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Wendy Erickson RN
Declotting Question

When you have one lumen of a multi-lumen catheter (PICC, CVC, IVAD, etc) that is clotted, do you stop infusions into the PATENT lumens while you declot the clotted lumen?  If so, why?  If so, do you then start a peripheral IV to continue infusions that may be life-sustaining?

lynncrni
 I don't recall ever having

 I don't recall ever having such a situation. Just thinking about it, I do think it is important to re-open the occluded lumen. I would check for compatibility between the thrombolytic agent and the infusing drug. If there is incompatiblity or no information can be found, I would stop the infusing drug during the declotting procedure. You do not want these drugs mixing at the catheter tip and forming a precipitate which could cause particulate matter to be trapped in the lungs or further occlude the open lumen or both. If patient stability during the procedur is an issue, you would have to find some other means for infusion such as a peirpheral catheter. But if that drug is a vesicant I would make sure the infusion was switched back to the CVAD ASAP and remove the peripheral. You don't want to add extravasation to the problem list! Lynn

Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Wendy Erickson RN
How would this be different

How would this be different from when we run incompatible medications via separate lumens?  Wouldn't the medications be instantly diluted and mixed into the blood stream as they come out of the tip?  Isn't this the point of multilumen catheters?

Wendy Erickson RN
Eau Claire WI

Ellen James
Yes, treat all lumens

Per the Alteplase instructions, we should treat all lumens of a multiple lumen line at the same time even if only one is occluded.  This is because of the high probablility of a fibrin tail buildup down the back side of the lumen even if it is functioning well which needs to be treated or it will shortly be encroaching on the lumen if left untreated. 

We start peripherals on meds of an appropriate pH.  If not, we try to get the lines fully functioning as quickly as possible so that the patient's  down time is at a minimum.  Our nurses have been aggressively educated to recognize the signs and symptoms of a partial occlusion and are asked to treat early so again, we can minimize down time.  I work in homecare.    

Ellen James, RN, CNS, CRNI, MS

VNA Colorado

[email protected]

ptrn
I would agree with Ellen.

I would agree with Ellen. Also, compatibility can still be an issue if the multilumen is not a staggered tip. Though the tip may be in a high flow/dilution area, it can still precipitate where the solutions meet.   

lynncrni
 It can precipitate with or

 It can precipitate with or without a staggered lumen exit site. The distance between each lumen may not be enough to prevent contact. Lynn

Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

pfintonis
Wait a minute. I have a

Wait a minute. I have a couple of issues. First, the question was "do we stop infusions on the patent lumens while we declot the occluded lumen". If I have a triple lumen PICC, and two lumens have a brisk blood return and flush, and one is totally occluded, then I would continue to use the functioning lumens and TPA the occluded one. There is nothing in the "Cathflo" dosing and administration that says to treat all lumens if only one is dysfunctional. Futhermore, they say they have no study data on any dosing greater than 4mg, meaning one dose not working to declot, and a second dose to attempt to declot. So really we have no grounds to use 3 doses(6mg) of TPA at one time.

Also, I'm sorry Lynn, but I'm not sure I understand what you are saying. Are you suggesting that we should not be infusing incompatable medications through Different lumens of a multilumen central catheter? Like Ellen said, Isn't that the whole point of a multilumen catheter? The high volume, turbulent flow of the lower SVC/ ra junction dilutes the infusates as they exit the catheter.

pfintonis
Wait a minute. I have a

Wait a minute. I have a couple of issues. First, the question was "do we stop infusions on the patent lumens while we declot the occluded lumen". If I have a triple lumen PICC, and two lumens have a brisk blood return and flush, and one is totally occluded, then I would continue to use the functioning lumens and TPA the occluded one. There is nothing in the "Cathflo" dosing and administration that says to treat all lumens if only one is dysfunctional. Futhermore, they say they have no study data on any dosing greater than 4mg, meaning one dose not working to declot, and a second dose to attempt to declot. So really we have no grounds to use 3 doses(6mg) of TPA at one time.

Also, I'm sorry Lynn, but I'm not sure I understand what you are saying. Are you suggesting that we should not be infusing incompatable medications through Different lumens of a multilumen central catheter? Like Ellen said, Isn't that the whole point of a multilumen catheter? The high volume, turbulent flow of the lower SVC/ ra junction dilutes the infusates as they exit the catheter.

lynncrni
 Sorry for the confusion.

 Sorry for the confusion. Yes, multiple lumen catheters are for the purpose of infusing fluids that are not compatible with each other through separate lumens. I was only attempting to address the issue of staggered lumen exit sites. There has only been one (1) published study on this issue from more than 20 years ago. It was an in vitro study in an anatomical model with circulating fluid to simulate osmolarity, pH, etc of blood. They infused TPN and Dilantin through catheter with staggered lumens and nonstaggered lumens. They were able to document precipitate occuring at the catheter tip with the nonstaggered lumens but none with the staggered lumens. This is the only study over the past 20 years and only a very few brands of all CVADs have staggered lumen exits. I question how important staggering is if our entire body of knowledge is 1 small invitro study. Given the large number of nonstaggered exit lumens, I think we would have seen more clinical problems by now if staggering is necessary. Also, we know from the dialysis literature that about 25% of blood is recirculated through the system when lumen exits are separated by 2 to 2.5 cm. Most infusion catheter have a separation of only 0.5 cm. So how much fluid are we pulling from the other lumen when there is this small distance between the lumens? It also seems very easy for meds with the worst incompatiblities to come into contact with each other at the catheter tip when there is this small distance. The previous message had emphasized the need for staggered lumens and simply do not believe that staggering brings that many benefits. Lynn

Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

cbusch
stopping infusion

Genetech does not reccomend to treat all lumens if they are not partially occluded or complete occlusion present. Have had lengthy discussions about this with the rep and their recomendation is to treat the one that has the occlusion or partial occlusion only. There have not been any studies that show treating all lines is benefical. I also have to agree that it does not make sense to stop all infusions, and in some cases you are unable to stop them, ie CCU on vasoactive drips, when you are declotting the port that is occluded. This causes a complete disruption in therapy. Have been reseraching this and there are no reccomendations one way or the other on stopping the infusions or not.

Carol

Carol Busch RN,VA-BC, CPUI
PICC/Vascular Access Nurse

lynncrni
 I would agree that there are

 I would agree that there are no studies and thus no guidelines, recommendations or standards. However I would be concerned about incompatibility when the thrombolytic meets infusing fluids at the catheter tip. We do know this happens and at the very least you need to know the compatibility information. If there is a serious risk of precipitate forming, I would stop the infusing drug based on this information. Lynn

Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Wendy Erickson RN
I appreciate the discussion. 

I appreciate the discussion.  I believe that we can continue to infuse through patent lumen(s) while declotting one lumen.  Remember we are trying to declot, so we are not injecting the TPA through the whole lumen and out the end - it is sitting at the level of the thrombosis.  So the risk of it coming in contact with the infusing fluid is pretty small other than when we do hopefully get a blood return and aspirate.  But that syringe of aspirate gets tossed, the line gets flushed with saline and/or heparin and the lumen is back in service. 

So I guess I have answered my own question!  Appreciate the dialogue though - gets us all thinking!

 

Wendy Erickson RN
Eau Claire WI

kathykokotis
incompatibles

Trissels will give you a list of incompatible drugs with TPA if there are any.  I am on the road so cannot look it up

I doubt the list is very extensive as its pH is identical to blood

Kathy

pfintonis
I'm sorry to be hung up on

I'm sorry to be hung up on this point, but I can't understand why we are talking about med compatibility of TPA in an occluded lumen and concurent infusions in other lumens of this multi-lumen catheter. Lynn, really, I have to ask you again with the utmost respect to clarify, you say you would shut off other infusions while declotting an occluded lumen with TPA until their compatability is determined. This seems to me to be a fundamental principle of infusion therapy practice. Are you saying that there is concern about infusing noncompatable infusions through different lumens of a multi-lumen central catheter? To be fair, I have never done any search of the literature on this topic, I have learned it over the many years of my nursing career as a "matter of fact principle" that the high volume of blood flow dilutes the infusions upon exit of the catheter preventing opportunity for precipitate to form. If you are suggesting otherwise, then this is a serious issue that needs to be looked at. Please help to clarify this for me! thanks

pfintonis
addendum: Hi again,   Lynn

addendum:

Hi again,   Lynn I'm sorry again but I just reread your previous post after I posted my last question. To be a little more specific, you say that there is "a serious risk of precipitation forming" ..."when the thrombolytic meets infusing fluids at the catheter tip". You mentioned the only study adressing this to be 20 years old and basically cliically irrelevent based on how much has changed in 20 year of infusion therapy. I'm curious how you can say that there is serious risk. Based on what evedence. This is a fundamental principle.  am just staggered by this discussion. I'm sorry, I respect your work greatly, I am just trying to understand the implications here.

lynncrni
 OK, let me try to explain

 OK, let me try to explain this again. 

Fact - you will never know with 100% accuracy what is the internal volume of any CVC. They are trimmed to a patient-specific length during insertion. Do you always know that inserted length and know the specfic formula for calculating a close estimate of this internal volume? If not, see fact 2

Fact - there will always be overspill when locking any CVC with any solution such as tPA, heparin, saline, etc. This is a well known fact from the literature. If you use the full 2 mL of tPA, there will be a lot of overspill. If you use an amount that is equal to the original catheter length there could easily be overspill because you don't have the precise internal volume. 

Fact - this overspill exits the tip of the catheter into the bloodstream as you inject the fluid. 

Fact - this overspill can mix with the infusing fluid in the bloodstream and it is possible that precipitate will form.

Fact - a multiple lumen catheter is for the purpose of preventing contact between incompatible fluids and meds inside the catheter lumen only. but no catheter instructions for use will tell you what may happen when the 2 fluids or meds come into contact at the catheter tip. We like to think that the rapid bloodflow in the SVC is enough to prevent that contact, but we simply do not have any knowledge about this.

Fact - all incompatibility information is derived from studies conducted in 3 ways - mixed together inside a fluid container, mixed together inside a syringe, and infused together at a Y site. No info about what is happeing at the catheter tip. No info means we must assume for safety sake that there could be an incompatiblity and separate these infusions as much as possible.

So the bottom line is that tPA could mix with infusing fluids at the catheter tip of a multiple lumen catheter and the safest practice would be to stop all infusions if at all possible. Of course this requires a thorough assessment of what practice produces the least risk for the patient and the best benefit.  

I hope I have answered your questions this time. Lynn

Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Daphne Broadhurst
Another rationale for

Another rationale for stopping concurrent infusions (whenever feasible) might be to facilitate lysis of a fibrin sheath on the exterior of the catheter (anecdotal). If there is overfill of Alteplase, it may then be trapped between the sheath and catheter and thus iniitate fibrinolysis. If there is an infusion running, the overfill would be lost, thus losing the potential fibrinolysis on the external surface of the catheter.

Daphne Broadhurst, RN, BScN, CVAA(c)
Desjardins Pharmacy
Ottawa ON
 

 

 

Daphne Broadhurst
Desjardins Pharmacy
Ottawa, Canada

donlussi
I came to this forum to get

I came to this forum to get answers and I am leaving totally confused. 

First of all, the purpose of multi-lumens catheters is to have the ability to administer incompatible meds.  This business about it possibly coming into contact at the tip destroys all reason for why they were created and approved.  I am sure that studies have shown that it was safe to administer incompatible meds through double, triple, and quad set lumens otherwise they would have never made it to the market.

Second, if I have for instance  a critical drip running, such as dilantin, then this cannot be stopped and administered through a peripheral while a line is being declotted.  The patient's safety is far more important in keeping this patient either sedated or their siezures under control.  The point that there may a mix of incompatible that may cause crystalization is unsupported in multi-lumen lines that are made specifically for the purpose of administering incompatible meds.

Third, I too heard that if one line has an issue that all lumens be treated so that an issue doesn't present itself again soon after treating the one line.  Reason being because it is possible that the other lumens are forming fibrinolytic deposits as well.  Of course then, this would be cause to stop all infusions; however, critical nursing judgement comes into play here.  If you are running critical meds, in my nursing judgement, keep them running and administer alteplase through the affected line only.  If then a few days down the line, the critical med line becomes sluggish or displays a lack of blood return, then switch to the clean line and declot the sluggish line.  In the case of a double lumen that is running intermittent abx, or even cyclic TPN, then I treat all lumens.  That way there if there are any culprit fibrinolytic critters lurking in these lumens, which undoubtedly there are, then all lines are eradicated clean.

thanks

Donna

Donna Lussier

lynncrni
 Sorry you are so confused

 Sorry you are so confused that you will leave this discussion. I need to correct one misstatement in your message. The sad state is that studies have not shown that it is safe to administer incompabile meds through a multiple lumen catheter. Devices such as catheters (Class II device) come to the US marketplace through what is known as the 510(k) process at the Centrs for Devices and Radiological Health at the FDA. The manufacturer submitting the applicaiton for each product does NOT have to submitt an clinical studies. All that manufacturer has to do is provide information about how the proposed new product is "substantially equivalent" to a similar device already on the market. This is knows as the predicate device. So, no clinical studies, only product comparisons. Clinical studies with devices are not available until after the device has been in clinical use and then some facility/agency/group decides they want to do a clinical study on that device. Please see the chapter on Infusion Therapy Equipment in the INS textbook for a complete explanation of this process. Lynn

Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

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