Managing Central Line Occlusions

Staffing Education on Managing Central Line Occlusion: Declotting: Adult and Pediatrics

1. Perform hand hygiene and don gloves.
2. Verify correct patient using two identifiers.
3. Assess the patient’s need for the procedure by attempting to draw blood from the catheter. During attempts to determine catheter occlusion, avoid vigorous suction, which could cause damage to the vessel wall, release of a fibrin clot, or collapse of the catheter walls (e.g., do NOT “pop” the syringe by letting go after pulling back—this creates excessive negative pressure).
4. Perform a thorough assessment, to include:
   1. Ruling out external mechanical catheter obstruction
   2. Ruling out patient positioning-related mechanical catheter obstruction
   3. Ruling out obstruction caused by lipid or drug precipitate
   4. Reviewing cautions for alteplase treatment
5. Assess the patient for specific contraindications to receiving alteplase and advise the practitioner accordingly.
6. Assess the catheter insertion site for signs of infection, such as redness, exudate, or being warm to the touch. Notify the practitioner if you suspect an infection, because the action of alteplase in an infected catheter may disseminate the localized bacteria systemically.

Instillation

1. Ensure the ºfive rights of medication safety: right medication, dose, time, route, and patient.
2. Using the same 10-ml syringe, administer the appropriate dose of solution from the reconstituted vial. Instill the dose of alteplase into the occluded catheter. If resistance is met, avoid the risk of catheter rupture by never forcibly pushing the solution into the catheter. If unable to instill the solution, use one of the following techniques to instill the alteplase.
3. ºNOTE:  For silicone PICC lines, use ONLY the Negative Pressure Technique as noted below:
4.  
   1. Use the single 10-ml syringe containing the alteplase solution, which is attached directly to the hub of the catheter’s dysfunctional lumen. After unclamping the catheter, gently pull back on the syringe plunger until it reaches the 8- or 9-ml mark and hold it to create negative pressure in the catheter. While holding the syringe in a vertical position to keep the solution at the syringe tip, slowly release the plunger and the negative pressure on the syringe. This will allow the alteplase solution to be drawn into the catheter. The procedure may need to be repeated to instill the dose of alteplase.
   2. Use two 10-ml syringes and a three-way stopcock. In this technique, the syringe containing the alteplase is attached to the horizontal hub of the stopcock and an empty 10-ml syringe is attached to the vertical hub. After unclamping the catheter, turn the stopcock off to the alteplase syringe and open to the empty syringe, and gently aspirate the empty syringe until the plunger reaches the 8- to 9-ml mark. While holding the plunger on the empty syringe to create negative pressure, turn the stopcock open to the syringe containing the alteplase solution and allow it to be drawn into the catheter. Additional attempts may be required to instill the complete dose of alteplase into the occluded lumen.
5. Wait 30 minutes, and then assess catheter function by attempting to withdraw blood. If the catheter is functional, then aspirate 4 to 5 ml of blood in patients weighing 10 kg or more, or 3 ml in patients weighing less than 10 kg, to remove the alteplase and residual clot. Gently irrigate the catheter with a 10-ml syringe containing normal saline. During attempts to determine catheter occlusion, avoid vigorous suction, which could cause damage to the vessel wall, release of a fibrin clot, or collapse of the catheter walls (e.g., do NOT “pop” the syringe by letting go after pulling back—this creates excessive negative pressure).
6. If catheter function is not restored after 30 minutes, then relock the catheter and assess again in 90 minutes (120 minutes after the first instillation). If the catheter is functional, follow the same irrigation process described in the step immediately preceding this one. If catheter function has not been restored, the dose of alteplase may be repeated, following the same steps described previously. If the catheter remains occluded, contact the practitioner.

Completing the Procedure:

1. To avoid recurrent occlusions, flush the catheter with solution (e.g., heparin, normal saline). Discard supplies, remove gloves, and perform hand hygiene. Document the procedure in the patient’s record.

Excerpted and adapted from Emergency Nursing Procedures, Fourth Edition, by Jean A. Proehl, RN, MN, CEN, CCRN, FAEN, St. Louis: Saunders, 2009.Comprehensive clinical review: S. Kay Sedlak, RN, MS, CEN, FAEN, January 2011Revised: July 2011ºApproved by Clinical Practice Council (CPC) - November 2011ºApproved by Nurse Exec Council (NEC) - November 2011
ºContent updated - December 2011