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
my PATIENT MY my LINE Tm TM Help maintain quality care in patients with central lines Types of CVADs • Central venous access devices (CVADs), also known as central venous catheters or Nontunneled catheters2,5 • More than 7 million CVADs are implanted every year in patients in the United States • Also called subclavian, percutaneous, or short-term catheters • Typically used for days or weeks for all types of IV therapy, to draw blood, and to Access to central venous circulation • May be placed bedside or, if necessary, in an emergency setting, without sedation • The tip of a CVAD is generally placed in the lower third of the superior vena cava (SVC) near its Peripherally inserted central catheters (PICCs)5 central lines, have become a mainstay for patients requiring intravenous (IV) administration of medications and other fluids 1,2 junction with the right atrium.2,3 Because the blood-flow rate here is approximately 2 liters per minute, infusates are rapidly hemodiluted and distributed in the central venous system4 catheter management The role of central venous access devices monitor central venous pressure • Can be used for a variety of IV therapies, as well as for obtaining blood samples in a variety of care settings from diverse patient populations • May be placed bedside or in an outpatient setting CVAD insertion and tip sites3,5 Tunneled catheters2,5 • Designed for long-term use and frequent venous access • Provide more reliable IV access for extended courses of antibiotics, chemotherapy, and parenteral nutrition InTernAl juGulAr • Surgically inserted SubClAVIAn SuperIor VenA CAVA ( TIp loCATIon ) CephAlIC brAChIAl bASIlIC InFerIor VenA CAVA (AlTernATe TIp loCATIon) Implanted ports2,5 • Consist of 2 attached parts: the catheter and portal body with reservoir • Long-term dwell capacity, requiring little maintenance when not in use • Useful for cyclically infused therapies, such as chemotherapy. Blood draws may also be done through the port • Surgically inserted FemorAl 2 3 Administration, cont’d One in 4 catheters may become occluded6 7 Nonthrombotic catheter occlusions Catheter occlusion is the most common noninfectious complication in the long-term use of CVADs7 INSTILL 8the appropriate dose of Cathflo into the occluded catheter Mechanical occlusions • Occlusions may occur in up to 25% of CVADs 6 — May occur soon after insertion of a device or develop at any time during the course of IV therapy 8 Causes of catheter occlusions • About 58% of catheter occlusions are thrombotic • Thrombotic occlusions result from the formation of a thrombus within, surrounding, or at the tip of the catheter 6,8 • About 42% of catheter occlusions are due to nonthrombotic causes, including precipitates, malpositioning, mechanical obstructions, and other factors6,8 using an appropriately sized syringe (see dosing chart below). • Mechanical occlusions may result from malposition during insertion and use, or catheter migration 8 • Factors influencing the incidence of malposition include an increase in intrathoracic pressure from coughing, sneezing, or vomiting; arm movements; flushing of the catheter; and After 30 minutes of DWELL forceful time, assess the catheter function by thrombus attemptingformation 30 8 minutes Precipitates 30 9 minutes 6 to aspirate blood. If the catheter is functional, go to step 10; if not functional, go to step 9. a result of drug crystallization, incompatibilities, or time by catheter function after drug-drug a total of 120 minutes of dwell • Precipitates can form asASSESS 58% thrombotic drug-solution incompatibilities attempting to aspirate blood. If catheter is functional, go to step 10. If catheter is still occluded, a second dose of equal amount may be Drug120 precipitates in the catheter may occur in conjunction with thrombus formation and should always instilled. Repeat steps 1 through 8. minutes 120 be considered during assessment of an occlusion, since this may have implications for how the occlusion minutes 10 should be managed If catheter function has been restored, ASPIRATE 4 mL to 5 mL of blood in patients ≥10 kg or 3 mL in patients <10 kg to remove Cathflo and residual 8 clot. Then gently irrigate the catheter with 0.9% Sodium Chloride, USP. Lipid residue Any unused solution should be discarded. Lipid residue can accumulate in central venous catheters, often following the administration of lipid-containing, three-in-one total parenteral nutrition admixtures or drugs with oleaginous vehicles 17 • 42% nonthrombotic • Dosing with Cathflo 2 mg Patient weight Cathflo dose 30 kg (66 lb) 2 mg in 2 mL Salvaging catheters with nonthrombotic occlusions8 • In many instances, mechanical problems, such as kinked tubing or clogged in-line filters, can be identified and corrected 110% of the internal lumen volume of <30 kg (66 lb) CVAD, not to exceed 2 mg in 2 positioning, mL — Possible interventions to reposition catheters include patient rapid flushing of the catheter Note: Store lyophilized Cathflo at refrigerated temperature (2˚C-8˚C/36˚F-46˚F). Cathflo should be guidewire catheter exchange, fluoroscopic catheter guidance, or partial catheter withdrawal reconstituted immediately before use. The solution may be used within 8 hours if stored at 2˚C to 30˚C (36˚F-86˚F). No other medication should be added to solutions containing Cathflo. • Catheters occluded by calcium-phosphate precipitates can be treated with 0.1 N hydrochloric acid function(1ismEq/mL) not restored at 120 after known 1 dose to of Cathflo, doseenvironment may be instilled bicarbonate is used forminutes substances dissolve a in second an alkaline • If catheter • Sodium • Studies have not been performed with administration of total doses greater than 4 mg (two 2-mg doses) • Lipid occlusions have been treated with ethanol (70%) or sodium hydroxide (0.1 mmol/mL) • The use of incompatible drugs or solutions should be avoided References: 1. Brown M. The impact of safety product use on catheter-related infections. J Infus Nurs. 2004;27(4):245-250. 2. Richardson D. Vascular access nursing: standards of care, and strategies in the prevention of infection: a primer on central venous catheters (part 2 of a 3-part series). JAVA. 2007;12(1):19-27. 3. Infusion Nurses Society. Infusion therapy standards of practice. J Infus Nurs. 2016;39(suppl 1):S1-S159. 4. Mohiaddin RH, Wann SL, Underwood R, Firmin DN, Rees S, Longmore DB. Vena caval flow: assessment with cine MR velocity mapping. Radiology. 1990;177(2):537-541. 5. Camp-Sorrell D, ed. Access Device Guidelines: Recommendations for Nursing Practice and Education. 3rd ed. Pittsburgh, PA: Oncology Nursing Society; 2011:1-170. 6. Stephens LC, Haire WD, Kotulak GD. Are clinical signs accurate indicators of the cause of central venous catheter occlusion? J Parenter Enteral Nutr. 1995;19(1):75-79. 7. McKnight S. Nurse’s guide to understanding and treating thrombotic occlusion of central venous access devices. Medsurg Nurs. 2004;13(6):377-382. 8. National Institutes of Health. Management of central venous catheter occlusions. Pharm Update. 1999 Nov/Dec:1-4. 9. Ryder M. The role of biofilm in vascular catheter-related infections. N Dev Vasc Dis. 2001;2:15-25. 10. Hadaway LC. Reopen the pipeline for IV therapy. Nursing. 2005;35(8):54-61. 11. Haire WD, Herbst SF. Consensus conference on the use of alteplase (t-PA) for the management of thrombotic catheter dysfunction. J Vasc Access Devices. Summer 2000:1-8. 12. Wingerter L. Vascular access device thrombosis. Clin J Oncol Nurs. 2003;7(3):345-348. 13. Cummings-Winfield C, MushaniKanji T. Restoring patency to central venous access devices. Clin J Oncol Nurs. 2008;12(6):925-934. 14. Kokotis K. Cost containment and infusion services. J Infus Nurs. 2005;28(suppl 3):S22-S32. 15. Harpel J. Best practices for vascular resource teams. J Infus Nurs. 2013;36(1):46-50. 16. Blaney M, Shen V, Kerner JA, et al; for CAPS Investigators. Alteplase for the treatment of central venous catheter occlusion in children: results of a prospective, open-label, single-arm study (the Cathflo Activase Pediatric Study). J Vasc Interv Radiol. 2006;17(11 Pt 1):1745-1751. 17. Cathflo Prescribing Information. Genentech USA, Inc. 18. Kaler W, Chinn R. Successful disinfection of needleless access ports: a matter of time and friction. JAVA. 2007;12(3):140-142. 4 17 1 5 Thrombotic catheter occlusions Catheter occlusions can be partial or complete7 When introduced into the body, all catheters begin to accumulate fibrin. This is the body’s natural attempt to protect itself against a foreign body. The fibrin starts to form a layer around the outside of the catheter within minutes of insertion, beginning at either the line entry site or where the tip contacts the vein.9,10 • Partial occlusion: ability to infuse but not withdraw fluids, or the presence of sluggish flow* • Complete occlusion: inability to infuse or aspirate Partial occlusion Complete occlusion Intraluminal thrombus11 • Occurs when blood refluxes inside the catheter lumen • Common causes of reflux include patient coughing, inadequate (B) flushing after blood draws or after checking for blood return, or improper use of flush syringes (A) Intraluminal thrombus Fibrin tail, or flap11 • Extends from the catheter tip but is drawn inward, blocking the © Penny Offer, CRNI © Penny Offer, CRNI Recovered triple-lumen catheter showing a fibrin tail (A). Fibrin sheath encases a completely occluded catheter (B). opening of the catheter lumen on aspiration attempts • Results in an ability to infuse fluids but an inability to withdraw blood Mural thrombus10-12 Aspirating for a positive blood return may reveal a partial occlusion Fibrin tail Fibrin tail allowing infusion Beginning to flap back with start of withdrawal Blocking aspiration of the catheter © Penny Offer, CRNI © Penny Offer, CRNI © Penny Offer, CRNI • Forms where the catheter touches or “rubs” the vein wall • Common sites are the entry site, anywhere along the catheter path, and the catheter tip Fibrin sheath10,11 • Forms when fibrin adheres to the external catheter surface, often beginning at the entry site, and may encase all or part of the catheter like a sock Mural thrombus • May completely cover the opening of the catheter tip Fibrin sheath Flushing the line is not enough—you must be able to withdraw blood to rule out a partial occlusion before administering critical therapies.3 *One quantitative measure for sluggish flow is a blood return of less than 3 mL in 3 seconds, as recommended by the Oncology Nursing Advisory Board.13 6 7 Catheters deliver life-sustaining therapies Why is it important to ensure central line patency? Catheters can be used either short or long term for the infusion of 2 • An occluded line may compromise patient care by 7,14 — Disrupting therapies or delaying procedures — Interrupting administration of medications and solutions • Parenteral nutrition • Chemotherapy or other vesicant or • Replacement of an occluded line may 7 — Increase patient discomfort and trauma — Increase cost of care irritating solutions • Blood and blood products • Antibiotics Satisfaction with infusion care is linked to a hospital’s patient satisfaction scores.15 • Medication/solutions in patients with limited peripheral access • Therapy that is ongoing or continued at home CVADs are also useful when frequent blood tests are required, reducing the need for repeated venipuncture.2 Documentation of CVAD functionality assessment is recommended by key societies, and should include3,5 • Device patency • Absence of signs and symptoms of complications • Lack of resistance when flushing • Presence of a blood return upon aspiration “Documentation reflects the continuity, quality, and safety of care.” 3 —INS Infusion Therapy Standards of Practice, 2016, page S28, standard 10.4 INS=Infusion Nurses Society. 8 9 Recognizing signs of CVAD occlusion “Central vascular access devices (CVADs) [should be] regularly assessed for patency and proper function as defined by the ability to flush the catheter without resistance and the ability to yield a blood return.” 3 —INS Infusion Therapy Standards of Practice, 2016, page S104, standard 48.1 With a blood flow through the SVC of approximately 2 liters per minute, a free-flowing blood return should be readily achievable.4 Superior vena cava Lack of blood return or a sluggish flow may indicate a catheter occlusion or a malpositioned tip, and further assessment of the line will be necessary.3 Signs of a CVAD occlusion include3 “Vascular access devices (VADs) [should be] flushed and aspirated for a blood return prior to each infusion to assess catheter function and prevent complications.” 3 —INS Infusion Therapy Standards of Practice, 2016, page S77, standard 40 .1 Prior to the administration of any medications or solutions, the nurse should always3 • Aspirate for a positive blood return • Check for other indications of an occlusion • Attempt to flush to determine resistance, flushing with an adequate volume of saline or appropriate solution • Inability to withdraw blood • Palpate the insertion site to determine tenderness • Assess the patient for any pain or discomfort or sluggish blood return • Sluggish flow • Inability to flush or infuse Recommended routine assessment of catheter patency Blood flow ~2 L/min through the CVAD • Frequent occlusion alarms on electronic infusion device • Infiltration/extravasation or swelling/leaking at the infusion site Catheter tip CVAD occlusions should not be left untreated because another lumen is patent3 © Adam Questell, A KYU Design “Catheter salvage is preferred over catheter removal for management of CVAD occlusions.” 3 —INS Infusion Therapy Standards of Practice, 2016, page S104, standard 48.3 10 Institutions should adopt standardized procedures to manage thrombotic occlusions. This includes educational and skill-development needs of team members, followed by the design of appropriate educational materials and training.13 —Clinical Journal of Oncology Nursing, 2008 Volume 12, Issue 6, page 931 11 Recommended algorithm for assessing and treating occluded catheters7 Sluggish g flow or inability to withdraw blood or infuse fluid d th through h th the catheter Flow restored Check for presence of nonthrombotic b ti obstruction b • Cathflo, a recombinant form of t-PA, is the only lytic that is FDA approved for the restoration of function Obstruction remains to CVADs16 Suspect thrombotic occlusion l Function restored Insti Cathflo® Activase Instill vase® (alteplase) l ) 2 mg Function restored Obstruction remains Cathflo—a fibrin-specific* MOA17 Obstruction remains Repeat Cathflo 2 mg Yes Cathflo Activase (alteplase) plays a key role in helping to restore function to catheters with thrombotic occlusions • The fibrin-specific mechanism of action (MOA) of Cathflo addresses the root cause of thrombotic occlusions • Cathflo binds to fibrin in the thrombus, converting entrapped plasminogen to plasmin, initiating local fibrinolysis Obstruction remains Suspect nonthrombotic occlusion l Administer appropriate solvents per h hospital it protocol No Flow restored 2 Activation Consult with medical team to consider alternative etiologies and additionall management strategies Adapted from McKnight S. • Cathflo is recommended for the treatment of partial or complete thrombotic occlusions, after ruling out nonthrombotic obstruction, by clinical practice guidelines of the INS, the Association for Vascular Access, the Oncology Nursing Society, and other treatment algorithms3,5,7,11,13 1 A t-P Plasmin m Plas Thrombus Dissolves fibrin 3 Fibrin degradation products Fibrin threads 1 Recombinant t-PA (alteplase) binds to fibrin in thrombus 2 converts entrapped plasminogen to plasmin that 3 initiates local fibrinolysis. product information Indication Cathflo® Activase® (alteplase) is indicated for the restoration of function to central venous access devices as assessed by the ability to withdraw blood. Important Safety Information Contraindications Cathflo Activase should not be administered to patients with known hypersensitivity to Alteplase or any component of the formulation. Precautions General Certain causes of catheter dysfunction should be considered before treatment with Cathflo Activase (e.g. catheter malposition, mechanical failure, constriction by a suture and lipid deposits or drug precipitates within the catheter lumen). Bleeding The most frequent adverse reaction associated with all thrombolytics in all approved indications is bleeding. Should serious bleeding in a critical location (e.g., intracranial, gastrointestinal, retroperitoneal, pericardial) occur, treatment with Cathflo Activase should be stopped and the drug should be withdrawn from the catheter. Infections Cathflo Activase should be used with caution in the presence of known or suspected infection in the catheter. Adverse Reactions In clinical trials, the most serious adverse events reported after treatment were sepsis, gastrointestinal bleeding, and venous thrombosis. t-PA en inog *The clinical significance of fibrin specificity is unknown. Cathflo pharmacokinetics • Cathflo 2 mg does not reach pharmacologic levels in systemic circulation 17 Please see accompanying full Prescribing Information for additional Important Safety Information. 12 13 Cathflo® Activase® (alteplase) may restore catheter function Cathflo safety profile in adult and pediatric patients • In the pivotal trials COOL-1 and COOL-2, the efficacy of Cathflo was evaluated Cathflo has a safety profile studied in both adult and pediatric patients as young as 2 weeks of age.16,17 in 1122 primarily adult patients17 88% 75% 72% 74% Cumulative efficacy In COOL-1, Cathflo restored function to 88% (112/127) of central lines after up to 2 doses using a 120-minute dwell time for each in catheters with occlusions present for up to 24 hours. In COOL-1 and COOL-2, Cathflo restored function to 68% (796/1043) of central lines after 1 dose and 88% (902/1043) of central lines after 2 doses in catheters with occlusions present for less than 14 days. First-dose efficacy In COOL-2, Cathflo restored function after 1 dose in 75% (747/995) of central lines after up to 120 minutes of dwell time in catheters with occlusions present for any duration. Occlusions >14 days efficacy In COOL-2, Cathflo restored function to 57% (30/53) of central lines after 1 dose and 72% (38/53) of central lines after 2 doses in catheters with occlusions present for longer than 14 days. Maintained patency In a subset of patients (n=346) who had a successful treatment outcome, 74% (256/346) of central lines maintained patency up to 30 days after treatment with Cathflo. COOL=Cardiovascular Thrombolytic to Open Occluded Lines. COOL-1 was a double-blind, randomized, placebo-controlled study of 150 patients to evaluate the efficacy of Cathflo 2 mg/2 mL, in up to 2 doses, with function assessed at 120 minutes. COOL-2 was a phase III, single-arm, open-label, multicenter study of 995 patients to evaluate the safety of serial administration of up to 2 doses of Cathflo. Secondary objectives included assessing success rates at 30 minutes and 120 minutes. • In the pivotal trials COOL-1 and COOL-2, the safety profile of Cathflo was evaluated in 1122 primarily adult patients17 • CAPS evaluated the safety profile of Cathflo in 310 pediatric patients. The youngest patient in the study was 2 weeks old16,17 COOL-1 and COOL-2 (N=1122): Serious adverse events17 Event CAPS (N=310): Serious adverse events16 (%) Event (%) Sepsis 0.4% Catheter-related complications 1.3%* Major hemorrhage 0.4% Sepsis 1.0% Gastrointestinal bleeding 0.3% Fever Venous thrombosis 0.3% Intracranial hemorrhage 0.0% Intracranial hemorrhage 0.0% Major hemorrhage 0.0% Embolic event 0.0% Thrombosis 0.0% Embolic event 0.0% <1.0% Adapted Blaney M, et rupture al. *At least from one due to catheter *At least 1 due to catheter rupture. CAPS=Cathflo Activase Pediatric Study. CAPS was an open-label, single-arm trial in 310 patients between the ages of 2 weeks and 17 years to evaluate the safety of Cathflo. Secondary objectives included assessing restoration rates at 30 minutes and 120 minutes, and serious adverse events within 48 hours.16,17 • No reports of intracranial hemorrhage or embolic events with Cathflo in clinical trials, including infants as young as 2 weeks of age16,17 The instillation of alteplase 2 mg (Cathflo Activase) is safe and effective in restoring catheter patency in patients.3 — INS Infusion Therapy Standards of Practice, 2016, page S105, standard 48, practice criterion G Please see Indication and Important Safety Information on back cover. Please also see accompanying full Prescribing Information. 14 15 Reconstitution, dosing, and administration of One in 4®catheters become occluded6 Cathflo Activase® may (alteplase) Administration, cont’d 7 INSTILL the appropriate dose of Cathflo into the occluded catheter Cathflo is occlusion available in is a single-use, vial. noninfectious complication Catheter the most 2-mg common 7 inPreparation the long-term use of CVADs 17 of solution 17 WASHING hands using aseptic technique, reconstitute Cathflo to a final Occlusions may occur in up to 25% of CVADs •After 6 using an appropriately sized syringe (see dosing chart below). 8 concentration of 2 mg/2 mL: — May occur soon after insertion of a device or develop at any time during the course of IV therapy 8 After 30 minutes of DWELL time, assess the catheter function by attempting to aspirate blood. If the catheter is functional, go to step 10; if not functional, go to step 9. 1 Causes of catheter occlusions Aseptically WITHDRAW 2.2 mL of Sterile Water for Injection, USP (diluent 6 About 58% of catheter is occlusions are thrombotic not provided). Do not use Bacteriostatic Water for Injection, USP. 9 • • 2Thrombotic occlusions result from the formation ASSESS catheter function after a total of 120 minutes of dwell time by of a thrombus within, surrounding, or at the tip of the catheter 6,8 INJECT the 2.2 mL of Sterile Water for Injection, USP, into the Cathflo vial, 58% 42% to nonthrombotic causes, including thrombotic 3precipitates, malpositioning, mechanical 6,8 nonthrombotic obstructions, and otherMix factors by gently SWIRLING until the contents are completely dissolved. Complete dissolution should occur within 3 minutes. DO NOT SHAKE. The reconstituted preparation results in a colorless to pale yellow transparent solution at a pH of approximately 7.3. After WASHING hands and applying gloves: 4 120 120 minutes minutes the diluent stream into the powder. Slight foaming is not unusual; occlusions are due • About 42% of catheter directing let the vial stand undisturbed to allow large bubbles to dissipate. Administration17,18 30 30 minutes minutes 10 If catheter function has been restored, ASPIRATE 4 mL to 5 mL of blood in patients ≥10 kg or 3 mL in patients <10 kg to remove Cathflo and residual clot. Then gently irrigate the catheter with 0.9% Sodium Chloride, USP. Any unused solution should be discarded. Dosing with Cathflo 2 mg17 Patient weight Cathflo dose 30 kg (66 lb) 2 mg in 2 mL <30 kg (66 lb) INSPECT the product prior to administration for foreign matter and discoloration. Solution should be inspected immediately before use. attempting to aspirate blood. If catheter is functional, go to step 10. If catheter is still occluded, a second dose of equal amount may be instilled. Repeat steps 1 through 8. 110% of the internal lumen volume of CVAD, not to exceed 2 mg in 2 mL Note: Store lyophilized Cathflo at refrigerated temperature (2˚C-8˚C/36˚F-46˚F). Cathflo should be reconstituted immediately before use. The solution may be used within 8 hours if stored at 2˚C to 30˚C (36˚F-86˚F). No other medication should be added to solutions containing Cathflo. • If catheter function is not restored at 120 minutes after 1 dose of Cathflo, a second dose may be instilled • Studies have not been performed with administration of total doses greater than 4 mg (two 2-mg doses) 5 WITHDRAW 2 mL (2 mg) of reconstituted solution from the vial. 6 SCRUB the hub. Apply vigorous friction to the hubs for 15 to 30 seconds. References: 1. Brown M. The impact of safety product use on catheter-related infections. J Infus Nurs. 2004;27(4):245-250. 2. Richardson D. Vascular access nursing: standards of care, and strategies in the prevention of infection: a primer on central venous catheters (part 2 of a 3-part series). JAVA. 2007;12(1):19-27. 3. Infusion Nurses Society. Infusion therapy standards of practice. J Infus Nurs. 2016;39(suppl 1):S1-S159. 4. Mohiaddin RH, Wann SL, Underwood R, Firmin DN, Rees S, Longmore DB. Vena caval flow: assessment with cine MR velocity mapping. Radiology. 1990;177(2):537-541. 5. Camp-Sorrell D, ed. Access Device Guidelines: Recommendations for Nursing Practice and Education. 3rd ed. Pittsburgh, PA: Oncology Nursing Society; 2011:1-170. 6. Stephens LC, Haire WD, Kotulak GD. Are clinical signs accurate indicators of the cause of central venous catheter occlusion? J Parenter Enteral Nutr. 1995;19(1):75-79. 7. McKnight S. Nurse’s guide to understanding and treating thrombotic occlusion of central venous access devices. Medsurg Nurs. 2004;13(6):377-382. 8. National Institutes of Health. Management of central venous catheter occlusions. Pharm Update. 1999 Nov/Dec:1-4. 9. Ryder M. The role of biofilm in vascular catheter-related infections. N Dev Vasc Dis. 2001;2:15-25. 10. Hadaway LC. Reopen the pipeline for IV therapy. Nursing. 2005;35(8):54-61. 11. Haire WD, Herbst SF. Consensus conference on the use of alteplase (t-PA) for the management of thrombotic catheter dysfunction. J Vasc Access Devices. Summer 2000:1-8. 12. Wingerter L. Vascular access device thrombosis. Clin J Oncol Nurs. 2003;7(3):345-348. 13. Cummings-Winfield C, MushaniKanji T. Restoring patency to central venous access devices. Clin J Oncol Nurs. 2008;12(6):925-934. 14. Kokotis K. Cost containment and infusion services. J Infus Nurs. 2005;28(suppl 3):S22-S32. 15. Harpel J. Best practices for vascular resource teams. J Infus Nurs. 2013;36(1):46-50. 16. Blaney M, Shen V, Kerner JA, et al; for CAPS Investigators. Alteplase for the treatment of central venous catheter occlusion in children: results of a prospective, open-label, single-arm study (the Cathflo Activase Pediatric Study). J Vasc Interv Radiol. 2006;17(11 Pt 1):1745-1751. 17. Cathflo Prescribing Information. Genentech USA, Inc. 18. Kaler W, Chinn R. Successful disinfection of needleless access ports: a matter of time and friction. JAVA. 2007;12(3):140-142. Please see Indication and Important Safety Information on back cover. Please also see accompanying full Prescribing Information. 16 4 17 1 Don’t let sluggish flow disrupt therapy Take charge with Cathflo Activase (alteplase) and help restore central line function • Is there routine assessment of CVAD patency at your hospital? your Genentech representative about resources to help you implement CVAD education and • Ask skill development Indication Cathflo Activase (alteplase) is indicated for the restoration of function to central venous access devices as assessed by the ability to withdraw blood. Important Safety Information Contraindications Cathflo Activase should not be administered to patients with known hypersensitivity to alteplase or any component of the formulation. Precautions General Certain causes of catheter dysfunction should be considered before treatment with Cathflo Activase (e.g. catheter malposition, mechanical failure, constriction by a suture and lipid deposits or drug precipitates within the catheter lumen). Excessive pressure should be avoided when Cathflo Activase is instilled into the catheter. Bleeding The most frequent adverse reaction associated with all thrombolytics in all approved indications is bleeding. Cathflo Activase has not been studied in patients known to be at risk for bleeding events that may be associated with the use of thrombolytics. Caution should be exercised with patients who have any condition for which bleeding constitutes a significant hazard. Should serious bleeding in a critical location (e.g., intracranial, gastrointestinal, retroperitoneal, pericardial) occur, treatment with Cathflo Activase should be stopped and the drug should be withdrawn from the catheter. Infections Cathflo Activase should be used with caution in the presence of known or suspected infection in the catheter. Using Cathflo Activase in patients with infected catheters may release a localized infection into the systemic circulation. Adverse Reactions In clinical trials, the most serious adverse events reported after treatment were sepsis, gastrointestinal bleeding, and venous thrombosis. Please see full Prescribing Information for additional Important Safety Information. To learn more about the management of thrombotically occluded catheters, please visit www.cathflo.com or call Genentech Customer Service at 1-800-551-2231 to locate your local Genentech clinical specialist. www.cathflo.com © 2016 Genentech USA, Inc. All rights reserved. CAT/020215/0005(1) Printed in USA. Keep central lines open