Process for Routine Assessment

Does your institution have a process for routine assessment of catheter patency?

Employ best practice standards and routine patency evaluation to optimize outcomes and minimize complications

The INS Infusion Therapy Standards of Practice recommend1:

  • CVADs should be regularly assessed for patency and proper function as defined by the ability to flush the catheter without resistance and the ability to yield a blood return
  • CVAD occlusions should not be left untreated because another lumen is patent

 01:04: Prior to any infusion, it is important to first assess catheter patency. The Infusion Nurses Society states, "The nurse should identify signs of CVAD occlusion, including the inability to withdraw blood, sluggish flow, and/or inability to flush or infuse through the device." Catheter occlusions can be partial or complete. With a partial occlusion infusion is possible but aspiration is not. Sluggish flow may also be an indicator of a partial occlusion. In the case of a complete occlusion, you will be unable to infuse or aspirate.

01:40 Before administration of medications and solutions, always obtain supplies, perform hand hygiene, don gloves, and disinfect the needleless connector.

Prior to the administration of any medications or solutions, a nurse should always1:

  • FLUSH to determine resistance, flushing with an adequate volume of saline or appropriate solution
  • ASPIRATE for a positive blood return that is the color and consistency of whole blood
  • Check for other indications of an occlusion
  • Palpate the insertion site to determine tenderness
  • Assess the patient for any pain or discomfort

Again, it is critical to always flush and aspirate the CVAD for a positive blood return. Flushing the line is not enough, you must be able to withdraw blood in order to rule out a partial occlusion. Assess the catheter for brisk blood return that is the color and consistency of whole blood. This may occur before, during, or after flushing. Check your CVAD protocol.

02:18 Next, it's time to flush. First inject with preservative free 0.9% Sodium Chloride USP into the CVAD using a 10-milliliter syringe, noting any resistance or sluggish flow. Do not forcibly flush. Consider the pulsatile flush or push pause technique.

Depending on the status of the catheter, patent or not patent, select a tab to view the next step

Where there are signs that the catheter is not patent—including resistance, or no blood return when flushing or aspirating, or blood return that is sluggish or not the color and consistency of whole blood—it is important to troubleshoot to rule out the presence of a nonthrombotic obstruction. Nonthrombotic obstructions may include mechanical issues or presence of drug precipitates within the catheter lumen. In order to rule out a mechanical obstruction, first examine the tubing, extension set, CVAD, and needleless connector. Then attempt to reposition the patient by raising the head of the bed or asking them to take a deep breath. Remember you are trying to change intrathoracic pressure.

03:48 If none of these methods work, you should then consider the possibility of drug precipitates within the catheter. Review the intravenous medications previously administered via CVAD to detect incompatibilities. If mechanical obstruction and medication precipitation can be ruled out, a thrombotic occlusion should be suspected. Follow your CVAD policy for subsequent intervention.

  • RESISTANCE (or no blood return) when flushing or aspirating
  • Blood return that is SLUGGISH or not the color and consistency of whole blood
  • Need to TROUBLESHOOT

Troubleshoot1,17

A. Check for presence of nonthrombotic obstruction

  • Mechanical
    • EXAMINE tubing, extension set, CVAD, and needleless connector
    • REPOSITION patient (eg, raise arm, turn head)
  • Medication precipitation
    • REVIEW intravenous medications administered via CVAD for incompatibilities

B. Suspect thrombotic occlusion after ruling out mechanical obstruction and medication precipitation

  • Thrombotic occlusion
    • FOLLOW your CVAD policy for subsequent intervention

If the catheter is patent, you should observe no resistance when flushing and aspirating, as well as brisk and free flowing blood return, that is the color and consistency of whole blood. If the catheter is patent, the final step is to document your findings in a patient's electronic health record or nursing notes.

  • NO RESISTANCE when flushing and aspirating
  • BRISK, free-flowing blood return that is the color and consistency of whole blood
  • Ready to ADMINISTER medications and solutions

Documentation

DOCUMENT whether patency was confirmed prior to administration of medications and solutions

Documentation of catheter patency is a clinical practice standard and should include device patency, signs and symptoms of complications, lack of resistance when flushing, and presence of blood return upon aspiration. Ensuring CVAD patency is a critical component of quality patient care. By utilizing these evidence-based recommendations, you can help to avoid interruptions in patient care, delays in discharge, and additional procedures such as catheter replacement.

Institutions should monitor competency in catheter care upon hiring of staff and periodically thereafter.1

In addition, use the following recommended algorithm for assessing and treating occluded catheters4:

Chart: Guide to patecy and assessing catheter function

Adapted from McKnight S.

Stethoscope

The INS Infusion Therapy Standards of Practice state that catheter salvage is preferred over catheter removal for management of central venous access device (CVAD) occlusions.1

Indication

Cathflo® Activase® (alteplase) is indicated for the restoration of function to central venous access devices as assessed by the ability to withdraw blood.

Contraindications

Cathflo Activase should not be administered to patients with known hypersensitivity to alteplase or any component of the formulation.

Precautions

General

Certain causes of catheter dysfunction should be considered before treatment with Cathflo Activase (e.g. catheter malposition, mechanical failure, constriction by a suture and lipid deposits or drug precipitates within the catheter lumen). These types of conditions should be considered before treatment with Cathflo Activase.

Excessive pressure should be avoided when Cathflo Activase is instilled into the catheter. Such force could cause rupture of the catheter or expulsion of the clot into the circulation.

Bleeding

The most frequent adverse reaction associated with all thrombolytics in all approved indications is bleeding. Cathflo Activase has not been studied in patients known to be at risk for bleeding events that may be associated with the use of thrombolytics. Caution should be exercised with patients who have any condition for which bleeding constitutes a significant hazard.

Should serious bleeding in a critical location (e.g., intracranial, gastrointestinal, retroperitoneal, pericardial) occur, treatment with Cathflo Activase should be stopped and the drug should be withdrawn from the catheter.

Infections

Cathflo Activase should be used with caution in the presence of known or suspected infection in the catheter. Using Cathflo Activase in patients with infected catheters may release a localized infection into the systemic circulation. As with all catheterization procedures, care should be used to maintain aseptic technique.

Hypersensitivity

Hypersensitivity, including urticaria, angioedema and anaphylaxis, has been reported in association with use of Cathflo Activase. Monitor patients treated with Cathflo Activase for signs of hypersensitivity and treat appropriately if necessary.

Drug Interactions and Drug/Laboratory Test Interactions

The interaction of Cathflo Activase with other drugs has not been formally studied. Concomitant use of drugs affecting coagulation and/or platelet function has not been studied.

Potential interactions between Cathflo Activase and laboratory tests have not been studied.

Carcinogenesis, Mutagenesis, Impairment of Fertility

Long-term studies in animals have not been performed to evaluate the carcinogenic potential or the effect on fertility.

Pregnancy

There are no adequate and well-controlled studies in pregnant women. Cathflo Activase should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Adverse Reactions

In clinical trials, the most serious adverse events reported after treatment were sepsis, gastrointestinal bleeding, and venous thrombosis.

You may report side effects to the FDA at (800) FDA-1088 or www.fda.gov/medwatch. You may also report side effects to Genentech at (888) 835-2555.

Please see accompanying full Prescribing Information for additional Important Safety Information.

    • Infusion Nurses Society. Infusion therapy standards of practice. J Infus Nurs. 2021:44(suppl 1):S1-S224.

      Infusion Nurses Society. Infusion therapy standards of practice. J Infus Nurs. 2021:44(suppl 1):S1-S224.

    • Blaney M, Shen V, Kerner JA, et al; for CAPS Investigators. Alteplase for the treatment of central venous catheter occlusion in children: results of a prospective, open-label, single-arm study (the Cathflo Activase Pediatric Study). J Vasc Interv Radiol. 2006;17(11, pt 1):1745-1751.

      Blaney M, Shen V, Kerner JA, et al; for CAPS Investigators. Alteplase for the treatment of central venous catheter occlusion in children: results of a prospective, open-label, single-arm study (the Cathflo Activase Pediatric Study). J Vasc Interv Radiol. 2006;17(11, pt 1):1745-1751.

    • Camp-Sorrell D, Matey L, ed. Access Device Standards of Practice for Oncology Nursing. 4th ed. Oncology Nursing Society; 2017.

      Camp-Sorrell D, Matey L, ed. Access Device Standards of Practice for Oncology Nursing. 4th ed. Oncology Nursing Society; 2017.

    • McKnight S. Nurse's guide to understanding and treating thrombotic occlusion of central venous access devices. Medsurg Nurs. 2004;13(6):377-382.

      McKnight S. Nurse's guide to understanding and treating thrombotic occlusion of central venous access devices. Medsurg Nurs. 2004;13(6):377-382.

    • Haire WD, Herbst SF. Consensus conference on the use of alteplase (t-PA) for the management of thrombotic catheter dysfunction. J Vasc Access Devices. 2000;5(2):28-36.

      Haire WD, Herbst SF. Consensus conference on the use of alteplase (t-PA) for the management of thrombotic catheter dysfunction. J Vasc Access Devices. 2000;5(2):28-36.

    • AVA. Study Guide for Vascular Access Certification. Association for Vascular Access; 2011:iii-164.

      AVA. Study Guide for Vascular Access Certification. Association for Vascular Access; 2011:iii-164.

    • Cummings-Winfield C, Mushani-Kanji T. Restoring patency to central venous access devices. Clin J Oncol Nurs. 2008;12(6):925-934.

      Cummings-Winfield C, Mushani-Kanji T. Restoring patency to central venous access devices. Clin J Oncol Nurs. 2008;12(6):925-934.

    • Cathflo Prescribing Information. Genentech USA, Inc.

      Cathflo Prescribing Information. Genentech USA, Inc.

    • Siegel JD, Rhinehart E, Jackson M, Chiarello L; Healthcare Infection Control Practices Advisory Committee (HICPAC). Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. 2007:1-226.

      Siegel JD, Rhinehart E, Jackson M, Chiarello L; Healthcare Infection Control Practices Advisory Committee (HICPAC). Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. 2007:1-226.

    • Deitcher SR, Fesen MR, Kiproff PM, et al; for the Cardiovascular Thrombolytic to Open Occluded Lines-2 Investigators. Safety and efficacy of alteplase for restoring function in occluded central venous catheters: results of the Cardiovascular Thrombolytic to Open Occluded Lines trial. J Clin Oncol. 2002;20(1):317-324.

      Deitcher SR, Fesen MR, Kiproff PM, et al; for the Cardiovascular Thrombolytic to Open Occluded Lines-2 Investigators. Safety and efficacy of alteplase for restoring function in occluded central venous catheters: results of the Cardiovascular Thrombolytic to Open Occluded Lines trial. J Clin Oncol. 2002;20(1):317-324.

    • Doellman D, Buckner JK, Garrett JH Jr, et al. Best practice guidelines in the care and maintenance of pediatric central venous catheters. 2015. http://www.ivas.online/newstyle/wp-content/uploads/2019/06/AVA-Pediatric-Guidelines-2nd-edition_web.pdf

      Doellman D, Buckner JK, Garrett JH Jr, et al. Best practice guidelines in the care and maintenance of pediatric central venous catheters. 2015. http://www.ivas.online/newstyle/wp-content/uploads/2019/06/AVA-Pediatric-Guidelines-2nd-edition_web.pdf

    • Frey AM. Intravenous therapy in children. In: Hankins J, Lonsway RAW, Hedrick C, Perdue M, eds. Infusion Therapy in Clinical Practice. 2nd ed. WB Saunders; 2001:561-591.

      Frey AM. Intravenous therapy in children. In: Hankins J, Lonsway RAW, Hedrick C, Perdue M, eds. Infusion Therapy in Clinical Practice. 2nd ed. WB Saunders; 2001:561-591.

    • Richardson D. Vascular access nursing: standards of care, and strategies in the prevention of infection: a primer on central venous catheters (part 2 of a 3-part series). JAVA. 2007;12(1):19-27.

      Richardson D. Vascular access nursing: standards of care, and strategies in the prevention of infection: a primer on central venous catheters (part 2 of a 3-part series). JAVA. 2007;12(1):19-27.

    • Mohiaddin RH, Wann SL, Underwood R, Firmin DN, Rees S, Longmore DB. Vena caval flow: assessment with cine MR velocity mapping. Radiology. 1990;177(2):537-541.

      Mohiaddin RH, Wann SL, Underwood R, Firmin DN, Rees S, Longmore DB. Vena caval flow: assessment with cine MR velocity mapping. Radiology. 1990;177(2):537-541.

    • Raaf JH. Results from use of 826 vascular access devices in cancer patients. Cancer. 1985;55(6):1312-1322.

      Raaf JH. Results from use of 826 vascular access devices in cancer patients. Cancer. 1985;55(6):1312-1322.

    • Stephens LC, Haire WD, Kotulak GD. Are clinical signs accurate indicators of the cause of central venous catheter occlusion? J Parenter Enteral Nutr. 1995;19(1):75-79.

      Stephens LC, Haire WD, Kotulak GD. Are clinical signs accurate indicators of the cause of central venous catheter occlusion? J Parenter Enteral Nutr. 1995;19(1):75-79.

    • National Institutes of Health. Management of central venous catheter occlusions. Pharm Update. 1999:1-4.

      National Institutes of Health. Management of central venous catheter occlusions. Pharm Update. 1999:1-4.

    • Ryder M. The role of biofilm in vascular catheter-related infections. N Dev Vasc Dis. 2001;2:15-25.

      Ryder M. The role of biofilm in vascular catheter-related infections. N Dev Vasc Dis. 2001;2:15-25.

    • Hadaway LC. Reopen the pipeline for IV therapy. Nursing. 2005;35(8):54-61.

      Hadaway LC. Reopen the pipeline for IV therapy. Nursing. 2005;35(8):54-61.

    • Wingerter L. Vascular access device thrombosis. Clin J Oncol Nurs. 2003;7(3):345-348.

      Wingerter L. Vascular access device thrombosis. Clin J Oncol Nurs. 2003;7(3):345-348.

    • Kaler W, Chinn R. Successful disinfection of needleless access ports: a matter of time and friction. JAVA. 2007;12(3):140-142.

      Kaler W, Chinn R. Successful disinfection of needleless access ports: a matter of time and friction. JAVA. 2007;12(3):140-142.

    • Ponec D, Irwin D, Haire WD, et al. Recombinant tissue plasminogen activator (alteplase) for restoration of flow in occluded central venous access devices: a double-blind placebo-controlled trial—the cardiovascular thrombolytic to open occluded lines (COOL) efficacy trial. J Vasc Inter Radiol. 2001;12(8):951-955.

      Ponec D, Irwin D, Haire WD, et al. Recombinant tissue plasminogen activator (alteplase) for restoration of flow in occluded central venous access devices: a double-blind placebo-controlled trial—the cardiovascular thrombolytic to open occluded lines (COOL) efficacy trial. J Vasc Inter Radiol. 2001;12(8):951-955.

    • Criddle LM. Ask the experts. Crit Care Nurse. 2007;27(3):78-81.

      Criddle LM. Ask the experts. Crit Care Nurse. 2007;27(3):78-81.