Forum topic

I've used both methods. Either way you are causing a negative pressure in the catheter that gently absorbs the cathflo as described above. Sometimes this may take me 15-20 minutes at the bedside to slowly play with it and gently allowing the cathflo to be absorbed into the catheter.  Pull up a chair and have a chat while you attempt to instill.  For safety reasons, if I cannot get it all in, I do not leave the syringe attached.  I'll come back in an hour or 2 and see if what had been instilled had been effective.  Need to calculate the 2ml volume in syringe to see if any was absorbed at all. 

Do people spend more time than this attempting to instill?  When do you call it quits?

Prior to using the cathflo, I change cap and sometimes this was all that was needed.  Then we confirm placement prior to cathflo

I've used the stopcock and single syringe method.  I prefer the single syringe.  You don't need any special equipment (i.e stopcock) and it's just as easy - less "bulky" so to say.  I attach the syringe with the cathflo directly to the hub of the line, removing the cap.  Pulling back creates the negative pressure that pulls any serum around the clot back, then releasing draws the cathflo (possibly mixed with some of the serum) back into the line.  It may take a while, but eventually you work the cathflo down around the clot and it dissolves, and Presto, blood return! It's rare it doesn't work, usually only unsuccessful if the cause of the occlusion in NOT clot, but a precipitate.   

Does anyone have a procedure written for catheter occlusions and or declotting cvads.

thanks,

Julie Mijatovich

Fort Wayne, in

There is another alternative to declotting PICCs. Its a product called Fibrin Analysis Catheter Testing System (FACTS).  It comes in a complete kit with an endoluminal brush which can be administered by a nurse or doctor.  The kits are all size specific since catheters come in various french sizes and lengths.

 The FACTS's primary use is to culture all CVCs/PICCs/Dialysis Catheters for sepsis WITHOUT having to remove the line from the patient.  Studies show results are 96% accurate with the FACTS method. Furthermore, results are determined by the lab within 60 minutes. 

 A secondary feature of the FACTS product is its ability to restore catheter patency.  The Endoluminal Brush has been widely used to restore patency and has an efficiency equal to or better than t-PA in thrombosed catheters. It has also been used in combination with thrombolytic drugs. However, the main advantage of the Brush is that it will remove all debris, regardless of its nature, and, that it physically removes, rather than dissolves, the debris and its colonizing micro-organisms. Researchers have shown that a single brushing, followed by the withdrawal of 10 ml of blood through the line, reduces the bacterial count between 70 and 90%.

 In addition, you don't have to wait for hours for results like with tPA.  The results with the FACTS are pretty immediate.

 If you would like additional information regarding the FACTS product, please email me - [email protected] with your contact information.

 Shawn

The reason Genentech says to "instill Cathflo" is because of legal reasons and the way the original clinical studies were set up.  It is confusing because the studies were designed to address only lack of blood return, but not complete intraluminal occlusions.  When I teach declotting techniques, I emphasize that there are 2 different types of thrombotic catheter occlusions that are addressed by Cathflo:  1.  intraluminal occlusion, which is what most nurses think of as a catheter occlusion.  2.  Lack of blood return or sluggish flow which is usually due to fibrin or thrombus OUTSIDE the catheter tip.  I teach to use a single syringe, attach it directly to the hub of the catheter, and pull gently back to "instill" the Cathflo---in other words it will mix with the saline in the catheter and get up to the clot interface deep in the catheter lumen and begin to delot.  You need to pull back on the syringe (GENTLY) repeatedly to help the Cathflo move up the catheter lumen as it is declotting.  The 3-way stopcock method also gets the Cathflo up to the clot interface, but from that point onward it is declotting passively.   If the occlusion is lack of blood return but you can infuse, then you want to gently and slowly instill the entire 2 mls.  the Cathflo needs to attach to all that fibrin or thrombus at the catheter tip.  Wait at least 30 minutes before checking for blood return.

Nadine Nakazawa, RN

PICC Nurse, Stanford Hospital

President-elect AVA 

what do you do if it is a double lumen catheter? do you declot both lumens?

I've been placing PICCs and declotting them and other CVCs for over 20 years in a 200 bed acute care hospital with average of 30 to 50 lines daily to assist w/ maintainenance.  I've used both methods and I prefer the single syringe method as many of you do for the reason of simplicity - it rarely takes more than 10 minutes to get the dose in, however, on rare occasion I've taken up to 30 minutes. I've also not ruptured a catheter using the single syringe method.

Length of dwell time is always predicated on urgency of catheter usage; if there isn't urgency or risk of delayed meds, we prefer leaving for 2 to 4 hours, just because it often takes a single dose that long; if there's more urgency we'll check Q 30 minutes and repeat a second dose @ 60 minutes; on occasion we'll leave overnight since we don't have 24-Hr IV Team coverage. Nearly, always, the catheter will be fully functional following this treatment. Our facility allows staff RN's to instill tPA for withdrawal occlusion only; not for total occlusion - only IV Team nurses do this.

Regarding the FACTS: I've not used this system since it was revised from FAS. I was totally excited about the potential for preserving lines from unnecessary removal r/t to all the literature I read about the FAS Brushing procedure and study results. However, when we did employ the FAS system for over a year. It was expensive for us keeping all the different size brushes in stock and quite a challenge getting physician support for ordering the procedure and relying on the results. It was also time consuming locating the information about out-patients regarding catheter length and FR size because pt's wouldn't carry their ID cards with them and sometimes the writing on their catheters had worn off etc, etc. Like w/ anything if its not being ordered on more routine or frequent basis, the IV Team nurses would get insecure about performing the procedure because they hadn't done it for several weeks or (if they worked parttime) even months. Maybe FACTS is much more simplified than FAS, though, you can't get much simpler than instilling tPA for strictly occlusion issues. However, as I understand it, the brushing benefit of FACTS is even more directed toward routine brushing to decrease biofilm load and prevent CRBSI or when CRBSI occur to use in conjuction w/ repeated brushings and anti-biotic lock Rx, to "resterilize" an intraluminally colonized catheter. It is certainly a hopeful answer to unnecessary catheter removal, but I see it as needing to be presented to physicians to get them educated and excited about its efficacy. We certainly didn't have then nor now the time or energy to be their educators on this technology.

At our pediatric institution, only our IV team, Nutrition Support Nurse Clinicians and Hem/Onc RNs are trained to administer Cathflo for partial/drawback occlusions.  However, only the IV team and Nutrition Support can administer it in the event of a two-way occlusion.  Doses are dispensed from pharmacy from in a 10 ml syringe and it is always administered from that 10 ml syringe.  For partial occlusions, we instill it directly from the syringe.  For 2-way occlusions, we use the stopcock method with another empty 5 or 10 ml syringe.  We also will go "back and forth" - withdrawing and instilling the Cathflo - until it is tinged pink.  Whether a partial or 2-way occlusion, we allow to dwell for 1 hour before attempting to withdraw.  If unsuccessful, we will allow it to dwell for another hour (total of 120 minutes). If still unsuccessful, we may repeat the dose.  As for dose/volume,  patients < 10 kg receive 0.5mg diluted to 110% of the specific catheter volume. Patients > 10 kg receive a 1mg/ml preparation of 110% of the catheter volume (max dose of 2mg), or 2ml for PICCs/Broviacs and 3ml for SIPs if volumes are unknown.

Morgan Dunn, BSN RN CPON

Nutrition Support Service Nurse Clinician