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Central Venous Access Device Occlusion - Adult/Pediatric/Neonatal - Inpatient

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1
Treatment of Central Venous Access
Device Occlusion –
Adult/Pediatric/Neonatal – Inpatient
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
EXECUTIVE SUMMARY ........................................................................................................... 3
SCOPE ................................................................................................................................... 4
METHODOLOGY .................................................................................................................... 5
DEFINITIONS.......................................................................................................................... 5
INTRODUCTION ..................................................................................................................... 7
RECOMMENDATIONS ............................................................................................................ 7
UW HEALTH IMPLEMENTATION ........................................................................................... 11
APPENDIX A. EVIDENCE GRADING SCHEME(S) ...................................................................... 13
APPENDIX B. SUMMARY OF INTERIM REVISIONS (AS APPROPRIATE) .................................... 14
REFERENCES ........................................................................................................................ 15
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2
Contact for Content:
Name: Anne Rose, PharmD - Pharmacy
Phone Number: (608) 263-9738
Email Address: arose@uwhealth.org
Contact for Changes:
Name: Philip Trapskin, PharmD, BCPS – Drug Policy Program
Phone Number: (608) 263-1328
Email Address: ptrapskin@uwhealth.org
Guideline Author(s):
Anne Rose, PharmD – Pharmacy
Coordinating Team Members:
Dawn Berndt, DNP, RN, CRNI – Nursing Practice Innovation
Ellen Donehower, RN, BSN, OCN – Oncology Clinic Coordinator
Emilie Fedorov, RN, MSN – Nursing Operations Support
Laura Konkol, RN – Clinical Nurse Specialist
Sara Shull, PharmD, MBA, BCPS – Drug Policy Program
Deb Soetenga, MS, RN, CCNS – Clinical Nurse Specialist
Joan Watson, RN – Hemodialysis
Committee Approvals/Dates:
Inpatient Anticoagulation Committee (10/2016)
Pharmacy & Therapeutics Committee (2/16/17)
Release Date: February 2017 | Next Review Date: February 2019
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3
Executive Summary
Guideline Overview
This clinical practice guideline is intended to promote the use of a standardized process for the
assessment and interventions needed to treat central venous access device (CVAD) occlusions.
For recommendations on prevention of CVAD occlusion please see recommendations in the
Flushing/Locking of Venous Access Devices – Adult/Pediatric – Inpatient/Ambulatory
The clinical interventions and practices recommended in this guideline are for mechanical,
thrombotic or chemical CVAD occlusions. Practices considered may include patient
repositioning or replacement of damaged devices for mechanical occlusions, alteplase for
thrombotic occlusions, and hydrochloric acid, sodium bicarbonate, sodium hydroxide and/or
ethanol for chemical occlusions.
Key Revisions (2017 Periodic Review)
1. Change in volume of alteplase for CVAD clearance
2. Removal of Hydrochloric acid as a recommendation for chemical occlusions as not able to
obtain medication from a high-risk sterile compounding pharmacy
Key Practice Recommendations
1. Assess CVAD patency and identify the type of occlusion by flushing affected lumen(s) and
attempting to withdraw blood using a 10 mL syringe of Preservative Free Normal Saline (UW
Health GRADE moderate quality evidence, strong recommendation)
2. Once the type of occlusion is identified it should be treated with the recommended
management strategy as outlined in this guideline (UW Health low quality evidence,
weak/conditional recommendation)
3. Assess for signs of mechanical occlusion (UW Health high quality evidence, strong
recommendation)
3.1 Visually inspect the CVAD and administration set for signs of kinked or clamped tubing,
loose tubing connections, clogged filter, tight sutures, or change in external catheter
length.
3.2 Inspect visually and by palpation for catheter damage as seen by swelling, bulging and
leaking from CVAD.
3.3 Consider subjective complaints from patients that may suggest occlusion like hearing a
swishing sound or pain during infusion or having altered sensation during infusion.
4. Resolve the mechanical Occlusion (UW Health moderate quality evidence, weak/conditional
recommendation)
4.1 Attempt to move catheter tip away from vessel wall by repositioning patient (raise arms
and sit forward), forced coughs, or deep inhalations
4.2 Remove any add-on devices (cap/needleless connectors)
4.3 Change dressings and loosen sutures to ensure no kinking
4.4 Replace clogged filter
4.5 Repair or replace a damaged catheter
5. For thrombotic occlusions attempt to resolve the thrombotic occlusion by using the alteplase
dose that corresponds to the volume of the CVAD. (UW Health high quality evidence, strong
recommendation)
5.1 Alteplase dosing is based on a concentration of 1 mg/mL. The addition of 0.2 mL will be
supplied for overfill. The following standardized doses/volumes will be supplied
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5.1.1 Alteplase 0.5 mg/0.5 mL (common pediatric CVAD volume)
5.1.2 Alteplase 1.2 mg/1.2 mL
5.1.3 Alteplase 2.2 mg/2.2 mL
5.2 Administer enough volume to fill the CVAD with an additional 0.2 mL for overfill and
allow to dwell for 60 minutes (UW Health moderate quality evidence, strong recommendation)
6. If patient is not restored then attempt to withdraw the first dose of alteplase and administer a
second dose of alteplase. Allow alteplase to remain the catheter for an addition 60 minutes
(total 120 minutes of alteplase) UW Health low quality evidence, weal/conditional
recommendation)
7. Assess for signs of a chemical occlusion through visual observation of precipitate or
identification of co-administration of incompatible agent. (UW Health high quality evidence,
strong recommendation)
8. Select the corresponding clearance agent and instill sufficient volume to fill catheter lumen.
8.1 There is no data to support overfill (UW Health very low quality evidence, weak/conditional
recommendation)
9. If patency not restored then consult a physician or DVI (UW Health very low quality evidence,
weak/conditional recommendation)
Companion Documents
1. Appendix B. Management of Central Venous Access Device Occlusion Algorithm
2. Flushing/Locking of Venous Access Devices - Adult/Pediatric - Inpatient/Ambulatory
Scope
Disease/Condition(s): Occluded central venous access devices
Clinical Specialty: Hospitalists, Oncology, Cardiology, Surgical Specialities, Hemodialysis,
Nursing, and Pharmacy
Intended Users: Physicians, Advanced Practice Providers, Nurses, and Pharmacists
Objective(s): This clinical practice guideline is intended to promote the use of a standardized
process for the assessment and interventions needed for central venous access device
occlusions.
Target Population: The recommendations within the guideline would apply to adult, pediatric
and neonatal patients with a catheter occlusion in a tunneled cuff catheter (i.e. Hickman,
Groshong), PICC, dialysis, triple lumen subclavian/femoral/jugular or implanted venous port
catheter.
Interventions and Practices Considered: The clinical interventions and practices
recommended in this guideline are for mechanical, thrombotic or chemical CVAD occlusions.
Practices considered may include patient repositioning or replacement of damaged devices for
mechanical occlusions, alteplase for thrombotic occlusions, and hydrochloric acid, sodium
bicarbonate, sodium hydroxide and/or ethanol for chemical occlusions.
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Major Outcomes Considered: The major outcome considered in this guideline is for the
preservation of the CVAD through correct identification of the type of occlusion and the
selection of the most appropriate method for resolving the occlusion.
Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches (e.g., PUBMED) were conducted by the guideline author(s) and
workgroup members to collect evidence for review. Expert opinion and clinical experience were
also considered during discussions of the evidence.
Methods Used to Formulate the Recommendations:
The workgroup members agreed to adopt recommendations developed by external
organizations and/or arrived at a consensus through discussion of the literature and expert
experience. All recommendations endorsed or developed by the guideline workgroup were
reviewed and approved by other stakeholders or committees (as appropriate).
Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:
Recommendations developed by external organizations maintained the evidence grade
assigned within the original source document and were adopted for use at UW Health.
Internally developed recommendations, or those adopted from external sources without an
assigned evidence grade, were evaluated by the guideline workgroup using an algorithm
adapted from the Grading of Recommendations Assessment, Development and Evaluation
(GRADE) methodology (see Figure 1 in Appendix A).
Rating Scheme for the Strength of the Evidence/Recommendations:
See Appendix A for the rating scheme(s) used within this document.
Cost Analysis: (As Appropriate) Describes any formal cost analysis performed and any
published cost analyses reviewed.
Medication Price per 1 mL Price per 2 mL
Alteplase 1 mg/mL $77 (1.2 mL) $141
Sodium Bicarbonate $0.15 $0.30
Ethanol 70% $11.27 $22.54
L-Cysteine $0.55 $1.10
Recognition of Potential Health Care Disparities: none recognized
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Definitions
1. Common catheter types with adult and pediatric volumes are listed in Table 2.
Table 2: Central venous catheter type and capacitance
Catheter Type Adult Capacity Pediatric Capacity Neonatal Capacity
Dialysis-Pheresis Catheters Volume on
catheter lumen
(common 2 mL)
1 mL or less
Implanted Venous Port 2 mL 1 mL or less
Non-tunneled Triple Lumen
(ex. Arrow)
1 mL 1 mL or less
PICC 1 mL 1 mL or less 0.1 mL (1.9 fr)
Powerline 1 mL 1 mL or less
Tunneled Cuff Catheter
(ex. Groshong)
1 mL 1 mL or less
Tunneled or Non-Tunneled
Central
(ex. Hickman, Broviac)
2 mL 1 mL or less
Umbilical Catheters (Double
and Single Lumen 3.5 and 5 fr)
0.5 mL or less
2. Type of occlusions1,2
2.1 Mechanical – may be caused by kinks in catheter or tubing, CVAD dislodgement or tip
migration, a clogged connector or filter, or incorrect positioning of patient or catheter.
2.2 Chemical – caused by precipitate when incompatible drugs are administered or from
lipid build up
2.3 Thrombotic – caused by fibrin build up within or around CVAD or surrounding vessel
3. Type of thrombotic occlusion3,4
3.1 Intraluminal – Thrombus forms within the lumen from insufficient flushing, inadequate
flow through lumen or frequent blood aspirations. This may cause partial or complete
occlusions.
3.2 Fibrin Tail – Occurs when fibrin adheres to the end of the catheter and extends into the
blood stream. This causes a withdrawal type of occlusion.
3.3 Fibrin Sheath – Occurs when fibrin covers the external surface of a catheter. This
causes a withdrawal type of occlusion.
3.4 Mural – Thrombus forms when fibrin from a vessel wall binds to fibrin on the catheter
surface. This may cause partial catheter occlusion and can progress into a venous
thrombosis.
4. Degree of occlusion (Table 3.)
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Table 3. Degree of CVC occlusions2,5,6
Degree of Occlusion Signs Causes
Partial Sluggish flow through catheter
Resistance with flushing and aspiration
Mechanical
Chemical
Thrombotic
Withdrawal Able to infuse without resistance
Unable to withdraw blood
Mechanical
Thrombotic
Complete Unable to infuse or withdraw blood Mechanical
Chemical
Thrombotic
Introduction
Central venous access devices (CVAD) facilitate the administration of drugs, fluids, blood
products, and parenteral nutrition and the aspiration of blood samples, providing essential
therapy for and management of patients in inpatient and ambulatory settings. Compromised
CVAD function may interrupt treatment, increase morbidity, decrease patient comfort, and
require catheter replacement and/or removal. The lumen(s) of a CVAD may become occluded
due to mechanical, chemical or thrombotic factors; accumulation of a thrombotic fibrin sheath
accounts for 58% of all occlusions.7-12 In the event of a CVAD occlusion, the goal of therapy is to
salvage the CVAD rather than replace or remove it, with the exception of the midline catheter.
At this time it is not recommended to use catheter clearance techniques for thrombotic or
chemical occlusions and instead removing or replacement the midline is recommended. For
other CVADs there are recommended interventions that can successfully restore patency to
CVADs for each type of occlusion.10,11
Recommendations
Assessment of catheter patency should be done by a health care professional who is
knowledgeable in CVAD use and maintenance.
1. Assess CVAD patency and identify the type of occlusion by flushing affected lumen(s) and
attempting to withdraw blood using a 10 mL syringe of Preservative Free Normal Saline3,5
(UW Health GRADE moderate quality evidence, strong recommendation)
1.1 Sluggish blood flow is present when it is difficult to flush the CVAD or inability to withdraw >
3 mL of blood in 3 seconds or > 1 minute in PICC5,6 (UW Health GRADE moderate quality
evidence, strong recommendation)
1.2 Table 4 lists common signs of CVAD occlusion and can assist in the assessment of
occlusion type.
Table 4. Signs of CVAD occlusion3-5,12
Infusion or Flushing Aspiration
Resistance when flushing
Sluggish flow
Unable to infuse fluids
Frequent occlusion pump alarm
Infiltration, extravasation, swelling or leaking
at insertion site
Unable to withdraw blood
Sluggish blood return
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2. Once the type of occlusion is identified it should be treated with the recommended
management strategy as outlined in this guideline13 (UW Health low quality evidence,
weak/conditional recommendation)
2.1 Attempt to resolve occlusion using mechanical manipulations first13,14 (UW Health
moderate quality evidence, strong recommendation)
2.2 If unable to determine the type of occlusion treat first as a thrombotic occlusion6,13 (UW
Health low quality evidence, weak/conditional recommendation)
2.3 Alteplase is not effective in restoring patency to a CVAD due to mechanical or
chemical occlusion2-5,11,15. (UW Health high quality evidence, strong recommendation)
Mechanical Occlusions
A CVAD occlusion caused by a mechanical process can be either internal or external. Common
external causes include catheter tubing which has been clamped or kinked. Common internal
causes include incorrect positioning of the catheter tip, kinking of catheter inside vein, or the
catheter tip adhering to the vessel wall.2,13,16
3. Assess for signs of a mechanical occlusion2,13,14,16 (UW Health high quality evidence, strong
recommendation)
3.1 Visually inspect the CVAD and administration set for signs of kinked or clamped
tubing, loose tubing connections, clogged filter, tight sutures, or change in external
catheter length.
3.2 Inspect visually and by palpation for catheter damage as seen by swelling, bulging and
leaking from CVAD.
3.3 Consider subjective complaints from patients that may suggest occlusion like hearing a
swishing sound or pain during infusion or having altered sensation during infusion.
4. Resolve the mechanical occlusion2,13,14,16 (UW Health moderate quality evidence,
weak/conditional recommendation)
4.1 Attempt to move catheter tip away from vessel wall by repositioning patient (raise arms
and sit forward), forced coughs, or deep inhalations
4.2 Remove any add-on devices (cap/needleless connectors)
4.3 Change dressings and loosen sutures to ensure no kinking
4.4 Replace clogged filter
4.5 Repair or replace a damaged catheter
5. Consider a chest x-ray if catheter placement is questionable or to assess for internal kinking,
pinch-off syndrome, and positioning of catheter tip.13 (UW Health low quality evidence,
weak/conditional recommendation)
6. Document assessment, intervention and response to intervention in the electronic medical
record. (UW Health very low quality evidence, strong recommendation)
Thrombotic Occlusions
In the event of a thrombotic occlusion, alteplase (tPA) has become the agent of choice for
catheter clearance.6,17 Alteplase is indicated for use in catheter clearance in a variety of catheter
types (see Table 1.) and has also shown to be beneficial in restoring hemodialysis catheter
function.15,18,19 While utilization of low dose thrombolytic therapy used locally is well established,
the doses and techniques outlined in the literature are variable. Most randomized, controlled trials
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evaluate alteplase 2 mg versus placebo.6,17,20 There is limited published data available for lower
dosing of alteplase.21,22
One small trial sought to evaluate two dosing options of alteplase for thrombotic occlusions in
tunnel catheters and ports in 45 patients (61 lumens). This trial evaluated alteplase 1 mg/mL
versus 2 mg/2mL. Similar clearance rates were seen between these two dosing options with
81.1% and 83.3% respectively. This trial, however, was not powered for significance.21
7. Assess for signs of a thrombotic occlusion2-4,13 (UW Health high quality evidence, strong
recommendation)
7.1 Review patient allergies and consider contraindications, adverse events, preparation
and administration requirements of alteplase prior to administration.
8. Attempt to resolve the thrombotic occlusion by using the alteplase dose that corresponds to
the volume of the CVAD.6,13-15,17-21,23 (UW Health high quality evidence, strong recommendation)
8.1 Determine the volume of the CVAD (Table 2) to determine the dose/volume of
alteplase needed for adequate fill.
8.2 Alteplase dosing is based on a concentration of 1 mg/mL. The addition of 0.2 mL will
be supplied for overfill. The following standardized doses/volumes will be supplied:
8.2.1 Alteplase 0.5 mg/0.5 mL (common pediatric CVAD volume)
8.2.1 Alteplase 1.2 mg/1.2 mL
8.2.2 Alteplase 2.2 mg/2.2 mL
9. Administer enough volume to fill the CVAD with an additional 0.2 mL for overfill and allow to
dwell for 60 minutes.6,13-15,17-21,23 (UW Health moderate quality evidence, strong recommendation)
For pediatric patients may consider utilizing 110% of the CVAD volume15 (UW Health low
quality evidence, weak/conditional recommendation)
9.1 Follow the procedures outlined in Nursing and Patient Care Policy AP 1.56 Central
Vascular Access Device Use, Maintenance, and Removal (Adult and Pediatric)
(UW Health very low quality evidence, weak/conditional recommendation)
9.1.1 For partial occlusions utilize a syringe method for catheter clearance
9.1.2 For complete occlusions utilize a stopcock method for catheter clearance
9.2Treat occluded lumen(s) of the CVAD with corresponding dose of alteplase. Use caution
when treating triple lumen catheters. Maximum recommended dose of alteplase per
treatment is 4 mg.15 (UW Health low quality of evidence, weak/conditional recommendation)
9.3 Document assessment, alteplase dose, administration time, removal time, total dwell
time, and response to intervention in the medical record. (UW Health very low quality
evidence, strong recommendation)
10. If patency is restored then follow the procedures outlined in Nursing and Patient Care Policy
AP 1.56 Central Vascular Access Device Use, Maintenance, and Removal (Adult and
Pediatric)
10.1 Adults: withdraw 5 mL, discard and flush catheter with 20 mL 0.9% sodium chloride
(UW Health very low quality evidence, strong recommendation)
10.2 Pediatrics: withdraw 1-2 mL, discard and flush catheter with 5-10 mL of 0.9% sodium
chloride (UW Health very low quality evidence, strong recommendation)
10.3 Resume IV fluids, medications, or lock CVAD as appropriate (UW Health very low quality
evidence, weak/conditional recommendation)
11. If patency is not restored then attempt to withdraw the first dose of alteplase and administer
second dose of alteplase. Allow alteplase to remain in catheter for an additional 60 minutes
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(total of 120 minutes of alteplase)6,13-15,17-21,23 (UW Health low quality evidence, weal/conditional
recommendation)
12. If unsuccessful after a second alteplase dose then consult a physician3,13 (UW Health low
quality evidence, weal/conditional recommendation)
12.1. Consider a chest X-ray to verify catheter tip placement (UW Health low quality evidence,
weal/conditional recommendation)
12.2 Consider a dye study to rule out mechanical occlusion or vessel thrombosis (UW Health
low quality evidence, weal/conditional recommendation)
13. Monitor for potential adverse effects, including minor bleeding and bruising. (UW Health very low
quality evidence, weak/conditional recommendation)
Chemical Occlusions
Chemical occlusions occur when precipitates form within the lumen of the CVAD and when lipid
residue builds from continuous 3 in 1 parenteral nutrition. Common causes of chemical
occlusions include co-administration of incompatible medications or lipid infusions.1,14 Catheter
salvage is still the main goal and attempts to clear chemical precipitate or lipid residue should
be tried. Agents known to dissolve precipitate can be considered to restore patency. Chemical
occlusions make up a smaller percentage of catheter occlusions therefore thrombotic and
mechanical occlusions should be ruled out before treating for chemical occlusion.1
14. Assess for signs of a chemical occlusion through visual observation of precipitate or
identification of co-administration of incompatible agent14,23-28 (UW Health high quality evidence,
strong recommendation)
14.1 Select the corresponding clearance agent (Table 5) and instill sufficient volume to fill
the catheter lumen.
14.3.1 There is no data to support the use of overfill13 (UW Health very low quality
evidence, weak/conditional recommendation)
14.1.2 Use of 70% ethanol in a polyurethane catheter may result in damage to the
catheter. Use with caution.15 (UW Health low quality evidence, weak/conditional
recommendation)
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Table 5. Types of Chemical Occlusion and Treatment Options14,23-28
Cause Clearance Agent Dwell Time
Calcium Phosphate Precipitate
L-Cysteine
Irrigate with gentle to and
fro motion for 1-2
minutes.
If not restored dwell 60
minutes and repeat
above hourly
Acidic Drug Precipitate – pH < 6
(ex. vancomycin, piperacillin,
parenteral nutrition amino acids) L-Cysteine
60 minutes
Alkaline Drug Precipitate – pH > 7
(ex. phenytoin, ganciclovir,
ampicillin, heparin)
Sodium bicarb (NaHCO3) 8.4%
1 meq/mL
60 minutes
Lipid Deposition
(ex. parenteral nutrition)
70% Ethanol 60 minutes
15. If patency is restored then follow the procedures outlined in Nursing and Patient Care Policy
AP 1.56 Central Vascular Access Device Use, Maintenance, and Removal (Adult and
Pediatric)
15.1 Adults: withdraw 5 mL, discard and flush catheter with 20 mL 0.9% sodium chloride
(UW Health very low quality evidence, strong recommendation)
15.2 Pediatrics: withdraw 1-2 mL, discard and flush catheter with 5-10 mL of 0.9% sodium
chloride (UW Health very low quality evidence, strong recommendation)
15.3 Resume IV fluids, medications, or lock CVAD as appropriate (UW Health very low quality
evidence, weak/conditional recommendation)
16. If patency not restored then consult a physician or DVI13 (UW Health very low quality evidence,
weak/conditional recommendation)
17. Document assessment, intervention and response to intervention in the electronic medical
record. (UW Health very low quality evidence, strong recommendation)
UW Health Implementation
Potential Benefits:
The benefits of implementation of this guideline include preserving CVAD patency in a
standardized process that limits therapy interruptions, reduces complications and decreases
costs that are associated with catheter replacement. Additionally, this guideline will provide
guidance for the provision of safe and cost-effective use of alteplase for the clearance of
thrombotic CVAD occlusions.
Potential Harms:
While it is anticipated that the overall safety and quality of CVAD clearance will be improved in
this patient population there is a risk for hemorrhagic complications when alteplase is used for
thrombotic occlusions. With the low doses of alteplase used in CVAD clearance this risk is
considered to be minor. The use of ethanol for chemical occlusions may affect blood levels.
Ethanol should also be used with caution with polyurethane CVADs as it may damage the
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catheter. Additionally for thrombotic and chemical occlusions treatment strategies may delay
therapies while waiting for appropriate dwell times.
Qualifying Statements:
None
Pertinent UW Health Policies & Procedures
1. UWHC Nursing and Patient Care Policy 1.56 AP Central Vascular Access Device Use,
Maintenance, and Removal (Adult and Pediatric)
Guideline Metrics
Using a numbered list, describe metrics to assess compliance with the stated recommendations or to
gauge improvement resulting from implementation of the guideline.
NOTE: All metrics required or reported externally should be included (consider guidance from QSI).
1. Alteplase, HCL, L-cysteine, NaHCO3, an/or 70% ethanol administration data (time to
administration, dose, dwell time)
2. Success of CVAD clearance
3. Number of attempts at clearance
4. CVAD replacement
Implementation Plan/Clinical Tools
Include an education plan, methods of communication, and identification of related tools. Guideline
content is expected to have some integration into the Health Link documentation system.
1. Guideline will be posted on uConnect in a dedicated location for Clinical Practice Guidelines.
2. Release of the guideline will be advertised in the Physician/APP Briefing newsletter.
3. Content and hyperlinks within clinical tools, documents, or Health Link related to the
guideline recommendations (such as the following) will be reviewed for consistency and
modified as appropriate.
Delegation Protocols
[16] – Central venous access device clearance – adult/pediatric/neonatal
Order Sets & Smart Sets
[3600] – IP - Catheter Clearance – Supplemental Order Set
Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
intended to replace a clinician’s judgment or to establish a protocol for all patients. It is
understood that some patients will not fit the clinical condition contemplated by a guideline and
that a guideline will rarely establish the only appropriate approach to a problem.
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Appendix A. Evidence Grading Scheme(s)
Figure 1. GRADE Methodology adapted by UW Health
GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate We are quite confident that the effect in the study is close to the true effect, but it
is also possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.
GRADE Ratings for Recommendations For or Against Practice
Strong The net benefit of the treatment is clear, patient values and circumstances
are unlikely to affect the decision.
Weak/conditional
Recommendation may be conditional upon patient values and
preferences, the resources available, or the setting in which the
intervention will be implemented.
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Appendix B. Central Venous Access Device Occlusion – Adults/Pediatric CPG
Management of Central Venous Access Device Occlusion – Algorithm
CPG Contact for Changes:
Name: Philip J Trapskin, PharmD, BCPS
Phone Number: 263-1328
Email Address: ptrapskin@uwhealth.org
Revised: 10/2016
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References
1. Van Miert C, Hill R, Jones L. Interventions for restoring patency of occluded central venous
catheter lumens. Cochrane Database Systematic Reviews. 2012(4):Art.No.:CD007119.
DOI:007110.001002/14651858.CD14007119.pub14651852.
2. Baskin JL, Reiss U, Wilimas JA, et al. Thrombolytic therapy for central venous catheter occlusion.
Haematologica. 2012;97(5):641-650.
3. McKinght S. Nurse’s guide to understanding and treating thrombotic occlusions of central venous
access devices. Medsurg. 2004;13(6):377-82.
4. Moureau N, McKinnon B, Douglas C. Multidisciplinary management of thrombotic catheter
occlusions in vascular access devices. J Vasc Access Devices. 1999;4(2):22-29.
5. Cummings-Winfield C, Mushani-Kanji T. Restoring patency to central venous access devices.
Clin J Oncol. 2008;12(6):925-34.
6. Deitcher S, Fesen M, Kiproff P, et al. Safety and efficacy of alteplase for restoring function in
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