TPA for central Line clots??

chenoaspirit, ASN, RN · Sep 17, 2008

We just had an inservice on this today. You have a set of Y tubing set that connects to the clogged port (leaving two open lines). Each open line has a syringe....one with the TPA and the other one empty. There is a stopcock in the middle of the Y so you can "open" whichever tubing you want. With the stopcock opening the empty syringe, you pull back to collapse the clogged PICC tubing (creating a vacuum), then turn the stopcock to open the syringe with the TPA. The vacuum you have created sucks the TPA into the clogged port. Once you allow the clot to disolve, you HAVE to aspirate the TPA out of the PICC, then flush with NS. Its so hard to explain with words on here. It is very interesting. The drug itself is TPA, but is administered with the name "Cathflo".

chenoaspirit, ASN, RN · Sep 17, 2008

I found this online. It may explain it better....

Alteplase (Cathflo) Instillation to Clear a Clotted PICC

Instillation may be performed by APNs, and PICC-team members.

1. Wipe the PICC hub with 2% chlorhexidine gluconate and allow it to air dry for 30 s. Remove the extension set.

2. Using sterile technique, attach a three-way stopcock primed with Cathflo to the PICC hub. Attach a 3-ml syringe with the appropriate Cathflodosage (PICC = 0.3 ml); to one port of the stopcock and an empty 10-ml syringe to the other port.

3. Close the stopcock to the Cathflo syringe and open it to the empty 10-ml syringe. Gently aspirate the catheter with the 10-ml syringe until resistance is felt.

4. Close the stopcock to the aspirating syringe and open it to the Cathflo syringe while maintaining pull on the aspirating syringe. The Cathflo should be drawn into the PICC catheter. The procedure may be repeated immediately to ensure full instillation of the catheter.

5. Close the stopcock and allow the Cathflo to remain in the PICC catheter for at least 2 hr. Then, open the stopcock and check for blood return. If blood is returned, aspirate 1 ml of waste and flush the line with normal salinebefore infusing or flushing with heparinized normal saline solution. If no blood is returned, the procedure may be repeated, allowing Cathflo to remain instilled for 8 hr. When infant status allows, leave Cathflo in the catheter for 8 hr with initial instillation for improved declotting results and initiate PIV for fluid.

6. Once catheter patency has been established, the stopcock can be removed. The extension set and the IV tubing should be replaced after being wiped with 2% chlorhexidine gluconate or betadine and allowed to dry for 30 sec.

iluvivt, BSN, RN · Sep 17, 2008

You can also use a syringe method. None of the IV nurses I work with like the stopcock method as described in previous posts. Always use a 10 ml syringe and attach it directly to hub of the catheter or at the cap. Pull syringe back to the 8 ml mark do this over and over again while very gently pushing some in. It can take up to 20 min or so to get it in. If you get some in....leave it in and let it work and come back in 30 min or so and try to get the rest in. It is best if someone with some experience shows you so you get the feel of how much pressure to apply (it is very little). The max dwell time is 2 hours. I usually leave it in at least an hour b/f I check it...but you can check it every 1/2 hour if you like. Yes you can use Tpa on any occluded lumen either a complete or partial occlusion. You should use it on any lumen of a CVC that you can instill but not withdraw. A lot of nurses do not realize that if you leave a clotted lumen or a lumen that will not draw blood b/c of a fibrin buid-up it increases the the pts risk for infection. So treat all occlusions complete and partial related to fibrin and clotting. This drug will not work on a precipitate. PS I find CVCs made of silicone easier to declot.

classicdame, MSN, EdD · Sep 17, 2008

when we started using Cathflo nurses were reluctant because they had been taught that Tpa is for strokes and can be deadly. That is true. But Cathflo is a MUCH smaller dose and safe with kids )I forget the size kid). Itsimply sets there eating the clot. Sometimes a second dose is required. Amazing how well it works. VERY expensive.

GrumpyRN63, ADN, RN · Sep 17, 2008

I agree, I don't use the stopcock method, just create a vacuum w/ a 10 cc syringe, clamp to maintain the vacuum, before instilling the TPA, sometimes it does require a bit of pressure (even w/ the vacuum) to get the TPA to go in. I usually wait 45min to an hr and 15" to aspirate. I've used this on PICC's, POC's,TLC's

blondy2061h, MSN, RN · Sep 17, 2008

We use TPA with all our central lines & piccs. We use 2mg in 2ml. It doesn't have to be pushed through the port, as it acts topically on the clot. We let it sit there for 30 minutes, then check on it and see if we can get blood return. It not, 30 more minutes and so on and so forth. When we get blood return, we try to pull back the 2mls we put in. Usually the syringe the TPA came in stays connected to the lumen the whole time.

wooh, BSN, RN · Sep 17, 2008

Just make sure on PICC lines to try a dressing change before using the super expensive Cathflo. Sometimes there's just a tiny kink under the dressing that's the actual "clog." I've actually had orders for the Cathflo, and before using it, changed the dressing and was able to save myself a bunch of time and the hospital a bunch of money.:)

chenoaspirit, ASN, RN · Sep 17, 2008

Well, if you try to apply pressure, you can blow the PICC and a new PICC will have to be placed. This is my hospital policy and is how I do it. It works great because it allows the cath to be completely filled with TPA and allows penetration to the clot at the end. However is best or not, you need to do it by YOUR hospital policy.

imanedrn · Sep 18, 2008

Here is how I was taught to do it / how it works:

I received 1 syringe with 2ml of TPA in it. #1 port was clogged completely; I couldn't push anything through it. #2 port was VERY sluggish; I could push IV meds but could not run anything IV because the pump perceived an occlusion.

For port #1, I pushed the TPA in. It seemed like nothing went it, but (in actuality), I got about 0.2ml in the line. I pushed the rest into port #2.

When I came back in 1 hr, I pulled back on both lines. Port #1 had some blood clots slowly come out, but still no flow. Port #2 was now functional. For port #2, I pulled back approx 6ml (to pull the TPA that was in the line in addition to clotted & fresh blood), then I flushed w/ 10ml NS & 10 ml heparin.

I got another syringe (another 2ml) of TPA from pharmacy. I put as much as it as I could in port #1 -- approx 1ml. Then you leave it for 2hrs. (I can't remember the exact times, but pharmacy has a protocol.) When I came back & pulled on port #1, blood came out. Again, I pulled about 6ml which included the TPA, declotted blood & fresh blood. Again, I flushed with NS & heparin.

Basically, TPA is a VERY STRONG anticoagulant. It is designed to stay in the line ONLY. (If you FLUSH the line with TPA in it, you can actually kill someone. Side note: ALWAYS label the ports, with tape or something, to CLEARLY indicate when TPA is in the line, so anyone coming in contact with it knows NOT to flush the lines! I also put a sign on the pt's door / over their bed, just to make sure.) Considering how long a PICC line is, if you push up to 2ml, that is not enough to reach the SVC. It's only enough to stay in the line. It does it's declotting work, then you pull back, and you're pulling the TPA, declotted blood, and fresh blood. Then the line is almost as good as new.

And, yes, it can be used for port-a-caths also because they have the long line like PICCs do.

It's actually pretty cool to see the stuff in action -- to see a PICC port go from completely clotted to free flushing!

catshowlady · Sep 18, 2008

The Cathflo dose of TPA is very small - 2mg. While you would ideally be able to aspirate it, if you somehow dose the pt with it, you are *not* going to kill them. It is only active in the body for about 30 minutes. This is per the Cathflo rep, who was at my hospital giving inservices yesterday, and also per the pharmacist at my hospital. (I asked because I had to do this when I was in orientation on nights last fall - I was scared to death, and no one on my unit knew how to do it either. The pharmacist helped me out, and reassured me that I was not going to kill my pt with 2mg (or even 4) of Cathflo.)

Cathflo is safe in children as young as two weeks old.

I just don't want anyone to be terrified to use this med like I was. :)

10MG-IV · Sep 18, 2008

You described it to a T . I would declott piccs etc also, Make sure you tape off the line with a huge piece of tape and label it DO NOT USE! TPA . I am so glad you included that info.

One thing I would do, create a vacuum with a 10 cc syringe and "pop" the stopper causing a VIBRATION down the picc tube. I would do this repeatedly, and found the TPA would seep around the clot easily, ever so slightly, or some time the clot would aspirate sponatanously. Make sure you are not giving the TPA as a push, just enough to come in contact with the clot so the enzyme like action works in breaking down the clot.

Don't use tuberculin syringes. They have too much PSI and will blow out a

PICC line.

What do you think?

Here is how I was taught to do it / how it works:
I received 1 syringe with 2ml of TPA in it. #1 port was clogged completely; I couldn't push anything through it. #2 port was VERY sluggish; I could push IV meds but could not run anything IV because the pump perceived an occlusion.
For port #1, I pushed the TPA in. It seemed like nothing went it, but (in actuality), I got about 0.2ml in the line. I pushed the rest into port #2.
When I came back in 1 hr, I pulled back on both lines. Port #1 had some blood clots slowly come out, but still no flow. Port #2 was now functional. For port #2, I pulled back approx 6ml (to pull the TPA that was in the line in addition to clotted & fresh blood), then I flushed w/ 10ml NS & 10 ml heparin.
I got another syringe (another 2ml) of TPA from pharmacy. I put as much as it as I could in port #1 -- approx 1ml. Then you leave it for 2hrs. (I can't remember the exact times, but pharmacy has a protocol.) When I came back & pulled on port #1, blood came out. Again, I pulled about 6ml which included the TPA, declotted blood & fresh blood. Again, I flushed with NS & heparin.
Basically, TPA is a VERY STRONG anticoagulant. It is designed to stay in the line ONLY. (If you FLUSH the line with TPA in it, you can actually kill someone. Side note: ALWAYS label the ports, with tape or something, to CLEARLY indicate when TPA is in the line, so anyone coming in contact with it knows NOT to flush the lines! I also put a sign on the pt's door / over their bed, just to make sure.) Considering how long a PICC line is, if you push up to 2ml, that is not enough to reach the SVC. It's only enough to stay in the line. It does it's declotting work, then you pull back, and you're pulling the TPA, declotted blood, and fresh blood. Then the line is almost as good as new.
And, yes, it can be used for port-a-caths also because they have the long line like PICCs do.
It's actually pretty cool to see the stuff in action -- to see a PICC port go from completely clotted to free flushing!