Cathflow

Pediatric Critical Care Columnist · Jun 4, 2010

Cathflo will dissolve the clot. Usually in a situation like you describe, the only way to introduce the Cathflo into the line is to "coax" it in. Instill a little, wait a little bit, try to aspirate a wee bit, instill a little more, wait, try to aspirate again, instill a little more... until you get the final volume into the line. Then it has to sit there for 30-60 minutes to do its job. In my experience, you aren't going to be able to budge that clot into the vein without about 1000 PSI... and you'll never get that kind of pressure with a 10mL syringe. Besides, you'd shred the line and it would be useless.

IVRUS, BSN, RN · Jun 4, 2010

Cathflo will dissolve the clot. Usually in a situation like you describe, the only way to introduce the Cathflo into the line is to "coax" it in. Instill a little, wait a little bit, try to aspirate a wee bit, instill a little more, wait, try to aspirate again, instill a little more... until you get the final volume into the line. Then it has to sit there for 30-60 minutes to do its job. In my experience, you aren't going to be able to budge that clot into the vein without about 1000 PSI... and you'll never get that kind of pressure with a 10mL syringe. Besides, you'd shred the line and it would be useless.

So.. Are you advocating the use of something less than a 10 cc syringe? That is dangerous and against policies for Cathflo use. Years ago manufacturers showed you how to use Urokinase for catheter clearance and they would tell you to draw it up in a small syringe, 1 or 3 cc, however, with advancements in knowledge base, "most' clinicians now realize that that is totally unacceptable. The manufacturers of Cathflo also instruct you to draw up the cathflo after you reconstitute it in a 10-12 cc syringe.

Also, Most catheters aren't "power injectable" catheters.. and therefore won't take PSI's > 300 (Which is the max for most power injectable IV catheters) much less 1000!!!

Using small syringes can rupture the IV catheter sending a catheter emboli, or it can send a thrombus as a PE.

Now, is a 10 cc syringe always a fail-safe? No, excessive hand pressure on a 10 cc syringe can still be problematic, but using a 10cc syringe with normal hand pressure is the ideal situation. Also, try using the stopcock method to instill the Cathflo.

:)

Asystole RN · Jun 4, 2010

Calm down IVRUS, I am sure jan is not advocating using small bore syringes. the fact she states 1000 psi is an indication of that... a 3cc syringe with a bore of .3 inches will only produce 1000 psi with 90 lbs of force. I don't know about you but I am a 195lb man in great shape, I am not sure I can push a syringe that hard without breaking the syringe, or my hand...

Question

could attempting to instill the cathflow force a clot into the patients system?

Answer　

In my experience, you aren't going to be able to budge that clot into the vein without about 1000 PSI... and you'll never get that kind of pressure with a 10mL syringe.

The caution statement of attempting to use a high psi or smaller bore syringe.

Besides, you'd shred the line and it would be useless.

Besides...the cc of the syringe makes no difference on psi, it is the bore diameter...we typically only stock 5cc, 15mm bore flushes.

iluvivt, BSN, RN · Jun 8, 2010

Yes absolutely , this is an appopriate time to use it. It will work for thrombotic occlusions but not for any drug or mineral precipitates. Anytime you have a thrombotic occlusion you really need to treat it and not just to restore function although that is great and necessary. The patient if left untreated in this case, will be at an increased risk for infection so in other words...it is not acceptable to leave it occluded or even to leave it with a PWO which is a persistant withdrawl occlusion (able to instill but not withdraw). Your hospital should have a policy in place that correlates to the manfacturers recomendations.As IVRUS has stated you can not just draw it up and try to instill it...you have to use the stopcock method or the syringe/POP method. I really prefer the syringe method. I draw up my 2 mg of cath-flo after reconstituting with 2.2 ml SW in a 10 ml syringe..then attach the syringe....I draw back to about the 8 ml mark and let it pop back down......sometimes you have to do this a lot..maybe 10-20 times before you can squeeze a little in..usually once I get some in..I can get the rest in easily..sometimes I can get a bit in..let it sit for 15-30min and come back and get the rest in.....once in you can check it every 30 min with a max dwell of 2 hrs..if I am busy..sometimes I just label it and let it sit..always label it....if you just try to push it and you have a complete occlusion and not a PWO the odds are you are going to fracture the catheter..often with silicone catheters you think all is OK and then within 48 hrs it will start leaking close to the insertion site from a pinpoint hole.....I have seen nurses instill incorrectly so many times I can dx the problem over the phone so make sure you know what you are doing before attempting the procedure OK

SamyRN · Jun 19, 2012

Does your hospital have a policy or have you ever let the Activase dwell in the catheter for longer than 2 hours?

I received instruction at one point to let the Activase stay in the cath overnight and have the patient come the next a.m., instead of having them sit in the department for 2+ hours. It worked like a charm...

I can find no literature one way or the other. My only concern might be the effect on the catheter material? I have no qualms about leaving it in the central line: it's not going anywhere...

Anna Flaxis, BSN, RN · Jun 19, 2012

I work in Home Infusion, and our policy allows us to leave TPA in the line overnight if catheter patency is not achieved after 30 minutes of dwell time. This is because we simply do not have the time or resources to stay at the client's home for 120 minutes, nor return to the client's home 120 minutes later. So, the TPA is instilled, an attempt at aspiration is made after 30 minutes, and if unable to aspirate, the line is labeled and left until the next day when an RN will return to aspirate the TPA and assess patency.

iluvivt, BSN, RN · Jun 27, 2012

Yes you can leave it in overnight without any problem and you will not damage the catheter material. What will damage the catheter or cause a fracture is the incorrect administration usually by applying too much force. I work PD for a home infusion company and sometimes will do this or just come back in 2 hours.

Asystole RN · Jun 28, 2012

Out of curiosity, where is everyone getting the idea that it is OK to leave alteplase overnight? Is there a study somewhere that says it is OK?

The Association for Vascular Access does not support leaving alteplase overnight.

The Infusion Nursing Society does not support leaving alteplase overnight.

The Federal Drug Administration does not support leaving alteplase overnight.

Genetech does not support leaving alteplase overnight.

Did some industrious nurse turned inventor decide that it was OK and so invented a policy for this or something?

MunoRN, RN · Jun 29, 2012

Out of curiosity, where is everyone getting the idea that it is OK to leave alteplase overnight? Is there a study somewhere that says it is OK?

There are studies that look at the use of TPA for locking catheters, which not only show no harm but some added benefit compared to just heparin locking, inferring that an extended dwell time is indeed safe.

The Association for Vascular Access does not support leaving alteplase overnight.
The Infusion Nursing Society does not support leaving alteplase overnight.

Do they have specific statements opposing this practice? Otherwise, facilities and other providers don't need to wait for specific approval from these groups to implement a practice. These are not regulatory groups, nor are they an overwhelmingly reliable sources of practice guidelines (INS in particular).

The Federal Drug Administration does not support leaving alteplase overnight.

If you mean that alteplase was not FDA approved for use as locking agent/long term use then yes, you are correct, however heparin has never been FDA approved for the purpose of flushing or locking catheters either, it's an off-label use. Medications don't have be used as they were approved by the FDA, in fact many medications are primarily used "off-label". Companies cannot market medications outside of their FDA approvals, but how they are used by end-users are pretty much a free-for-all in terms of the FDA.

Genetech does not support leaving alteplase overnight.

Considering they sponsored a study on using alteplase as a locking agent they don't seem opposed to it. They can't actively market it for use with a long-dwell time as they are limited to the FDA approved language.

Did some industrious nurse turned inventor decide that it was OK and so invented a policy for this or something?

In my experience a surprising number of policies were pulled directly out of some "inventive" Nurses a&$, so yes this is quite possible.

iluvivt, BSN, RN · Jul 1, 2012

Yes..off label but you need to ask yourself "what harm will come to the patient if left in the catheter overnight". Label it properly and I would much rather do this then let someone work with the catheter that is not experienced. I have just seen too many catheter fractures. I do not routinely do this though...have only done it in certain situations .

Asystole RN · Jul 3, 2012

...

So basically you are saying that there is no foundation of support from a professional health association, no approval from any entity, and no recommendation from any entity either?

BUT it is still OK because some guy online named MunoRN says so. Awesome.

That's a real defensible argument. :rolleyes: