Management of blocked central venous access devices (CVADs)

In NHS Ayrshire & Arran, it is the synerkinase brand of Urokinase that is used. Reconstitute and instill Urokinase 25000 units (synerkinase) as follows:

• 1 lumen CVAD: 2mls of 0.9% sodium chloride
• 2 lumen CVAD: 4mls of sodium chloride (2mls per lumen)
• Port: 5mls of sodium chloride (chest and arm ports)

1. Attach 3 way-tap and syringes.

   

2. Open clamp (if there is one)
3. Open stopcock to the empty syringe and the blocked catheter.
4. Pull back on the plunger of the empty syringe to create a vacuum in the catheter. You will need to pull quite forcibly.
5. Maintain suction with one hand and with the other hand turn stopcock so it is closed to the syringe containing thrombolytic which will be sucked into the catheter. Don't worry if it seems that that very little thrombolytic is sucked in - even a tiny volumes will reach several cm into the catheter.
6. Leave for 1-2 hours. Do not clamp catheter as this will prevent the thrombolytic from penetrating into the line.
7. After this time, attempt withdrawal of blood. If this is not possible, attempt to flush the catheter using 0.9% sodium chloride in a 10ml syringe. Do not use excessive force.
8. This procedure often needs to be repeated several times before it works - sometimes leaving the thrombolytic in overnight seems to help.
9. If the procedure fails despite repeated attempts discuss with patient's consultant/oncologist.

Additional information: Urokinase is contraindicated in recent (<1 month) GI bleed, cerebrovascular accident (CVA), trauma, surgery, coagulation defects.
N.B. If precipitate is indicated rather than a thrombus (e.g. if total parenteral nutrition (TPN) is being given), use a precipitate clearing agent according to the manufacturer's guideline.

References:
Hamilton H, Boderham AR. Central venous catheters. Wiley-Blackwell, 2009. 
Hamilton H. Complications associated with central venous access devices. Nursing standard. 2006. 20(12), 59-65.
Hull and east Yorkshire Hospitals. Guidelines for management of persistent withdrawal occlusion in central venous catheters. 2007.
Leeds Teaching Hospitals. Guidelines for the management of CVADs that display persistent withdrawal occlusion. 2007.
Royal College of Nursing. Standards for infusion therapy. London, RCN, 2003.
Syner-kinase (urokinase). Summary of product characteristics. 2009

Clinical pathway for oncology patients with central venous access device complications outwith normal working hours

Contact details for the oncology teams working at Ayr and Crosshouse hospitals are available in the NHS Ayrshire & Arran Oncology Handbook

Competency pack

Note: hand washing must always be carried out a minimum of 2 meters away from the dressing trolley.

• An aseptic non touch technique (ANTT) must be used when accessing CVADs.
• If sepsis is suspected, blood cultures must be taken peripherally and then from each lumen of the CVAD.
• IV antibiotics and therapy should be administered via the CVAD unless systematically unwell following CVAD use earlier in the day.

1. Gather and set up dressing trolley, dressing pack and required equipment.
2. Follow hand hygiene procedures  and put on PPE (sterile gloves must be worn)
3. • Using an ANTT draw up 10mls of 0.9% sodium chloride in a 10ml luer lok syringe.
   • If not using the CVAD for an infusion:
     • Using an ANTT draw up 2mls of 10iu heparinised sodium chloride in a 10ml luer lok syringe (only use heparin if the CVAD has clamps)
   • OR if connecting an infusion:
     • Open the giving set and fluid for infusion directly onto the dressing pack.
     • Prime this using an ANTT and leave on the dressing pack ready for connection.
4. Hold the CVAD with a sterile swab with one hand and with the other decontaminate the bionector with a chlorhexide gluconate and alcohol wipe (clinell) for 20-30 seconds and allow to dry.
5. Continuing to hold the CVAD with the sterile swab, attach a 10ml luer lok syringe and remove 5-10mls of blood (discard or send for culture if sepsis is suspected)
6. At this point you can now, using an ANTT:
   • Take bloods.
   • Flush with the 10mls of 0.9% sodium chloride in a 10ml luer lok syringe and then administer antibiotics or connect an infusion of IV fluids / medication.
7. If the CVAD is not required to be used:
   • Flush each lumen used with the pre-drawn up 10mls of 0.9% sodium chloride using a push pause technique.
   • If the CVAD has clamps then lock with the 2mls of 10iu heparinised sodium chloride.

Please note that, if disconnecting an infusion, an ANTT must be used as described above. A saline infusion does not constitute a flush. It must be a bolus 10ml 0.9% sodium chloride flush using a push pause technique to avoid CVAD occlusion. This should be followed by heparin as above if the CVAD has clamps.

Note: hand washing must always be carried out a minimum of 2 meters away from the dressing trolley.

• An aseptic non touch technique (ANTT) must be used when accessing ports.
• If sepsis is suspected, blood cultures must be taken peripherally and then from each lumen of the CVAD.
• IV antibiotics and therapy should be administered via the CVAD unless systematically unwell following CVAD use earlier in the day.

1. Gather and set up dressing trolley, dressing pack and required equipment.
2. Follow hand hygiene procedures  and put on PPE (sterile gloves must be worn)
   • Using an ANTT draw up 2 x 10mls of 0.9% sodium chloride in a 10ml luer lok syringe.
   • If not using the port for an infusion:
     • Using an ANTT draw up 5mls of 100iu heparinised sodium chloride in a 10ml luer lok syringe 
   • OR if connecting an infusion:
     • Open the giving set and fluid for infusion directly onto the dressing pack.
     • Prime this using an ANTT and leave on the dressing pack ready for connection.
3. 
   
   • Prime the port needle with sodium chloride (approximately 2 mls)
   • Decontaminate the skin with chloraprep and allow to dry
   • Using your non-dominant hand, hold the port steady and insert the port needle into the centre of the port, then secure the port needle in place with IV Tegaderm advance.
4. Hold the lumen of the port with the sterile swab, attach a 10ml luer lok syringe and remove 5-10mls of blood (discard or send for culture if sepsis is suspected)
5. At this point, you can now use an ANTT to take bloods or
   • Flush with the 20mls of 0.9% sodium chloride in a 10ml luer lok syringe and then administer antibiotics or connect an infusion of IV fluids/medication.
6. If the port is not required to be used:
   • Flush the port with the two pre-drawn up 10mls of 0.9% sodium chloride using a push pause technique followed by 5mls of 100iu heparinised sodium chloride. The port needle can be left in place for up to 7 days and must be cared for similarly to any other CVAD in accordance with guideline G004.

Please note that, if disconnecting an infusion an ANTT must be used as described above. A saline infusion does not constitute a flush. It must be a bolus 2 x 10ml 0.9% sodium chloride flush using a push pause technique to avoid port occlusion. This should be followed by heparin as above.

Adult central venous access device (CVAD) care and maintenance bundle.

Peripherally inserted central catheter (PICC) removal competency assessment for nurses.