Check for blood return ? No blood return Good blood return obtained Evaluate continued need for VAD. Consider alternateive routes for medication delivery Proceed with Infusion Therapy as ordered Notify and collaborate with MD/NP. Re-examine initial or last chest x-ray and repeatt x-ray of catheter/port. Consider referral to IR for imaging (venogram/cathetergram) studies If definitive catheter occlusion, determine occlusion source and follow appropriate algorithm Care Pathway for Assessment of Central VAD Occlusion I. Mechanical Obstruct8ionsII. Thrombotic OcclusionIII. Non-Thrombotic Occlusions

I. Suspected Mechanical Obstruction Consider all external mechanical mal-positions or problems. Check catheter and tubing for clamps, kinks, tight sutures, dislodged HPN. Remove dressing material to visualize external catheter/exit site. Re-access implanted ports with new HPN. Attempt to aspirate blood Good blood return obtained Proceed with infusion therapy as ordered Mechanical obstruction corrected Assess for internal mechanical obstruction. Patient to change positions,mover arms overhead, Valsalva, deep breath, cough, Trendelenberg, knee- to-chest positoning. No mechanical obstruction found and Unable to withdraw blood Suspect Thrombotic or Non-Thrombotic Occlusions Assess for signs/symptoms for venous thrombosis: jugular distension, superficial collateral circulation on chest wall, arm swelling ipsilateral to VAD If signs/symptoms of Venous Thrombosis Present: Refer to physician for follow-up diagnosis and treatments

II. Suspect Non-Thrombotic Occlusion No Blood Return with Aspiration Consider occlusion of drug precipitates, mineral deposits or lipid sludge. Review and evaluate recent infusastes for suspect cause of occlusion (See Table 2.) Obtain medical order for dissolving agent for mineral or lipid deposits (See Table 3.) Instill appropriate dissolving agents per this proceudre. Aspirate/ discard all precipitate and 3-5cc blood,. Then flush with 10cc NS. Proceed with infusion therapy as ordered Notify MD and nursing staff of outcomes. Document procedure in Medical Records

III. Suspect Thrombotic Occlusion Mechanical and non-thrombotic obstructions ruled-out. Evaluation indicates high probability for fibrin related occlusion Consult with MD/NP and obtain orders for instillation of thrombotic agent per this procedure. (See Table 4 and this Procedure) Instill thrombolytic agent. Wait minutes. Aspirate and discard fibrin clot and thrombolytic agent along with 3-5cc blood. Flush with 10-20cc sterile NS (preservative-free recommended) Patency /Flow Restored Thrombotic occlusion remains/No blood return obtained Resume VAD use. Notify MD and nursing staff of outcomes. Document procedure and outcomes in Medical Record Consult with medical team. Consider 2 nd dose and / or 2 hr infusion of thrombolytic agent. Consider additional diagnostic approaches and management of occluded VAD for continued infusion therapy

Clearance Agent Decision Tree Central Vascular Access Device with Obstruction Check for Mechanical (Extrnal/Internal) Obstructions Prior to Agent or Medication Administration (Obtain Chest X-Ray) Assess Use-History of VAD for past 12 hours Choose Most Appropriate Agent Thrombotic or Unknown Alteplase Ethanol HCL Drug Precipitate (Mineral) HCL Ethanol Alteplase Drug Precipitate (i.e. Dilantin) Sodium Bicarbonate Ethanol Alteplase Lipid Sludge Ethanol HCL Alteplase