Occluded Vascular Catheter

Get CMEOccluded Vascular CatheterChildren with chronic medical problems may require a variety of specialized tools, but what do you do when those tools become the problem. We have previously reviewed issues with Baclofen Pumps as well as Vagal Nerve Stimulators.  We have also discussed more commonly encountered equipment like VP Shunts, but one that deserves specific attention is the Central Vascular Line.  What can be done to fix the Occluded Vascular Catheter?

 

Vascular Access In Children

  • Emergent access in children is a challenge!
    • See Access Denied!
    • See Interosseous Needle (for Neonates and Video)
    • Attaining central venous access in children is more difficult to than in adults – small target vs bigger target
      • Obviously, this is a gross generalization based solely on my personal experience…
      • But, it is still “true.”
    • IO should be favored over Central Venous Access (CVC) or Triple Lumen Catheter (TLC) in true emergent states.
      • Actually, I’d also argue that IOs should be used before CVC or TLC in adults who need immediate access as well!
  • Some children require long-term central venous access.
    • Some examples frequently encountered in the ED:
      • Patients who require frequent medication administrations (ex, Chemotherapy, Antibiotic regimens)
      • Patients who require nutritional support
      • Patients who require blood product administration
      • Patients who require hyper-osmolar medications
    • These central vascular catheters can be:
      • Tunnelled (ex, Broviac, Hickman, Groshong)  or implanted
      • Inserted Peripherally (ex, PICC)
      • Single Lumen or Multi-lumen

 

Occluded Vascular Catheter

  • An occluded vascular catheter may be:
    • Totally occluded – cannot infuse or aspirate
    • Partial occluded – can infuse, but cannot aspirate
  • Unfortunately, maintaining long-term catheters is also a challenge.
    • 14-36% of patients with CVCs will have a complication within 2 years of placement. [Baskin, 2009]
    • CVCs can be complicated by:
      • Mechanical failure / issues
        • Kinked tube
        • Dislodged or displaced catheter
        • Lumen orifice occluded by abutting vessel wall
      • Infection 
        • Localized infection / cellulitis
        • Nidus of systemic infection
      • Thrombosis
        • CVCs are the most frequent cause of thrombosis in children
        • May prevent function of line.
        • May lead to Deep Vein Thrombosis or Pulmonary Embolism

 

Occluded Vascular Catheter Management

  • Start Simple!
    • Look for external compression (ex, clamps, sutures)
    • Adjust position
      • Lift arm
      • Shrug shoulder forward
    • Have patient cough or Valsalva [Giordano, 2015; Kerner, 2006]
    • Look for signs of infection or DVT [Kerner, 2006]
  • Don’t underestimate the potential for mechanical failure!
    • In addition to external compression, there may be internal kinking or migration.
    • Chest radiograph is first option for imaging. [Giordano, 2015]
    • The CXR can be done with contrast infused through line if it is partially occluded.
  • Don’t overlook potential for associated Venous Thrombosis
    • Consider the potential for a CVC-associated venous thrombus that is external to the catheter.
    • Ultrasound can be useful to help with this investigation and may also visualize thrombus at the apex of the catheter.
    • If U/S is inconclusive, or pre-test probability is high in the setting of a possible false negative U/S, may need to use CT or MRI. [Giordano, 2015]
  • Dissolve the Occlusion!
    • Occluded vascular catheters can be due to:
      • Chemical occlusions
        • Precipitants from infused drugs and minerals
        • Residue from infused lipids
      • Thrombus formation
    • If occluded vascular catheter due to Chemical Occlusion, then: [Giordano, 2015]
      • Use NaOH 0.1 N for Basic Substances (ex, Phenytoin)
        • Allow up to 150% of the volume of the CVC capacity to sit in situ for up to 6 hours
      • Use HCL 0.1 N for Acidic Substances (ex, Vancomycin) or Calcium Phosphate Crystals
        • Allow 100% of the volume of the CVC capacity to sit in situ for up to 1 hour
      • Use Ethilic Alcohol 70% for Lipids
        • Use up to 3 mL (maximum of 0.55ml/kg)
        • Can only be used for silicone CVCs, not Polyurethane CVCs.
    • If occluded vascular catheter due to thrombus formation, then: [Giordano, 2015]
      • Instill a quantity sufficient to fill the CVC capacity of either:
        • Alteplase (t-PA) 1 mg/ml, left in situ for 15 – 60 min
          • t-PA has been shown to be both safe and effective in restoration of function on CVC in kids. [Anderson, 2013; Blaney, 2006]
          • t-PA has also been effective as an infusion as well as a dwell. [Ragsdale, 2014]
        • Urokinase 5,000 IU/ml, left in situ for 15-60 min
      • One published protocol [Kerner, 2006] recommends:
        • After 30 min, attempt to aspirate 3 ml; if able to do so, flush; if unable, wait additional 90 min then repeat.
        • If not able to aspirate after 120 min, then re-dose t-PA.
      • If persistent thrombotic occlusion may need to consider systemic infusion of thrombolytic, but need to ensure no other CVC-associated thrombosis as therapy for that is different.

 

Moral of the Morsel

  • The use of indwelling central lines can be life-saving / changing for many children.
  • These lines do have associated risks and complications that may cause the patients to present to your ED.
  • These lines should be viewed as highly valuable, and all attempts to salvage appropriate CVCs should be made.
  • Keep it simple and don’t overlook simple mechanical issues.
  • Know your hospitals resources… many already have protocols for evaluation and management of occluded vascular catheters.

 

References

Giordano P1, Saracco P2, Grassi M1, Luciani M3, Banov L4, Carraro F5, Crocoli A6, Cesaro S7, Zanazzo GA8, Molinari AC4; Italian Association of Pediatric Hematology and Oncology (AIEOP). Recommendations for the use of long-term central venous catheter (CVC) in children with hemato-oncological disorders: management of CVC-related occlusion and CVC-related thrombosis. On behalf of the coagulation defects working group and the supportive therapy working group of the Italian Association of Pediatric Hematology and Oncology (AIEOP). Ann Hematol. 2015 Nov;94(11):1765-76. PMID: 26300457. [PubMed] [Read by QxMD]

Ragsdale CE1, Oliver MR, Thompson AJ, Evans MC. Alteplase infusion versus dwell for clearance of partially occluded central venous catheters in critically ill pediatric patients. Pediatr Crit Care Med. 2014 Jul;15(6):e253-60. PMID: 24751787. [PubMed] [Read by QxMD]

Pai VB1, 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. 2014 Oct;29(5):636-8. PMID: 25118177. [PubMed] [Read by QxMD]

Anderson DM1, Pesaturo KA, Casavant J, Ramsey EZ. Alteplase for the treatment of catheter occlusion in pediatric patients. Ann Pharmacother. 2013 Mar;47(3):405-9. PMID: 23463740. [PubMed] [Read by QxMD]

Baskin JL1, Pui CH, Reiss U, Wilimas JA, Metzger ML, Ribeiro RC, Howard SC. Management of occlusion and thrombosis associated with long-term indwelling central venous catheters. Lancet. 2009 Jul 11;374(9684):159-69. PMID: 19595350. [PubMed] [Read by QxMD]

Kerner JA Jr1, Garcia-Careaga MG, Fisher AA, Poole RL. Treatment of catheter occlusion in pediatric patients. JPEN J Parenter Enteral Nutr. 2006 Jan-Feb;30(1 Suppl):S73-81. PMID: 16387916. [PubMed] [Read by QxMD]

Blaney M1, Shen V, Kerner JA, Jacobs BR, Gray S, Armfield J, Semba CP; CAPS Investigators. Alteplase for the treatment of central venous catheter occlusion in children: results of a prospective, open-label, single-arm study (The Cathflo Activase Pediatric Study). J Vasc Interv Radiol. 2006 Nov;17(11 Pt 1):1745-51. PMID: 17142704. [PubMed] [Read by QxMD]

Werlin SL1, Lausten T, Jessen S, Toy L, Norton A, Dallman L, Bender J, Sabilan L, Rutkowski D. Treatment of central venous catheter occlusions with ethanol and hydrochloric acid. JPEN J Parenter Enteral Nutr. 1995 Sep-Oct;19(5):416-8. PMID: 8577023. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

You may also like...

Leave a Reply