is alteplase EVER contraindicated for central line occlusions?

[holdensjane1]

is there any instance where Alteplase for central line occlusion is contraindicated? I know there is for heparin, but i was told that alteplase for central line occlusion has a very short half life and there is no contraindication. is this true? I'm not talking about therapeutic alteplase, just the 2ml used for central lines.

If you put it in a line twice and its still occluded but you can flush but no return, I've alway just left it in even beyond the 90 mins its supposed to be in. I know the half life is short and if I can't get it out then I can't get it out. If placement is an issue of course I would get that checked first, but I just wanted to know how other nurses do it. I find that eventually I get return, just not in the time my policy dictates.

[Cheyenne RN,BSHS]

Perhaps the policy may need to be revisited and in the meantime research what material is out there on the use of Alteplase and dwell times. If you are working outside the policy then you are walking on thin ice, IMO

[Guttercat, ASN, RN]

As far as contraindications, refer to your policy. If it's not in the policy, start asking around...a good resource is to call the guys and gals at your hospital's Interventional Radiology department.

While Alteplase for central line occlusion is weak, it is still a "clot buster" drug and needs to be administered with consideration of each patient's own respective situation.

And no, you don't want to go throwing more and more Alteplase at them just because you can't withdraw from the line. I think the most I have administered is two rounds.

Central lines (and the problems associated with them) are numerous in variety. There are also numerous tricks in dealing with them, which I won't go into at length here. I will say to think about them in a different way. What is the size of the lumen(s)? What is its length, where is it placed, and how long has it been in?

Just because the catheter flowed fine when pushing but you were unable to withdraw, does not mean the Alteplase didn't work. Think about "why" it wouldn't withdraw. Sometimes it's a "positional" issue--I've had numerous patients where simply tipping their head to one side meant I could not withdraw. Sometimes the inability to withdraw is due to the negative pressure causing the catheter to "suck up" against the wall of the heart (or a vessel...depending on length).

Other times, there are fibrin chunks hanging off of the end of the catheter's lumen openings, and when you attempt to withdraw they suck back into the openings. These kind of chunks kind of hang on to the openings, flapping in the breeze. No amount of Alteplase is likely to fix that scenario.

[NotReady4PrimeTime, RN]

Don't forget that clots are not the only problem that causes obstruction in central lines. Ever seen what happens when you mix phenytoin (Dilantin) with a dextrose-containing solution? When the obstruction is caused by inadequate flushing of incompatible meds, all the alteplase in the world isn't going to restore patency. That's when you'd want to use hydrochloric acid. It must be prepared by pharmacy and should come with complete instructions for use. On one occasion I was ordered to use HCl for restoring patency and it failed. I had been able to flush the line prior but had no blood return after 2 doses of alteplase. So after much consultation, it was determined that I would infuse saline through that lumen at 0.5 mL per hour for 6 hours to dilute the acid down enough not to upset the kid's acid-base balance. I was sweating bullets for a while, I'll tell you.

[meanmaryjean, DNP, RN]

Have a kid right now who you have to about hang her upside down and twirl her counterclockwise to get the line to draw- but it draws beautifully when in exactly the right position. This is particularly 'fun' at 0400....

[iluvivt, BSN, RN]

Yes absolutely Cath-flo can be used for a fibrin sheath or tail That is exactly they type of occlusion that can be fixed. There are a few contraindications of Cath-flo such as allergy and know catheter infection but it is very safe and yes you must look at the entire clinical picture and weigh the risk versus the benefit. The majority of the times the benefit outweighs the minimal risk. Not only do you restore catheter function but you decrease the rate of infection. When you leave a thrombotic occlusion/clotted line) the blood is just sitting in or at the tip of the catheter and/or is stagnant and it is does increase the rate of infection.

Yes ...keep in mind that a thrombotic occlusion is NOT always the cause of a complete or partial occlusion or an inability to obtain a brisk blood return. You always want to rule out a mechanical cause and a drug or mineral precipitate first. I can't tell you how many times I have been called AFTER a nurse treated a CVC (usually x 2) with Cath-flo and with a few questions I can tell that it is most likely a mechanical cause and then I run up to the unit and it is mechanical and I fix it. Drug and mineral precipitates have different treatments for example hydrochloric acid is used drugs that occlude a CVC that have a high ph (alkaline). Lipid occlusion can be treated with sodium hydroxide. Somewhere I have a great algorithm for catheter occlusion and will see if I can find it!

[blondy2061h, MSN, RN]

Have a kid right now who you have to about hang her upside down and twirl her counterclockwise to get the line to draw- but it draws beautifully when in exactly the right position. This is particularly 'fun' at 0400....

Yeah, we had a patient like that. Did it for about a week, then had the line changed. A simple rewire and beautiful blood return in all positions. And it's a good thing, too, because she started going down the tubes shortly thereafter.

[CarryThatWeight, BSN]

Some of our hem-onc docs won't let us TPA the lines if the patients' platelets are too low. Just FYI.