Related | Treatment of Central Venous Access Device Occlusion - Adult/Pediatric/Neonatal - Inpatient/Ambulatory/Emergency Department
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 .................................................................................................................... 7
Methodology ................................................................................................................................. 9
Appendix A. Pediatric PICC Volume Tables for Patients < 10 kg ............................................... 10
Appendix B. Management Algorithm .......................................................................................... 11
Collateral Tools & Resources ..................................................................................................... 12
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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, Northern Illinois
Rhiannon Goudreau, RN – Vascular Access, 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
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: May 2024
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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
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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
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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
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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 Appendix A
d. Implanted ports: 2 mg/2 mL regardless of weight or age
e. Doses should not exceed 2 mg/2 mL
Appendix A. 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.
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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.
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
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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 4) 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 4. 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
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.
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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.)
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Appendix A. Pediatric PICC Volume Tables for Patients < 10 kg
Neonatal PICC’s *Volumes listed below do not include microclave volume (0.05 mL). Best practice: attach syringe directly to the catheter hub to instill alteplase
Line Size
1.0 French
Single Lumen
1.4 French
Single Lumen
1.9 French
Single Lumen
1.9 French
Single Lumen
1.9 French
Single Lumen
1.9 French
Single Lumen
2.6 French
Double Lumen
Total Length 20 cm 30 cm 30 cm 30 cm 50 cm 50 cm 50 cm
Brand
Vygon
Footprint
Polyurethane
Footprint
Silicone
Argon / L-Cath
Argon/ First PICC
Medcomp Medcomp
Uncut Volume 0.09 mL 0.14 mL 0.12 0.1 mL 0.13 mL 0.21 mL 0.22 mL
Cut Length *Volumes for Cut Lines 110% Lumen Priming Volume (mL)
10-15 cm 0.07 0.08 0.07 0.06 0.04 0.07 0.07
16-20 cm 0.10 0.10 0.09 0.07 0.06 0.09 0.1
21-30 cm - 0.15 0.13 0.11 0.09 0.14 0.15
31-40 cm - - - - 0.12 0.18 0.19
41-50 cm - - - - 0.14 0.23 0.24
Pediatric PICC’s
Line Size
3 French
Single Lumen
4 French
Single Lumen
4 French
Double Lumen
Total Length 45 cm 55 cm 55 cm
Brand Bard PowerPICC Bard PowerPICC Bard PowerPICC
Uncut Volume 0.53 mL 0.67 mL 0.52 mL
Cut Length *Volumes for Cut Lines 110% Lumen Priming Volume (mL)
10-15 cm 0.19 0.20 0.16
16-25 cm 0.32 0.34 0.26
26-35 cm 0.45 0.47 0.36
36-45 cm 0.58 0.60 0.47
46-55 cm - 0.75 0.57
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Appendix B. CVAD Occlusion 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.
Dose may not exceed 2 mg/2 mL
Repeat clearance agent
B
Dose 2
Patency restored at 60 minutes?
NO
NO
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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)
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