Presentation on theme: "Central Venous Catheter Occlusion Management"— Presentation transcript:
1Central Venous Catheter Occlusion Management Learning ModuleSeptember 2013adapted from Calgary Zone Alberta Health Services Education
2Table of Contents Introduction 3 Qualification 6 Objectives 7 Target Audience8Required Reading9Types of Occlusion10Non-Thrombotic Occlusions13Thrombotic Occlusions26Assessment of Occlusion37Catheter Clearance Agents44Calculating Catheter Lumen Volume72Instillation of Catheter Clearance Agents77Education and Documentation85Learning Resources and Activities91Frequently Asked Questions97Post-Test104Skills Checklist112
3IntroductionOcclusion is one of the most common complications associated with central venous cathetersIt is a significant complication because it can result in:Infusion therapy being disruptedThrombosis of the blood vesselInfectionInfiltration and extravasationNeed for catheter removal or replacement
4Whenever possible…“Salvaging the dysfunctional catheter, as opposed to removal and insertion of a replacement, is the preferred approach” (Haire, WD., & Herbst, SF., 2000)
5If 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)
6QualificationManagement 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 protocolsLearning moduleQualification examination - Obtain 85% prior to demonstration of skillsSkill demonstration as per checklistWhen you leave here you’ll need to complete a skills checklist with a qualified RN to complete your qualificationOnce completed, enter the course information in as an external event.Follow your area process for storing your checklist and re-certifying on a yearly basis
7ObjectivesOn completion of the learning module, the learner will be able to:Identify the different types of central venous catheter occlusionsDescribe assessment of an occluded catheterDescribe methods to restore catheter patencyDifferentiate the various types of catheter clearance agentsDescribe how to calculate catheter clearance volumeDistinguish between the various methods of catheter clearance instillationDescribe required patient and staff educationDescribe required documentationSuccessfully demonstrate occlusion management procedures as per checklist
8Nurses who will be a Unit resource Target AudienceNurses who will be a Unit resourceNurses in specialized areas where this skill is deemed necessaryPrior to undertaking this module, the nurse must be qualified in:CVC - General Care and MaintenanceCVC - Removal.
9Required ReadingCovenant Health- Central Venous Catheter Occlusion Management Procedure –Appendix A Medical Protocol for Occlusion ManagementAppendix B Priming Volumes and Catheter CompositionCovenant Health Latex Allergy Precautions – Care of the Patient/ Client/Resident, Corporate Policy #VII-B-105
11Types of OcclusionsIt is estimated that 25% of catheters will become occludedSigns that may indicate a catheter occlusion include:Unable to flush or aspirate - complete occlusionAble to flush but unable to aspirate - withdrawal occlusionIncreased resistance to flushing - sluggish catheter
12Types of Occlusions Types of occlusions include: Thrombotic Non-thromboticWhile the majority of occlusions are thrombotic, the literature states 42% are nonthromboticOcclusions may have more than one causeThese stats are from the literature, but in reality, most occlusions will be thrombotic.Example of occlusions having more than one cause – a medication precipitate may be present and then fibrin and blood adhere also causing a thrombotic occlusion – this may require more than one unblocking agentGenentech Inc.
14Non-thrombotic Occlusions There are 4 types of non-thrombotic occlusions including:MechanicalMalpositioned tipDrug or mineral precipitateLipid residue
15Mechanical Occlusions Mechanical occlusions are caused by an external factor that prevents flushing or aspirationExamples of mechanical occlusions include:Closed clampsTight sutures around catheterKinked catheter or tubingClogged injection capCatheter collapsing with forceful aspirationIncorrect placement of non-core needle in implanted portIncorrect length of non-coring needle in implanted portPinch-off syndrome
16Mechanical Occlusions When a catheter appears to be occluded, the first step is to rule out a mechanical obstruction
17Mechanical Occlusions Incorrect Placement of Non-Core NeedleRemember, if unable to flush or aspirate blood with an implanted port - the first step is to re-access to rule out needle malposition
18Mechanical Occlusions Pinch-Off SyndromeCatheters inserted into the subclavian vein may be “pinched off” between the clavicle and first ribSigns 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 syndromeIf pinch-off syndrome confirmed on CXR – catheter must be removed due to risk of catheter rupture or fracture
19Catheter Tip Malposition Ideal CVC tip placement is in the lower 1/3 of the SVCIncidence of malposition has been reported to be as high as 29% for CVCs inserted in the subclavian vein and up to 55% for PICCsFactors that may increase the incidence of malposition include:Initial tip placement not in the lower 1/3 of SVCIncreased intrathoracic pressure - coughing and vomitingVigorous movements of upper extremitiesInadequate catheter securement
20Catheter 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 catheterArm or shoulder discomfortArrhythmiasFeeling a sensation in neck or hearing a gurgling sound during infusion
21Catheter 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 agentPossible interventions to assist with tip reposition include:repositioning patientcoughingvigorous flushing of catheter, if appropriate
22Drug or Mineral Precipitates Causes of drug or mineral precipitates include:Drug crystallizationDrug-drug incompatibilityDrug-solution incompatibilityDrugs that are notorious causes of precipitate include:PhenytoinHeparin (given after a drug without first flushing with normal saline)Calcium and phosphatesafeinfusiontherapy.com
23Drug 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).
24Lipid 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
25Lipid ResidueIt 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.
27Thrombotic 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 thrombusFibrin tailFibrin sheath or sleeveMural thrombusHover over each type and get a picture
28Thrombotic 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 thrombusFibrin tailFibrin sheath or sleeveMural thrombus
29Four Types of Thrombotic Occlusions Four different types of thrombotic occlusion can occur in catheters An intraluminal thrombus forms inside the lumen of the catheter when blood products or fibrin build up. This may cause a partial or a complete occlusion.A fibrin tail, or flap, can form when fibrin extends from the end of the catheter. This may cause a partial occlusion, where during infusion, the tail is pushed outward allowing fluid to flow out. However, an attempt to aspirate will draw the tail inward like a one-way valve, thereby blocking the opening of the lumen and preventing blood from being drawn.A mural thrombus forms when fibrin from a a vessel wall injury binds to the fibrin covering the catheter surface, and may lead to formation of a venous thrombus in addition to catheter obstruction.A fibrin sheath forms when fibrin adheres to the external surface of the catheter and encases it like a sock, covering the openings of the catheter tip. It may extend the full length of the catheter.Haire WD, Herbst SF. Consensus conference on the use of alteplase (t-PA) for the management of thrombotic catheter dysfunction. J Vasc Access Devices. Highlights Bulletin: Summer 2000: 1-8.Wingerter L. Vascular access device thrombosis. Clin. J. Oncol. Nurs ;7(3):McKnight S. Nurses guide to understanding and treating thrombotic occlusion of central venous access devices. Medsurg Nurs. 2004;13(6):Forms inside catheter lumenMay cause partial or complete occlusionFibrin extends from the end of the catheterCan act as a one-way valve causing a partial occlusionFibrin from vessel wall injury binds to fibrin on catheter surfaceMay cause venous thrombus as well as catheter obstructionForms when fibrin adheres to the external catheter surface, encasing it like a sock, covering the opening of the catheter tipImages courtesy of Genentech, Inc. used with permission.Haire WD. J Vasc Access Devices. 2000; Wingerter. L. Clin J Oncol Nurs. 2003; 7:435
32Blood clotting is the transformation of liquid blood into a semisolid gel. The blood contains about a dozen clotting factors, proteins that exist in an inactive state, but can be called into action when tissues or blood vessels are damaged. The activation of clotting factors occurs in a sequential manner. The first factor in the sequence activates the second factor, which activates the third factor and so on. This series of reactions is called the coagulation (clotting) cascade.Coagulation is a multistep process that involves two pathways—an “intrinsic” pathway and an “extrinsic” pathway. The extrinsic pathway requires tissue factor, which is not normally present in the blood (hence the name). Tissue factor is exposed following injury to the vessel wall and triggers the coagulation cascade. The intrinsic pathway is initiated by the exposure of plasma to the skin or collagen of damaged vessels. A series of clotting factors present in the blood are activated sequentially and lead to the formation of thrombin, an activated clotting factor. Thrombin catalyzes the conversion of fibrinogen, a soluble blood protein, to fibrin, insoluble strands which form the scaffolding upon which platelets and red blood cells aggregate to form the hemostatic clot or thrombus.Blood clots are designed to be temporary. Once the vessel is healed, the blood clot is no longer needed. The clot itself stimulates secretion of tissue plasminogen activator (tPA) from surrounding vascular epithelium. tPA catalyzes the conversion of plasminogen to plasmin, the enzyme that dissolves the clot. Plasmin levels are not very high, so the clot removal process is slow.Fibrinolytic agents such as alteplase (recombinant tPA) (CATHFLO®) remove clots by dissolving the fibrin strands to break apart the thrombus.Fuster V, Verstraete M. Hemostasis, thrombosis, fibrinolysis, and cardiovascular disease. In: Braunwald E, Heart Disease: A Textbook of Cardiovascular Medicine. 5th ed. Philadelphia, Pa: WB Saunders;1997:
33Intraluminal 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.
34Fibrin TailPlatelet 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.
35Fibrin 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.
36Mural ThrombusEndothelial 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.If mural or venous thrombosis involves the tip of the catheter, obstruction may occur.Genentech Inc.
37An “instillation occlusion’ may occur with a port catheter An “instillation occlusion’ may occur with a port catheter. In this case, blood can be aspirated but the device cannot be flushed or the medication cannot be administered. The occlusion is a “sludge” of debris which contain both thrombus as well as precipate.It is important to ensure adequate flushing between therapies to prevent this type of occlusion.
39Risk vs. BenefitAlthough 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 precipitateAdverse reactions to catheter clearance agentCatheter damageEmbolization of clot, precipitate or catheter
40Risk vs. BenefitWhen assessing risk vs. benefit, the following questions may assist indetermining if the occlusion should be managed or the catheterremoved: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 tosalvage this catheter outweigh the risks associated with treatingthe occlusion?
41AssessmentPrior to initiating occlusion management the qualified nurse must confirm:The type of catheterThat an occlusion exits and the most likely causeThe qualified nurse must also review the patient’s physical status, allergies and any other contraindications to using the catheter clearance agent
42Assessing Type of Catheter Tunneled CVCs, PICCs and Implanted PortsUnblocking procedures may be used if deemed appropriateDirect Percutaneous CVCs and MidlinesBlocked 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 CathetersBlocked lumens must be managed by qualified staff in those specialty areasIn some cases a decision will be made to salvage a direct percutaneous CVC/short term CVC if the risk of catheter insertion is high. Catheters with occlusions should be removed or the occlusion managed.
43Assessing 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?
44Assessing the CauseAre 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?TNA = total nutrition admixture
46Catheter Clearance Agents IndicationClearance AgentThrombotic OcclusionsAlteplase (Cathflo)Lipid OcclusionsEthyl AlcoholPrecipitates of low pH (acidic) drugs orcalcium phosphorus precipitatesHydrochloric AcidPrecipitates of high pH (alkaline) drugsi.e. gancyclovir, acyclovir, ampicillin, phenytoin, septraSodium BicarbonateThe most common type of occlusion is thrombotic. If an occlusion is caused by precipitate or lipid, contact site resource for assistance with occlusion management.
47Note...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.
48pH of common drugs Medication pH Unblocking Agent Alkaline Acidic Ampicillin8 - 10Sodium BicarbonateDilantinAcyclovirGancyclovir11AcidicVancomycin2.5 – 4.5Hydrochloric AcidCiprofloxacin3.5 – 4.6Dopamine3.3 – 3.6Gentamicin3.0 – 5.5Morphine2.5 – 6.5Amikacin3.5 – 5.5Piperacillin/Tazobatam4.5 – 6.9Note: Information regarding pH of medications is located in Micromedix – Trissel’s IV CompatibilityNote: 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
49Cathflo Description Indications and Usage Converts plasminogen to plasmin which initiates local fibrinolysis.Indications and UsageCathflo is indicated for restoration of function to CVCs - as assessed by the ability to withdraw blood.Genentech Inc.
51See How Cathflo Works http://www.cathflo.com/moa/index.jsp Cut and past into browser to see how Cathflo works
52CathfloEfficacyEfficacy has been shown in 2 major studies – COOL-1 andCOOL-2
53After the first 120 min treatment, function was restored in 74% (51 of 69) of the CATHFLO® treatment group compared to 17% (12 of 70) in the placebo arm (p< ). After the second dose of CATHFLO®, the cumulative restoration of function was 90%.There were no serious study drug-relate adverse events, no intracranial hemorrhage, no major hemorrhage, and no embolic events.All types of central catheters, including single-, double- and triple-lumen, ports, Groshong catheters, Hickman catheters, apheresis catheters and PICCs were studied in this trial. Catheters used for hemodialysis were not included, however catheters of similar type (tunneled 14-F apheresis catheters) were included and showed efficacy rates similar to those seen in the overall study.Ponec D, Irwin D, Haire DW et al. Recombinant tissue plasminogen activator (Alteplase) for restoration of flow in occluded central venous access devices: A double-blind Placebo-controlled trial—The Cardiovascular Thrombolytic to Open Occluded Lines (COOL) efficacy trial J Vasc Interv Radiol. 2001;12(8):
54Function was restored in 52% and 75% of catheters at 30 and 120 minutes after the first dose of alteplase, and in 84% and 87% at 30 and 120 minutes after the second dose, respectively.There were no cases of Intra Cranial Hemmorhage during the study. There were no cases of death, major bleeding episodes, or embolic events attributable to the treatment.Rare adverse reactions included five cases of sepsis, three cases of GI bleeding and one injection site hemorrhage in patients with underlying disease, and three cases of deep vein thrombosis that may have been related to the underlying disease.346 patients who had successful treatment outcomes were available for follow-up evaluation at 30 days after treatment. 74% of these patients had functional catheters; 26% had recurrent catheter dysfunction.Deitcher S, Fesen MR, Kiproff PM et al. Safety and efficacy of alteplase for restoring function in occluded central venous catheters: Results of the Cardiovascular Thrombolytic to Open Occluded Lines Trial. J Clin Oncology, 2002; 20(1):
55The COOL-2 trial demonstrated that shorter duration of occlusion correlates with higher rate of restored catheter function.Catheter function was restored in 91% of patients with an occlusion lasting less than 24 hr after up to 2 doses of alteplase using a 2 hr dwell.Function was restored in 84% of patients after up to 2 doses of alteplase using a 2 hour dwell with an occlusion lasting 1 to 14 days.Restoration rates continued to decrease as the duration of occlusion increased.Deitcher S, Fesen MR, Kiproff PM et al. Safety and efficacy of alteplase for restoring function in occluded central venous catheters: Results of the Cardiovascular Thrombolytic to Open Occluded Lines Trial. J Clin Oncology, 2002; 20(1):
56Cathflo Concentration Preparation Stability 2mg vial – 1 mg/mL Add 2.2 mL of sterile water for injection (non-bacteriostatic)Do not shake vial – swirl and/or invert gently to mixAttach a 5 micron filter needle to 10mL syringeWithdraw 2mL (2mg) of solution from the reconstituted vialRemove the filter needle from syringeNote: For patients with a latex allergy, prepare medication according Covenant Health Policy & Procedure.StabilityReconstituted vial may be stored for 8 hours when stored between ° CUnreconstituted vials must be refrigeratedGenentech Inc.
57Cathflo Instillation Volume 2 mL or equal to volume of catheter lumen, if indicatedDwell TimeminutesMay be left in catheter overnight if requiredAspirate 4-5mLs and discardMay repeat dose x 1MonitoringBaseline BP, pulse, respirations and temperatureIf you have a dual lumen catheter with both lumens blocked - it's up to your discretion if you choose to instill 1mg into each lumen or the full 2mg dose in each - the type of catheter and lumen volume might help you decide. The weekly maximum dose is 4 mg.Genentech Inc.
59Cathflo Contraindications Precautions Cathflo should not be administered to patients with known hypersensitivity to Alteplase or any component of the formulation.PrecautionsCaution with patients who have active internal bleeding or who have had any of the following within 48 hours:SurgeryObstetrical deliveryPercutaneous biopsy of viscera or deep tissues or puncture of non-compressible vesselsCaution 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 fetusCaution in the presence of known or suspected infection in the catheterGenentech Inc.
60Reconstituting Cathflo See Resource List for videoYou may need to open the video file attached to see the video
61Ethyl Alcohol Description Indications and Usage Efficacy Acts as a solvent to dissolve the lipid residueIndications and UsageLipid occlusions in central venous cathetersEfficacyIn a study by Werlin (1995), 58% of catheters thought to be occluded with lipid were cleared with ethyl alcohol.
62Ethyl Alcohol Concentration Preparation Stability 70% ethyl alcohol for injectionPreparationPrepared by pharmacySupplied in vialStabilityMay be stored for 24 hours at room temperatureInstillation VolumeEqual to volume of catheter lumen
63Ethyl Alcohol Dwell Time Monitoring 60 minutes Aspirate 3mLs and discardMay repeat dose x 1MonitoringBaseline BP, pulse, respirations and temperature
64Ethyl Alcohol Adverse Reactions Contraindications Precautions Sepsis TirednessHeadachesDizzinessNauseaContraindicationsHypersensitivity to ethanolDO NOT use with polyurethane cathetersPrecautionsPatients should be advised not to drive following instillation of ethanolCaution in the presence of known or suspected infection in the catheter
65Hydrochloric Acid Description Dissolves drug precipitate by altering the pH in the catheter. Acidic drugs become more soluble in an acidic environmentIndications and UsageCalcium phosphorus precipitates or precipitates of low pH drugs in CVCs i.e. amikacin, piperacillin, vancomycin, heparin, morphine, adriamycin, ciprofloxacinEfficacyIn a study by Duffy, et al (1989), 58% of occlusions attributed to mineral precipitate cleared with HCl
66Hydrochloric Acid Concentration Preparation Stability 0.1 N (molar)PreparationPrepared by pharmacySupplied in vialStabilityMay be stored for 24 hours at room temperatureInstillation VolumeEqual to volume of catheter lumen
67Hydrochloric Acid Dwell Time Monitoring 20-60 minutes Aspirate 3mL and discardMay repeat dose x 3MonitoringBaseline BP, pulse, respirations and temperature
68Hydrochloric Acid Adverse Reactions Contraindications Precautions Febrile reactionSepsisOtherwise, minimal risk of adverse reactions when used for occlusion managementContraindicationsNonePrecautionsDO 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
69Sodium Bicarbonate Description Indications and Usage Efficacy Dissolves drug precipitate by altering the pH in the catheter. Alkaline drugs become more soluble in an alkaline environmentIndications and UsagePrecipitates of high pH drugs in CVCs i.e. gancyclovir, acylovir, ampicillin, phenytoin, septraEfficacyAlthough literature describes the use of sodium bicarbonate, there are no reported statistics on the efficacy
70Sodium Bicarbonate Concentration Preparation Stability 8.4% NaHCO3PreparationPrepared by pharmacySupplied in vialStabilityMay be stored for 24 hours at room temperatureInstillation VolumeEqual to volume of the catheter lumen
71Sodium Bicarbonate Dwell Time Monitoring 20-60 minutes Aspirate 3mLs and discardMay repeat dose x 1MonitoringBaseline BP, pulse, respirations and temperature
72Sodium Bicarbonate Adverse Reactions Contraindications Precautions Febrile reactionsSepsisOtherwise, minimal risk of adverse reactions when used for occlusion managementContraindicationsNonePrecautionsDO 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.
74Calculating Lumen Volume Calculating lumen volume may rarely be required when instilling catheter clearance agentsIf catheter has been trimmed on insertion you will need to calculate volume after trimmingTo calculate lumen volume refer to:catheter insertion recordAppendix 2 – Priming Volumes and Catheter Composition
75Calculating Lumen Volume Example4 FR Groshong PICC originally 60 cm long with a volume 0.45 mLInserted length 37 cm, external length 3 cm (remember to add 2 cm for hub)Calculation60 cm = 42 cm0.45 mL XLumen Volume = 0.32mL
76Calculating Lumen Volume ExampleImplanted port: Bard PowerPort isp MRI implanted port – (no documentation of trimmed length)Non-Core Needle: Bard Safestep 22 gauge without needleless y-siteCalculationPower Port: 1.5 mL volumeSafestep Non-Coring Needle: 0.3mL volumeLumen Volume = 1.8mL (before trimming)
78Instillation of Catheter Clearance Agents TechniqueIndicationDirect Instillation TechniqueWithdrawal occlusion or sluggish catheterNegative Pressure Technique Without StopcockComplete occlusionNegative Pressure Technique Using StopcockComplete occlusion when catheter clearance agent is supplied in syringe smaller than 10 mL .Insert Pictures
79Direct Instillation Technique IndicationWithdrawal occlusion or sluggish catheterTechniqueFlush catheter with salineDirect instillation of agentAllow agent to dwell for appropriate amount of timeWithdraw and discard agentFlush catheter well with NS20-30 mL. of saline is used to flush the catheter after blood is withdrawn. Lock the catheter with the appropriate locking solution.
80Negative Pressure Technique No Stopcock IndicationComplete OcclusionTechniqueCreate negative pressure with empty syringeInstill agent using gentle push/pull action – DO NOT use force when pushingAllow agent to dwell for appropriate amount of timeWithdraw and discard agentFlush catheter well with NS
81Negative Pressure Technique No Stopcock See Resource List for video
82Negative Pressure Technique Stopcock IndicationComplete occlusion when catheter clearance agent is supplied in syringe smaller than 10mLTechniqueUsing stopcock create negative pressureOpen stopcock to catheter clearance agentAllow agent to dwell for appropriate amount of timeWithdraw and discard agentFlush catheter well with NS
83Negative Pressure Technique Stopcock Preparing SuppliesSee Resource List for video
84Negative Pressure Technique Stopcock ProcedureSee Resource List for video
86EducationPrior to instillation of an agent, explain the procedure and instruct the patient regarding possible adverse effects of the catheter clearance agentPost instillation of an agent, instruct the patient about safe behaviours and mandatory restrictions regarding the use of the catheter, including:Lumen to remain labelledAdverse reactionsLumen not to be used until agent removedAny agent specific precautions
87Documentation signature Label the lumen with a “Medication Added” label with the following:DO NOT USEMedicationamountdatetimesignature
88DocumentationPost instillation of agent, document in patient’s health record:EducationBaseline vital signs (if required)Catheter clearance agent instilledLumens instilledDo not use labeled lumenDwell time required
89DocumentationPost aspiration of agent, document in patient’s health record:Number of attemptsOutcome of procedurePatient’s response to procedureRecommendations for any required changes in procedures for maintenance of catheter patency.
92Additional Learning Resources Site / Provincial Drug MonographsPackage insert for the appropriate declotting/unblocking agentCathflo website:
93Learning 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 occlusionWhat 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?Most likely cause: lipid occlusionMost appropriate catheter clearance agent: ethyl alcoholCan agent be used with this catheter? YesIf pt. had power PICC solo – could not use ethyl alcohol as it may damage the catheterPriming volume of catheter – unable to determine exact volume because trimmed length not documented. Volume before trimming would be 1.8mL. Discussion with physician may be done re: some of the agent will be given systemicallyVolume of catheter clearance agent – 1.8mL
94Learning 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 occlusionWhat is the most appropriate catheter clearance agent?Calculate the lumen volume of the catheterWrite out how the order should be sent to pharmacyAre there any precautions to consider prior to instilling the unblocking agent?Most likely cause of occlusion: medication precipitateMost appropriate catheter clearance agent: Sodium BicarbonateLumen Volume: 0.35mLPharmacy Order: NaHC03 8.4% instill 0.35mL into lumen. Allow to dwell for 20 – 60 minutes then aspirate and discard. May repeat dose x 1.Precautions: Do not mix in catheter with HCl and caution in the presence of known or suspected infection in the catheter.
95Learning 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?Do you agree with nurse that you should not be concerned? No.Failure to treat an occluded catheter increases the risks of: Infusion therapy being disrupted, Thrombosis of the blood vessel, Infection, Infiltration or extravasation,Need for catheter removal or replacementIs it worth treating occlusion: Yes, the efficacy of Cathflo is 84% for a catheter that has been occluded for 1 – 14 days
96Learning 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 rationaleMost appropriate catheter clearance agent: CathfloWould you instill agent? Prior to deciding whether or not to instill cathflo, the nurse should consider: Does the patient have other venous access options? Would alternate venous access be easily obtained? Is there a suspected or confirmed catheter infection? Are there any contraindications or cautions to using Cathflo? (hypersensitivity to alteplase, active internal bleeding, recent surgery, hemostatic defects, high risk for embolic complications, pregnant)
98Frequently 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.
99Frequently 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.
100Frequently 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?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.
101Frequently 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.
102Frequently 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
103Frequently 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.