1 Treatment of Central Venous Access Device Occlusion - Adult/Pediatric/Neonatal - Inpatient/Ambulatory/Emergency Department Consensus Care Guideline Table of Contents Introduction ................................................................................................................................... 3 Definitions: .................................................................................................................................... 3 Recommendations ........................................................................................................................ 5 Mechanical Occlusions ................................................................................................................. 5 Thrombotic Occlusions ................................................................................................................. 6 Chemical Occlusions .................................................................................................................... 8 Methodology ............................................................................................................................... 10 Appendix. Management Algorithm .............................................................................................. 11 Collateral Tools & Resources ..................................................................................................... 12 References .................................................................................................................................. 13 Effective 12/21/23. Contact CCKM@uwhealth.org for previous versions Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 12/2023 2 Content Expert: Name: Anne Rose, PharmD - Pharmacy Email Address: arose@uwhealth.org Contact for Changes: Name: Drug Policy Program Email Address: DrugPolicyProgram@uwhealth.org Guideline Author(s): Anne Rose, PharmD – Pharmacy Workgroup Members: Laura Brunner, RN – Nursing, Practice Innovation Hannah Garippo, RN – Nursing, Practice Innovation Ann Girardi, RN – Vascular Access, UW Northern Illinois Carrie Hamilton, RN – Nursing, Professional Development, Northern Illinois Michael Kessler, MD – Department of Medicine, Infectious Diseases/Immunology Kirsten Koffarnus, RN – Nursing, Practice Innovation Jen Mack, RN – Nursing, Quality & Safety Emily McQuade, RN – Nursing, Practice Innovation Jenna Meier Payne, RN – Nursing, Practice Innovation Erin Robinson, PharmD – Drug Policy Program Kyla Schoenwetter, DNP, RN – Nursing, Practice Innovation Elaine Stenstrup, RN – Nursing, Practice Innovation Lisa Thompson, PharmD – Pharmacy, UW Northern Illinois Justin Whipple, RN – Clinical Informatics, UW Northern Committee Approvals/Dates: Inpatient Anticoagulation Committee (December 2023) Pharmacy & Therapeutics Committee (December 2023) Effective 12/21/23. Contact CCKM@uwhealth.org for previous versions Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 12/2023 3 Introduction: Central venous access devices (CVAD) are used in the clinical care of adult, pediatric, and neonatal patients in both the inpatient and ambulatory settings. They facilitate the administration of drugs, fluids, blood products, and parenteral nutrition. They also allow for the aspiration of blood samples. Compromised CVAD function may interrupt treatment, increase morbidity, decrease patient comfort, and require catheter removal ± replacement resulting in inefficiency and increased cost.1-6 In the event of a CVAD occlusion, the goal of therapy is to salvage the CVAD rather than replace or remove it. The purpose of this guideline is to provide recommendations for standardizing the management of mechanical, thrombotic, and chemical occlusions.4,5 Appropriate flushing and locking may help prevent CVAD occlusion. For flushing and locking recommendations, refer to: Adult – Flushing and Locking of Venous Access Devices and Pediatric – Flushing and Locking of Venous Access Devices. Catheter clearance techniques for thrombotic or chemical occlusions of mid-line catheters are not included in this guideline since these are not central venous catheters. Recommendations provided in this guideline should be useful to physicians, advance practice providers, nurses, and pharmacists. They address appropriate action necessary for the assessment and management of occlusions due to mechanical, thrombotic, or chemical causes in adult, pediatric, and neonatal patients. Definitions: 1. Type of occlusions7,8 1.1 Mechanical – may be caused by kinks in catheter or tubing, CVAD dislodgement or tip migration, a clogged connector or filter, or incorrect positioning of patient or catheter. 1.2 Chemical – caused by precipitate when incompatible drugs are administered or from lipid build up 1.3 Thrombotic – caused by fibrin build up within or around CVAD or surrounding vessel 2. Degree of occlusion (Table 1) Table 1. Degree of CVAD Occlusions8-11 Degree of Occlusion Signs Causes Diagram Partial Sluggish flow through catheter Resistance with flushing and aspiration Mechanical Chemical Thrombotic Withdrawal Able to infuse without resistance Unable to withdraw blood Mechanical Thrombotic Effective 12/21/23. Contact CCKM@uwhealth.org for previous versions Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 12/2023 4 Complete Unable to infuse or withdraw blood Mechanical Chemical Thrombotic 3. Type of thrombotic occlusion (Table 2)11 Table 2. Type of Thrombotic Occlusion Type of Thrombotic Occlusion Description Diagram Fibrin tail or flap Extends from the catheter tip but is drawn inward, blocking the opening of the catheter lumen on aspiration attempts, resulting in an ability to infuse fluids but an inability to withdraw blood Intraluminal thrombus Occurs when blood refluxes inside the catheter lumen, commonly caused by coughing, inadequate flushing after blood draws or after checking for blood return, or improper use of flush syringes Mural thrombus Forms where the catheter touches or “rubs” the vein wall Fibrin sheath Forms when fibrin adheres to the external catheter surface, which may include the entry site, and may encase all or part of the catheter like a sock and could completely cover the opening of the catheter tip Effective 12/21/23. Contact CCKM@uwhealth.org for previous versions Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 12/2023 5 Recommendations 1. Assessment of catheter patency should be done by a health care professional who is knowledgeable in CVAD use and maintenance. 2. Assess CVAD patency and identify the type of occlusion by flushing affected lumen(s) and attempting to withdraw blood using a 10 mL syringe of preservative free normal saline9,12 (UW Health GRADE moderate quality evidence, strong recommendation) Sluggish blood flow is present when it is difficult to flush the CVAD or inability to withdraw less than 3 mL of blood in 3 seconds.9,10 Table 3 lists common signs of CVAD occlusion and can assist in the assessment of occlusion type. Table 3. Signs of CVAD Occlusion6,9,12,13 Infusion or Flushing Aspiration Resistance when flushing Sluggish flow Unable to infuse fluids Frequent occlusion pump alarm Infiltration, extravasation, swelling or leaking at insertion site Unable to withdraw blood Sluggish blood return 3. Once the type of occlusion is identified it should be treated with the recommended management strategy.14 4. Attempt to resolve occlusion using mechanical manipulations first14,15 (UW Health moderate quality evidence, strong recommendation) 5. If unable to determine the type of occlusion, initially treat as a thrombotic occlusion10,14 (UW Health low quality evidence, conditional recommendation) 6. Alteplase is not effective in restoring patency to a CVAD due to mechanical or chemical occlusion5,8,9,12,13,16 It should be used only to restore patency to lines occluded by thrombus. Mechanical Occlusions A CVAD occlusion caused by a mechanical process can be either internal or external. Common external causes include clamped or kinked catheter tubing. Common internal causes include incorrect positioning of the catheter tip, kinking of catheter inside vein, or the catheter tip adhering to the vessel wall.8,14,17 1. Assess catheter for signs of a mechanical occlusion8,14,15,17 a. Visually inspect the CVAD and administration set for signs of kinked or clamped tubing, loose tubing connections, clogged filter, tight sutures, or change in external catheter length. b. Inspect visually and by palpation for catheter damage as seen by swelling, bulging, or leaking from CVAD. c. Consider subjective complaints from patients that may suggest occlusion (e.g., report of audible swishing sound, pain during infusion, or experiencing altered sensation during infusion) 2. Resolve the mechanical occlusion8,14,15,17,18 a. Remove any add-on devices (cap/needleless connectors) b. Change dressings and assess sutures or other securement devices to ensure no kinking Effective 12/21/23. Contact CCKM@uwhealth.org for previous versions Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 12/2023 6 c. Replace clogged filter d. Repair or replace a damaged catheter 3. Attempt to move catheter tip away from vessel wall by repositioning patient (raise arms and sit forward, rolls shoulders backward, lie down, forced coughs, or deep inhalations)18,19 4. Consider a chest x-ray if catheter placement is questionable or to assess for internal kinking, pinch-off syndrome, and positioning of catheter tip.14 5. If initial radiographic examination is unremarkable, consider a dye study for further evaluation of possible catheter tip malposition, extensive fibrin formation, or thrombosis.20,21 Thrombotic Occlusions Alteplase (Cathflo Activase®) is FDA approved (2005) for restoration of function to central venous access devices. Three clinical studies which demonstrate safety and efficacy were performed in patients with improperly functioning central venous access devices (CVADs). The trials are described in the prescribing information.16 When used as directed, systemic plasma levels of alteplase are not expected to reach pharmacologic concentrations. If a 2 mg dose was administered by bolus injection into the systemic circulation, the concentration of circulating alteplase would be expected to return to endogenous circulating levels (5-10 ng/mL) within 30 minutes. UW Health has utilized Cathflo Activase® for catheter occlusion clearance for several years. 1. Assess for signs of a thrombotic occlusion (visible blood in the catheter or add-on devices, inability to infuse or aspirate blood, or sluggish flow)8,12-14,18 2. Alteplase (Cathflo Activase®) should be used to resolve thrombotic occlusions a. Anticoagulants such as heparin are ineffective for restoring catheter patency.22 3. Alteplase weight-based dose (*If the line is a double or triple lumen, the dose listed is sufficient to use for each occluded lumen): (UW Health very low-quality evidence; conditional recommendation) a. 30 kg or greater: 2 mg/2 mL16 b. 10-30 kg: 1 mg/1 mL c. Less than 10 kg: select appropriate volume from Table 4 below d. Implanted ports: 2 mg/2 mL regardless of weight or age e. Doses should not exceed 2 mg/2 mL Table 4. Pediatric PICC Line Volume (weight less than 10 kg)16,22-24 : The objective is to instill 110% of the internal lumen volume with alteplase, allowing the overfill to act on any clot outside of the catheter (Table 2). The systemic exposure of this additional alteplase is generally considered to be clinically negligible, and the benefit of ensuring adequate exposure of the clot to the instilled alteplase outweighs the risk in most situations. 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. Priming volume = [ Reduced length (cm) / total length (cm) ] x total length priming volume *If line is a double or triple lumen, the volume listed for the size of catheter is sufficient to use for each occluded lumen. Effective 12/21/23. Contact CCKM@uwhealth.org for previous versions Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 12/2023 7 Table 4. 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 4. Alteplase (Cathflo Activase®) kits are stocked on some patient care units in refrigerated Acudose cabinets or the kit will be sent from the central pharmacy Kit contents a. One vial of alteplase injection (Cathflo Activase®) for reconstitution 2 mg b. One bottle of sterile water for injection 10 mL c. Instructions for reconstitution 5. Reconstitute alteplase immediately before use. 6. Aseptically reconstitute by adding 2.2 mL sterile water for Injection to the vial, directing the diluent stream into the powder.16 a. Let the vial stand undisturbed to allow large bubbles to dissipate. b. Mix gently, swirling until completely dissolved. Complete dissolution should occur within 3 minutes. DO NOT SHAKE. c. Inspect the solution to ensure it is free from foreign matter or discoloration. It should be a colorless to pale yellow transparent solution. d. The final concentration is 1 mg/1 mL. 7. Using a 10 mL syringe, draw up the appropriate dose and administer per procedure outlined in Nursing and Patient Care Policy AP 1.56 Central Vascular Access Device Use, Maintenance, and Removal (Adult and Pediatric). a. Do not force solution into catheter. Effective 12/21/23. Contact CCKM@uwhealth.org for previous versions Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 12/2023 8 8. After a 30-minute dwell time, assess catheter function by attempting to aspirate blood. If the catheter is functional, go to step 10.; if not functional, go to step 9. 9. If catheter remains nonfunctional, let alteplase dwell for another 90 minutes (total dwell time is 120 minutes) and reassess function. If the catheter is functional, go to step 10. If the catheter is still occluded, a second alteplase dose of equal amount may be instilled, repeating steps 6-8. a. Consider extending dwell to 24-72 hours after consulting with the provider22 b. No more than two doses of alteplase may be administered per occluded lumen. 10. If catheter function has been restored, aspirate blood volume indicated to remove alteplase and residual clot: a. For weight greater than or equal to 30 kg, aspirate 4-5 mL b. For weight less than 30 kg, aspirate a blood volume that is twice the administered volume of alteplase (e.g. aspirate 2 mL of blood when 1 mL of alteplase is administered) [UW Health very low quality evidence; conditional recommendation] c. Discard aspirate and flush catheter with 0.9% sodium chloride. 11. Discard any unused alteplase solution. 12. Contact provider if CVAD function is not restored after second alteplase administration. a. Consider chest Xray to verify catheter tip position b. Consider dye study to rule out mechanical occlusion or vessel thrombosis. 13. If CVAD function is restored, resume IV fluids, medications, or lock as appropriate. 14. Monitor for adverse effects, including bleeding. Chemical Occlusions Chemical occlusions occur when precipitates form within the lumen of the CVAD and when lipid residue builds from continuous administration of 3-in-1 parenteral nutrition. Common causes of chemical occlusions include co-administration of incompatible medications or lipid infusions.7,15 Catheter salvage is the main goal of treatment and attempts to clear chemical precipitate or lipid residue should be tried. Agents known to dissolve precipitate can be considered to restore patency. Chemical occlusions make up a smaller percentage of catheter occlusions therefore thrombotic and mechanical occlusions should be ruled out before treating for chemical occlusion.7 1. Assess for signs of a chemical occlusion through visual observation of precipitate or identification of co-administration of incompatible medications and/or fluids15,25-29 2. Select the corresponding clearance agent (Table 5) and instill sufficient volume to fill the catheter lumen. 3. Do not administer overfill.14 4. Use of 70% ethanol in a polyurethane catheter may result in damage to the catheter. Use with caution. Table 5. Types of Chemical Occlusion and Treatment Options15,25-29 Cause Clearance Agent Dwell Time Calcium Phosphate Precipitate L-Cysteine 50 mg/mL Irrigate with gentle to and fro motion for 1-2 minutes. If not restored, dwell 60 minutes and repeat above hourly Effective 12/21/23. Contact CCKM@uwhealth.org for previous versions Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 12/2023 9 Acidic Drug Precipitate – pH < 6 (ex. vancomycin, piperacillin, parenteral nutrition amino acids) L-Cysteine 50 mg/mL 60 minutes Alkaline Drug Precipitate – pH > 7 (e.g. phenytoin, acyclovir, ganciclovir, ampicillin, heparin) Sodium bicarbonate (NaHCO3) 8.4% 1 meq/mL 60 minutes Lipid Deposition (e.g. parenteral nutrition) 70% Ethanol 60 minutes 5. May repeat instillation of catheter clearance agent once if necessary18 6. If patency is restored, then follow the procedures outlined in Nursing and Patient Care Policy AP 1.56 Central Vascular Access Device Use, Maintenance, and Removal (Adult and Pediatric) a. Adults: withdraw 5 mL, discard, and flush catheter with 20 mL 0.9% sodium chloride b. Pediatrics: withdraw 1-2 mL, discard, and flush catheter with 5-10 mL of 0.9% sodium chloride 6. Resume IV fluids, medications, or lock CVAD as appropriate 7. If patency is not restored, consult provider.14 Disclaimer Consensus care guidelines assist clinicians by providing a framework for the evaluation and treatment of patients. This guideline outlines the preferred approach for most patients. It is not intended to replace a clinician’s judgment or to establish a protocol for all patients. It is understood that some patients will not fit the clinical condition contemplated by a guideline and that a guideline will rarely establish the only appropriate approach to a problem. Effective 12/21/23. Contact CCKM@uwhealth.org for previous versions Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 12/2023 10 Methodology Table 1. GRADE Ranking of Evidence High We are confident that the effect in the study reflects the actual effect. Moderate We are quite confident that the effect in the study is close to the true effect, but it is also possible it is substantially different. Low The true effect may differ significantly from the estimate. Very Low The true effect is likely to be substantially different from the estimated effect. Table 2. GRADE Ratings for Recommendations for or Against Practice Strong (S) Generally, should be performed (i.e., the net benefit of the treatment is clear, patient values and circumstances are unlikely to affect the decision.) Conditional (C) May be reasonable to perform (i.e., may be conditional upon patient values and preferences, the resources available, or the setting in which the intervention will be implemented.) Effective 12/21/23. Contact CCKM@uwhealth.org for previous versions Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 12/2023 11 Appendix. Management Algorithm 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 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 12/21/23. Contact CCKM@uwhealth.org for previous versions Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 12/2023 12 Collateral Tools & Resources Delegation Protocols [16] – Central venous access device clearance – adult/pediatric/neonatal Order Sets & Smart Sets [3600] – IP/OP - Catheter Clearance – Supplemental Order Set Policies UWHC Nursing and Patient Care Policy1.56 AP Central Vascular Access Device Use, Maintenance, and Removal (Adult and Pediatric) Effective 12/21/23. Contact CCKM@uwhealth.org for previous versions Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 12/2023 13 References 1. Moureau N, Poole S, Murdock MA, Gray SM, Semba CP. Central venous catheters in home infusion care: outcomes analysis in 50,470 patients. J Vasc Interv Radiol. Oct 2002;13(10):1009-16. doi:10.1016/s1051-0443(07)61865-x 2. Walshe LJ, Malak SF, Eagan J, Sepkowitz KA. Complication rates among cancer patients with peripherally inserted central catheters. J Clin Oncol. Aug 1 2002;20(15):3276-81. doi:10.1200/JCO.2002.11.135 3. Wingerter L. Vascular access device thrombosis. Clin J Oncol Nurs. May-Jun 2003;7(3):345-8. doi:10.1188/03.CJON.345-348 4. Herbst SL. Options for venous access in ambulatory care: issues in selection and management. J Infus Chemother. Fall 1996;6(4):186-94. 5. Lokich JJ, Bothe A, Jr., Benotti P, Moore C. Complications and management of implanted venous access catheters. J Clin Oncol. May 1985;3(5):710-7. doi:10.1200/JCO.1985.3.5.710 6. Stephens LC, Haire WD, Kotulak GD. Are clinical signs accurate indicators of the cause of central venous catheter occlusion? JPEN J Parenter Enteral Nutr. Jan-Feb 1995;19(1):75-9. doi:10.1177/014860719501900175 7. van Miert C, Hill R, Jones L. Interventions for restoring patency of occluded central venous catheter lumens. Cochrane Database Syst Rev. Apr 18 2012;(4):CD007119. doi:10.1002/14651858.CD007119.pub2 8. Baskin JL, Reiss U, Wilimas JA, et al. Thrombolytic therapy for central venous catheter occlusion. Haematologica. May 2012;97(5):641-50. doi:10.3324/haematol.2011.050492 9. Cummings-Winfield C, Mushani-Kanji T. Restoring patency to central venous access devices. Clin J Oncol Nurs. Dec 2008;12(6):925-34. doi:10.1188/08.CJON.925-934 10. Deitcher SR, Fesen MR, Kiproff PM, et al. Safety and efficacy of alteplase for restoring function in occluded central venous catheters: results of the cardiovascular thrombolytic to open occluded lines trial. J Clin Oncol. Jan 1 2002;20(1):317-24. doi:10.1200/JCO.2002.20.1.317 11. Adult catheter management brochure. Genentech USA, Inc.; San Francisco, CA 2019. 12. McKnight S. Nurse's guide to understanding and treating thrombotic occlusion of central venous access devices. Medsurg Nurs. Dec 2004;13(6):377-82. 13. Moureau N, McKinnon B, Douglas C. Multidisciplinary management of thrombotic catheter occlusions in vascular access devices. . J Vasc Access Devices. 1999;4(2):22-29. 14. Canadian Vascular Access Association. Occlusion Management Guideline for Central Venous Access Devices. Dundas, ON: Andrew John Publishing Inc 2013. 15. Baskin JL, Pui CH, Reiss U, et al. Management of occlusion and thrombosis associated with long- term indwelling central venous catheters. Lancet. Jul 11 2009;374(9684):159-69. doi:10.1016/S0140-6736(09)60220-8 16. Alteplase (Cathflo® Activase®) [prescribing information]. Genentech, Inc.; San Francisco, CA. 2019. 17. Bhutta ST, Culp WC. Evaluation and management of central venous access complications. Tech Vasc Interv Radiol. Dec 2011;14(4):217-24. doi:10.1053/j.tvir.2011.05.003 18. Gorski LA, Hadaway L, Hagle ME, et al. Infusion Therapy Standards of Practice, 8th Edition. J Infus Nurs. Jan-Feb 01 2021;44(1S Suppl 1):S1-s224. doi:10.1097/nan.0000000000000396 19. Mason TM, Ferrall SM, Boyington AR, Reich RR. Central venous access devices: an investigation of oncology nurses' troubleshooting techniques. Clin J Oncol Nurs. Aug 2014;18(4):421-5. doi:10.1188/14.Cjon.421-425 20. Barnacle A, Arthurs OJ, Roebuck D, Hiorns MP. Malfunctioning central venous catheters in children: a diagnostic approach. Pediatr Radiol. Apr 2008;38(4):363-78, quiz 486-7. doi:10.1007/s00247-007-0610-2 21. Doellman D. Prevention, assessment, and treatment of central venous catheter occlusions in neonatal and young pediatric patients. J Infus Nurs. Jul-Aug 2011;34(4):251-8. doi:10.1097/NAN.0b013e31821da2ae 22. Broadhurst D, Cernusca C, Cook C, et al. CVAA Occlusion Management Guideline for Central Venous Access Devices (CVADS) 2019 Second Edition Vascular Access. 2019;13(Supplement 1):1-30. Effective 12/21/23. Contact CCKM@uwhealth.org for previous versions Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 12/2023 14 23. Becton Dickinson and Company. Central IV Catheters. Accessed July 26, 2021. https://www.bd.com/en-us/offerings/capabilities/vascular-access/vascular-access-devices/central- iv-catheters 24. Medical Components Inc. Pediatric Vascu-PICC. Accessed July 26, 2021. http://medcompnet.com/products/pediatrics/pediatric_vascu-picc.html#ifu 25. Kerner JA, Jr., Garcia-Careaga MG, Fisher AA, Poole RL. Treatment of catheter occlusion in pediatric patients. JPEN J Parenter Enteral Nutr. Jan-Feb 2006;30(1 Suppl):S73-81. doi:10.1177/01486071060300S1S73 26. Werlin SL, Lausten T, Jessen S, et al. Treatment of central venous catheter occlusions with ethanol and hydrochloric acid. JPEN J Parenter Enteral Nutr. Sep-Oct 1995;19(5):416-8. doi:10.1177/0148607195019005416 27. Pai VB, Plogsted S. Efficacy and safety of using L-cysteine as a catheter-clearing agent for nonthrombotic occlusions of central venous catheters in children. Nutr Clin Pract. Oct 2014;29(5):636-8. doi:10.1177/0884533614539177 28. Pennington CR, Pithie AD. Ethanol lock in the management of catheter occlusion. JPEN J Parenter Enteral Nutr. Sep-Oct 1987;11(5):507-8. doi:10.1177/0148607187011005507 29. ter Borg F, Timmer J, de Kam SS, Sauerwein HP. Use of sodium hydroxide solution to clear partially occluded vascular access ports. JPEN J Parenter Enteral Nutr. May-Jun 1993;17(3):289- 91. doi:10.1177/0148607193017003289 Effective 12/21/23. Contact CCKM@uwhealth.org for previous versions Copyright © 2023 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission. Contact: CCKM@uwhealth.org Last Revised: 12/2023