We are researching how to manage occlusion of multiple lumens. What is the safest practice? To instill 2 mg of cathflo into each lumen and then repeat if unsuccessful? In doing that - after the 2nd dose into 3 lumens you will have given 12 mg (total of 8 mg overfill)
Or is it safer to instill 110% lumen volume or 1 mg into each lumen in the case of a multiple lumen occlusion.
I know that each case should be considered individually but just wondering what opinions are on this.
Thanks very much
The treatment of catheter thrombotic occlusion began back in the middle 1980's with urokinase. At that time, we were using a volume that was equalivant to the internal lumen of the catheter, sorry don't remember the exact dose. Urokinase had problems and was removed from the market for a while in 1999 and that is when we began to use alteplase. A conversion was made of the urokinase dose to the alteplase dose and that was 2 mg. Genentech recommended a dilution of 2 mL and that was what was used in the trials of alteplase for catheter clearance. In my opinion, I would feel comfortable using an amount that is equal to the internal volume of the catheter - a single lumen of a PICC or other percutaneous CVAD will be much less than an implanted port where you would need to fill the catheter, port body and access needle. I do think that all lumens of a mutliple lumen catheter should be treated and any overfill will reach what is at the catheter tip inside the vein. Even a total dose of 12 mg does not come close to a therapeutic dose of 50 mg and the half life is very short.
I would also investigate why this is an issue. What is the frequency of needing to declot lumens? How many are happening and most of all, why are they happening? What can be done to reduce the number? The declotting procedure is not cheap so prevention should be the primary goal. 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
Thanks very much for your response. That helps a lot. There seems to be so many different approaches to treating multiple lumen occlusions.
Regarding the issue of occlusions I am happy to say that we have greatly reduced our occlusions. We did a lot of education on flushing clamping sequence using the interlink needleless connector that we currently use. Plus the nurses are recognizing occlusions much earlier and promptly treating so that has made a big difference as well. But we are trying to figure out what to do in the event of a multiple lumen occlusion. So thanks very much for your response.
Andie
From the Cathflo website:
Dosing with Cathflo 2 mg
You should always use the ordered amount in each lumen,as noted in the manufacturers IFU (see above) and most likely your physician's orders
It is recommended you instill Cathflo in one lumen at a time - you may find once you restore patency to one lumen you have patency in the other lumens. After you restore patency to the first lumen, recheck for a blood return in the next lumen,if you still do not have patency in that lumen you will instill Cathflo in that lumen, then go on to the third one and repeat.
Ann Marie
disclaimer - I am a CNT for Genentech
Thanks for this response. We have never heard before that it is recommended that you should instill cathflo into one lumen at a time. Can you suggest where we can find this recommendation? Our practice is to treat all occluded lumens simultaneously. It is what we were taught and we find this to be very effective. But if there is a recommendation for this we want to know so that we can change our practice.
Thank you
The need to treat and d-well with 2mg/2ml of Cathflo is clearly indicated in the clinical trials. What many seem to forget is that we need to “overfill” and not just use the priming volume because we don’t know the type of an occlusion you are treating (mural, fibrin sheath, fibrin tail or an intrauminal thrombus). All we know is that there is no blood return or inability to flush. The overfill is needed to reach the thrombus formation on the outside of the catheter treating with priming volume does not reach the problem and only delays patient care longer than needed.
With a half-life of 5 minutes and the risk of serious adverse events at 0-.04% in the COOL 1 and COOL2 studies that included infants why don’t we treat with the therapeutic does?
Treating multiple lumens, treat the most serious (complete occlusion) first with 2mg/2ml in many cases all lumens will be restored with 1 or 2 does. This happens due to the over fill that can reach the other openings. Occlusions can occur as the body’s natural response to having a foreign object inside it as well. Some patients will get many doses of cathflo over the life of their catheter while others will never need a dose of Cathflo.
I would agree that the overfill will reach extraluminal fibrin/thrombus but only what is located directly at the catheter tip. Rapid blood flow and the short half life would not allow the drug to reeach the majority of the fibrin sheath covering virtually all catheters. You would need an infusion over several hours to reach this sheath. 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
So, would you place a peripheral IV catheter distal to the PICC so as to enable the infusion to flow around the external catheter?
No, you could infuse it through the CVAD, but this is a low dose over 3 hours so it would reach the entire extraluminal side of the catheter and fibrin sheath. Can't remember the details of these protocols but several have been published. 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
Without staggered lumens, how is it going to reach the outside of the catheter?
It is given by infusion over 3 hours, so it is in the total circulation. 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
Okay,
So even though we know that once a medication is given into the circulation it reaches systemically in about 23 seconds, and though Cathflo has a really short half-life, giving it over three hours will eventually result in the lysis of the fibrin/thrombus. Thanks, I see that. You're always so helpful.
DD