Treatment of Central Venous Access Device Occlusion – Adult/Pediatric/Neonatal – Consensus Care Guideline Summary Target Population: Adult/pediatric/neonatal patients with occlusion of a central venous access device (CVAD) Full Guideline: Treatment of Central Venous Access Device Occlusion Consensus Care Guideline Guideline Overview • Assessment of catheter patency and signs of CVAD occlusion • Occlusion types: mechanical, thrombotic, and chemical • Attempt to resolve occlusions using mechanical manipulations first • Thrombotic occlusions should be considered if mechanical manipulation unsuccessful • Treat thrombotic occlusion with alteplase (Cathflo Activase®) at appropriate weight-based dose • Chemical occlusion due to acidic drugs, alkaline drugs or lipids should be considered if both mechanical and thrombotic cause are ruled out NO NO • Check clamps, CVAD tubing kinks/twists, tubing connections, filters, sutures, or change in external catheter length; assure catheter is not damaged • Reposition patient/catheter; ask patient to cough or breathe deeply • Change add-on devices, caps, clogged filters, or dressings • Verify IVAD needle placement and change if required • Consider dye study or chest Xray if catheter damage or tip malposition is suspected • Repair catheter if indicated. Patency restored? 2. Possible Thrombotic Occlusion 3. Possible Chemical Occlusion AlteplaseA Dose 1 Patency restored at 30-120 minutes? AlteplaseA Dose 2 Contact provider for consideration of chest Xray/ dye study, extending dwell time up to 72 hours, or CVAD removal/replacement Resume CVAD Use Cause? Acidic drug (pH < 6) TPN-amino acid mix Basic [alkaline] drug (pH > 7) Lipid L-cysteine B Sodium bicarbonate 8.4% B 70% Ethanol B Patency restored at 60 minutes? Contact provider for consideration of CVAD removal/replacement 1. Possible Mechanical Occlusion NONO YES Appendix B. Algorithm for Management of CVAD Occlusion Patency restored at 30-120 minutes? AAlteplase Dose BChemical Clearance Agent Dose: fill volume of lumen YES YES YES Broadhurst D, Cernusca C, Cook C, et al. CVAA Occlusion Management Guideline for Central Venous Access Devices. Vascular Access. 2019;13(1):1-30. Adapted with permission of the Canadian Vascular Access Association. Patient Weight Alteplase dose 30 kg or greater 2 mg/2 mL 10 - 30 kg 1 mg/1 mL Less than 10 kg See Table 3 for volume Implanted port 2 mg/2 mL regardless of weight or age Dose may not exceed 2 mg/2 mL Repeat clearance agent B Dose 2 Patency restored at 60 minutes? NO NO Effective 7/21/2022. Contact CCKM@uwhealth.org for previous versions Copyright © 2022 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 07/2022 Table 3. ALTEPLASE DOSE PEDIATRIC PICC LINES Cut Length 1.0 French Single Lumen Total Length 20 cm 1.9 French Single Lumen Total Length 30 cm 1.9 French Single Lumen Total Length 50 cm 2.6 French Double Lumen Total Length 50 cm 110% Lumen Priming Volume (mL) < 5 cm 0.02 0.02 0.02 - 6-10 cm 0.04 0.03 0.02 0.05 11-15 cm 0.06 0.04 0.03 0.07 16-20 cm 0.07 0.05 0.04 0.1 21-25 cm - 0.06 0.06 0.12 26-30 cm - 0.08 0.07 0.15 31-35 cm - - 0.08 0.17 36-40 cm - - 0.09 0.19 41-50 cm - - 0.11 0.24 Cut Length 3 French Single Lumen Total Length 60 cm 4 French Single, Double Lumen Total Length 60 cm 5 French Single, Double, Triple Lumen Total Length 60 cm 110% Lumen Priming Volume (mL) < 10 cm 0.1 0.12 0.13 11-20 cm 0.2 0.2 0.3 21-30 cm 0.3 0.4 0.4 31-40 cm 0.4 0.5 0.5 41-50 cm 0.5 0.6 0.6 51-60 cm 0.58 0.74 0.77 NOTE: Pediatric central lines may be cut to fit smaller patients and so are not the original length provided by the manufacturer. Please review Lines, Drains, and Airways (LDA) Properties in Health Link for the line length after cutting. Table 4. Types of Chemical Occlusion and Treatment Options Cause Clearance Agent Dwell Time Calcium phosphate precipitate L-Cysteine Irrigate with gentle to and fro motion for 1-2 minutes; if patency not restored, dwell 60 minutes and repeat above hourly Acidic drug precipitate pH < 6 (e.g. vancomycin, piperacillin, parenteral nutrition amino acids L-Cysteine 60 minutes Alkaline drug precipitate pH > 7 (e.g. phenytoin, ganciclovir, ampicillin, heparin) Sodium bicarbonate (NaHCO3) 8.4% 1 meq/mL 60 minutes Lipid deposition (e.g. parenteral nutrition) 70% ethanol 60 minutes Effective 7/21/2022. Contact CCKM@uwhealth.org for previous versions Copyright © 2022 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 07/2022