- Email: [email protected]
Pediatric Central Venous Catheter Management: A Review of Current Practice
O R I G I N A L
A R T I C L E
Pediatric Central Venous Catheter Management: A Review of Current Practice Mary Beth Hovda Davis, MSN, RN, VA-BC University of Iowa Children’s Hospital, Iowa City, IA
Abstract Due to small vessel size, obtaining stable access in pediatric patients is difficult. In addition, because needle stick pain is a concern for patients with chronic illness, central venous catheters are often utilized to provide intravenous treatment. Catheter occlusion is a common complication in pediatric patients and must be addressed to salvage the catheter and ensure successful therapy. The use of fibrinolytics for occlusion treatment have been successful in pediatric populations. Keywords: Pediatric, central venous catheter, catheter maintenance, central venous catheter occlusion
Introduction entral venous catheters (CVCs) are required to carry out numerous treatment plans for pediatric patients. Many life-threatening conditions require reliable and stable access for the infusion of medications and drawing of blood samples.1 Pediatric patients have different vascular access needs than adults. For example, they have smaller veins to select from, creating fewer options for vascular access.2,3 Added concerns for pediatric patients are the chronic side effects of unresolved needle stick pain. To reduce the trauma of repeated venipuncture, central lines are maintained for long periods of time. Long-term catheters are at a higher risk for developing complications, including occlusions.3,4 CVCs that are often utilized in pediatric patients are implanted ports, tunneled catheters, and peripherally inserted central catheters (PICCs). Skilled care and maintenance of CVCs is crucial for the longevity of the catheter and treatment success. An estimated 40% to 46% of CVCs develop complications.1 A nonfunctional catheter can lead to a number of complications, including delays in treatment, an inability to provide nutrition for patients with intestinal failure, and additional needle sticks to obtain blood draws and additional access. In addition, an untreated CVC occlusion can increase a patient’s risk for a central line-associated blood stream infection (CLABSI). It has been reported that pediatric patients with cancer have a CVC-related thrombosis 50% of the time. And another study showed that having a dysfunctional CVC was
C
Correspondence concerning this article should be addressed to [email protected] http://dx.doi.org/10.1016/j.java.2013.04.002 Copyright Ó 2013, ASSOCIATION FOR VASCULAR ACCESS. Published by Elsevier Inc. All rights reserved.
an independent risk factor of having a poor outcome in pediatric patients with a non-central nervous system cancer.1 This article evaluates the use of CVCs in pediatric populations, causes for CVC occlusion, evidence-based research and current practice on preventing catheter occlusion, and methods of treatment. Venipuncture and Pediatric Patients Evidence shows that venipuncture is an important source of pain in pediatric patients. Venipuncture and peripheral intravenous (PIV) cannulation are 2 of the most common sources of pain reported by hospitalized children.5 Pain experienced early in life can have lasting negative effects. These effects vary across a wide range but affect a patient’s neurological development, pain threshold, coping strategies, and pain perception. Unresolved childhood pain has been associated with adult fear, pain, and avoidance of health care.6 The brain rapidly matures shortly after birth. Repeated painful events can alter the formation of neuronal circuits. This can result in children becoming hypersensitive to pain.6 A child born with a chronic medical condition may have a lifetime of access requirements. Repeat venipuncture can damage smaller vessels making future treatment difficult to initiate. It is imperative that venous access needs are assessed early in treatment planning to minimize the amount of venipuncture a pediatric patient may require. Catheter Selection Catheter selection for a pediatric patient should take into account several factors. These include treatment requirement, length of treatment, catheter placement options, and maintenance requirements. The implanted port will provide stable long-term access. Using numbing cream, the port can be accessed relatively
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painlessly. It is also associated with fewer catheter occlusions when compared with tunneled catheters.7 However, due to needing to be accessed with a needle it is not the best option if long-term daily access is required. A tunneled catheter, such as a Broviac or Hickman catheter, is a good option for long-term treatment requiring daily access. Due to their external design, daily care and maintenance of these catheters are crucial to prevent CLABSI and complications. Caregivers of pediatric patients are often required to provide daily flushing and scheduled dressing changes for these lines and must be educated on aseptic and sterile technique. PICC is a good option for short-term treatment. The PICC line is associated with the lowest frequency of catheter occlusion, most likely due to its short-term nature.7 In pediatric patients PICC lines are at a high risk for accidental dislodgment, either during a dressing change or if the patient disrupts the dressing. Assessment of the catheter is important before initiating treatment to ensure that the PICC line has not been accidentally dislodged and remains in a central location. Catheter selection is limited due to patient size. Smallergauged catheters used frequently in neonates and small pediatric patients are associated with higher incidence of complications.4 When selecting a catheter, consideration must include duration of treatment needed and what device is available in the patient’s size. Sizes fluctuate from 1-Fr PICC line to 12-Fr tunneled catheter. The inserter must consider all treatment requirements when selecting an appropriately sized catheter.
note that due to the different sizes of patients, the caregiver of the line must be aware of the size requirements to prevent occlusion and complications. Small-gauge catheters, such as a 1.9 Fr and smaller, must have fluids run continuously through the catheter to maintain patency. It is incapable of being locked off.4 According to research4,8 and guidelines from the Joint Commission,9 and the Infusion Nurses Society,10 all CVCs should be flushed with normal saline before and after an infusion is administered or a blood sample is obtained from the line. Heparin assists in preventing occlusion. A standard amount of 10 units/mL heparin is used to maintain externalized catheters such as tunneled catheters and PICCs to fill the volume of the line. An implantable port requires monthly access and heparin flush with 100 units/mL heparin4 (see Table 1). It is important to note that although heparin may aid in preventing a thrombus, it will do nothing to treat an established clot. Catheter salvaging is preferential over replacement to preserve a patient’s veins and access for future use.4 Along with proper flush technique, the catheter site must be maintained by ensuring dressing changes are being performed at appropriate intervals and utilizing sterile technique. All tubing must be changed out at scheduled frequencies based on the product that was infusing. All access into the tubing must be done aseptically. By following these recommendations the CVC should be able to be maintained throughout the treatment without developing an infection or device-related complication (see Table 2).
Catheter Maintenance To prevent a catheter occlusion, it is important the catheter is maintained correctly. This includes ensuring that the line is correctly flushed at the appropriate interval. It is important to
Occlusion An occlusion occurs when the CVC is no longer patent, and can either be a partial or complete occlusion.4 A partial occlusion is when the catheter will infuse fluids, but not have a blood
Table 1. Catheter Flush Volume and Frequency for Pediatric Patients. Based on References 4 and 7-10 Peripherally inserted central catheter
d d d
d
Port/tunneled line
d
d
d
Alteplase
d
d
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Lines 3 Fr and greater may be heplocked with 1 mL/10 units heparin Lines <1.9 Fr cannot be heplocked, and may not be reliable for blood draws Line dressing changes should be done weekly and as needed. An initial dressing change is recommended within 24 to 48 hours of insertion Line waste and flush volumes B 1 cc waste B 1 cc 10 units/mL heparin Port flush and waste volumes B 5 cc waste B 5 mL 10 units/mL heparin for 24-hour lock B 5 mL 100 units/mL heparin for 30 day lock Hickman/Broviac >6 Fr flush and waste volumes B 3 mL waste B 3 mL 10 units/mL heparin for 24-hour lock Broviac 2.7 Fr and 4.2 Fr flush and waste volumes B 1 mL waste B 1 mL 10 units/mL heparin for 24-hour lock Indicated in the presence of an inability to withdraw blood through the catheter, sluggish blood return, increased resistance while flushing, or inability to flush the catheter Useful only for thrombotic occlusions
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Table 2. Pediatric Catheter Maintenance. Based on References 4 and 7-10 Catheter site dressing
d d d
d d d
d
Accessing lines
d d d d
Central line tubing
d d d d
Add-on devices stopcocks
d d
Needless connectors
d
d
Assess at the beginning of every shift Initial dressing change within 24-48 hours of insertion Change every 7 days or when damp, loosened, or visible drainage if using chlorhexidine gluconate Change every Monday, Wednesday, Friday for betadine dressing Wear sterile gloves and mask when performing dressing changes Use chlorhexidine for 30 seconds, skin antisepsis for >2 months adjusted gestational age unless contraindicated Betadine for <2 months adjusted gestational age or allergy/intolerance to chlorhexidine gluconate Limit the number of times a line is accessed Perform nonemergent blood draws at scheduled times Avoid drawing from a lumen infusing central venous nutrition if possible Before accessing any lines: - Perform hand hygiene - Wear gloves - Scrub the hub with alcohol for 15 seconds - Ensure all entry ports are free of flushes and are covered with a needleless access device Change Change Change Change
every every every every
96 24 12 24
hours hours hours hours
for for for for
continuous fluid administration total parenteral nutrition and lipid administration propofol syringe blood product administration
Limit the number and use of add-on devices Change add-on devices every 96 hours, with every tubing change, or when blood/debris is present Change the needleless connector - Every 96 hours, with each extension set or stopcock change - When blood, lipids, or debris is present - Before drawing a blood culture - Upon contamination Scrub the hub for 15 seconds and let it dry
return. A complete occlusion occurs when the catheter will neither infuse nor aspirate blood. Onset of occlusion can be gradual or sudden and diagnosing the cause of occlusion assists in successful resolution of the occlusion. The main three types of catheter occlusions are: mechanical, precipitate, and thrombotic. Mechanical Occlusion Mechanical occlusions are caused by external compression of the line. These occlusions are most commonly caused by kinked tubing, a catheter secured over a joint, or a clamped line.8 Another cause of a mechanical occlusion is pinch-off syndrome. This is when the catheter passes through the space between the clavicle and first rib. A common sign of this complication is if the catheter restores patency after postural changes, such as moving the shoulder forward. Additional causes of mechanical obstruction could include a catheter tip lodged against the vessel wall or port needle either becoming dislodged or not correctly placed in an implanted port.7
Precipitate Occlusion A precipitate occlusion occurs when incompatible medications combine in the catheter lumen. Patients who receive parenteral nutrition can also experience precipitate occlusions due to lipid residue. If the catheter experiences a sudden occlusion, this can be a sign that precipitate was the cause. Due to smaller vessel size and lack of options for alternate access, many pediatric patients’ CVC lines have a single lumen catheter for treatment. All medications must be reviewed before administration to screen for drug incompatibilities. Ensuring proper flushing before and after medications will assist in prevention. See Figure 1. Treatment for a precipitate occlusion depends on the agent that precipitated. Occlusions from a presumed lipid residue are treated with a 70% ethanol solution.4,8 Medications with low pH or those containing calcium phosphate can be treated with hydrochloric acid. Medications with high pH are treated with sodium bicarbonate.7,4,8 Consult a pharmacist to determine which treatment modality will work best with your precipitate (see Table 3).
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Figure 1. Precipitate in a peripherally inserted central catheter line. Thrombotic Occlusion It is estimated that thrombotic occlusions occur in an estimated 60% of all catheter occlusions.8 The most common types of catheter thrombosis in children are mural thrombi, catheter tip thrombi, catheter tip against a vessel wall, and fibrin sleeve thrombi.11 Within 2 weeks of insertion most catheters develop a fibrin sheath.7 A fibrin sheath does not necessarily indicate catheter malfunction, but its presence can eventually lead to a partial occlusion. Central venous catheters with the tip of the catheter in the lower third of the superior vena cava have a lower risk for occlusion.7 Thrombotic occlusions provide another level of complication. A thrombotic occlusion can lead to a CLABSI. The thrombus provides the perfect medium for bacteria growth.8 As the thrombus develops bacteria have an opportunity to proliferate and if released into the bloodstream will lead to sepsis.3 Onset of a thrombotic occlusion is typically gradual and it is important to treat a catheter as soon as a potential line issue is noticed. The patency of the CVC should be assessed before each use. A thorough assessment of the catheter and potential treatment should be considered for the catheter at the first sign of resistance during flushing or sluggish to no blood return. The sooner treatment is initiated the higher the chance of restored patency11 (Figure 2). Fibrinolytics Alteplase is a tissue plasminogen activator. It treats a thrombus by binding to fibrin in the thrombus. It then converts plasminogen
Table 3. Precipitate Treatment Options Precipitate
Treatment
Lipid
70% ethanol
Mineral precipitate
Hydrochloric acid
Calcium phosphate
Hydrochloric acid
Low drug pH
Hydrochloric acid
High drug pH
Sodium bicarbonate
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to plasmin and initializes local fibrinolysis, which breaks down the thrombus.7 Alteplase has an affinity for fibrin-bound plasminogen and thus is more drawn to clot-bound plasminogen than free-circulating plasminogen.12 The use of alteplase has been effective in restoring catheter patency with reported rates of 83% to 95%.7 New thrombolytics on the market show promise in decreasing treatment time and increasing success rate in adults; however, no studies have been done in pediatric patients. Once the dose of alteplase has been ordered and obtained, it is administered to dwell in the catheter lumen. Manufacturer recommendations advise to check patency after 30 minutes. If there is no blood return present, the alteplase is left to dwell for another 90 minutes. If patency is not restored after 120 minutes, the dose may be repeated. Studies have reported success after treatment in 83% to 95% of catheters after a second dose was administered.7 If a double lumen catheter requires treatment, treat 1 lumen at a time. In the event of complete occlusion (in which the catheter will neither infuse or have a blood return) alteplase can be instilled using the stopcock method. A stopcock is attached to the end of the catheter hub with the dose of alteplase at 1 port and an empty 10-cc syringe at the other port. Turn the stopcock off to the alteplase and open to the catheter and empty syringe. Pull back on the empty syringe. This creates negative pressure in the line. Maintaining pressure with the empty syringe, turn the stopcock off to the 10-cc syringe and open to the alteplase. The negative pressure in the line will draw the alteplase into the catheter. This technique will need to be repeated until the alteplase is drawn into the catheter.4 Dosing of Fibrinolytics Numerous studies have reported safety and success using alteplase in pediatric patients. However, there is a variant of how the catheter was treated regarding dosing and length of treatment. Multiple studies in the pediatric population have used the following dosing: for child weight >30 kg: 2 mL 2ml/2mL alteplase. All patients weighing <30 kg, but at least 10 kg, received a dose of alteplase equal to 110% of the internal volume of the CVC, not to exceed 2 mg.3,11-14 Patency restoration was achieved in 83% to 95% of treatment, typically after administering the second dose. Another study used a dose escalation protocol to restore patency.15 Fifty-eight pediatric and adult patients were enrolled in the study. An initial dose of 0.5 mg alteplase in 1 mL sterile water was instilled in the catheter. If the volume of the catheter lumen was >1 mL, 0.9% sodium chloride was injected after the alteplase filled the catheter. The 0.5-mg dose was allowed to dwell for 60 minutes. If patency was not restored after 60 minutes the procedure was repeated with a dose of 1 mg alteplase and then consequently if that dose was not successful then 2 mg alteplase was instilled. Out of 66 catheters, 50 were cleared with the initial dose of 0.5 mg alteplase, a 86% success rate. Five more were cleared after the 1-mg escalation, and 1 more was cleared after the escalation to 2 mg.15 It is important to note that the definition of successful clearance was determined based on if the occlusion was complete or partial. In the event of a complete occlusion, success was based on an ability to infuse
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Catheter occlusion Catheter NOT flushing, no blood return
Catheter flushing, no blood return
Assess for mechanical occlusion • • • •
Assess port for needle displacement • •
Reaccess port with new needle Look for kink in tubing Line clamped Pinch off syndrome Have patient perform Valsalva, move shoulder and neck
NO
Assess for Catheter Integrity
• • •
YES
Pain upon flushing Edema at the port site
Redo dressing to fix kink Unclamp Obtain line study to assess pinch off syndrome
•
Leaking at insertion site
•
Hole/break in catheter
Assess for precipitate occlusion • •
Incompatible meds Precipitate in tubing
NO
• •
Change out tubing Contact pharmacist to determine treatment of catheter based on pH of precipitate
YES
Assess for thrombotic occlusion • • •
Assess when catheter last obtained a blood return Was catheter flushed at appropriate intervals If NO, re-educate caregiver on proper line maintenance cares
Catheter NOT flushing, no blood Return
Catheter flushing, No blood return Blood return?
Instill alteplase using the stopcock method and let dwell for 30 minutes
Instill alteplase and allow to dwell for 30 minutes
NO
YES
Allow to dwell for an additional 90 minutes
Waste blood appropriate for catheter volume and resume infusion
Blood Return?
NO
Blood return? Will need to order a line study or an x-ray to evaluate line placement and integrity
Repeat alteplase dose, allow to dwell for 2 hours
NO
Figure 2. Catheter occlusion decision tree.4,9 solution with or without an ability to withdraw blood. Successful restoration for a partial occlusion included being able to infuse and withdraw blood.15
Another alteplase dosing protocol that has been utilized in pediatric patients is weight-based dosing. In 1 study,13 if a patient weighed <10 kg he or she received 0.5 mg to the
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catheter volume. If the patient weighed >10 kg he or she received 1 to 2 mg to fill the catheter lumen. The alteplase was allowed to dwell for 2 to 4 hours. Out of 34 catheter lumens treated, 29 were restored to full patency (ie, the ability to infuse and withdraw blood). Using this method, 85% of catheters were successfully restored.13 Most of the protocols derived from the evidence require knowledge of the intraluminal catheter volume. In pediatric patients the exact volume can often be difficult to determine. With a majority of catheters being trimmed and potentially not documented,3 it is important to utilize manufacturer information regarding volume to calculate the dose for all catheters utilized in the institution. A documentation system should be in place where the inserter can easily document the length of catheter. This information should be easily accessible to prescribing practitioners and nurses administering alteplase to promptly order a fibrinolytic when occlusion is determined. Pediatric Behaviors/Dislodgement and Device Malfunction Natural behaviors of children lend themselves to a greater challenge in securing CVCs.12 These behaviors can include, but are not limited to, self-removal of dressing and dislodging the CVC, running without realizing they are attached to intravenous line tubing, or having a parent pick up the child without realizing the catheter is caught. Concerning symptoms that warrant a more in-depth assessment include change in external catheter length, redness and pain at the site, and pain upon flushing. In pediatric patients a central line flush may feel cold and can be perceived as scary, but it should never be painful. Using a distraction method during a central line flush can help determine if the child is experiencing pain. Pain upon flushing can be a sign of catheter or port needle dislodgement. It is important to ensure that the line is carefully secured and that the dressing is assessed often. Conclusions Pediatric patients require CVCs to provide stable and reliable access for treatment. Maintenance of these catheters is crucial for successful treatment and patient survival. An occlusion can lead to interruption in therapy, risk for catheter-related infections, and increased health care costs.12 Proper selection of the vascular access catheter will help enable successful outcomes. Line caregivers should be aware of the different types of catheter occlusion and next steps required to treat and salvage a catheter. Fibrinolytics assist in maintaining optimal patency and each institution shall determine a protocol for dosing that facilitate simple and timely ordering. Acknowledgment The author thanks everyone involved with the University of Iowa evidence-based practice internship as well as Lisa Binegar, Anna Englehart, and Austin Davis, who provided proofreading support. The author also thanks Renee Kramer for providing secretarial support.
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References 1. Athale U, Sicilianao S, Cheng J, et al. Central venous line dysfunction is an independent predictor of poor survival in children with cancer. J Pediatr Hematol Oncol. 2012;34(3): 188-193. 2. Revel-Vilk S, Yacobovich J, Tamary H, et al. Risk factors for central venous catheter thrombotic complications in children and adolescents with cancer. Cancer. 2010;116 (17):4197-4205. 3. Blaney M, Shen V, Kerner J, et al. Altepase for the treatment of central venous catheter occlusion in children: results of a prospective, open-label, single-arm study (The Cathflo Activase Pediatric Study). J Vasc Interv Radiol. 2006;17(11 Pt 1):1745-1751. 4. Doellman D. Prevention, assessment, and treatment of central venous catheter occlusions in neonatal and young pediatric patients. J Infus Nurs. 2011;34(4):251-258. 5. Kennedy RM, Luhmann J, Zempsky W. Clinical implications of unmanaged needle-insertion pain and distress in children. Pediatrics. 2008;122(Suppl 3):S130-S133. 6. Cohen LL. Behavioral approaches to anxiety and pain management for pediatric venous access. Pediatrics. 2008;122(Suppl 3):S134-S139. 7. Baskin J, Reiss U, Willimas J, Metzger ML, Ribeiro RC, Pui CH, et al. Thrombolytic therapy for central venous catheter occlusion. Haematologica. 2012;97(5):641-650. 8. Kerner J, Garcia-Careaga M, Fisher A, Poole R. Treatment of catheter occlusion in pediatric patients. JPEN J Parenter Enteral Nutr. 2006;30(Suppl 1):S73-S81. 9. The Joint Commission. Preventing Central Line-Associated Bloodstream Infections: A Global Challenge, A Global Perspective. Oak Brook, IL: Joint Commission Resources; 2012. 10. Infusion Nurses Society. Infusion nursing standards of practice. J Infus Nurs. 2011;34(Suppl 1):S1-S110. 11. Shen V, Li X, Murdock M, et al. Recombinant tissue plasminogen activator (alteplase) for restoration of function to occluded central venous catheters in pediatric patients. J Pediatr Hematol Oncol. 2003;25(1):38-45. 12. Gilarde J, Chung A, Vidal R, Falkos S. Efficacy and economic evaluation of a volume-based cathflo activase protocol versus a fixed-dose alteplase protocol for catheter occlusions in pediatric patients. J Pediatr Pharacol Ther. 2006;11(4):237-244. 13. Choi M, Massicotte MP, Marzinotto V, Chan AKC, Andrew M. Use of tissue plasminogen activator to clear blocked central venous lines in pediatric patients: a prospective cohort study. Blood. 1999;94(Suppl 1):25a. Abstract 96-1. 14. Jacobs BR, Haygood M, Hingl J. Recombinant tissue plasminogen activator in the treatment of central venous catheter occlusion in children. J Pediatr. 2001;139(4):593-596. 15. Davis SN, Vermeulen L, Banton J, et al. Activity and dosage of alteplase dilution for clearing occlusions of venous-access devices. Am J Healthy Syst Pharm. 2000;57(11):1039-1045.
2013
A R T I C L E
Pediatric Central Venous Catheter Management: A Review of Current Practice Mary Beth Hovda Davis, MSN, RN, VA-BC University of Iowa Children’s Hospital, Iowa City, IA
Abstract Due to small vessel size, obtaining stable access in pediatric patients is difficult. In addition, because needle stick pain is a concern for patients with chronic illness, central venous catheters are often utilized to provide intravenous treatment. Catheter occlusion is a common complication in pediatric patients and must be addressed to salvage the catheter and ensure successful therapy. The use of fibrinolytics for occlusion treatment have been successful in pediatric populations. Keywords: Pediatric, central venous catheter, catheter maintenance, central venous catheter occlusion
Introduction entral venous catheters (CVCs) are required to carry out numerous treatment plans for pediatric patients. Many life-threatening conditions require reliable and stable access for the infusion of medications and drawing of blood samples.1 Pediatric patients have different vascular access needs than adults. For example, they have smaller veins to select from, creating fewer options for vascular access.2,3 Added concerns for pediatric patients are the chronic side effects of unresolved needle stick pain. To reduce the trauma of repeated venipuncture, central lines are maintained for long periods of time. Long-term catheters are at a higher risk for developing complications, including occlusions.3,4 CVCs that are often utilized in pediatric patients are implanted ports, tunneled catheters, and peripherally inserted central catheters (PICCs). Skilled care and maintenance of CVCs is crucial for the longevity of the catheter and treatment success. An estimated 40% to 46% of CVCs develop complications.1 A nonfunctional catheter can lead to a number of complications, including delays in treatment, an inability to provide nutrition for patients with intestinal failure, and additional needle sticks to obtain blood draws and additional access. In addition, an untreated CVC occlusion can increase a patient’s risk for a central line-associated blood stream infection (CLABSI). It has been reported that pediatric patients with cancer have a CVC-related thrombosis 50% of the time. And another study showed that having a dysfunctional CVC was
C
Correspondence concerning this article should be addressed to [email protected] http://dx.doi.org/10.1016/j.java.2013.04.002 Copyright Ó 2013, ASSOCIATION FOR VASCULAR ACCESS. Published by Elsevier Inc. All rights reserved.
an independent risk factor of having a poor outcome in pediatric patients with a non-central nervous system cancer.1 This article evaluates the use of CVCs in pediatric populations, causes for CVC occlusion, evidence-based research and current practice on preventing catheter occlusion, and methods of treatment. Venipuncture and Pediatric Patients Evidence shows that venipuncture is an important source of pain in pediatric patients. Venipuncture and peripheral intravenous (PIV) cannulation are 2 of the most common sources of pain reported by hospitalized children.5 Pain experienced early in life can have lasting negative effects. These effects vary across a wide range but affect a patient’s neurological development, pain threshold, coping strategies, and pain perception. Unresolved childhood pain has been associated with adult fear, pain, and avoidance of health care.6 The brain rapidly matures shortly after birth. Repeated painful events can alter the formation of neuronal circuits. This can result in children becoming hypersensitive to pain.6 A child born with a chronic medical condition may have a lifetime of access requirements. Repeat venipuncture can damage smaller vessels making future treatment difficult to initiate. It is imperative that venous access needs are assessed early in treatment planning to minimize the amount of venipuncture a pediatric patient may require. Catheter Selection Catheter selection for a pediatric patient should take into account several factors. These include treatment requirement, length of treatment, catheter placement options, and maintenance requirements. The implanted port will provide stable long-term access. Using numbing cream, the port can be accessed relatively
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painlessly. It is also associated with fewer catheter occlusions when compared with tunneled catheters.7 However, due to needing to be accessed with a needle it is not the best option if long-term daily access is required. A tunneled catheter, such as a Broviac or Hickman catheter, is a good option for long-term treatment requiring daily access. Due to their external design, daily care and maintenance of these catheters are crucial to prevent CLABSI and complications. Caregivers of pediatric patients are often required to provide daily flushing and scheduled dressing changes for these lines and must be educated on aseptic and sterile technique. PICC is a good option for short-term treatment. The PICC line is associated with the lowest frequency of catheter occlusion, most likely due to its short-term nature.7 In pediatric patients PICC lines are at a high risk for accidental dislodgment, either during a dressing change or if the patient disrupts the dressing. Assessment of the catheter is important before initiating treatment to ensure that the PICC line has not been accidentally dislodged and remains in a central location. Catheter selection is limited due to patient size. Smallergauged catheters used frequently in neonates and small pediatric patients are associated with higher incidence of complications.4 When selecting a catheter, consideration must include duration of treatment needed and what device is available in the patient’s size. Sizes fluctuate from 1-Fr PICC line to 12-Fr tunneled catheter. The inserter must consider all treatment requirements when selecting an appropriately sized catheter.
note that due to the different sizes of patients, the caregiver of the line must be aware of the size requirements to prevent occlusion and complications. Small-gauge catheters, such as a 1.9 Fr and smaller, must have fluids run continuously through the catheter to maintain patency. It is incapable of being locked off.4 According to research4,8 and guidelines from the Joint Commission,9 and the Infusion Nurses Society,10 all CVCs should be flushed with normal saline before and after an infusion is administered or a blood sample is obtained from the line. Heparin assists in preventing occlusion. A standard amount of 10 units/mL heparin is used to maintain externalized catheters such as tunneled catheters and PICCs to fill the volume of the line. An implantable port requires monthly access and heparin flush with 100 units/mL heparin4 (see Table 1). It is important to note that although heparin may aid in preventing a thrombus, it will do nothing to treat an established clot. Catheter salvaging is preferential over replacement to preserve a patient’s veins and access for future use.4 Along with proper flush technique, the catheter site must be maintained by ensuring dressing changes are being performed at appropriate intervals and utilizing sterile technique. All tubing must be changed out at scheduled frequencies based on the product that was infusing. All access into the tubing must be done aseptically. By following these recommendations the CVC should be able to be maintained throughout the treatment without developing an infection or device-related complication (see Table 2).
Catheter Maintenance To prevent a catheter occlusion, it is important the catheter is maintained correctly. This includes ensuring that the line is correctly flushed at the appropriate interval. It is important to
Occlusion An occlusion occurs when the CVC is no longer patent, and can either be a partial or complete occlusion.4 A partial occlusion is when the catheter will infuse fluids, but not have a blood
Table 1. Catheter Flush Volume and Frequency for Pediatric Patients. Based on References 4 and 7-10 Peripherally inserted central catheter
d d d
d
Port/tunneled line
d
d
d
Alteplase
d
d
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Lines 3 Fr and greater may be heplocked with 1 mL/10 units heparin Lines <1.9 Fr cannot be heplocked, and may not be reliable for blood draws Line dressing changes should be done weekly and as needed. An initial dressing change is recommended within 24 to 48 hours of insertion Line waste and flush volumes B 1 cc waste B 1 cc 10 units/mL heparin Port flush and waste volumes B 5 cc waste B 5 mL 10 units/mL heparin for 24-hour lock B 5 mL 100 units/mL heparin for 30 day lock Hickman/Broviac >6 Fr flush and waste volumes B 3 mL waste B 3 mL 10 units/mL heparin for 24-hour lock Broviac 2.7 Fr and 4.2 Fr flush and waste volumes B 1 mL waste B 1 mL 10 units/mL heparin for 24-hour lock Indicated in the presence of an inability to withdraw blood through the catheter, sluggish blood return, increased resistance while flushing, or inability to flush the catheter Useful only for thrombotic occlusions
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Table 2. Pediatric Catheter Maintenance. Based on References 4 and 7-10 Catheter site dressing
d d d
d d d
d
Accessing lines
d d d d
Central line tubing
d d d d
Add-on devices stopcocks
d d
Needless connectors
d
d
Assess at the beginning of every shift Initial dressing change within 24-48 hours of insertion Change every 7 days or when damp, loosened, or visible drainage if using chlorhexidine gluconate Change every Monday, Wednesday, Friday for betadine dressing Wear sterile gloves and mask when performing dressing changes Use chlorhexidine for 30 seconds, skin antisepsis for >2 months adjusted gestational age unless contraindicated Betadine for <2 months adjusted gestational age or allergy/intolerance to chlorhexidine gluconate Limit the number of times a line is accessed Perform nonemergent blood draws at scheduled times Avoid drawing from a lumen infusing central venous nutrition if possible Before accessing any lines: - Perform hand hygiene - Wear gloves - Scrub the hub with alcohol for 15 seconds - Ensure all entry ports are free of flushes and are covered with a needleless access device Change Change Change Change
every every every every
96 24 12 24
hours hours hours hours
for for for for
continuous fluid administration total parenteral nutrition and lipid administration propofol syringe blood product administration
Limit the number and use of add-on devices Change add-on devices every 96 hours, with every tubing change, or when blood/debris is present Change the needleless connector - Every 96 hours, with each extension set or stopcock change - When blood, lipids, or debris is present - Before drawing a blood culture - Upon contamination Scrub the hub for 15 seconds and let it dry
return. A complete occlusion occurs when the catheter will neither infuse nor aspirate blood. Onset of occlusion can be gradual or sudden and diagnosing the cause of occlusion assists in successful resolution of the occlusion. The main three types of catheter occlusions are: mechanical, precipitate, and thrombotic. Mechanical Occlusion Mechanical occlusions are caused by external compression of the line. These occlusions are most commonly caused by kinked tubing, a catheter secured over a joint, or a clamped line.8 Another cause of a mechanical occlusion is pinch-off syndrome. This is when the catheter passes through the space between the clavicle and first rib. A common sign of this complication is if the catheter restores patency after postural changes, such as moving the shoulder forward. Additional causes of mechanical obstruction could include a catheter tip lodged against the vessel wall or port needle either becoming dislodged or not correctly placed in an implanted port.7
Precipitate Occlusion A precipitate occlusion occurs when incompatible medications combine in the catheter lumen. Patients who receive parenteral nutrition can also experience precipitate occlusions due to lipid residue. If the catheter experiences a sudden occlusion, this can be a sign that precipitate was the cause. Due to smaller vessel size and lack of options for alternate access, many pediatric patients’ CVC lines have a single lumen catheter for treatment. All medications must be reviewed before administration to screen for drug incompatibilities. Ensuring proper flushing before and after medications will assist in prevention. See Figure 1. Treatment for a precipitate occlusion depends on the agent that precipitated. Occlusions from a presumed lipid residue are treated with a 70% ethanol solution.4,8 Medications with low pH or those containing calcium phosphate can be treated with hydrochloric acid. Medications with high pH are treated with sodium bicarbonate.7,4,8 Consult a pharmacist to determine which treatment modality will work best with your precipitate (see Table 3).
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Figure 1. Precipitate in a peripherally inserted central catheter line. Thrombotic Occlusion It is estimated that thrombotic occlusions occur in an estimated 60% of all catheter occlusions.8 The most common types of catheter thrombosis in children are mural thrombi, catheter tip thrombi, catheter tip against a vessel wall, and fibrin sleeve thrombi.11 Within 2 weeks of insertion most catheters develop a fibrin sheath.7 A fibrin sheath does not necessarily indicate catheter malfunction, but its presence can eventually lead to a partial occlusion. Central venous catheters with the tip of the catheter in the lower third of the superior vena cava have a lower risk for occlusion.7 Thrombotic occlusions provide another level of complication. A thrombotic occlusion can lead to a CLABSI. The thrombus provides the perfect medium for bacteria growth.8 As the thrombus develops bacteria have an opportunity to proliferate and if released into the bloodstream will lead to sepsis.3 Onset of a thrombotic occlusion is typically gradual and it is important to treat a catheter as soon as a potential line issue is noticed. The patency of the CVC should be assessed before each use. A thorough assessment of the catheter and potential treatment should be considered for the catheter at the first sign of resistance during flushing or sluggish to no blood return. The sooner treatment is initiated the higher the chance of restored patency11 (Figure 2). Fibrinolytics Alteplase is a tissue plasminogen activator. It treats a thrombus by binding to fibrin in the thrombus. It then converts plasminogen
Table 3. Precipitate Treatment Options Precipitate
Treatment
Lipid
70% ethanol
Mineral precipitate
Hydrochloric acid
Calcium phosphate
Hydrochloric acid
Low drug pH
Hydrochloric acid
High drug pH
Sodium bicarbonate
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to plasmin and initializes local fibrinolysis, which breaks down the thrombus.7 Alteplase has an affinity for fibrin-bound plasminogen and thus is more drawn to clot-bound plasminogen than free-circulating plasminogen.12 The use of alteplase has been effective in restoring catheter patency with reported rates of 83% to 95%.7 New thrombolytics on the market show promise in decreasing treatment time and increasing success rate in adults; however, no studies have been done in pediatric patients. Once the dose of alteplase has been ordered and obtained, it is administered to dwell in the catheter lumen. Manufacturer recommendations advise to check patency after 30 minutes. If there is no blood return present, the alteplase is left to dwell for another 90 minutes. If patency is not restored after 120 minutes, the dose may be repeated. Studies have reported success after treatment in 83% to 95% of catheters after a second dose was administered.7 If a double lumen catheter requires treatment, treat 1 lumen at a time. In the event of complete occlusion (in which the catheter will neither infuse or have a blood return) alteplase can be instilled using the stopcock method. A stopcock is attached to the end of the catheter hub with the dose of alteplase at 1 port and an empty 10-cc syringe at the other port. Turn the stopcock off to the alteplase and open to the catheter and empty syringe. Pull back on the empty syringe. This creates negative pressure in the line. Maintaining pressure with the empty syringe, turn the stopcock off to the 10-cc syringe and open to the alteplase. The negative pressure in the line will draw the alteplase into the catheter. This technique will need to be repeated until the alteplase is drawn into the catheter.4 Dosing of Fibrinolytics Numerous studies have reported safety and success using alteplase in pediatric patients. However, there is a variant of how the catheter was treated regarding dosing and length of treatment. Multiple studies in the pediatric population have used the following dosing: for child weight >30 kg: 2 mL 2ml/2mL alteplase. All patients weighing <30 kg, but at least 10 kg, received a dose of alteplase equal to 110% of the internal volume of the CVC, not to exceed 2 mg.3,11-14 Patency restoration was achieved in 83% to 95% of treatment, typically after administering the second dose. Another study used a dose escalation protocol to restore patency.15 Fifty-eight pediatric and adult patients were enrolled in the study. An initial dose of 0.5 mg alteplase in 1 mL sterile water was instilled in the catheter. If the volume of the catheter lumen was >1 mL, 0.9% sodium chloride was injected after the alteplase filled the catheter. The 0.5-mg dose was allowed to dwell for 60 minutes. If patency was not restored after 60 minutes the procedure was repeated with a dose of 1 mg alteplase and then consequently if that dose was not successful then 2 mg alteplase was instilled. Out of 66 catheters, 50 were cleared with the initial dose of 0.5 mg alteplase, a 86% success rate. Five more were cleared after the 1-mg escalation, and 1 more was cleared after the escalation to 2 mg.15 It is important to note that the definition of successful clearance was determined based on if the occlusion was complete or partial. In the event of a complete occlusion, success was based on an ability to infuse
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Catheter occlusion Catheter NOT flushing, no blood return
Catheter flushing, no blood return
Assess for mechanical occlusion • • • •
Assess port for needle displacement • •
Reaccess port with new needle Look for kink in tubing Line clamped Pinch off syndrome Have patient perform Valsalva, move shoulder and neck
NO
Assess for Catheter Integrity
• • •
YES
Pain upon flushing Edema at the port site
Redo dressing to fix kink Unclamp Obtain line study to assess pinch off syndrome
•
Leaking at insertion site
•
Hole/break in catheter
Assess for precipitate occlusion • •
Incompatible meds Precipitate in tubing
NO
• •
Change out tubing Contact pharmacist to determine treatment of catheter based on pH of precipitate
YES
Assess for thrombotic occlusion • • •
Assess when catheter last obtained a blood return Was catheter flushed at appropriate intervals If NO, re-educate caregiver on proper line maintenance cares
Catheter NOT flushing, no blood Return
Catheter flushing, No blood return Blood return?
Instill alteplase using the stopcock method and let dwell for 30 minutes
Instill alteplase and allow to dwell for 30 minutes
NO
YES
Allow to dwell for an additional 90 minutes
Waste blood appropriate for catheter volume and resume infusion
Blood Return?
NO
Blood return? Will need to order a line study or an x-ray to evaluate line placement and integrity
Repeat alteplase dose, allow to dwell for 2 hours
NO
Figure 2. Catheter occlusion decision tree.4,9 solution with or without an ability to withdraw blood. Successful restoration for a partial occlusion included being able to infuse and withdraw blood.15
Another alteplase dosing protocol that has been utilized in pediatric patients is weight-based dosing. In 1 study,13 if a patient weighed <10 kg he or she received 0.5 mg to the
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catheter volume. If the patient weighed >10 kg he or she received 1 to 2 mg to fill the catheter lumen. The alteplase was allowed to dwell for 2 to 4 hours. Out of 34 catheter lumens treated, 29 were restored to full patency (ie, the ability to infuse and withdraw blood). Using this method, 85% of catheters were successfully restored.13 Most of the protocols derived from the evidence require knowledge of the intraluminal catheter volume. In pediatric patients the exact volume can often be difficult to determine. With a majority of catheters being trimmed and potentially not documented,3 it is important to utilize manufacturer information regarding volume to calculate the dose for all catheters utilized in the institution. A documentation system should be in place where the inserter can easily document the length of catheter. This information should be easily accessible to prescribing practitioners and nurses administering alteplase to promptly order a fibrinolytic when occlusion is determined. Pediatric Behaviors/Dislodgement and Device Malfunction Natural behaviors of children lend themselves to a greater challenge in securing CVCs.12 These behaviors can include, but are not limited to, self-removal of dressing and dislodging the CVC, running without realizing they are attached to intravenous line tubing, or having a parent pick up the child without realizing the catheter is caught. Concerning symptoms that warrant a more in-depth assessment include change in external catheter length, redness and pain at the site, and pain upon flushing. In pediatric patients a central line flush may feel cold and can be perceived as scary, but it should never be painful. Using a distraction method during a central line flush can help determine if the child is experiencing pain. Pain upon flushing can be a sign of catheter or port needle dislodgement. It is important to ensure that the line is carefully secured and that the dressing is assessed often. Conclusions Pediatric patients require CVCs to provide stable and reliable access for treatment. Maintenance of these catheters is crucial for successful treatment and patient survival. An occlusion can lead to interruption in therapy, risk for catheter-related infections, and increased health care costs.12 Proper selection of the vascular access catheter will help enable successful outcomes. Line caregivers should be aware of the different types of catheter occlusion and next steps required to treat and salvage a catheter. Fibrinolytics assist in maintaining optimal patency and each institution shall determine a protocol for dosing that facilitate simple and timely ordering. Acknowledgment The author thanks everyone involved with the University of Iowa evidence-based practice internship as well as Lisa Binegar, Anna Englehart, and Austin Davis, who provided proofreading support. The author also thanks Renee Kramer for providing secretarial support.
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References 1. Athale U, Sicilianao S, Cheng J, et al. Central venous line dysfunction is an independent predictor of poor survival in children with cancer. J Pediatr Hematol Oncol. 2012;34(3): 188-193. 2. Revel-Vilk S, Yacobovich J, Tamary H, et al. Risk factors for central venous catheter thrombotic complications in children and adolescents with cancer. Cancer. 2010;116 (17):4197-4205. 3. Blaney M, Shen V, Kerner J, et al. Altepase for the treatment of central venous catheter occlusion in children: results of a prospective, open-label, single-arm study (The Cathflo Activase Pediatric Study). J Vasc Interv Radiol. 2006;17(11 Pt 1):1745-1751. 4. Doellman D. Prevention, assessment, and treatment of central venous catheter occlusions in neonatal and young pediatric patients. J Infus Nurs. 2011;34(4):251-258. 5. Kennedy RM, Luhmann J, Zempsky W. Clinical implications of unmanaged needle-insertion pain and distress in children. Pediatrics. 2008;122(Suppl 3):S130-S133. 6. Cohen LL. Behavioral approaches to anxiety and pain management for pediatric venous access. Pediatrics. 2008;122(Suppl 3):S134-S139. 7. Baskin J, Reiss U, Willimas J, Metzger ML, Ribeiro RC, Pui CH, et al. Thrombolytic therapy for central venous catheter occlusion. Haematologica. 2012;97(5):641-650. 8. Kerner J, Garcia-Careaga M, Fisher A, Poole R. Treatment of catheter occlusion in pediatric patients. JPEN J Parenter Enteral Nutr. 2006;30(Suppl 1):S73-S81. 9. The Joint Commission. Preventing Central Line-Associated Bloodstream Infections: A Global Challenge, A Global Perspective. Oak Brook, IL: Joint Commission Resources; 2012. 10. Infusion Nurses Society. Infusion nursing standards of practice. J Infus Nurs. 2011;34(Suppl 1):S1-S110. 11. Shen V, Li X, Murdock M, et al. Recombinant tissue plasminogen activator (alteplase) for restoration of function to occluded central venous catheters in pediatric patients. J Pediatr Hematol Oncol. 2003;25(1):38-45. 12. Gilarde J, Chung A, Vidal R, Falkos S. Efficacy and economic evaluation of a volume-based cathflo activase protocol versus a fixed-dose alteplase protocol for catheter occlusions in pediatric patients. J Pediatr Pharacol Ther. 2006;11(4):237-244. 13. Choi M, Massicotte MP, Marzinotto V, Chan AKC, Andrew M. Use of tissue plasminogen activator to clear blocked central venous lines in pediatric patients: a prospective cohort study. Blood. 1999;94(Suppl 1):25a. Abstract 96-1. 14. Jacobs BR, Haygood M, Hingl J. Recombinant tissue plasminogen activator in the treatment of central venous catheter occlusion in children. J Pediatr. 2001;139(4):593-596. 15. Davis SN, Vermeulen L, Banton J, et al. Activity and dosage of alteplase dilution for clearing occlusions of venous-access devices. Am J Healthy Syst Pharm. 2000;57(11):1039-1045.
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