We have had more success clearing mediports by overnight TPA instillation. During regular hours patients come to us outpatient through the pediatric sedation unit (not for sedation just for the treatment room). Using orders from the requesting physician, one of the Peds vascular access nurses will assess the line, instill TPA if indicated, and discharge the patient with instructions not to use the line over night. They are instructed to return the following morning to have the peds vascular access nurse re-evaluate, aspirate TPA, and flush the line.
In our outpatient Medical Day Care unit, if tPa does not work to clear the line , we instill a second dose and send the patient home. They return the next day and the tPa is aspirated, and the line flushed per protocol
There is another option now. It is a product called Fibrin Analysis Catheter Testing System (FACTS). It has recently been FDA approved to restore patency in all indwelling catheters. It is an endoluminal brush kit which the nurse or doc can administer. It is very cost effective and is quite simple. It comes in a kit where you run a size specific brush in the inner lumen of the catheter to clear the occlusion. No need to wait overnight. The effects are immediate. Kits are available for CVC/PICC/Hemodialysis Catheters.
If you would like additional information on this product, please email me privately - [email protected]
The last information I have about FACTS is that the indication was for diagnostic purposes only. I am interested in receiving the written information about FDA clearance for restoring catheter patency. Can you post this as an attachment to your message on this forum? If not, please email to me at [email protected]. Thanks, Lynn
Leaving Cathflo in overnight or longer is an off-label use of Cathflo. But most outpatient infusion units have done this. Just instill it by pulling back on the syringe and allowing the Cathflo to gently go into the catheter lumen up to the clot interface. Remove the syringe and cap it off. The Cathflo will work passively. In vitro work (not published) showed that Cathflo is still 90% active at 37 deg C. up to 1 week, and 50% active at 2 weeks. The concern is risk of CRBSI as Cathflo is reconstituted with preservative-free sterile water, and there may be bacteria imbedded in the fibrin or thrombus in the catheter lumen. We did this with a patient post kidney transplant who could not maintain patency of his catheter with heparin (this was many years ago), but he had full use of his catheter for 2 months of daily outpatient IV therapy (daily DHPG, twice a week lab draws, etc), with no infections or any other complications. I've also instillied Cathflo into a PICC with intraluminial occlusion overnight, and it worked!!
Contact Genentech's Drug Info: 800-626-3553 and ask for the following article:
Schenk, P, et al.Recombinant Tissue Plasminogen Activator is a Useful Alternative to Heparin in Priming Quinton Permcath, Am J. of Kidney Dis, 2000.
Schenk locked dialysis catheter for 2 months with heparin 1,000 units/ml, catheter fill volume, and then crossed over to locking with 2 mg/2 ml of alteplase (Cathflo) for 2 months, OR alteplase for 2 months, and then to heparin lock for 2 months. Unfortunately because patients got their catheters out or died, he ended up with only 9 or 11 evaluable patients. The results showed that the alteplase arm had better dialysis outcomes, better flow rates, and fewer thrombotic complications, and NO infections.
Our criteria for instilling Cathflo in a patient's PICC who will be returning home with the Cathflo indwelling is that he return to clinic the following day for Cathflo extraction and catheter assessment/flushing and that the line be labeled "Do not use. Cathflo indwelling." The patient and the home health care nurse should be aware as well so that the Cathflo isn't inadvertently flushed through. If patient compliance is questionable, we would aspirate the Cathflo prior to sending the patient home.
We had looked into instilling the Cathflo in clinic and having the home health nurses aspirate the Cathflo & flush the line the following morning; however, this was denied as the nurses are not presently authorized/trained to administer Cathflo.
As Nadine discussed, there is both in vitro and in vivo published evidence supporting Cathflo dwelling within catheters for an extended period of time. Weck et al also demonstrated that Alteplase reconstituted in sterile water and bacteriostatic water maintains protein stability and remains biologically active when at 37°C for 7 days.
Daphne Broadhurst,RN Ottawa Canada
Weck S et al. Alteplase as a Catheter Locking Solution: In Vitro Evaluation ofBiochemical Stability and Antimicrobial.J Vasc Interv Radiol 2005; 16:379–383
For my curiosity, why are you so concerned about aspiration of this low dose of Cathflo? The dose is so small and the half life is so short, I have never seen anyone put this much emphasis on aspiration before. Thanks, Lynn
We had an interesting experience this week that started on Sunday. As best as we can put together, RN drew blood from an implanted chest port. There is a question about whether or how well it was flushed, but the next RN noted blood in the extension set of the Huber--this was about 5 hrs later. Unable to flush or draw back. It took the tpa-trained RN a couple of hours to get in to do the declot. Able to get 1 ml into the system. My suggestion was to reaccess with tpa primed needle/ext set. Still no success after working for about 30 min. Monday am: I worked for 1 hr using push pull and only instilled 0.2 ml. Mon pm: Another hour with another 0.2 ml instilled. Left it overnight as we could withdraw tpa. We knew it was working as our syringe fluid was turning pink to more cherry. Tues am: Another hour spent pushing-pulling with nil instilled, but same color changes. Tues pm: another 10 min of pushing-pulling and Viola! it was open with some blood return. We instilled more tpa and let it sit about 30 min and then got good blood return. I have NEVER worked SO HARD to declot a line! I was motivated because the patient had already had a second surgery for a port revision about 6 weeks prior as there was a port catheter problem. Also, they knew the nurse had not reattached his IV.
I guess I have the same question like Lynn! Usually alteplase works on contact, if you need 1 h for 0,2 ml I would think there is something else wrong. What kind of medication was given before? How does the chest xray look like?
Activase has a half-lifetime from 5-7 min....and remember, if you push 2 ml inside the line you have at least 1 ml in the bloodstream. The treatment is inside and outside of the catheter on purpose!
And, by the way, to leave activase overnight in you line is an off lable use.
Andre, leaving Cathflo indwelling overnight is off-label, no doubt. There is however published evidence supporting the safety of this practice, in Nancy Moureau’s PICCOLO II study. We leave the Cathflo indwelling overnight if the lumen is not needed; otherwise it’s usually removed in 2 hours. Basically, if there’s a chance that we might have greater success with a longer dwell time, why not go for it?Our premise for the longer dwell time is that the longer it’s left in the catheter, the greater the likelihood of complete fibrinolysis (i.e, efficacy rate of 52% at 30 minutes as opposed to77% at 2 hours in the COOL II study).Is it not true that the ~5 min. plasma half-life refers to Cathflo in the bloodstream; however, Cathflo remains bioactive in the catheter in the presence of fibrin & thus continues to convert plasminogen as it works its way through the clot? Therefore, if you remove the Cathflo as soon as you get blood return, there could still be some residual clot which would quickly bind to further blood proteins & propogate further clotting?
Cathflo does indeed have a short plasma half-life which lends to its safety. Lynn, I completely agree that instilling Cathflo systemically is most likely going to cause no harm, as it’s not likely to reach pharmacologic concentration. However, what if you have a patient who hemorrhages & it’s discovered that he recently received Cathflo & the RN didn’t aspirate the Cathflo. I would be very concerned that the nurse would end up as a Walmart greeter (to use Sue Masoorli’s term) as she contravened hospital policy and manufacturer’s IFUs, even though the bleed was likely not due to the Cathflo.
Of course, it is a coomon practice to leave alteplase over night, no doubt there. And yes, inside the catheter it is still 90% after 1 week...I agree and was not pointing the finger.
If you refer to the COOL study you see there are no contra indications. My own opinion is: alteplase is safer than aspirin.
2mg alteplase is 2% of a regular dosage! Yes you have to go with your hospital policy. If you have the removal placed in your policy, you have to go with it.
anyway, my point was to think about other possibilities regarding you occlusion. Still, 1 hour for 0.2ml is not common for my experience.
Regarding your comment, "Usually alteplase works on contact" . . . If a clot is the entire length of the port catheter and in the port reservoir, I would certainly expect that one would need to work it all the way through the catheter which could take some time. It may dissolve the clot at the interface with the tpa, but there is alot more clot that needs to be dissolved prior to the catheter functioning fully. I do believe that a clot was the reason for this line's malfunction for several reasons: 1) the history of no or inadequate flushing after blood draw, 2) blood in the Huber extension set found by the nurse following, 3) continuing to get pink to cherry red in the tpa syringe while trying to work the tpa in and 4) ultimately, the catheter clearing and providing good blood return.
Yes, I did not say anything else!! TPA contact and dissolve the clot! Instead of trying to place it 1 h, just place what you can get, let it dwell for 10 min and try to place more. I did not question what you and your team did, I try to help! It would be still nice to be friendly with the answers!
This is not in policy, but we do follow up with many "occlusions" that want another PICC placed or a PICC placed because the port is occluded. They have tried tPA 2 times without results of good blood return.
The staff nurses think that we do "magic", but all that we do is to go assess the CVC the next day (after treatment with tPA). We aspirate and get blood return! All that we have done is to allow the tPA to be in the line longer. We have avoided replacing many lines by doing this assessment hours later than their assessment of no blood return or lack of flushing. This occurs with outpatients and inpatiemts.
We don't do magic, of course, but we do check to see if the tPA worked before we proceed with other measures to replace the line (whatever type it is).
We have had more success clearing mediports by overnight TPA instillation. During regular hours patients come to us outpatient through the pediatric sedation unit (not for sedation just for the treatment room). Using orders from the requesting physician, one of the Peds vascular access nurses will assess the line, instill TPA if indicated, and discharge the patient with instructions not to use the line over night. They are instructed to return the following morning to have the peds vascular access nurse re-evaluate, aspirate TPA, and flush the line.
Marla Neilson, RN
There is another option now. It is a product called Fibrin Analysis Catheter Testing System (FACTS). It has recently been FDA approved to restore patency in all indwelling catheters. It is an endoluminal brush kit which the nurse or doc can administer. It is very cost effective and is quite simple. It comes in a kit where you run a size specific brush in the inner lumen of the catheter to clear the occlusion. No need to wait overnight. The effects are immediate. Kits are available for CVC/PICC/Hemodialysis Catheters.
If you would like additional information on this product, please email me privately - [email protected]
Shawn
The last information I have about FACTS is that the indication was for diagnostic purposes only. I am interested in receiving the written information about FDA clearance for restoring catheter patency. Can you post this as an attachment to your message on this forum? If not, please email to me at [email protected]. Thanks, Lynn
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
Leaving Cathflo in overnight or longer is an off-label use of Cathflo. But most outpatient infusion units have done this. Just instill it by pulling back on the syringe and allowing the Cathflo to gently go into the catheter lumen up to the clot interface. Remove the syringe and cap it off. The Cathflo will work passively. In vitro work (not published) showed that Cathflo is still 90% active at 37 deg C. up to 1 week, and 50% active at 2 weeks. The concern is risk of CRBSI as Cathflo is reconstituted with preservative-free sterile water, and there may be bacteria imbedded in the fibrin or thrombus in the catheter lumen. We did this with a patient post kidney transplant who could not maintain patency of his catheter with heparin (this was many years ago), but he had full use of his catheter for 2 months of daily outpatient IV therapy (daily DHPG, twice a week lab draws, etc), with no infections or any other complications. I've also instillied Cathflo into a PICC with intraluminial occlusion overnight, and it worked!!
Contact Genentech's Drug Info: 800-626-3553 and ask for the following article:
Schenk, P, et al. Recombinant Tissue Plasminogen Activator is a Useful Alternative to Heparin in Priming Quinton Permcath, Am J. of Kidney Dis, 2000.
Schenk locked dialysis catheter for 2 months with heparin 1,000 units/ml, catheter fill volume, and then crossed over to locking with 2 mg/2 ml of alteplase (Cathflo) for 2 months, OR alteplase for 2 months, and then to heparin lock for 2 months. Unfortunately because patients got their catheters out or died, he ended up with only 9 or 11 evaluable patients. The results showed that the alteplase arm had better dialysis outcomes, better flow rates, and fewer thrombotic complications, and NO infections.
Nadine Nakazawa, RN
PICC Nurse, Stanford Hospital
& President-Elect, AVA
Nadine Nakazawa, RN
Nadine Nakazawa, RN, BS, VA-BC
Our criteria for instilling Cathflo in a patient's PICC who will be returning home with the Cathflo indwelling is that he return to clinic the following day for Cathflo extraction and catheter assessment/flushing and that the line be labeled "Do not use. Cathflo indwelling." The patient and the home health care nurse should be aware as well so that the Cathflo isn't inadvertently flushed through. If patient compliance is questionable, we would aspirate the Cathflo prior to sending the patient home.
We had looked into instilling the Cathflo in clinic and having the home health nurses aspirate the Cathflo & flush the line the following morning; however, this was denied as the nurses are not presently authorized/trained to administer Cathflo.
As Nadine discussed, there is both in vitro and in vivo published evidence supporting Cathflo dwelling within catheters for an extended period of time. Weck et al also demonstrated that Alteplase reconstituted in sterile water and bacteriostatic water maintains protein stability and remains biologically active when at 37°C for 7 days.
Daphne Broadhurst,RN
Ottawa Canada
Weck S et al. Alteplase as a Catheter Locking Solution: In Vitro Evaluation of Biochemical Stability and Antimicrobial. J Vasc Interv Radiol 2005; 16:379–383
Daphne Broadhurst
Desjardins Pharmacy
Ottawa, Canada
For my curiosity, why are you so concerned about aspiration of this low dose of Cathflo? The dose is so small and the half life is so short, I have never seen anyone put this much emphasis on aspiration before. Thanks, Lynn
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
I guess I have the same question like Lynn! Usually alteplase works on contact, if you need 1 h for 0,2 ml I would think there is something else wrong. What kind of medication was given before? How does the chest xray look like?
Activase has a half-lifetime from 5-7 min....and remember, if you push 2 ml inside the line you have at least 1 ml in the bloodstream. The treatment is inside and outside of the catheter on purpose!
And, by the way, to leave activase overnight in you line is an off lable use.
Andre Schotte, clinical nurse educator, Genentech
Andre, leaving Cathflo indwelling overnight is off-label, no doubt. There is however published evidence supporting the safety of this practice, in Nancy Moureau’s PICCOLO II study. We leave the Cathflo indwelling overnight if the lumen is not needed; otherwise it’s usually removed in 2 hours. Basically, if there’s a chance that we might have greater success with a longer dwell time, why not go for it? Our premise for the longer dwell time is that the longer it’s left in the catheter, the greater the likelihood of complete fibrinolysis (i.e, efficacy rate of 52% at 30 minutes as opposed to77% at 2 hours in the COOL II study). Is it not true that the ~5 min. plasma half-life refers to Cathflo in the bloodstream; however, Cathflo remains bioactive in the catheter in the presence of fibrin & thus continues to convert plasminogen as it works its way through the clot? Therefore, if you remove the Cathflo as soon as you get blood return, there could still be some residual clot which would quickly bind to further blood proteins & propogate further clotting?
Cathflo does indeed have a short plasma half-life which lends to its safety. Lynn, I completely agree that instilling Cathflo systemically is most likely going to cause no harm, as it’s not likely to reach pharmacologic concentration. However, what if you have a patient who hemorrhages & it’s discovered that he recently received Cathflo & the RN didn’t aspirate the Cathflo. I would be very concerned that the nurse would end up as a Walmart greeter (to use Sue Masoorli’s term) as she contravened hospital policy and manufacturer’s IFUs, even though the bleed was likely not due to the Cathflo.
Regards,
Daphne Broadhurst,
Ottawa ON
Daphne Broadhurst
Desjardins Pharmacy
Ottawa, Canada
Daphne,
Ok, let's talk off label!
Of course, it is a coomon practice to leave alteplase over night, no doubt there. And yes, inside the catheter it is still 90% after 1 week...I agree and was not pointing the finger.
If you refer to the COOL study you see there are no contra indications. My own opinion is: alteplase is safer than aspirin.
2mg alteplase is 2% of a regular dosage! Yes you have to go with your hospital policy. If you have the removal placed in your policy, you have to go with it.
anyway, my point was to think about other possibilities regarding you occlusion. Still, 1 hour for 0.2ml is not common for my experience.
Andre
Andre,
Regarding your comment, "Usually alteplase works on contact" . . . If a clot is the entire length of the port catheter and in the port reservoir, I would certainly expect that one would need to work it all the way through the catheter which could take some time. It may dissolve the clot at the interface with the tpa, but there is alot more clot that needs to be dissolved prior to the catheter functioning fully. I do believe that a clot was the reason for this line's malfunction for several reasons: 1) the history of no or inadequate flushing after blood draw, 2) blood in the Huber extension set found by the nurse following, 3) continuing to get pink to cherry red in the tpa syringe while trying to work the tpa in and 4) ultimately, the catheter clearing and providing good blood return.
Yes, I did not say anything else!! TPA contact and dissolve the clot! Instead of trying to place it 1 h, just place what you can get, let it dwell for 10 min and try to place more. I did not question what you and your team did, I try to help! It would be still nice to be friendly with the answers!
This is an off lable comment!
Andre
This is not in policy, but we do follow up with many "occlusions" that want another PICC placed or a PICC placed because the port is occluded. They have tried tPA 2 times without results of good blood return.
The staff nurses think that we do "magic", but all that we do is to go assess the CVC the next day (after treatment with tPA). We aspirate and get blood return! All that we have done is to allow the tPA to be in the line longer. We have avoided replacing many lines by doing this assessment hours later than their assessment of no blood return or lack of flushing. This occurs with outpatients and inpatiemts.
We don't do magic, of course, but we do check to see if the tPA worked before we proceed with other measures to replace the line (whatever type it is).
Gwen Irwin
Austin, Texas