Occlusion Management Guideline for Central Venous Access ...

1 Journal of the Canadian Vascular Access AssociationPublication Mail Agreement 40025049 ISSN 1913-6692 Canadian Vascular Access AssociationAssociation Canadienne d Acc s Vasculairenal of the Canadian VJour as he Canadian V Vascular Access Association ascular Access Association ascular Access Association Association Canadienne d Acc s Vascular Access AssociationCanadian V easculairAssociation Canadienne d Acc s Vascular Access AssociationOcclusion Management Guideline for Central Venous Access Devices(CVADs) 7 Supplement 1 Vascular Access 3 ContributorsContributorsAuthorsJocelyn Hill, MN, RN, OCN, CVAA(c), VA-BCProvidence health CareVancouver, British ColumbiaCo-Chair and CVAA Board LiaisonDaphne Broadhurst, BScN, RN, CVAA(c)Desjardins PharmacyOttawa, OntarioCo-Chair and CVAA Board LiaisonKim Miller, MScN, RN, CVAA(c)Saint Elizabeth health Care Markham, OntarioCVAA Board LiaisonCheryl Cook, RN, CVAA(c)London health Sciences CentreLondon, OntarioJody Dumanski, BN, RNSouth health Campus HospitalCalgary, AlbertaNancy Friesen, RN, CVAA(c), VA-BCSt.

2 Boniface HospitalWinnipeg, ManitobaInara Karrei, BScN, MEd, RN, CON(c)Ottawa Hospital Cancer CentreOttawa, OntarioRenee Logan, RN, CVAA(c)University Hospital of Northern British ColumbiaPrince George, British ColumbiaFrance Paquet, MScN, RN, CVAA(c), VA-BCMcGill University health CentreMontr al, Qu becLinda Pittendreigh, RN, CVAA(c)St. Michael s HospitalToronto, OntarioAngela Whynot, BSN, RN, CON(c)Capital HealthHalifax, Nova ScotiaCorresponding AuthorJocelyn Hill Nurse Educator, IV Therapy (Vascular Access ) andHome Infusion ProgramsProvidence health CareSt. Paul's HospitalVancouver, British ColumbiaExternal ReviewersJanet Barr, RN, CVAA(c) Venous Access Consultant (PCVC)London health Sciences Centre, Victoria Hospital& Children's HospitalLondon, ONCathy Berry, RN, MNClinical Nurse EducatorMedical Outpatients (HPTP, P & E Nutrition, DayMedicine, AMS, AVAS)Foothills Medical CentreCalgary, AlbertaDonna Burkart, RN, BN, CVAA(c)

3 Telemedicine Coordinator/Clinical EducatorLake of the Woods District HospitalKenora, OntarioCathy Davidson, RNClinician, IV Resource TeamBC Children s HospitalVancouver, British ColumbiaKathy Grouchy, RN, BSNH emoglobinopathy Nurse ClinicianHem/Onc/BMT DepartmentBC Children's HospitalVancouver, British ColumbiaContributorsLinda Jang, BSc Pharm, ACPRTPN/Chemotherapy PharmacistProvidence health CareSt. Paul s HospitalVancouver, British ColumbiaTami Jemson, RN, BSN, CVAA(c), VA-BCPatient Care Coordinator, Central Okanagan IVProgramKelowna General HospitalKelowna, British ColumbiaJos e L Esperance, RN, BSc, MPAM anager, Clinical Access and ProgramsBaxter Corporation CanadaMississauga, OntarioMargaret Lenny, RN, BScN, CNCC(c) CCN(c)Clinical Nurse Educator, ICUQ ueensway Carleton HospitalOttawa, OntarioMarianna Leung, BSc Pharm, ACPR, PharmD,BCPP, BCPS, FCSHP, CDEC linical Pharmacy Specialist, NephrologyProvidence health CareSt.

4 Paul's HospitalClinical Assistant Professor, Faculty of Pharmaceutical SciencesUniversity of British ColumbiaPauline Mosberian, BSc Pharm, ACPRI nterim Supervisor, Parenteral Services, Lower Mainland Pharmacy ServicesFraser health /Providence health Care/ProvincialHealth Services Authority/ vancouver CoastalHealthSt. Paul's Hospital PharmacyVancouver, British ColumbiaKristine Paton, RN, CVAA(c)Clinical Leader, Vascular Access TherapyHamilton health SciencesHamilton, OntarioCherie Pinkerton, RN, BN, VA-BCNurse Educator, Clinical Support ServicesWinnipeg health Sciences CentreWinnipeg, Manitoba(CVAA Board of Directors, 2013 2014)Diane Sharp, RN, CVAA(c)Care Facilitator, Vascular Access TeamChildren s Hospital of Eastern Ontario (CHEO)

5 Ottawa, OntarioJohn Scott Whittaker, BSc, MD, FRCPCC linical Assistant Professor, University of British ColumbiaMedical Director, BC Home Enteral and ParenteralNutrition ProgramVancouver, British ColumbiaGail Wilson, RN, MScNDirector of Nursing Practice, Clinical Systems AdoptionSt. Michael's HospitalToronto, OntarioThe Canadian Vascular Access Association and theauthors/national task force would like to thank andacknowledge the contributions, time, and efforts ofthe external reviewers in the development of thisguideline. 4 Vascular Access Volume 7 Supplement Canadian Vascular Access Association and the publisher shall not be held responsible for any liability incurred as a consequence of the use orapplication of any of the contents of this Guideline .

6 This document serves only as a guide to practice. Readers must make an independent assessment ofthe appropriateness and applicability of the OMG content and should also consider the applicable federal, provincial, and professional laws and regulations,as these take Vascular Access AssociationAssociation Canadienne d Acc s VasculaireVolume 7, Supplement 1 2013_____For Instructions to Authors, please Publications Agreement Number 40025049 ISSN 1913-6692_____The publisher and the Canadian Vascular Access Association shall not be liable for any of the views expressed by the authors published in Vascular Access , nor shall these opinions necessarily reflect those of the publisher.

7 Authors are responsible for ensuring the originality of their Access is published 3 times a year by Andrew John Publishing Inc., with offices located at 115 King Street West, Suite 220, Dundas, ON L9H welcome editorial submissions but cannot assume responsibility or commitment for unsolicited material. Any editorial material, including photographs that are accepted from an unsolicited contributor, will become the property of Andrew John Publishing 7 Supplement 1 Vascular Access 5 Contents3 Contributors: Authors and Reviewers6 Abstract6 Summary of Key Assessment of CVAD Assessment and Management of Mechanical Assessment and Management of Thrombotic Assessment and Management of Chemical Prevention of CVAD Occlusion27 Monitoring and Auditing Criteria for CVAD Occlusion27 Implementation Strategies28 Acknowledgements28 Glossary29 Appendix 1.

8 Types and Features of CVADs30 Appendix 2. Algorithm for Management of CVAD Occlusion31 References Volume 7, Supplement 1 2013 EDITOR-IN-CHIEFS arah Burns-GibsonCVAA EXECUTIVE DIRECTORM elissa McQueenMANAGING EDITORS usan HarrisonART DIRECTORA ndrea MulhollandCOPY EDITORM ichael PeeblesPROOF READERS cott BryantADVERTISINGJohn Birkby - COORDINATORB renda McClungGROUP PUBLISHERJohn D. BirkbyCopyright 2013. All Rights Management Guideline for ASSESSMENT OF CVAD PATENCYA ssess catheter patency and identify type of catheter Occlusion ( , partial, withdrawal, or complete) if present. [IB]*Flush each lumen with sterile, , preservative-free, sodiumchloride solution/normal saline (NS), and attempt to aspirateblood from each lumen to determine ease of flush and aspiration.

9 [IB]Document catheter patency assessment and signs andsymptoms of catheter Occlusion . [IB] ASSESSMENT AND Management OF MECHANICALOCCLUSION Assess for signs of mechanical Occlusion of the Central venousaccess device (CVAD). [IB]Resolve the mechanical obstruction accordingly. [IB]Consider changing the dressing, ensuring no twisting/kinking ofthe catheter. [IB]Consider chest x-ray to rule out internal kinking, malposition, orpinch-off syndrome [IB] ASSESSMENT AND Management OF THROMBOTICOCCLUSIONA ssess catheter Occlusion to identify if the Occlusion is causedby a thrombotic obstruction of the CVAD. [IB]Manage as thrombotic Occlusion if unable to determine type ofocclusion. [IB]Promptly administer thrombolytic agents approved for restoringCVAD patency in catheter with partial, withdrawal, or completeocclusion suspected to be caused by blood/fibrin.

10 [IB]Treat all catheter lumens with partial, withdrawal, or completeocclusion. Do not leave an occluded lumen untreated becauseanother lumen is functional. Applicable to all types of CVADs.[IB] Let thrombolytic dwell for 30 120 minutes. [IB] Considerextending dwell to 24 72 hours (to permit longer contact time ofthrombolytic with the fibrin in the catheter or around the cathetertip in the case of a mural thrombus or fibrin sheath). [IC] Consider use of thrombolytic for CVAD occlusions in thecommunity and long-term care settings. [IB] ASSESSMENT AND Management OF CHEMICALOCCLUSIONA ssess catheter Occlusion to identify if the Occlusion is causedby a chemical obstruction of the CVAD. [IB]Promptly attempt to restore patency of CVADs occluded bychemical precipitate by instillation of clearing agent(s)recognized to dissolve precipitate.