|------------------------+-------------------------------+---------------|
| THE NORWALK HOSPITAL | SUBJECT | SECTION NO. |
| |
|I.V. Services Policies &| ALTEPLASE( tPA. ACTIVASE) FOR | |
| Procedures | CATHETER CLEARANCE FOR SELECT | |
| | CENTRAL LINES | |
|------------------------+-------------------------------+---------------|
| | | |
| | | |
| DISTRIBUTION | REVISION DATE | EFFECTIVE DATE|
| ALL | REVIE| |
| | W | |
| | DATE | |
| | | |
| -------------------------------+ |
| | | |
| | | |
| | APPROVED BY | |
| | DATE | |
| | Jan Mola | |
| | 11/01| |
| | /2004| |
| | | |
|------------------------+-------------------------------+---------------|
PURPOSE:
To ensure safe administration of atleplase. To restore patency or improve
flow to central venous catheters (e.g, PICC, Port-a-Cath, Hickman) blocked
by clotted blood or fibrin.
ACTION:
Alteplase (tPA, Activase) or tissue plasminogen activator is produced by
recombinant DNA technology. The drug binds fibrin in the thrombus and
converts the entrapped plasminogen to the enzyme, plasmin. Plasmin
initiates local fibrinolysis with limited systemic fibrinolytic effect.
POLICY:
Prior to instilling tPA, (atleplase) use the following troubleshooting
steps to rule out alternative reasons for catheter occlusion:
Check catheter and IV tubing for leaks, kinks, and/or clamps. If the
catheter is a Port-a-Cath, ensure that the Huber needle is properly
placed.
Instruct patient to move in a variety of positions, take deep
breaths, and cough.
Remove dressing and check for leaking, edema, erythema, pain at
catheter exit site.
Clamp catheter tubing, remove "clave" adaptor, attach 12 ml normal
saline syringe, and attempt to aspirate and gently flush with normal
saline several times. Do not use force.
Obtain physician's order for " tPA (atleplase) catheter clearance per
protocol".
CONTRAINDICATIONS:
Note: the manufacturer's product information frequently lists many
contraindications. Few contraindications are absolute, most are relative.
tPA for catheter clearance delivers the drug into a catheter with only a
small amount of drug reaching the systemic circulation. Nevertheless, the
physician must carefully weigh the risks and benefits of therapy in an
individual patient.
Absolute:
active internal bleeding
recent (within 2 months) CVA or other active intracranial process (e.g.
intracranial neoplasm or AV malformations or aneurysms, recent
intracranial or intraspinal surgery or trauma). Evidence suggests that
thrombolytic therapy may induce cerebral hemorrhage in those with a
recent history of stroke. Note: when indicated, tPA may be used for
treatment of acute thromboembolic stroke.
known hypersensitivity to tPA or any component in its formulation.
Relative:
Major:
recent (< 10 days) major surgery, obstetric delivery, organ
biopsy, previous puncture of non-compressible vessels.
recent serious gastrointestinal bleeding (within 2 weeks)
recent serious trauma
severe arterial hypertension (> or = 185 mm Hg systolic or > or
= 110 mm Hg diastolic)
Minor:
recent minor trauma including cardiopulmonary resuscitation
high likelihood of a left heart thrombus (e.g. mitral disease
with atrial fibrillation)
bacterial endocarditis
hemostatic defects (e.g., thrombocytopenia, severe hepatic or
renal disease)
pregnancy (Category C)
diabetic hemorrhagic retinopathy
PHARMACY CONSIDERATIONS:
Upon written order for TPA (alteplase) for catheter clearance the
pharmacy will supply TPA (alteplase) in a 2 mg. dose. (either powder or
frozen) If the powder form reconstitute per protocol, if frozen, to
thaw gently roll the syringe in the palms of hands. Under no
circumstances should the syringe be microwaved. TPA (alteplase) is
stable for 8 hours following thaw at room temperature.
NURSING CONSIDERATIONS:
Know fill volume for catheter to be cleared
Do not mix TPA (alteplase) with other medications
PROCEDURE:
Verify physician order
Review patient's medical record for contraindications
Obtain med from pharmacy and prepare (reconstitution or thaw)
Verify patient identification and explain procedure to patient
Clamp line and remove clave, connect 12 cc syringe with TPA (alteplase)
directly to catheter
Unclamp and slowly instill required amount of TPA (alteplase) into
catheter and clamp
Leave 12 cc syringe attached to clamped catheter with label (time and
date) DO NOT USE - TPA INSTILLED (notify patient's RN)
Wait appropriate amount of time (30 - 60 minutes)
Unclamp catheter and attempt to aspirate blood. If unsuccessful TPA may
be left in catheter for an additional 30 - 60 minutes. Attempt to
aspirate blood and catheter contents, if still unsuccessful reattach
clave and flush per protocol.
Notify floor RN of results
If successful (blood return obtained) withdraw 5 cc blood and discard
syringe.
Attach new clave to catheter and flush per protocol.
Notify floor RN of results.
Chart medication in computer.
Document in patient's medical record:
Steps taken to restore patency prior to TPA (alteplase)
administration
Reason for drug administration
Identify catheter and specific lumen'Time (inc. dwell time) - dose
-amount administered
Response to drug
Notify floor RN of results
Elizabeth A. Raucci, RN, MSN, MHA, OCN, CNS
ADMINISTRATIVE MANAGER: IV Services
MANAGER: Dialysis and Apheresis Contracts
Phone: (203) 855-3891
FAX: (203) 855-3893
Beeper: (203) 831-7593
