May 2013

Sarah Burns-Gibson, Kim Miller and Daphne Broadhurst

CENTRAL VENOUS ACCESS DEVICE OCCLUSIONS IN

HOME CARE

OBJECTIVES • Overview of CVADs, types, causes, and complications

associated with occlusions

• Discuss occlusion assessment

• Identify strategies in preventing and managing CVAD occlusions

• Identify the uniqueness of caring for and maintaining CVADs in home care

• Review of CVAD occlusion and current practices in home care

• Review tools to aid in the assessment and management of CVAD related occlusions

CENTRAL VENOUS ACCESS DEVICE (CVAD)

• Catheter inserted into a centrally located vein with the tip residing in the vena cava

• Permits intermittent or continuous infusion and/or access into the venous system.

RNAO, 2008

• Facilitate the administration of intravenous (IV):

– Medications

– Fluids

– Blood products

– Parenteral nutrition

• Blood sampling

CVADS ARE USED TO:

• Occlusions can lead to

– Interruption in therapy

– Device replacement

– Device removal

– Visit to the emergency room

– Hospital visit (Moureau, 2002)

– Relationship with infection (Ajenjo, Morley, Russo, McMullen, Robinson,

Williams, and Warren, 2011)

WHAT WE KNOW ABOUT OCCLUSIONS

CVAD OCCLUSION – WHAT IS IT?

Catheter occlusion is a partial or complete

obstruction of the CVAD that limits of prevents the

ability to withdraw blood, flush the catheter,

and/or administer medications or solutions. (INS, 2010)

• Mechanical Associated with mechanical problems with the catheter, drug precipitates, kinked tubing, tip migration

• Non-thrombotic

• Thrombotic – formation of thrombus within or around central venous line (intraluminal thrombus, fibrin tail or flap, fibrin sheath or sleeve)

OCCLUSIONS CATEGORIES

Mechanical

• Mechanical obstruction of the CVAD can be either internal or external.

• External occlusions can be caused by issues such as clamped or kinked tubing.

• Internal occlusions can be caused by improper catheter tip placement as well as kinking or compression of the catheter internally (Bagnell-Reeb, 1998).

OTHER TYPES OF OCCLUSIONS

Types of Occlusions Type Causes Symptoms

Partial Mechanical, chemical or thrombotic occlusion

Decreased ability to infuse fluids

into the CVAD Resistance with

flushing and aspiration. Sluggish flow through the catheter.

Withdrawal Mechanical or thrombotic

Inability to aspirate blood but

ability to infuse without any

resistance. Lack of free—flowing blood return.

Complete Mechanical, chemical or thrombotic occlusion

Inability to infuse or withdraw blood or fluid into the CVAD

TYPES OF THROMBOTIC OCCLUSIONS

Fibrin tail or

flap

Fibrin sheath

or sleeve

Intralumial

occlusion

Mural

thrombus

THROMBOTIC OCCLUSIONS

Types of Thrombotic Occlusions Type Features Symptoms

Fibrin tail or flap Fibrin extends from the end of the

catheter causing partial occlusion (fibrin tail acts as one-way valve).

Ability to infuse but not withdraw blood.

Fibrin sheath Fibrin adheres to the external

surface encasing the catheter,

possibly extending the length of

the catheter; thrombi trapped between sheath and catheter tip.

Inability to infuse and/or withdraw blood.

Mural thrombus Fibrin from vessel wall injury binds

to fibrin-covered catheter;

increased risk of venous thrombosis.

Leakage of infusate from the

insertion site, swelling, pain, tenderness, engorged vessels.

Intraluminal thrombus Fibrin forms inside catheter lumen

causing partial or complete occlusion.

Inability to infuse and/or withdraw blood.

(Besarab, A. and Pandey, R., 2011)

• Inability to aspirate blood

• Resistance to flushing

• Sluggish infusion

• Complete inability to flush or infuse

• Electronic infusion device – increase infusion alarms

• Infiltration or extravasation or swelling or leaking at the insertion site

SIGNS OF CVAD OCCLUSION

“The nurse should assess for and identify signs of CVAD occlusion, including the inability to withdraw blood, sluggish flow, and/or inability to flush or infuse through the device.” (INS Standards of Practice, 2011)

ASSESSING FOR OCCLUSION

“The nurse should aspirate for positive blood return from the vascular access device to confirm patency prior to administration of parenteral medications and solutions.” (INS Standards of Practice, 2011)

ASSESSING FOR OCCLUSION

OCCLUSION ASSESSMENT : 1. ASSESS CATHETER PATENCY

• Flush and aspirate CVAD to assess ease of

flushing and blood return

• Try “gentle push-pull” with saline syringe or

use 3 mL syringe (for aspiration only) if no

blood return

OCCLUSION ASSESSMENT: 2. RULE OUT MECHANICAL OCCLUSION

PINCH-OFF SYNDROME

Photos courtesy of Lisa Schulmeister, RN

OCCLUSION ASSESSMENT: 2. RULE OUT MECHANICAL OCCLUSION

MISPLACEMENT OF NON-CORING NEEDLE ON RIM OF SEPTUM OF PORT

Photo courtesy of Lisa Schulmeister, RN

OCCLUSION ASSESSMENT

3. ASSESS FOR THROMBOTIC OCCLUSION

• Assess for blood visible in CVAD or

administration set

• No blood return on aspiration

• Question type of occlusion – manage

as a thrombotic occlusion

OCCLUSION ASSESSMENT:

4. ASSESS FOR CHEMICAL OCCLUSION

• Observe catheter or IV tubing for visible

precipitates

• Check recent medication administration

history (two incompatible medications

given recently? CVAD flushed pre/in

between and post medication?)

Restore function of

the CVAD

Partial or

complete

occlusion

Goal for

Occluded CVAD

• Infiltration/extravasation in presence of fibrin sheath

• Catheter-related thrombosis increases the risk and

incidence of catheter-related bloodstream infection

• Blood may reflux into catheter tip as a result of

changes in intrathoracic pressure (sneezing, coughing).

(Cummings, 2006)

RISKS OF LEAVING AN OCCLUDED CVAD UNTREATED

Do not leave a

catheter lumen with a

partial, withdrawal or

complete occlusion

untreated

Home Care Acute Care

WHAT CHALLENGES DO YOU EXPERIENCES?

• Process for managing an occluded CVAD

• Use of best practices for CVAD occlusions – not all practitioners are using best practices

• Experts

– Rural areas not able to access or have experts to care for lines – causing clients to return to major centre

– Difficulty exists with accessing experts in CVADs at local hospital

• Ownership of line – “Whoever put the line in is responsible for it “

– No blood return or any problem the response is “have local hospital manage it. “

CHALLENGES IN MANAGING CVAD OCCLUSIONS IN HOME CARE

• Responses: Home care nurses call to hospital to report inability to aspirate – are told just push harder on the plunger OR don’t worry about it just continue to flush or client sent into the hospital for assessment we get back that " it is fine to use“.

• Education - Nurse knowledge i.e. recognizing that sluggish is not normal, who to contact, correct process

• Complicated or frustration for home care nurses in getting help

• Why can’t home care nurses use cathflo in the community?

CHALLENGES IN MANAGING CVAD OCCLUSION IN HOME CARE

TOOLS AVAILABLE TO GUIDE CLINICIANS IN THE COMMUNITY

• Organization specific tools

Occlusion

Management

Guideline Release

Fall 2013

• Alexander, M., A. Corrigan, L. Gorski, J.Hankins, R. Perucca. (2010). Infusion Nursing Society Infusion Nursing; An Evidence Based Approach.

• Registered Nurses Association of Ontario. Care and Maintenance to Reduce Vascular Access Complications – Nursing Best Practice Guidelines, 2008

• Moureau N., McKinnon B.,& Douglas C. Multidisciplinary management of thrombotic catheter occlusions in vascular access devices, Journal of Vascular Access Devices. 1999; 4(2):22-29.

• Infusion nurses society. Infusion Nursing Standards of Practice, Journal of Infusion Nursing, 2011. 34,1S January/February Need a more complete reference

• Cummings-Winfield, C. and T. Mushani-Kani. (2008). Restoring Catheter Patency to Central Venous Access Devices.

REFERENCES