Download Management of blocked Haemodialysis Central Venous

Renal: Management of Blocked Haemodialysis CVDC using Alteplase – Doc #
Guideline and
Procedure
Management of blocked Haemodialysis Central Venous Catheter Using
Alteplase
Document Number:
Sites where Guideline and Procedure
applies:
Target audience:
Description:
Keywords:
Replaces Existing Guideline and
Procedure:
All sites where a Haemodialysis patient receives care.
Nephrology clinical staff who provide care to Haemodialysis
patients.
This document describes the management of blocked
central venous catheters using alteplase (Actilyase)
Central venous catheter, Haemodialysis, Alteplase tPA
No
Registration Number(s) and/or name and JHH Nephrology Department SWP N.1.05
of Superseded Documents:
Relevant or related Documents, Australian Standards, Guidelines etc:
 NSW Health Policy Directive 2007_079 Correct patient, Correct procedure, correct site
http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_079.pdf
 NSW Health Policy PD 2005_406 Consent to Medical Treatment
http://www.health.nsw.gov.au/policies/PD/2005/pdf/PD2005_406.pdf
 NSW Health Policy Directive PD 2007_036 Infection Control Policy
http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_036.pdf
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NSW Health Policy Directive 2007_077 – Medication Handling in NSW Public Hospitals
http://www.health.nsw.gov.au/policies/pd/2007/PD2007_077.html
NSW Health Department Circular 95/86 Principles for the preparation of pharmaceuticals in hospital pharmacy
departments in New South Wales
NSW Health Department Circular 98/99
Occupational Health & Safety Act 2000
NSW Nurses Act 1991 — No. 221
NSW Medical Practice Act — 1992 — Regulation 1995 No. 220
Prerequisites (if required):
Registered Nurses only. Instillation of alteplase (Actilyse) should only be
undertaken by appropriately experienced personnel. All personnel should have
had specific training in the use of central venous lines
Procedure Summary:
Guideline Note :
Version No.1
Current dialysis prescription / medication order
This Guideline and Procedure sets out the steps to be followed when
unblocking a dual lumen Haemodialysis central venous catheter for the
purpose of performing haemodialysis. This can be used only if first line
management has been unsuccessful. The procedural components of the
document such as, Preparation of patient, Preparation of equipment,
Technique, Cleaning up and Documentation are considered mandatory.
This document reflects what is currently regarded as safe and appropriate
practice. However in any clinical situation there may be many factors that
cannot be covered by a single document and therefore does not replace
the need for the application of clinical judgment in respect to each
individual patient.
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Renal: Management of Blocked Haemodialysis CVDC using Alteplase – Doc #
Date authorised:
Authorised by:
HNEAHS Renal Clinical Stream Leadership Group
Contact Person:
Dr Gillies- Clinical Stream Leader
Contact Details:
02 49214321
Review due date:
TRIM Number:
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Renal: Management of Blocked Haemodialysis CVDC using Alteplase – Doc #
OUTCOMES
1
To remove blood clots or fibrin from a dual lumen haemodialysis catheter which is essential for
dialysis treatment and not easily replaced
2
To safely and effectively deliver haemodialysis treatment
ABBREVIATIONS & GLOSSARY
CVDC
Central venous dialysis catheter , which is a vascular device where the
distal end (tip) lies in a major/central vein.
PPE
Personal Protective Equipment
tPA
tissue Plasminogen Activator (Alteplase)
Ml
Millilitre
Mg
Milligram
C
Centigrade
e.g
Example
PREAMBLE
Dialysis CVDC dysfunction is a significant cause of catheter loss and interrupted haemodialysis
sessions. Catheter dysfunction can be defined as the failure to attain or maintain adequate blood
flow. Blood flow problems can be initially related to mechanical issues, although, frequent and
prolonged problems are often related to thrombosis.
Alteplase for blocked central venous catheters should be used in Hunter New England Area Health
only after consultation with the team leader and treating medical officer. At times the Nephrologist
may order Alteplase as a once off routine lock on problematic catheters that will be removed at
next dialysis treatment session.
Note: 3 ml syringes should only be used for instilling medication, not for trouble shooting.
GUIDELINE
This Guideline does not replace the need for the application of clinical judgment in respect of each
individual patient.
Prior to administration of tPA steps listed below must be considered.
First Line Management:
1. Check for external obstruction e.g. closed clamps, kinked catheter.
2. Check insertion distance and for blood return as catheter may have migrated out of the vessel.
3. Ask the patient to
 Change their position (e.g. lay on their side), head down if not medically
contraindicated, move arm and/or head in different directions.
 Ask the patient to cough.
4. GENTLE alternate irrigation and aspiration (push-pull method) using a 10mL syringe of Normal
Saline.
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Renal: Management of Blocked Haemodialysis CVDC using Alteplase – Doc #
If first line management does not unblock the catheter, discuss using Alteplase with the team
leader and medical officer.
Nursing Alert: If Alteplase lock was used as a routine lock post last dialysis session and you are
unable to aspirate, do not push Alteplase forward into the patient without express order from
Medical Officer due to increased potential of bleeding.
CONTRAINDICATIONS
A known hypersensitivity to alteplase or any component of the formulation.
PRECAUTIONS
If there is active bleeding, a history of surgery or invasive procedures in the preceding 48 hours,
thrombocytopenia or other bleeding defects or pregnancy.
Suspected line infection – may release localised infection into the systemic circulation.
PROCEDURE
The procedure requires mandatory compliance.
Patient Preparation
It is mandatory to ensure that the patient has received appropriate information to provide informed
consent and, that patient identification, correct procedure and correct site process is completed
prior to any procedure.
Staff Preparation
It is mandatory for staff to follow relevant: “Five moments of hand hygiene”, infection control,
moving safely/safe manual handling, and documentation practices. Check for patient allergies and
medication history.
Equipment Requirement
 Valid medication order
 Alcohol hand gel
 Personal Protective Equipment
 Sterile gloves
 Sterile pack
 Alcohol wipes
 Drawing up needle x2
 10ml syringe x 2
 3ml syringes x 2
 10mg vial of Alteplase
 10mL ampoule sterile water for injection
 Lumen Cap(s)
Procedure
To be used in conjunction with HNELHD Guideline & Procedure: Commencement of
Haemodialysis using CVDC.
1. Wash hands
2. Using aseptic non touch technique to reconstitute the 10mg vial of Alteplase with 10mL of
water for injection to give a 1mg/mL solution.
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Renal: Management of Blocked Haemodialysis CVDC using Alteplase – Doc #
3. Gently swirl the vial. Do not shake.
4. Look up the recorded volume of each lumen of the catheter.
5. Dosage of alteplase 1 mg/mL solution in an amount equivalent to the internal volume of the
catheter lumen. Using a 3ml syringe, withdraw the required volume of solution for each
blocked lumen from the vial. Do not exceed this volume. The aim is to avoid introducing
alteplase into the systemic circulation, which is inappropriate for unblocking a venous
catheter.
6. Gently instill the Alteplase into each occluded lumen (Do not use force), leave insitu for a
30 minutes dwell time or as prescribed by treating nephrologist
7. Connect an empty 10mL syringe and attempt to aspirate after dwell time is complete.
If unsuccessful try to aspirate blood again after 120 of minutes dwell time
8. If this fails: A second dose may be used and left to dwell for a further 120 minutes, or as
prescribed by treating nephrologist, before attempting to aspirate blood. A nephrologist may
prescribe the Alteplase to be instilled as a lock between scheduled dialysis treatment or
overnight.
9. If successful: Aspirate and discard 4 to 5mL of blood to remove Alteplase & residual clot
then flush line with 20mL of normal saline.
ALERT:
Label all syringes with name of drug, concentration, date and time to avoid
confusion.
NOTE:
DO NOT EXCEED A TOTAL OF 2 DOSES PER LUMEN
If unsuccessful after the second attempt, notify treating nephrologist or medical officer
Reconstituted solution in the vial can be stored refrigerated at 2 to 8ºC for up to 24 hours &
used for the same patient if a 2nd dose is required.
Following second unsuccessful attempt consider catheter replacement.
Important Drug Interactions
 Haemorrhage risk may be increased if used with drugs that prolong bleeding time.
 Angiotensin converting enzyme (ACE) inhibitors may enhance anaphylaxis risk.
Monitoring requirements
 Observe for signs of bleeding including minor bleeds or bruising. If evident (control the
bleeding), notify the Medical officer immediately.
APPENDICES
Five Moments for Hand Hygiene
REFERENCES
Hand Hygiene Australia 2008: Five Moments for Hand Hygiene
Deitcher, S.R., Li, X., McCluskey, E.R., Resnansky,L., Semba, C.P. and Tu.
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T. (2002) Treatment of occluded central venous catheters with alteplase: results in 1,064 patients.
Journal of Vascular & Interventional Radiology 13(12):1199-205.
JHH Medicines Committee, Sept 2008, Prescribing Protocol; Alteplase for Occluded Central
Venous Catheters(CVDCs)
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Appendix 1
Adopted from the World Health Organization and Hand Hygiene Australia.
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