Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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Haemodialysis, Alteplase tPA No Registration Number(s) and/or name and JHH Nephrology Department SWP N.1.05 of Superseded Documents: Relevant or related Documents, Australian Standards, Guidelines etc: NSW Health Policy Directive 2007_079 Correct patient, Correct procedure,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 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. December 2010 Page 1 of 7 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: Version No.1 December 2010 Page 2 of 7 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. Version No.1 December 2010 Page 3 of 7 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. Version No.1 December 2010 Page 4 of 7 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. Version No.1 December 2010 Page 5 of 7 Renal: Management of Blocked Haemodialysis CVDC using Alteplase – Doc # 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) Version No.1 December 2010 Page 6 of 7 Renal: Management of Blocked Haemodialysis CVDC using Alteplase – Doc # Appendix 1 Adopted from the World Health Organization and Hand Hygiene Australia. Version No.1 December 2010 Page 7 of 7