advice on using TPA for catheters?

  1. Being fairly new to dialysis, I wanted to ask how many times/how often can one pt receive TPA? We have one pt who received it beginning of treatment one day (nonfunctioning catheter) with moderate success- BFR 200 then another day beginning and end and yet another day beginning of treatment- about 4 times in one week. Pt was sent for new catheter and AV fistula , came back the next day and catheter still was non- functioning- catheter was rotated- pt gets 10,000 of heparin each tx, again we instilled TPA to one side (cause we ran out). Got it working to BFR 200 again. Since we have to wait for fistula to mature, what options are there beside TPA? The doc is aware and only said "make it work".
    Any advice appreciated!
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    Joined: Jan '04; Posts: 35

    5 Comments

  3. by   jnette
    Quote from sueinga
    The doc is aware and only said "make it work".
    Any advice appreciated!
    That is so typical of the docs and surgeons. Of course, they are not THERE listening to the alarms go off every two minutes because the darn thing won't run ! And at 200 BFR, the dialyzer is very likely to clot off, making things even worse.

    The doc ( the clininc nephrologist/medical director) should have written standing orders for the TPA... I if I remember correctly, we used to be able to administer it twice during the tx. Once, let it sit half hour, then try to run... if unsuccessful, one more attempt (of course waiting the half hour each time for it to take effect). If still no success, we would send the pateint back to the surgeon.

    Another thing, when the surgeons do get the patient and "run them", these patients are usually in a supine position in a hospital bed, unlike the sitting or semi-reclining position in the dialysis chair. So they always run "just fine" for the docs!

    You might try lying the patient back.. have him/her raise the arm.. all those positional changes.. couching.. etc.
    If the dialyzer is sluggish or clotting, do q half hour 100ml NS , be sure to add into your goal.

    If all else fails, I would have your DON insist the doc do something, because the pt, cannot run properly this way and you have more patients to tend to than to be doing a one on one with this poor patient.. just to keep him running.. and poorly, at that!

    Just one more reason I'm glad I'm no longer doing dialysis !
  4. by   diabo
    tPa is fine as long as the correct amount is instilled and aspirated, but the patient is essentially not getting dialysis. Sure you can pull some fluid off, but it's next to zero clearance. Sounds more positional than anything else. The docs will whine, but being on the side of the patient you must insist that it be replaced until you have one that works. Some surgeons give a nice slow pull on the syringe and are convinced that the catheter works fine. They need to visit the center and learn some things.
  5. by   DeLana_RN
    I have to agree with pp, the patient needs to be sent back to the vascular surgeon. Frequently, they don't test the perm cath at all after placement and depend on the dialysis nurses to let them know if it needs (yet another) revision.

    Good luck!

    DeLana
  6. by   penem10
    As far as I know, their is no limit to using TPA, however, In my experience, it is best to try to understand why it is not working and then fix the problem.

    For instance, how long has it been in? The longer the Cath has been in, the more apt it is to develop a fibrin tail and, the tpa cannot get to that, so the option would be to replace that cath. Is the problem mechanical? Kinked? Wrong placement? Migrated up against the wall? All these things would be problematic and the cath would need replaced.

    We will instill tpa and send the patient home dwelling until their next treatment, we have found that this works better than allowing it to dwell for 1 hour and then trying their treatment again.

    When they replaced that Cath, did they try the other side of the chest? Sometimes the patient is anatomically a problem too.

    If able, please try to get an access placed in an arm. It sounds like that patient's KT/V is low after many bad BFR days.

    Hope this helps.
    Robin A. Clark, RN, CDN
  7. by   penem10
    I would just like to add a comment to "make it work" You need to remind that doc that his KT/V's are probably bad and that is all documented nationally. At least in our facility, that is the motivator to get those caths out or to get them functioning.

    Robin A. Clark, RN, CDN

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