Hello,
I am currently interested in finding out if any facilities that utilize only 1mg of TPA for catheter clearance. I realize that manufacturer guidelines call for the 2mg dose and it seems that we should be using the dose according to manufacturer guidelines. Currently our facility mixes and freezes the 1mg (1ml) amount and then thaws it for use as needed.
Would like any and all opinion on this practice and if anyone has any literature to support the fact that the 1mg dose administration is not as effective as the 2mg dose. Would also be interested in hearing of any facilities who did use 1mg dose and who now use 2mg dose and if they have any data to support an improvement in catheter clearance.
Thanks for any assistance.
Virginia
We use a tPA dose appropriate for the catheter. I work in peds and the internal volume of some of our smaller PICCs may be less than .20 ml. In our older patients .50 ml or 1 ml may be enough to open the catheter. Determining the internal volume as accurately as possible will allow for more precise dosing. 1mg can certainly be as effective as 2 mg if the tPA reaches the occlusion and disolves it.
Our pharmacy freezes tPA in .5 mg doses and we order by dose. So .5mg maybe enough or a small catheter or we may order 2mg for a larger port or dialysis catheter. Thus, we would receive 4 syringes of .5ml
Additionally, if you know the volume of the catheter but don't have enough tPA to fill it, saline can be put behind the tPA to facilitate exposure of tPA to the clot. However, caution must be observed to not flush the tPA into the system before it has had a chance to lyse the blood cells.
With 1 mg syringes you have the option of using the smaller, more cost effective doses without waste. If you need a larger dose two syringes should be available to you.
In the adult population...out teaching hospital used 1mg/1cc aliquoted (frozen) TPA for catheter clearence and have no issues.
alteplase 2mg (1mg per 1ml) is the approved FDA recommended doseage for catheter clearance....wouldn't it just make sense to access the line just once in an adult patient to clear the line rather than repeatedly going back with small increments of the drug? I always thought that every time you access a line, you are increasing risk of infection. Just wondering why this drug is not uniformly given as per FDA recommendations and if anyone has switched from the 1mg to 2mg dose and had any improvements in reduction of occluded lines.
Evidence-based practice would indicate use of 2 mg in 2 mL for adults. I agree that increased hub manipulation increases risk of infection, Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I work in a prediatric setting as well. For the smaller babies we use 0.5 mg and 1 mg on most all other external catheters. If the child has a port we consider the 2 mg dose on the children a little older maybe 6 years old and up. It also depends on if they have a adult size port or a lower profile. It is rare that we have to do more than one dose. Theresa Reed, Texas Children's Hospital.
So....let me get this straight....
A total withdrawal occlusion on a catheter that's total prime volume is 0.9cc....and you want to use 2mg (1mg/1ml)...so 2cc. How much do you think you will get into the catheter...and how much is potential waste??
Help me understand the math......
Now a partial withdrawal occlusion might be a different story!
We reconstitute ourselves, I usually start working the line with 1cc of the 2 in the vial. My note reflects what volume I was able to instill in a totally occluded catheter. Since I may have to work the catheter again, I can then utilize the other 1cc and not waste it (@ some where around $40.00 a cc I believe). The cathflo insert states the there have been no studies done administering doses greater than 4mg. To answer the original question, sometimes patency is achived with 1cc, sometimes more and sometimes never.
Peter Marino R.N. BSN CRNI VA-BC Hospital based staff R.N. with no affiliation to any product or health care company.
I would like to remind everyone that while this is the practice that you are all doing with great success, this is not how the product is labeled. From a legal perspective, I can see how this can be an issue esepcially if you are doing the aliquoting yourself. It's one thing if it's coming from the pharmacy that way or if your procedure states that you can do it at the bedside, it's another if you are not covered.
I'm glad that the issue of partial occlusions was mentioned since this is an entirely different animal. To contend with the blood flow in the SVC means to me that you are going to need more than 1 mL.
Angelo M. Aguila, MSN, RN, VA-BC
Vascular Access Nurse
[email protected]
I read with great interest over the past few weeks on the use of tPA etc for clearing the cath line, but no real guidelines for that cursed of problems of the non withdrawal from a CVAD but easy push.
statements of remove the line etc, give me a cold chill, so interested in a more moderate approach or care
What policies do you have in place for treating a recurring problem, line in right place etc etc, but treatment with a urokinase infusion only last 1-3 days or with luck maybe 2 wks then occludes again. [ 10,000units over 10hrs]
Symptoms of pain on flushing, central back, and that is not the pulsatile flush [being a deciple of Lynn's] just steady 2x 10ml flushes of port via Right I.J. dizziness on changing position from bending over to standing, lasting 15-30 secs, and unable to have spurts of energy, body just doesnt adjust.. no facial swelling. so minor problem symptoms that all disappear when the fibrin is removed [or that the cath can be aspirated positively]
any thoughts would be gratefully received, this has now been going on for 20mths, so approx 17of those month been semi-occluded, The port is accessed 5 x nights week for PN
how often would you agree to having infusions done, would they be proactive or just reactive to the occlusion.. reaction to heparin, so use the citrate locks so line is clear and clean. and have history of frequent gastric bleeds [50yrs] of wee oozing etc. ..
think I have covered most of the history
thanks in advance