Managing dysfunctional central venous access devices: a practical approach to urokinase thrombolysis

Kumwenda, Mick; Dougherty, Lisa; Spooner, Helen; Jackson, Victoria; Mitra, Sandip; Inston, Nicholas

doi:10.12968/bjon.2018.27.2.s4

Cited by 8 publications

(11 citation statements)

References 16 publications

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“…Initial management in case of catheter malfunction is the same, regardless of the possible cause. First, any obvious mechanical obstruction should be excluded by carefully inspecting the catheter along its tunnel under the skin [ 44 ]. Then, non-invasive methods are tried, although their effectiveness is not fully verified.…”

Section: Management Of Catheter Dysfunctionmentioning

confidence: 99%

“…Then, non-invasive methods are tried, although their effectiveness is not fully verified. Patient repositioning (raising the ipsilateral arm, having the patient sit or stand, deep breathing or rolling from side to side), flushing the catheter with 10–20 mL 0.9% NaCl [ 43 ] or lumen reversal [ 15 , 42 , 44 ] may be potential solutions. This allows the reversible causes, such as a short-term obstruction of the catheter’s tip by the vein wall, to be eliminated [ 45 ].…”

Section: Management Of Catheter Dysfunctionmentioning

confidence: 99%

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Locked Away—Prophylaxis and Management of Catheter Related Thrombosis in Hemodialysis

Szymańska

Kakareko

Rydzewska–Rosołowska

et al. 2021

JCM

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Reliable vascular access is necessary for effective hemodialysis. Guidelines recommend chronic hemodialysis via an arteriovenous fistula (AVF), however, in a significant number of patients, permanent central venous catheters (CVCs) are used. The use of a tunneled catheter is acceptable if the estimated dialysis time is less than a year or it is not possible to create an AVF. The main complications associated with CVC include thrombosis and catheter-related bloodstream infections (CRBSIs), which may result in loss of vascular access. The common practice is to use locking solutions to maintain catheter patency and minimize the risk of CRBSI. This paperwork summarizes information on currently available locking solutions for dialysis catheters along with their effectiveness in preventing thrombotic and infectious complications and describes methods of dealing with catheter dysfunction. The PubMed database was systematically searched for articles about locking solutions used in permanent CVCs in hemodialysis patients. Additional studies were identified by searching bibliographies and international guidelines. Articles on end-stage kidney disease patients dialyzed through a permanent CVC were included. Information from each primary study was extracted using pre-determined criteria including thrombotic and infectious complications of CVC use, focusing on permanent CVC if sufficient data were available. Of the currently available substances, it seems that citrate at a concentration of 4% has the best cost-effectiveness and safety profile, which is reflected in the international guidelines. Recent studies suggest the advantage of 2+1 protocols, i.e., taurolidine-based solutions with addition of urokinase once a week, although it needs to be confirmed by further research. Regardless of the type of locking solution, if prophylaxis with a thrombolytic agent is chosen, it should be started from the very beginning to reduce the risk of thrombotic complications. In case of CVC dysfunction, irrespective of the thrombolysis attempt, catheter replacement should be planned as soon as possible.

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Section: Management Of Catheter Dysfunctionmentioning

confidence: 99%

Section: Management Of Catheter Dysfunctionmentioning

confidence: 99%

Locked Away—Prophylaxis and Management of Catheter Related Thrombosis in Hemodialysis

Szymańska

Kakareko

Rydzewska–Rosołowska

et al. 2021

JCM

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“…Methodology for in-centre standardised approach has previously been proposed by a national multidisciplinary group which comprised relevant clinical stakeholder and included nephrologists, renal access surgeons and clinical nurse specialists. 6 TCVC dysfunction was defined as catheter blood flow less than 200 mL/min in the absence of mechanical causes of reduction of blood flow. The use of chest x-rays or linograms to investigate mechanical causes of poor blood flow was at the discretion of participating centres depending on their protocols.…”

Section: Methodsmentioning

confidence: 99%

Prospective Audit to Study urokinaSe use to restore Patency in Occluded centRal venous caTheters (PASSPORT 1)

Kumwenda

Mitra²,

Khawaja

et al. 2019

J Vasc Access

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Objectives: Tunnelled central venous catheters dysfunction can be defined as failure to provide blood flow above 200 mL/min during dialysis often caused by thrombosis. Although urokinase is used routinely for thrombolysis, there is wide variation in dose regimens. A multidisciplinary group was formed to address this issue and offer guidance. Methods: Dialysis centres that used urokinase in the United Kingdom took part in a prospective study to determine the safety and outcomes of thrombolysis using agreed protocols. Data were collected anonymously from September 2017 until February 2018. Catheter blood flow was measured before and after the following interventions: catheter dwell or push locks with 12,500–50,000 IU or catheter infusion with 100,000–250,000 IU of urokinase. Interventions were repeated if the blood flow remained below 200 mL/min. Results: 10 centres took part and recruited 200 patients; 45.5% were female and 54.5% were male with mean age of 63.6 (±15.2) years. The cumulative success rate for thrombolysis was 90.5% after first intervention, 97% after second intervention, and 99% after more than 2 interventions. Although there was trend towards benefit with dose increments, the success rate between push/dwell locks and high-dose infusion of urokinase was not significantly different (p = 0.069). Seventeen (8.5%) tunnelled central venous catheters were removed due to failure of treatment. No urokinase-related adverse events were reported. Conclusion: In this study, urokinase was safe and efficacious; there was no difference between dwell and push locks. There was some benefit with high-dose infusion of urokinase compared to the dwell and push lock.

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“…This setting mandates time-sensitive vascular access most frequently accomplished via a two-port hemodialysis catheter allowing adequate flow rates [1]. Abundant literature details the many clinical issues encountered when hemodialysis is performed through use of venous catheters [3][4][5][6][7][8]. These include up to a seven-fold increase in rates of infection compared with surgically created arteriovenous (AV) fistulas and increased catheter-related thrombotic burden limiting flow rates and creating an embolic potential [9][10][11][12].…”

Section: Introductionmentioning

confidence: 99%

Hemodialysis Catheter-related Masses Case Report the Pro Inflammatory State in Chronic Kidney Disease

2019

JCRC

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Indwelling venous catheters provide essential functional vascular access for patients requiring emergent or urgent hemodialysis, though their long-term use is practically limited by known complications including increased rates of infection as compared with surgically created arteriovenous (AV) fistulas. Converging lines of evidence also support that chronic kidney disease (CKD) represents a pro-inflammatory state, an environment with active cellular and inflammatory pathobiology. Accordingly, implantation of catheters for even short-term use is associated with a fibrinthrombin-cellular matrix often forming around the catheter. This "biomass" long considered innocuous, can cause occlusion of the catheter, contributing to reduced flow rates during dialysis. It may also result in embolic injury of downstream structures. This case report identifies a complex catheter-related biomass remaining after removal of the hemodialysis catheter and focuses on two concerns. First, intravenous masses associated with the catheter, or remaining after removal may provoke embolic and direct hemodynamic-related injury. But perhaps less obvious is their potential linkage to vascular immunoreactivity found in CKD. This latter potential may need to be part of the larger discussion surrounding the outcomes of such pathologic immunoresponsiveness in CKD patients on hemodialysis. www.opastonline.com J Clin Rev Case Rep, 2019 Volume 4 | Issue 1 | 2 of 4 www.opastonline.com J Clin Rev Case Rep, 2019 Volume 4 | Issue 1 | 4 of 4 Copyright: ©2019 Dr. John D Rozich, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Managing dysfunctional central venous access devices: a practical approach to urokinase thrombolysis

Cited by 8 publications

References 16 publications

Locked Away—Prophylaxis and Management of Catheter Related Thrombosis in Hemodialysis

Locked Away—Prophylaxis and Management of Catheter Related Thrombosis in Hemodialysis

Prospective Audit to Study urokinaSe use to restore Patency in Occluded centRal venous caTheters (PASSPORT 1)

Hemodialysis Catheter-related Masses Case Report the Pro Inflammatory State in Chronic Kidney Disease

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