Priming
Volumes and Catheter
Composition
Calculating Lumen Volume
Example
• 4 FR Groshong PICC originally 60 cm
long with a volume 0.45 mL
• Inserted length 37 cm, external
length 3 cm (remember to add 2 cm
for hub)
Calculation
60 cm = 42 cm
0.45 mL
X
Lumen Volume = 0.32mL
Calculating Lumen Volume
Example
• Implanted port: Bard PowerPort isp MRI
implanted port – (no documentation of
trimmed length)
• Non-Core Needle: Bard Safestep 22
gauge without needleless y-site
Calculation
• Power Port: 1.5 mL volume
• Safestep Non-Coring Needle: 0.3mL
volume
Lumen Volume = 1.8mL (before trimming)
Instillation of Catheter
Clearance Agents
Instillation of Catheter
Clearance Agents
Technique
Indication
Direct Instillation Technique
Withdrawal occlusion or sluggish
catheter
Negative Pressure Technique
Without Stopcock
Complete occlusion
Negative Pressure Technique
Using Stopcock
Complete occlusion when catheter
clearance agent is supplied in syringe
smaller than 10 mL .
Direct Instillation Technique
Indication
• Withdrawal occlusion or
sluggish catheter
Technique
• Flush catheter with saline
• Direct instillation of agent
• Allow agent to dwell for
appropriate amount of time
• Withdraw and discard agent
• Flush catheter well with NS
Negative Pressure Technique
No Stopcock
Indication
• Complete Occlusion
Technique
• Create negative pressure with
empty syringe
• Instill agent using gentle push/pull
action – DO NOT use force when
pushing
• Allow agent to dwell for
appropriate amount of time
• Withdraw and discard agent
• Flush catheter well with NS
Negative Pressure Technique
No Stopcock
See Resource List for video
Negative Pressure Technique
Stopcock
Indication
• Complete occlusion when
catheter clearance agent is
supplied in syringe smaller than
10mL
Technique
• Using stopcock create negative
pressure
• Open stopcock to catheter
clearance agent
• Allow agent to dwell for
appropriate amount of time
• Withdraw and discard agent
• Flush catheter well with NS
Negative Pressure Technique
Stopcock
Preparing Supplies
See Resource List for video
Negative Pressure Technique
Stopcock
Procedure
See Resource List for video
Education and
Documentation
Education
• Prior to instillation of an agent, explain the procedure
and instruct the patient regarding possible adverse
effects of the catheter clearance agent
• Post instillation of an agent, instruct the patient about
safe behaviours and mandatory restrictions regarding
the use of the catheter, including:
– Lumen to remain labelled
– Adverse reactions
– Lumen not to be used until agent removed
– Any agent specific precautions
Documentation
•
Label the lumen with a
“Medication Added” label
with the following:
– DO NOT USE
– Medication
– amount
– date
– time
– signature
Documentation
Post instillation of agent, document in
patient’s health record:
• Education
• Baseline vital signs (if required)
• Catheter clearance agent instilled
• Lumens instilled
• Do not use labeled lumen
• Dwell time required
Documentation
Post aspiration of agent, document in patient’s
health record:
• Number of attempts
• Outcome of procedure
• Patient’s response to procedure
• Recommendations for any required changes in
procedures for maintenance of catheter patency.
Learning Resources and
Activities
Additional Learning
Resources
• Site / Provincial Drug Monographs
• Package insert for the appropriate declotting/unblocking
agent
• Cathflo website: http://www.cathflo.com/home/index.jsp
Learning Activities
Case Study
Mrs. J. is a 54 year old woman who has been receiving parenteral
nutrition at home through a Bard 9.6 FR single lumen tunneled
Hickman catheter which has been insitu for 2 years. The insertion
documentation does not indicate the length of the catheter. She
reported that over the last few weeks she had increasing resistance
while flushing and today she is unable to flush at all.
• Identify the most likely cause of the occlusion
• What is the most appropriate catheter clearance agent?
• Can the indicated unblocking agent be safely used in this type of
catheter? If she had a Power PICC Solo would you be able to treat the
occlusion?
• Can you determine the priming volume of the catheter?
• What volume of catheter clearance agent would you use?
Learning Activities
Case Study
Mr. G. has been in hospital for 6 days receiving ampicillin through his
#4FR Groshong PICC. Inserted length 42cm, external length 3cm.
Today the nurse infused ampicillin just after infusing an incompatible
medication and she forgot to flush in between medications.
Immediately after she started the pump it showed a downstream
occlusion and she was unable to flush the catheter.
– Identify the most likely cause of the occlusion
– What is the most appropriate catheter clearance agent?
– Calculate the lumen volume of the catheter
– Write out how the order should be sent to pharmacy
– Are there any precautions to consider prior to instilling the unblocking
agent?
Learning Activities
Case Study
On PICC rounds you notice that Mr. T’s 5FR dual lumen Groshong
PICC has tape around the white lumen and it is labeled “blocked-do
not use”. You note blood backed up into the injection cap. The nurse
tells you that it has been blocked for about a week, but they only
require one lumen so they are not concerned.
• Do you agree with the nurse that you should not be concerned?
• What are the risks of leaving a lumen blocked?
• Considering what you know about the efficacy of Cathflo, if the lumen
has been blocked for 1 week, is it worth trying to treat the occlusion?
Learning Activities
Case Study
Your are called to a unit to assess Mrs. C’s PICC. She has a
dual lumen 5FR Power PICC Solo. The purple lumen is
functioning well but the red lumen is completely occluded.
The nurse reports that the red lumen occluded yesterday,
shortly after she obtained blood samples from the lumen. Mrs.
C. has been on IV cefazolin for 5 days for left leg cellulitis and
it is anticipated that she will receive 2 more days of therapy.
• What is the most appropriate catheter clearance agent?
• Would you instill this agent? Explain your rationale
Frequently Asked Questions
Frequently Asked Questions
Q.
What happens if the catheter
clearance agent is unsuccessful and
you are not able to withdraw it? Can
you attempt to flush the catheter?
A.
The catheter clearance literature
recommends withdrawing and discarding
catheter clearance agents. However,
when catheter clearance has not been
effective, this may not be possible.
Unless, there is a clinical indication that
patient should not receive any of the
agent systemically (eg. haematological
disorder and Cathflo) you may need to
flush the agent in to fully assess the
patency of the catheter. If you have any
concerns you should review the patient’s
situation with his/her physician.
Frequently Asked Questions
Q.
A power PICC solo has had several
thrombotic occlusions which have
been treated successfully with
Cathflo. Flushing and locking
technique is appropriate and the tip
is positioned in the lower 1/3 of the
superior vena cava. Is there
anything else that should be tried
to prevent further occlusions?
A. Some patients may have issues with
hyper-coagulation. If your patient’s
history indicates that this could be an
issue, you may want to discuss with
the physician whether a heparin lock
or sodium citrate 4% lock should be
used to prevent further occlusions.
Frequently Asked Questions
Q.
What if you can’t determine the
lumen volume of the catheter and
the agent is supposed to be
instilled according to the lumen
volume?
A. In most situations, alteplase is not
ordered according to lumen volume.
As per monograph, the usual dosage
is 2mL. All other agents are ordered
according to lumen volume, so prior
to proceeding you must discuss with
the ordering physician if they want to
proceed knowing that some of the
agent may be injected into the venous
system.
Frequently Asked Questions
Q. What if you can’t determine
the most likely cause of the
occlusion?
A. If your assessment suggests
that it is appropriate to
proceed with occlusion
management – Cathflo should
be the first catheter clearance
agent used because the
majority of catheter occlusions
are thrombotic. Ensure that
there are no contraindications
to using Cathflo prior to
proceeding.
Frequently Asked Questions
Q. What if you can’t determine
what type of implanted port
a patient has and the
physician has ordered ethyl
alcohol to treat a lipid
occlusion?
A. If you are unable to determine
if the catheter is polyurethane
or silicone, you cannot
proceed with instillation of
ethyl alcohol because of the
risk of damaging the a
polyurethane catheter
Frequently Asked Questions
Q.
Do vital signs need to be taken
immediately prior to instilling a
catheter clearance agent?
A.
Baseline vital signs are necessary to
rule out such precautions as a
catheter related infection. Vital signs
also provide baseline data in case of
any adverse reaction to the catheter
clearance agent. If there are already
documented vital signs for the shift,
review these and if appropriate
proceed with instillation. If there are
no vital signs documented for the
shift, obtain vital signs prior to
instillation.

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