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cmpane
Frequent doses of TPA

 

I currently have an inpatient who has a triple lumen PICC placed for TPN one week ago.  For the last two consecutive days, she has received TPA to two of three lumens for loss of blood return which were effective.  Today, I found the line again with loss of blood return in the same two lumens.  TPN has been discontinued, and the only infusion she has is an insulin drip which expected to be discontinued within 24 hours.  I asked for an order to remove the PICC and run the insulin peripherally, but the physicians are fearful of IV infiltration.  By my assessment, she could be easily maintained with peripherals.  My question is about frequent doses of TPA.  Even if the line would need to be maintained, is it appropriate to administer daily doses of TPA, or should the PICC be removed and replaced if needed?  My opinion is that this is a non-functioning line and should be removed.  Feedback is appreciated. 

cmpane
I forgot to mention that tip

I forgot to mention that tip placement was reconfirmed to be at the caval-atrial junction, so this is not the issue.  It flushes easily.

Colleen M. Cavallo, RN, VA-BC

lynncrni
 My first question when I

 My first question when I read this was why did she need a triple lumen PICC to being with. This large size catheter may have contributed to the problem. I am not aware of any recommendations for a maximum number of tPA doses over a given period, but certainly a dose every day requires further investigation as to the cause and choosing another solution to that problem. So removing it was appropriate in this case, in my opinion. I would agree that insulin can easily be infused peripherally. Insulin is not a vesicant so no risk of tissue damage. Infiltration is always an issue but can be prevented with correct site and catheter selection, catheter stabilization, and joint stabilization if an area of joint flexion has to be used. 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

Constance
The Cathflo dose is 4 mg per

The Cathflo dose is 4 mg per lumen per 24 hours. Remember limited systemic exposure and a half-life of 5minutes. Did this patient get the triple lumen while in the ICU? And now only need it for the insulin? This line could be exchanged for a single lumen although bleeding may be an issue due to decreasing Fr size. How long will this patient need the PICCs? Is the current PICC at the lower 1/3 of the SVC? Is it being flushed adequately?  Do the nurses know the clamping sequence? Once Insulin is discontinued can she be managed with peripherals how much longer will this patient be in the hospital?

lynncrni
 All good points, but I was

 All good points, but I was thinking from a different standpoint. Yes, the half-life is only 5 minutes and you could give up to 4 mg in 24 hours, but that should not be interrupted as it being acceptable to do this procedure every day. I am thinking about the excess manipulation of the catheter hub with this procedure. This allws for the introduction of microorganisms to colonize the lumen causing biofilm to grow. I think there comes a point when the benefits associated with procedures such as declotting would increase the risk of other complications such as BSI. We do not have any outcome data on the exchange procedure except for one study in neonates showing that it increases the risk of BSI. So I would favor removal and replacement if a CVAD is necessary but in this case, it does sound like a peripheral cath is sufficient. 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

kathykokotis
Patieent Medical History

Does your patient have a medical history or laboratory rationale for the occlusions?

If so a PIV would end up with the same result of occlusion after occlusion

Kathy

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