Pre‐procedure

ActionRationale

1. 1.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [356], C).
2. 2.Show
   This procedure should be performed using an aseptic non‐touch technique.
   To minimize the risk of infection (DH [117], C; Fraise and Bradley [156], E; Rowley and Clare [388], E). (For further information on asepsis see Chapter c04: Infection prevention and control.)
3. 3.Show
   Wash hands with soap and water, or an alcohol‐based handrub, and dry. Place all equipment required on the bottom shelf.
   To minimize the risk of cross‐infection (DH [117], C).
4. 4.Show
   Open a sterile pack and empty the other equipment onto it.
   To create a clean working area (DH [117], C).
5. 5.Show
   Wash hands with soap and water, or an alcohol‐based handrub, and dry.
   Hands may have become contaminated by handling the outer packs (DH [117], C).

Procedure

1. 6.Show
   Clean the connections thoroughly with 2% chlorhexidine in 70% alcohol before disconnection.
   To minimize infection risk at the connection site (DH [117], C).
2. 7.Show
   Remove any extension sets or needle‐free connectors.
   The occlusion may be in the extension set/cap and not in the catheter. E
3. 8.Show
   Draw up 0.9% sodium chloride and attempt to flush the catheter using a 10 mL syringe.
   Smaller syringes create excessive pressure, which can result in catheter rupture (Conn [83], E).
4. 9.Show
   If there is pressure within the device lumen, attempt to gently instil the 0.9% sodium chloride using a ‘to and fro’ motion (push–pull) over a few minutes.
   To attempt to clear the catheter (Gabriel [161], E).
5. 10.Show
   If nothing can be aspirated:

   • If a peripheral device: remove the device and resite as necessary:
   • If a central venous access device: determine the cause of the occlusion:
    
   • • If blood: discuss with doctors, who may prescribe a fibrinolytic agent, e.g. urokinase or alteplase (Box 17.3).
   To break down fibrin (BNF [42], C; RCN [381], C).
   • • If precipitation: discuss with pharmacy to determine best antidote, e.g. ethyl alcohol or hydrochloric acid.
   To break down drug precipitate or fat emulsion (BNF [42], C).
6. 11.Show
   Draw up the prescribed solution in a 10 mL syringe.
   To prepare the appropriate treatment. E
7. 12.Show
   Attach a three‐way tap and attach an empty 10 mL syringe and the syringe containing the prescribed solution (Action figure 12).
   To commence the negative pressure technique (Gabriel [161], E; McKnight [307], E).
8. 13.Show
   Put on clean gloves.
   To minimize the risk of introducing infection (DH [117], C).
9. 14.Show
   Instil the solution via a three‐way tap using negative pressure technique (Action figure 14).
   To prevent catheter rupture (Conn [83], E).
10. 15.Show
    Attach the syringe and inject the priming volume plus 0.5 mL extra into the catheter lumen (Box 17.3).
    To allow the drug to come into contact with the fibrin (Syner‐Med [433], E).
11. 16.Show
    Wait 10 minutes.
    To allow the drug to come into contact with the fibrin (Syner‐Med [433], E).
12. 17.Show
    Inject another 0.5 mL.
    To allow the drug to come into contact with the fibrin (Syner‐Med [433], E).
13. 18.Show
    Wait 10 minutes.
    To allow the drug to come into contact with the fibrin (Syner‐Med [433], E).
14. 19.Show
    Inject last 0.5 mL.
    To allow the drug to come into contact with the fibrin (Syner‐Med [433], E).
15. 20.Show
    Attach an empty syringe to the catheter and attempt to aspirate any clots and solution.
    To unblock the catheter and ensure no clots are administered into the patient (Gabriel [161], E).
16. 21.Show
    If blood returns, withdraw at least 10 mL and discard.
    To ensure no clots are flushed into the patient (Gabriel [161], E).
17. 22.Show
    Flush the catheter with 10 mL 0.9% sodium chloride using a pulsatile flush.
    To ensure the catheter is flushed and patent (RCN [381], C).

Post‐procedure

1. 23.Show
   Remove gloves and dispose of waste.
   To prevent contamination of others (DH [117], C).
2. 24.Show
   If still unable to aspirate, consider the use of a second instillation of fibrinolytic agent at a higher dose or use an infusion. It may be necessary to remove the catheter (if a single lumen) or to refrain from using the occluded lumen and label ‘not for use’ (if multilumen).
   To allow a higher dose of drug to be in contact with the clot (Syner‐Med [433], E). To maintain some venous access for the patient. If the occlusion cannot be resolved, the catheter is no longer patent. In multilumen catheters, there may be another patent lumen for use (Gabriel [161], E). To follow the best evidence‐based practice (i.e. an algorithm for the management of occluded CVADs) (Kumwenda et al. [252], E).
3. 25.Show
   Document the procedure in the patient's records.
   To ensure adequate records are maintained and to enable continued care of device and patient (NMC [356], C).