I am wondering what best practice is when multiple lumens of a central line are occluded. I understand the best choice is to choose a VAD with the smallest number of lumens required to provide therapy. My facility does not have an IV team. Our Cathflo order set states a maximum dose of Cathflo is 4 mg per day. Here is a scenario I would like practitioner's thoughts on.
A ptient with a double lumen PICC is receiving Rocephin for several weeks. He is admitted from another facility. Upon assessment of the line you find both lumens totally occluded. All other assessments of the line appear OK.
What is the best first step? Chest x-ray, Cathflo, or exchanging line for a single lumen?
To administer Cathflo would you use a single dose to both occluded lumens at the same time (that is your max for the day) or would you try one dose of Cathflo to one lumen and have ability to administer second dose if first fails. Then on the following day administer Cathflo to second lumen.
Thank you,
Celia
If a line comes from any other facility, our policy is to have a CXR to confirm placement. I would not give Cathflo without checking first. So many times it is malpositioned.
We usually will treat one line at a time. There are times when one lumen opens, the other line opens as well. (Probably related to lysis of the fibrin sheath around the tip.
I am not aware of any limit to Cathflo doses per day. Can repeat once on same line if first doesn't work. Cathflo has a very short half-life (approx. 5 to 7 minutes)
I have treated more than one line on triple lumens in the past. I think Genentech could tell you if there is a limit.
Remember, this is instillation and dwell with the majority of the substance wasted with a brisk blood return.
Chris Thomas, RN, MSN, CNP, VA-BC
Manager of Vascular Access Services
Fairview Hospital of the Cleveland Clinic
When I first started using CathFlo, I would request 3 doses for a Triple Lumen PICC. But I've been finding in most cases, one dose is sufficient. I usually put 0.25 ml in each port and check it after 30 min. If still not producing a blood return, I leave it to dwell for another 60 min. I've been having great success with managing occlusions using CathFlo. It's a wonderful product!
Ann
PICC nurse
Ann Armstrong, RN
PICC Lines
MidMichigan Medical Center, Midland
The maximum dose has been set by your hospital policy and not by the instructions from the drug manufacturer. I would always look at the history of what led up to the occlusion - types of fluids, meds that had been given, investigate about the flushing practices between meds, flushing resistance, presense or absense of blood return, confirm catheter tip location, signs and symptoms of tip migration, to rule out drug precip problem or change in tip location. The last is only done with a chest xray, would be needed especially if there are s&s for tip migration. If I thought this was a thrombotic intraluminal occlusion, I would try Cathflo first. I would treat both lumens, but one at a time. It does you no good, IMHO, to treat only one lumen and leave the other occluded as this would still pose a risk of BSI, thrombosis/emboli, etc. Finally, if this is happening a lot, I would investigate why? And if the 4 mg or 2 dose max per day is not working, take it back to your appropriate committees to re-evaluate but bring your outcome data to that committee. Don't expect them to make this decision based on anecdotal 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
One thing I have found useful when educating nurses in Cath-flo procedures is to obtain the different types of central lines and flush with saline to determine the volume needed to reach the end of the catheter. PICC lines are no more than 0.5ml per lumen, Arrow triple lumen catheters are 0.5ml for distal (brown) and blue (medial) lumen and 0.75ml for the white(proximal) lumen. I only use one 2mg dose split between the lumens. For ports and external tunneled catheters I use a full 2mg dose for each lumen.
kladusau SAH Okcy
If your goal was to use the existing line,
First step...xray. How do you know if it's a central line, midline, mal-posisitioned? I would never trust any report...always do in-house verification. Also Cathflo is not indicated for midlines.
Second step...declot. As Lynn alluded to, you have policy that doesnt match Genetec's dosing instructions. I would advocate for the manufacturer's guidlines. You can dose multiple lumens at one time with a max of 2 doses per lumen per 24hrs. So it is assumed 3 ports is the most which would allow for a max of 6 doses in one 24 hours period.
Dose/port should be 2 mg or 110% of the intralumenal volume if patient is less than 30KG. Most PICC intralumenal volumes range from .5 to .7 ml depending on the gauge/length.
Dosing less than 2mg in patients above 30KG may lead to partial resoultion and more frequent repeat occlusions.
Cathflo's half life is about 5 minutes. Patient will be back to endogenous levels in 30 minutes. Out of the system in 72 hours.
I certainly agree that restoring only one lumen is not a good resolution. I would replace the line if every lumen could not be restored.
Kevin Arnold RN, MSN
I am curious as to why you included the patient's weight. Is this because of the overspill when you inject the full 2 mL? Half life only applies to the portion of the dose that actually gets into the bloodstream. Any lock solution that remains inside the lumen is not being metabolized, therefore there is no half-life. 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
Lynn, the weight guidelines are per Genetec's dosage instructions. In both weight classes, there will always be overspill into the bloodstream (unless you are using it on a device with greater and 2ml intralumenal volume). This ensures that the entire internal lumen space is filled and the overspill can help with fibrin tails beyond the lumen. So yes, the half life of < 5 minutes, etc would apply to the portion that enters the blood stream. - Kevin
Kevin Arnold RN, MSN
The literature calls it "overspill" as you did which is the amount of lock solution that leaks out of all catheters. Actually there is lots of information about this with heparin and the risk of anticoagulation when high heparin doses are used in dialysis caths. Thanks for your clarification. 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
In addition to what Kevin said there is also a greater risk of infection with continued use of the catheter if only one lumen is able to be declotted and the other one cannot .
Denelle Oliveros RN, CRNI
Nurse Manager
University Option Care
Columbus, Ohio
The drug references for Cathflo refer to a total dose of 4mg. All the studies were done on 2mg followed by 2mg if needed. I do not find a drug or manufacturer's reference to more than that. Yes, it's important to keep all lumens open for several reasons, especially high risk for infection. We are struggling with making a recommendation to treat multiple occluded lumens at the same time because the drug insert does not say 4 mg total per lumen.
We had a Genetech rep here yesterday doing cathflo teaching and I asked her this question. She stated that the manufacturer allowes up to 12mg per incident if all three lumens are clotted. It seldom happens that you can't get them open without using 2 doses per line , but it isn't a problem if you have to use 2mg per line. Of course, this is different for infants and children where the dose is by weight.
Diane Suter, RN, VAT
SAVAHCS