–Catheter-associated thrombosis is a potential complication in patients with central venous access devices. Fibrin or blood within or around a central venous access device or within the reservoir of an implanted port can slow down or disrupt catheter flow. Such occlusion is a common noninfectious complication associated with central venous access device use. A clotted catheter is not only nonfunctional but also provides a medium for bacterial growth, which increases the risk of vascular catheter-associated infection.
*Hospital-acquired condition alert:
–Keep in mind that the Centers for Medicare and Medicaid Services consider vascular catheter-associated infection a hospital-acquired condition because it can be reasonably prevented using a variety of best practices. Make sure to follow evidence-based infection prevention practices, such as maintaining sterile no-touch technique and performing a vigorous mechanical scrub of the injection port for at least 5 seconds using an antiseptic pad, when declotting a central venous access catheter to reduce the risk of vascular catheter-associated infections.
–Indicators of partial or complete catheter occlusion include the inability to infuse fluids, sluggish flow, lack of brisk blood return on aspiration, increased resistance when flushing or complete inability to flush the catheter, increased occlusion alarm activation when using an electronic infusion pump, and swelling or leakage at the infusion site.
–Troubleshooting is necessary to identify the potential cause of central venous access device occlusion. Before using a thrombolytic agent, the practitioner should rule out nonthrombotic and mechanical causes of occlusion, such as a tight suture securing the device; a clamped, kinked, or malpositioned catheter; kinked tubing; an obstructed filter; a nonfunctioning needleless connector; and pinch-off syndrome.
When thrombus formation is the likely cause of catheter occlusion, the most common treatment is administration of tissue plasminogen activator (TPA), also known as altepase.
–Currently, alteplase is the only thrombolytic agent approved by the U.S. Food and Drug Administration for the restoration of central venous access device function. Similar to naturally produced human TPA, alteplase acts specifically on fibrin-rich clots in the occluded catheter and converts plasminogen to plasmin. Plasmin then dissolves the clot’s fibrin, which promotes thrombotic breakdown. Residual debris can be aspirated from the catheter after the clot dissolves, restoring central venous access. Salvage of a central venous access device with alteplase is effective in 75% of cases, although some patients require two doses to restore line patency.
–Alteplase should be prescribed with caution in the presence of known or suspected vascular catheter-associated infection because alteplase administration can cause the release of organisms from the catheter into the systemic circulation. In addition, alteplase should be used with caution in any patient who has a known bleeding disorder; who has active internal bleeding; or who has had within the previous 48 hours surgery, obstetric delivery, percutaneous biopsy of viscera or deep tissue, or puncture of a noncompressible vessel because of the risk of bleeding associated with the use of thrombolytic.
Complete occlusion requires the use of the single syringe or stopcock method of declotting because these methods use a negative-pressure approach. The direct instillation method is indicated for partial thrombotic occlusions when the central venous access device can still be flushed but catheter flow is sluggish or aspiration of blood isn’t possible.
Tell the patient to report any new symptoms, such as shortness of breath, chest or abdominal discomfort, chills, and bleeding. Identify whether further patient teaching is necessary to prevent future clotting incidents, and provide instruction as indicated.
TPA is a naturally occurring component of the human clotting cascade, so allergic reactions are rare; however, intracatheter alteplase shouldn’t be administered to patients with known hypersensitivity to alteplase or to any other component of the formulation. Serious adverse events after intracatheter use of alteplase are rare but include sepsis, bleeding, and venous thrombosis.
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