TPN PICC Line Occlusion

blondy2061h, MSN, RN · Oct 3, 2017

If the patient is no longer on TPN do they still need central access? How do you know it is the TPN? I would try the TPA personally.

Wuzzie · Oct 3, 2017

Agree with above. How did you determine the occlusion was caused by the TPN? The swelling is concerning.

Okami_CCRN, BSN, RN · Oct 3, 2017

I would attempt to alteplase (tPA) the line as per protocol/policy. If it isn't patent and the patient no longer requires central venous access I would discuss with the team about discontinuing the line. If they require some sort of access you could request a midline.

Regarding the swelling, like you suggest upper extremity doppler study would be appropriate. Sometimes its small superficial thrombi that do not require intervention.

PixieRN1 · Oct 3, 2017

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.

Best luck.

iluvivt, BSN, RN · Oct 5, 2017

Are there lipids also being infused? It could be be a drug or mineral precipitate as opposed to a thrombotic cause,which Cath=flo can correct.The other potential cause is mechanical which should always be ruled out first.BARDs 5Fr Triple lumen and the Provena tend to have mechanical issues.Some of these occur between the skin level and catheters entrance into the vein.If you suspect its from the lipids 70% ethanol can be instilled to clear the lumen. The Calcium salts also tend to easily precipitate.Odds are it is thrombotic and it needs to be treated with Cath=flo.

Sunshine716 · Oct 7, 2017

Thanks for the comments everyone! Great, great input! The line ended up being cleared with TPA and works fine now. I just don't have a lot of experience with PICCs and TPN together. My main concern was that over 24 hrs after the TPN was dc'd it still wasn't flushing (that was reported) I didn't know how long it could take before worrying about harboring bacteria since it was the highest dextrose concentration etc if it was clogged with TPN? My dilemma was also that the MD mentioned that we could just use the one port that flushed even if the TPA didn't work (pt going home on 4-6 weeks of IV abx). It just got me thinking and wondering if the next shift didn't get it to work, what then? I know it's an MD call, but wanted to hear some ideas/experiences y'all have had and I got a WEALTH of info for later!!

Also, I ran into a PICC line nurse and asked him what he thought and he said that the TPA will typically dissolve TPN. He also said that if that didn't work he agreed they should pull it. The swelling resolved so maybe it was from a small superficial thrombi or something else? Thanks again everyone!