I am asking the experts out there if there is a contraindication for Cathflo use in a PICC that has inadvertently migrated out so that tip is in brachiocephalic/svc junction. Also, is it recommended to check tip location routinely prior to cathflo use?
CathFlo is a wonderful drug indicated for declotting central lines. The point here is that you no longer truly have a central line, which is probably one reason it is now clotted! Clinically the correct answer here is to replace this PICC with one whose tip terminates in the appropriate position. There have been some great articles published showing relationships between tip position and complications. I believe it was Peterson et. alia that showed a complication rate of above 80% in the position you describe vs. 2% for a cavo-atrial position. Of course as with any clinical scenario you should do a risk vs. benefit scenario, but if this patient needs a central line then they should get one.
Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness
A catheter that has been dislodged so that the tip is no longer at the CAJ should not be considered a central venous catheter any longer. It requires some action to correct the tip location such as exchange over a guidewire or total insertion of a new line - whatever will produce the least risk and best benefit for your patient. Cathflo is not indicated in a catheter that has been disloged to the SVC-brachiocephalic junction. Your patient is at a much higher risk for vein thrombosis and that may be what is causing the obstruction. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Thank you for your reply. I do understand the catheter is no longer central and needs replacement. However, my question is does the tip need to be verified before instilling cathflo?
Jahearn
I am a peds vascular access nurse and also on the speaker's bureau for Genentech.
In my practice, we have a systematic approach for occluded CVCs:
-R/O mechanical factors 1st (kinked catheter, clamped tubing, etc.)
-We remove any add-on devices (including the needleless connector) and attempt to flush/asp at the catheter hub
-If the CVC is occluded, we treat with Cathflo. If the CVC remains occluded after 2 doses of Cathflo, we do get an xray
**Many years ago, we use to get an xray with every catheter occlusion. In many cases, the catheter tip was positioned properly. Due to the fact that the majority of occlusions are related to fibrin, we changed our practice to treat first after a thorough assessment.
Darcy Doellman RN, BSN, CRNI, VA-BC
Cincinnati Childrens
I am still missing something in this discussion. lf a catheter tip is in the brachiocephalic vein, it is no longer considered to be a CVAD. And as you have stated, it needs to be changed. So why then would you even need to use Cathflo to open it up? Are you planning to do an exchange overwire where you would be sending a wire through the occluded catheter? That would be the only time that I believe Cathflo to be indicated. If you are going to remove and replace with a new catheter into the correct tip location, you do not need to use Cathflo before you remove the occluded PICC. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I think I understand her question, if she hadn't got the xray for placement and assumed line still SVC but occluded should she get a chest xray prior to using cath flo? or should she always get the chest xray to check tip placement before going to cath flo administration. I always xray first since the tip can migrate, I want to know what I am dealing with before putting cath flo in the line.
Yes, that was my question ...we use cathflo so frequently that it would not be very practical to get a CXR prior...thanks for your reply.
Jahearn
i work in the home setting. does this mean that someone with an occluded picc should be xrayed before using cathflo in the home. we don't use cathflo now, but are looking in to starting. we've heard that many home agencies are using cathflo.
The declotting procedure with a thrombolytic agent can be performed in the home. However if any setting has a high number or frequent use of this procedure, I would investigate why that is the case. This should not be happening at the level you are describing. My first thought is that your staff is not using the appropriate flush-clamp sequence for the type of needleless connector being used. Negative displacement must be flushed, clamped, then syringe disconnected. Positve displacement must be flushed, syringe disconnected, then clamped. If this sequence is not being done, this will certainly increase your number of occluded catheters. Neutral displacement is not dependent upon this sequence and can be done in any order. Catheter's original tip location is another factor. If it is too high in the SVC or has migrated to another vein, occlusion can be a problem, however this is more likely to be outside the catheter lumen and the declotting instillation procedure will be much less effective. The thrombus will redevelop after what is at the immediate lumen opening is destroyed. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Darcy,
Would email me personally about a similar issue I am experiencing; a facility wanting dye studies on ports before using Cathflo.
[email protected]
or work phone; 8637632151 ext 3611
Gina Ward R.N., VA-BC