Table of Contents

1. Purpose

2. Supportive Data

3. Policies

4. Critical Points

5. Guidelines

6. Supplies Needed

7. Procedures

   • Instillation Procedure for Nearly or Completely Occluded Catheters

8. Documentation

9. References

10. Procedure History

I. Purpose

The purpose of this protocol is to restore the patency of a clotted peripherally inserted central catheter (PICC) by instilling a thrombolytic agent, such as tissue plasminogen activator (tPA) or Alteplase®. Alteplase is a commercially available thrombolytic agent approved for the breakdown of blood clots.

II. Supportive Data

Catheter occlusion is commonly caused by a thrombus within or surrounding the catheter, with the catheter tip being the most frequent site of obstruction. The following signs can help identify the type of occlusion:

• Partial Thrombotic Occlusion: Characterized by sluggish flow and/or difficulty in withdrawing fluid or blood through the catheter.

• Complete Thrombotic Occlusion: Inability to infuse or withdraw fluid or blood through the catheter.

III. Policies

• A medical order is required to instill tPA in an occluded central venous catheter where blood cannot be withdrawn.

• All needleless connectors must be scrubbed with chlorhexidine (CHG) for 15 seconds and allowed to air dry for 15 seconds before access.

• Only PICC-trained RNs or MDs are authorized to administer tPA.

• The dose is per lumen: for multi-lumen catheters, treat one lumen at a time.

• The thrombolytic agent should not be infused into the patient and must be aspirated out after the dwell time.

IV. Critical Points

1. Patient Assessment: Before administration, the provider and RN must assess the patient's risk for bleeding, considering diagnosis, recent invasive procedures, bleeding complications, medication profile, and recent lab results (e.g., PT/PTT/INR, platelet count). Notify the prescribing provider if the patient is at high risk for bleeding to confirm the appropriateness of the order.

2. Infection Risk: Use Alteplase (Cathflo Activase®) with caution in cases of suspected or known catheter infection.

3. Rule Out Other Causes: Prior to Alteplase administration, rule out mechanical failures, kinks, catheter malposition, or occlusion due to drug precipitation.

4. Lumen Patency: Assess lumen patency by:

   • Ensuring infusion of a flush without resistance.

   • Checking for brisk (free-flowing) blood return that resembles whole blood in PICC lumens of size 1.9 Fr or larger. Lumen(s) that do not return brisk blood should be considered "sluggish."

5. Instillation Care: Alteplase should be instilled cautiously to avoid catheter rupture. Use a pull-release technique to allow Alteplase to enter a nearly or completely occluded catheter. Never use a syringe smaller than a standard 10 mL syringe to flush a PICC.

V. Guidelines

• Do not exceed 2 mg in 2 mL of thrombolytic agent.

• Reconstitute Alteplase by adding 2.2 mL of sterile water for injection to the vial. Mix gently until dissolved—do not shake. Allow the vial to stand to dissipate large bubbles, and swirl gently. Final concentration: 1 mg/mL.

• Recommended dwell time is 30 minutes to 2 hours. Do not exceed 2 hours per dose. Aspirate the solution from the catheter afterward.

• A second dose may be instilled if the catheter remains occluded after the initial dwell time.

Priming Volumes (PICCs):

• Footprint Medical 1.4 Fr Single Lumen: 0.14 mL @ 30 cm length (0.0047 mL per cm)

• Argon PICC 1.9 Fr Single Lumen: 0.13 mL @ 50 cm length (0.0026 mL per cm)

• Footprint Medical 1.9 Fr Double Lumen:

  • Primary/Clear Lumen: 0.2 mL @ 30 cm length (0.0067 mL per cm)

  • Secondary/Blue Lumen: 0.15 mL @ 30 cm length (0.005 mL per cm)

VI. Supplies Needed

• 10 mL syringes

• 1 mL syringe

• Safety needles/needleless connector (Micro-clave)

• Normal saline

• Three-way stopcock

• 10 mL 0.9% sodium chloride pre-filled syringes

• Chlorhexidine gluconate (Chlorascrub®) wipes

• Thrombolytic agent (tPA, Alteplase®)

VII. Procedures

Restoring Patency to Occluded PICC

1. Obtain an MD order for the thrombolytic agent (tPA) and send it to the pharmacy (not to exceed 1 mL).

2. Confirm that the catheter is obstructed by a suspected blood clot and not due to mechanical issues or drug precipitate. Mechanical issues may include external kinks, while precipitates can result from drug crystallization or incompatibilities.

   • Look for high-pressure alarms or occlusion alerts on the pump.

   • Confirm the inability to infuse or withdraw fluid or blood through the catheter.

3. Perform hand hygiene and maintain aseptic technique throughout the procedure, following standard or specific patient precautions.

4. Correct any external mechanical obstruction of the catheter. If needed, consider a chest X-ray to evaluate for internal kinks or abnormal catheter positioning.

5. Inspect external IV tubing for drug precipitate. Thrombolytic agents are not effective in removing drug precipitates and may result in the expulsion of the precipitate into the vascular system.

VIII. Documentation

Document the patient's Electronic Health Record (EHR) in Epic using the (DOT). PICCOUTCOMEMONITORING smart phrase, ensuring the following details are included:

a. Alteplase Administration: Accurately document the exact dose administered in the Medication Administration Record (MAR).

b. Outcome of Procedure: Record the outcome of the procedure within the nursing flowsheet, noting whether the ability to aspirate/flush was restored or if the procedure was unsuccessful.

References

1. UCSF Neonatal Pediatric Nursing Procedure

2. NeoFax, 2023: Alteplase

3. Argon Medical Devices, 2017: Clinical Education Manual Workshop - Peripheral Inserted Central Catheters in the Neonate; pp. 99-100

4. Brigham and Women’s Hospital: Department of Pediatric Newborn Medicine Clinical Practice Policy; pp. 1-7

5. NANN, 4th and 6th Edition, 2017-2018: Policies, Procedures, and Competencies for Neonatal Nursing Care

6. INS, 2021: The Art and Science of Infusion Nursing: Infusion Therapy Standard of Practice

7. Peripherally Inserted Central Catheters: Guideline for Practice, 4th Edition, 2017

8. Genentech USA, Inc., 2018: Genentech’s Thrombolytic Experience: Activase® (Alteplase); Lytics-Portfolio-Brochure-2.pdf (ukhc.org)