OCCLUSION MANAGEMENT of Central Vascular Access Devices in Adult Patients Competency Test Performance Criteria Checklist References

Transcription

1 OCCLUSION MANAGEMENT of Central Vascular Access Devices in Adult Patients Competency Test Performance Criteria Checklist References Score /36 = % Exam adapted from AHS Clinical Policy Occlusion Management Exam February 2017

2 CVAD Occlusion Management Qualification Exam Must obtain 80% prior to skills demonstration 1. The 4 types of thrombotic occlusions are intraluminal thrombus, mural thrombus, and - (2pts.) 2. Complications of catheter occlusions include: a. Interruption of therapy b. Infiltration or extravasation c. Infection d. Thrombosis of the blood vessel e. All of the above 3. When should the stop-cock method be used for occlusion management? a. Always b. For a complete occlusion when agent supplied in syringe smaller than 10mL c. For a withdrawal occlusion d. For a complete occlusion when agent supplied in a vial 4. Which of the following can cause catheter occlusions? a. Thrombus formation b. Lipid residue c. Drug or mineral precipitates d. Mechanical obstructions e. All of the above 5. Causes of mechanical obstruction include: a. Suture too tight b. Catheter tip malposition c. Clogged needleless connector d. Incorrect placement of needle in implanted port e. All of the above 6. Which of the following are indicators of catheter occlusion? a. Inability to infuse fluids b. Sluggish flow c. Lack of free-flowing blood return d. All of the above 7. Catheter occlusions: a. Can be complete and prevent infusions or aspirations b. Can be partial, allowing infusions but preventing aspirations c. Can occur in 1 out of 4 catheters d. All of the above 2/22/2017 Page 2 of 10

3 8. Questions to assist in determining if an occlusion should be managed or if the catheter should be removed include: a. Is the CVAD still required? b. Are there any other venous access options? c. Would alternate appropriate venous access be easily obtained? d. Is there a suspected or confirmed catheter related infection? e. All of the above 9. The inability to infuse solutions and the inability to aspirate blood is defined as a. a. Complete occlusion b. Sluggish catheter c. Withdrawal occlusion d. Partial occlusion 10. In the COOL-2 clinical trial, Cathflo demonstrated cumulative efficacy after up to 2 doses using a 2 hour dwell for each dose. a. 46% b. 61.3% c. 70.2% d. 87.2% 11. Occlusion management of a CVAD is Specialized Clinical Competency and may only be performed by a health professional qualified in this procedure. 12. Match the type of occlusion with the description. (3 points) a. Withdrawal occlusion i. catheter cannot be flushed or aspirated b. Complete occlusion ii. increased resistance to flushing c. Sluggish catheter iii. the inability to flush but able to aspirate blood 13. In the Cathflo clinical trials, serious adverse events reported after treatment included sepsis, gastrointestinal bleeding, and venous thrombosis. 14. If unable to flush or aspirate blood with an IVAD the first step is to re-access to rule out needle malposition. 2/22/2017 Page 3 of 10

4 15. Lipid occlusions make up the majority of all occlusions. 16. There is limited systemic exposure with Cathflo since it is instilled into the catheter in direct contact with the clot. 17. If signs and symptoms suggest a CVAD may be malpositioned, radiographic studies must be undertaken after instilling a catheter clearance agent 18. Catheter removal should be considered if catheter patency is not restored. 19. Drugs that are frequent causes of precipitate include: a. Phenytoin b. Heparin c. Calcium and phosphate d. All of the above 20. Signs and symptoms of catheter tip malposition may include: a. Inability to infuse or withdraw b. Change in length of external portion of catheter c. Arm or shoulder discomfort d. Arrhythmias e. All of the above 21. A physician has ordered 1.3 ml of Cathflo to treat a complete occlusion for a patient with a hemostatic defect. To ensure accuracy, the cathflo is drawn up in a 3 ml syringe. What method of instillation should be used? a. Direct instillation b. Negative pressure with stop-cock c. Negative pressure without stop-cock d. Any of the above 22. Indicate whether the following instances require a direct instillation of a catheter clearance agent, or a negative pressure technique. (3 points) You are able to infuse, but unable to withdraw blood You feel increased resistance when flushing Direct / Negative pressure Direct / Negative pressure You cannot infuse fluids or aspirate blood Direct / Negative pressure 2/22/2017 Page 4 of 10

5 23. You have instilled alteplase 2 mg/2 ml into a PICC catheter and left the agent to dwell for 120 minutes. You return and attempt aspiration. There is no blood return. This is your first attempt at clearing the occlusion. What do you do now? a. Remove the PICC b. Use the lumens that are working c. Instill agent again. Consider overnight dwell time. d. None of the above 24. What is the maximum weekly dose of alteplase? 25. How is the dose divided for a 3 lumen catheter when all three lumens have withdrawal occlusion? 26. List one situation in where you would get a chest X-ray prior to restoring patency to the catheter. 27. What is written on the label when the agent is insitu? 28. List four items that must be documented. (4 points) a. b. c. d. 2/22/2017 Page 5 of 10

6 Occlusion Management of CVADs in Adult Patients Checklist Name: Date: Demonstrated Occlusion Management Direct Installation Technique Correctly Yes No Confirms occlusion - Assesses for malposition, kinking, and broken catheter Reviews patient specific contraindications for clearance agent Confirms/obtains patient care order for clearance agent Identifies patient using 2 identifiers Explains the procedure to the patient including possible adverse effects of the catheter clearance agent Obtains baseline vital signs Cleans the work surface with appropriate disinfectant. Allows to air dry Performs hand hygiene Prepares the catheter clearance agent Vigorously scrubs the needleless connector for minimum 15 seconds using an approved antiseptic solution. Allows to air dry Attaches a 10mL syringe with NS to needleless connector Unclamps catheter (if required) Flushes lumen with 10 mls NS Attaches a 10 ml syringe with catheter clearance agent to lumen Gently instills the agent in the lumen Removes syringe and clamps catheter if present Labels the lumen with a Medication Added label with the following: DO NOT USE Medication (dose and volume) Date and time instilled Signature Reports to unit staff, identifying time they will return to aspirate Attempts to aspirate agent and minimum 4-5 ml of blood Flushes with at least 20 ml of normal saline If unable to clear needleless connector, replaces it with sterile connector If unable to aspirate, repeats procedure Documents final outcome and reports to staff as required May perform skill independently Please repeat Observer Name: Requires Prompting 2/22/2017 Page 6 of 10

7 Occlusion Management of CVADs in Adult Patients Checklist Name: Date: Demonstrated Occlusion Management Negative Pressure without stopcock Correctly Yes No Confirms occlusion - Assesses for malposition, kinking, and broken catheter Reviews patient specific contraindications for clearance agent Confirms/obtains patient care order for clearance agent Identifies patient using 2 identifiers Explains the procedure to the patient including possible adverse effects of the catheter clearance agent Obtains baseline vital signs Cleans the work surface with appropriate disinfectant. Allows to air dry Performs hand hygiene Prepares the catheter clearance agent Vigorously scrubs the needleless connector for minimum 15 seconds using an approved antiseptic solution. Allows to air dry Attaches a 10mL syringe with catheter clearance agent to needleless connector Unclamps catheter (if required) Gently withdraws plunger of syringe back to create negative pressure in the lumen of the catheter Slowly releases plunger to allow agent to be pulled back into the lumen Slowly instills the remaining agent in the catheter using a push-pull action. DOES NOT use force when pushing on the plunger Removes syringe and clamps catheter if present Labels the lumen with a Medication Added label with the following: DO NOT USE Medication (dose and volume) Date and time instilled Signature Reports to unit staff, identifying time they will return to aspirate Attempts to aspirate agent and minimum 4-5 ml of blood Flushes with at least 20 ml of normal saline If unable to clear needleless connector, replaces it with sterile connector If unable to aspirate, repeats procedure Documents final outcome and reports to staff as required May perform skill independently Please repeat Observer Name: 2/22/2017 Page 7 of 10 Requires Prompting

8 References Alberta Health Services (2007). Adult Drug Monograph Alteplase. Calgary, AB: Author. Baskin, J. L., Pui, C-H. Reiss, U., Wilimas, J.A., Metzger, M.L., Ribeiro, R.C. & Howard, S.C. (2009). Management of occlusion and thrombosis associated with long-term indwelling central venous catheters. Lancet, 374, Blaney, M., Shen, V., Kerner, J., Jacobs, B.R., Gray, S., Armfield, J., & Semba, C. (2006). Alteplase for the treatment of central venous catheter occlusion in children: results of a prospective, open-label single-arm study (the cathflo activase pediatric study). Journal of Vascular and Interventional Radiology, 17(11), Calgary Health Region. (2002). Central Venous Catheter Management of Occlusion Policy C Child Health Policies and Procedures Manual. Calgary, AB: Author. Cathflo Activase (Alteplase). Retrieved December 1, 2011, from Cathflo (Alteplase) Product Monograph, Genentech Inc Centers for Disease Control and Prevention (2011). Guidelines for the prevention of intravascular catheterrelated infections. Retrieved from: Capital Health/Caritas. (2004). Guideline for restoring patency of vascular access devices (vad). Edmonton, AB: Author. Cumming-Winfield, Cynthia, Mushani-Kanji, Tayreez. Restoring patency to central venous access devices. (2008) Clinical Journal of Oncology Nursing Volume 12, No Daeihagh, P., Jordan, J., Chen, G.J. and Rocco, M. (2000). Efficacy of tissue plasminogen activator administration on patency of hemodialysis access catheters. American Journal of Kidney Diseases, 36(1), Deitcher, S.R., Fesen, M.R., Kiproff, P.M., Hill, P.A., Li, X., McCluckey, E.R., & Semba, C.P. (2002). Safety and efficacy of Alteplase for restoring function in occluded central venous catheters: results of the cardiovascular thrombolytic to open occluded lines trial. Journal of Clinical Oncology, 20(1), Gorski, L.A. (2003). Central venous device occlusions: Part 1: Thrombotic causes and treatment. Home Healthcare Nurse, 21(2), Gorski, L.A. (2003). Central venous device occlusions: Part 2: Nonthrombotic causes and treatment. Home Healthcare Nurse, 21(3a), Hadaway, L. (2002). Catheter connection. Journal of Vascular Access Devices, Spring, 4. Hadaway, L.C. (2005). Reopen the pipeline: learn why a vein or catheter may become occluded, how to head off trouble, and what to do if your patient has problems. Nursing 2005, 35(8), Haire, W.D. & Herbst, S.L. (2000). Use of Alteplase (t-pa) for the management of thrombotic catheter dysfunction: guidelines from a consensus conference of the national association of vascular access networks (NAVAN). Nutrition in Clinical Practice, 15, Haire, W.D. & Herbst, S.F. (2000). Use of alteplase (t-pa) for the management of thrombotic catheter dysfunction. Journal of Vascular Access Devices, Summer, Hamilton, H. (2006). Complications associated with venous access devices: Part two. Nursing Standard, 20(27), /22/2017 Page 8 of 10

9 Hardy, G. & Ball, P. (2005). Clogbusting: Time for a concerted approach to catheter occlusions? Current Opinion in Clinical Nutrition and Metabolic Care, 8, Hemmelgarn, Brenda R., Moist Louise M., Lok Charmaine E., Tonelli, Marcello, Manns, BradenJ, Holder, Rachel M., et al. Prevention of dialysis catheter malfunction with recombinant tissue plasminogen activator The new England journal of medicine Vol. 364, No 4, Kerner, J. A., Garcia-Careaga, M. G., Fisher, A. A., & Poole, R. L. (2006). Treatment of catheter occlusion in pediatric patients. Journal of Parenteral and Enteral Nutrition, 30(1), S73-S81. Infusion Nurses Society (2011). Infusion Nursing Standards of Practice. Journal of Infusion Nursing, 34(1S), S1-S110. Jacobs, B.R., Haygood, M., & Hingl, J. (2001). Recombinant tissue plasminogen activator in the treatment of central venous catheter occlusion in children. The Journal of Pediatrics, 139(4), Mcknight, S. (2004). Nurse s guide to understanding and treating thrombotic occlusion of central venous access devices. Medsurg, 13(6), Mayo, D.J. (2001). Catheter-related thrombosis. Journal of Intravenous Nursing, 24(35), S13-S21. Moureau, N., Mlodzik, L., & Markel Pool, S. (2005). The use of alteplase for treatment of occluded central venous catheters in home care. Journal of the Association of Vascular Access, 10(3), Moureau, N., Poole, S., Murdock, M. A., Gray, S. M. & Semba, C. P. (2002). Central venous catheters in home infusion care: outcomes analysis in 50,470 patients. Journal of Vascular Interventional Radiology, 13, Ng, R., Li, X., Tu, T., & Semba, C.P. (2004). Alteplase for treatment of occluded peripherally inserted central catheters: Safety and efficacy in 240 patients. Journal of Vascular Interventional Radiology, 15, O Grady, N.P., Alexander, M., Patchen Dellinger, E., Gerberding, J.L., Heard, S.O., Maki, D.G., et al. (2002). Guidelines for the prevention of intravascular catheter-related infections. Morbidity and Mortality Weekly Report, 51(RR-10). Phillips, L.D. (2005). Manual of IV therapeutic. ( 4 th ed.). Philadelphia, PA: F.A. David Company. Ponec, D., Irwin, D., Haire, W. D., Hill, P. A., Li, X. & McCluskey, E. R. (2001). Recombinant tissue plasminogen activator (altplase) for restoration of flow in occluded central venous access devices: a double-blind placebo-controlled trial-the cardiovascular thrombolytic to open occluded lines (COOL) efficacy trial. Journal of Vascular Interventional Radiology, 12, Registered Nurses Association of Ontario (2005). Nursing best practice guideline: Care and maintenance to reduce vascular access complications. Toronto: Author. Safer Health Care Now (2006). Prevent Central Line Infections. How to Guide. Institute for Healthcare Improvement. Retrieved January 13, 2010, from 20Kit.pdf Savader, Scott J., Ehrman, Karen O., Porter, David J., Haikal Lee, C., Oteham Anne C. Treatment of hemodialysis catheter-associated Fibrin Sheaths by rt-pa infusion: critical analysis of 124 procedures Journal Vascular Radiology, 12: /22/2017 Page 9 of 10

10 Semba, C. P., Deitcher, S. R., Li, X., Resnansky, L. & McCluskey, E. R. (2002). Treatment of occluded central venous catheters with alteplase: results in 1,064 patients. Journal of Vascular Interventional Radiology, 13, Semba, C., P., Bakal, C.W., Calis, K. A., Grubbs, G.E., Hunter, D. W., Matalon, T.A.S., Murphy, T.P., Stump, D.C., Thomas, S., & Warner, D. L. (2000). Alteplase as an alternative to urokinase. Journal of Vascular Interventional Radiology, 11, Steiger, E. (2006). Dysfunction and thrombotic complications of vascular access devices. Journal of Parenteral and Enteral Nutrition, 30(1), S70-S72. Weinstein, S.M. (2007). Plumer s Principles & Practice of Intravenous Therapy. ( 8 th ed.). Philidelphia, PA: Lippincott Williams & Wilkins. Wingerter, L. (2003).Vascular access device thrombosis. Clinical Journal of Oncology Nursing, 7(3), /22/2017 Page 10 of 10