TPA use as an intervention in occluded central lines/PICC lines is evidence based practice and the standard of care. There is no way to determine if TPN is the culprit versus a thrombus. The evidence has shown that it is safe practice to start with TPA.
In my personal practice, I have seen TPA successfully de-occlude countless lines, some of which had a history of TPN running. You can’t tell and if the provider okays the use of TPA, you have no reason to refuse. While they may want to pull the line, they may want to hold onto it a day or so to see how the patient tolerated being off TPN. Maybe that person might need central potassium relacement? Or antibiotics still? I don’t know. That’s not an unheard of thing.
Sure, most places that I’ve worked want to pull lines ASAP, but attempted to establish patency on the off chance you need it in that 24 hours is not unreasonable. Places I have worked had a standing protocol about when a line was mandated to be pulled. Nurses were responsible to notify the physician when the line no longer met protocol, and the physician then had to either or it to be D/C’d or make keeping the line fit the criteria.
As for the swelling of the arm, that needs to be reported immediately to the provider to see if they even want the line being used moving forward. However, TPA dwells in the catheter and a minuscule amount makes it into the bloodstream. If protocol dictates and/or the provider orders it, I see no issue allowing TPA to dwell in that catheter. It dwells, you aspirate it back, and then check for patency. Lather, rinse, repeat.
If you just can’t sit with the protocol with your assessment of the line, call your provider and explain your concerns. Either you get the okay to continue, or you get an order to hold off. Or you get your order to D/C it. Document accordingly and follow the orders of your provider unless they seem quite egregious. And if you feel the orders are unreasonable, move up your chain of command.
You aren’t being asked to deocclude and then immediately run potassium or vancomycin into a swollen arm without the provider assessing the arm. The TPA will not aggravate that.
This doesn’t seem like a huge dilemma to me. But maybe I am missing something here...it’s something a quick call to the provider can easily clear up. It’s not my call to decide how to act on a central line. It’s my job to call and notify the provider of the facts and if that order is within reason, act accordingly.