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Karen RN
fibrin sheath causing no blood aspirations

Does anyone have any ideas how to prevent and/or correct fibrin sheaths.  We most often put in dual lumens since  nurses and patients prefer that extra lumen to do blood draws for labs.  Our usual approach is to first use activase.  This seldom works, since most of these lines you can still flush, which tells me it is not intraluminal.  I do not like to replace these piccs for this reason,  but sometimes we have to.  Any suggestions.

Karen RN

pallik
we successsfully use cath
we successsfully use cath flo activase for withdrawal occlusions with positive results
dfritz
We have also successfully
We have also successfully treated persistent withdrawal occlusions with Cath-flo.
lynncrni
There is no method to
There is no method to prevent a fibrin sheath from forming as this is the body's natural defense mechanism against the foreign object. The declotting procedure with any fibrinolytic drug will reach what is inside the lumen and what is directly at the catheter tip. However, it will not reach the fibrin around all extraluminal surfaces of the catheter. It may also not be successfull 100% of the time when you have a fibrin tail or flap because the injection moves the flap away from the catheter tip. The only method for reaching this fibrin is an infusion of the low dose over 2-3 hours. 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

Gail-Anne
We've had good luck with tPa
We've had good luck with tPa 3hr infusions (as Lynn says) with PICCs and ports with withdrawal occlusions. The renal unit does this quite frequently with their dialysis CVCs.
Halle Utter
I was told my an RN today
I was told my an RN today that does inservices for Cathflo that the drug can be used successfully for fibrin sheaths on midlines because the tPA in the blood stream will "find the fibrin or clot" and activate the plasminogen and dissolve the clot or sheath.  I had never heard of this before.  She said it wasn't even necessary to do the 2-3 hour infusion of the low dose that Lynn mentions above, that just the circulating tPa would take care of it, and that they had done it successfully a couple of times on a patient with a midline that was leaking at the site.  They did eventually have a PICC placed in this patient because it had occurred repeatedly, but I had never heard this before.  Anyone else gotten this new information?  Anyone else have any experience with this type of use?  I don't like midlines much anyway because they frequently form fibrin sheaths, but I had NEVER heard of this application of Cathflo.   Comments?

Hallene E Utter, RN, BSN Intravenous Care, INC

lynncrni
I have my doubts about this
I have my doubts about this theory and would have to see the results of a study. My reason for doubts is the half-life of the tPA. It is very short, only a few minutes. So it does not make sense that tPA injected in the SVC would have time to circulate through the entire system and return to the catheter location in the upper extremity and chest. Sales reps must be careful as what they say is considered to be product labeling. I would definitely asked to see this claim in writing! 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

ann zonderman
Ann Zonderman, BSN, JD,

Ann Zonderman, BSN, JD, CRNI, LHRM

Methods to eliminate/ remove fibrin sheatlhs seem to vary.  I wonder if an aggressive approach to try to force release from the catheter into the blood stream has any repercussions... what is the process/ timing  for the biofilm to be degraded/ broken down in the body,  will it become a clot hiding somewhere else?  Will resident bacteria opportunistacally invade another part of the body?   Very thought proviking .... Ann

Ann Zonderman, BSN, JD, CRNI

rivka livni
All our lines are Power PICC

All our lines are Power PICC so about 50% of the time it is possible to "dislodge" the fibrin sheath by poweful push-withdraw-push-withdraw a few times while the pt moves his arm around and coughs a little. If it fails, then cathflo.

Halle Utter
I am going to be going to an
I am going to be going to an inservie about this within the next month.  I wil find out if it's in writing and there are any studies to back it up.  I was dubious, but willing to listen.  I will report back afterward. 

Hallene E Utter, RN, BSN Intravenous Care, INC

Karen RN
What is the dosage and

What is the dosage and diluent amount for the 2-3 hours infusions of Cahtflo?  Is there any data/indications for the usage of cathflo this way?

Thanks

Karen RN

Robbin George
P Luptak (LITE) wrote the

P Luptak (LITE) wrote the quintessential document many years ago regarding the use lytic agents and she does mention the process of "dripping" TPA (2mg diluted in 50 ml isotonic fluid infused via pump at 25ml/hr)--I did confirm this technique at last years AVA conference with the cathflo gurus and have since successfully used the technique  

Robbin George RN VA-BC

Alma Kooistra
May I please resurrect an

May I please resurrect an issue.

I have been called to task for recommending a tPa drip (2 mg in 50 ml NS run in over 2 hours) for persistent withdrawl occlusion.  We hae successfully reestablished blood return in multiple centra lines (incl PICCs and Ports) by use of this method.  We have never seen any complications.

I have now been confronted by an ambitious staff member who suggests that this off-label use of tPa is wrong and I must provide evidence that it is not.  We will be meeting with management staff and pharmacy next week. 

I did a topic search at this web site and found the attached discourse.  I see a reference to P Luptak's document on this issue.  I would dearly love to have a copy of what she wrote. 

Also could benefit from any other resources.......help.....I'm going into battle!!!

 Alma K RN, CRNI

Robbin George
How does the clinician

How does the clinician LEGALLY work around an OFF LABEL use?--Does the manufacturer CATHFLO need to research/reevaluate/revise it's data?--The few times I suggested a TPA DRIP for persistant withdrawl occlusion I had the MD (IR or ID) write the order and the Vascular Access Nurse (ME) did the DEED with excellent results-- I believe this subject was once again addressed at Savannah AVA by the RAD MD who had speculative reservations about Tapered PICCs  

Robbin George RN VA-BC

lynncrni
The FDA does not control

The FDA does not control your practice, legally. They only have control over what the manufacturer can state verbally or in writing about indications for use. There must be significant financial incentives to motivate a manufacturer to go before the FDA to get clearance for a new labeled indication for any drug or device.  To support your practice, there are published studies to advise you about how, why and when the off-label use has been done, along with outcomes.

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

www.hadawayassociates.com

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

Alma Kooistra
Could I please have some

Could I please have some references then to support this? 

 I have a reference that discusses use of Urokinase......believe it was published in the Journal of Interventional Radiology......but it talks a lot about dialysis catheters, etc.

I would dearly love to be able to quote a published reference that discusses use of tPa to restore proper function of PICCs and other infusion catheters which have persistent withdrawl occlusion.

Can anyone give me info on how to access Patty Luptak's publication?

We have been doing the tPa drip (2mg in 50 ml NS over 2 hr) and successfully resolving this problem at our facility for quite some time.  A good track record however isn't enough to satisfy this nurse........I must bring information reflecting standard of care on a broader level.....  HELP!

A Kooistra RN CRNOI

Penny
We have been using Cath-flo
We have been using Cath-flo with great success. Usually works with one dose but occasionally have had to use 2ccc twice. Curious about the studies that say wait 30 minutes then 120 minutes before installing Cath-flo a second time. We usually put the second dose in after 1 hr and it has always worked. Are there any contraindications for doing the second dose at 60 minutes instead of 120?
Kristin Walker
I would also like to see
I would also like to see some published articles on this practice.  No one has yet to give any references.  Any help would be appreciated!  Thanks!

Kristin Walker RN, BSN, OCN Maui Memorial Medical Center IV dept.

kokotis
Kathy Kokotis Bard Access

Kathy Kokotis

Bard Access Systems

I guess I am going to get real basic because I need to ask the original author a few questions to see if we can reduce the issue:

do you use 2mg of drug and not an aliquoted dose or use 1 mg of the 2 mg dose in the line.  If you use less than 2 mg you are not using the recommeneded dose that is clinically studied

Do you declot each lumen with the 2 mg dose

Bottom line goal is to get to the fibrin tail

Do you have a policy to flush wiith 10 cc of saline after each drug and at least BID when the line is in use or not in use (Harnage article)

Do you flush with with 20 cc after blood draw, blood administration, and nutritional support or high dextrose concentrations which are thick

These help reduce the occurrence but not eliminate

Kathy

Kathy Kokotis

Bard Access Systems

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