GGC Paediatric Guidelines
Occlusion
[Separate processes exist for large bore renal dialysis lines – seek advice from Renal ANPs]
There are a number of reasons a CVAD may have patency problems. A CVAD may not bleed back (withdrawal occlusion) or may be totally occluded – unable to flush or withdraw. This can be caused by catheter tip malposition, intraluminal clot, drug precipitate, fibrin sheath, catheter kink, pinch off between the clavicle and first rib or catheter rupture.
NOTE; its highly inadvisable to attempt to aspirate a line (or lumen) less than 4Fench Gauge or 19g cannula/catheter diameter as these lines block very easily, lines 4FG and above can be aspirated for sampling but this may decrease the longevity of the line.
It is essential when any CVAD has signs of occlusion (poor or no blood return, sluggish flow or complete occlusion) that a full assessment of the site and surrounding area is documented on the CVC care plan.
Nursing staff must not attempt to clear an occlusion using a syringe smaller than 10mL (risk of line rupture).
A chest x-ray may need to be carried out to check the tip position of the CVC/gripper particularly if clinical suspicion is that the line tip may have migrated or the line is kinked at some point.
Local installation of Urokinase
Urokinase dissolves clot, check there are no contraindications with supervising staff.
Urokinase 2500-5000 i.u with maximum volume of 2 mls (to cover CVAD priming volume + around line tip).
- Single lumen CVAD
Dose 2500i.u instilled into lumen for 1-4 hours. - Double lumen CVAD
Dose 2500i.u instilled into each lumen 1-4 hours.
If unsuccessful in obtaining blood return, repeat once in 24 hours, or if possible, leave the Urokinase in situ for 24 hours.
Total occlusion
Using 10 ml syringe reconstitute the urokinase to achieve 5,000iu in 2mls per lumen.
Prime the 3-tap with urokinase solution at 3 o’clock access point on the tap. DO NOT DISCONNECT THE SYRINGE.
Using ANTT attach the empty syringe to the port at 6 o’clock position. Ensure the three way tap is open to the lumen and the 6 o’clock position. Pull gently back on the empty syringe plunger to create a vacuum in the catheter to approximately 6mls and hold the plunger at 6mls whilst turning the closed position onto the empty syringe. Turn 3 way tap so that it is open to the urokinase and the line.
A small amount of urokinase will then be drawn into the vacuum. REMOVE the empty syringe and expel air the empty syringe.
Repeat process of creating vacuum and administering urokinase until the 2ml volume is administered.
Leave for minimal 60 minutes (up to several hours / overnight) and then withdraw.
If the line remains blocked then seek advice from Haem/Onc or Renal ANPs as appropriate
Damaged lines
Please contact the surgical team for advice, the surgeons may refer to ANPs to repair.
Repair kits are found in Theatre 6 or Schiehallion ANP office. If the line is to be repaired there will need to be 5cm of undamaged line measured from the skin exit and 2.5cm undamaged line below the y connector (if present). Note the size of the line/lumen before referring.
Leaking lines
Advice on leaking PIC & mid-lines leaking at the insertion site
Mid-lines and other lines may generate leaks at the insertion site, these could be due to problems at the site itself e,g, difficult insertion with local venous trauma or problems with the line hub entering the vein. Manual pressure on the leaking site for 5 minutes may help, if ineffective please seek experienced help before removal. It may be possible to re-dress / glue / exchange the line.
Extravasation injury advice
Extravasation injuries: prevention and management (neonatal guideline) this is directly applicable to neonates but the principles of advice do apply to a wider range of patients.
Prevention, treatment & follow-up of extravasation with SACT is written specifically for chemotherapy related injuries, but again the principles are more widely applicable.