NURSING SERVICES POLICY AND PROCEDURE

Title: Management of clotted access /

Code: NSP/HM # 039.14
Extra corporeal circuit
Effective Date: August 20, 2018 Replaces: NSP/HM # 039.14 August 2015
Applies To: All Registered Nurses Nature: Multidisciplinary

I. DEFINITION:

Accesses are devices used as a life line for the acute and chronic renal failure patient
for the dialysis. It must be patent and functioning at all times, so proper Heparinization
of the permicath is necessary to prevent clotting of the access.

II. PURPOSES:
1. To achieve successful prescribed Hemodialysis treatment.
2. To keep the patient access functioning properly
3. To provide guideline for the nurses how to change the clotted blood lines and
dialyzer during dialysis treatment.
4. To establish procedures for declotting vascular access devices for adult patients
using tissue plasminogen activator (t-PA).
5. To assess the arterial blood line for cracks or defects that may cause the
introduction of air into the blood circuit or the loss of blood
6. To safety and quickly replace a defective arterial blood line during Hemodialysis
with minimal blood loss.

III. POLICY STATEMENTS:

1. A Nephrologists written order is required for administration of tissue Plasminogen
activator (t-PA).
2. The Hemodialysis Nurse performs the procedure taking into account the special
consideration in the administration of Tissue Plasminogen Activator, t-PA
(attachment A) and monitors the patient continuously.
3. If catheter does not function, either by inability to flush and/or draw back blood,
refer to. Guidelines for the use of Alteplase for the occluded Hemodialysis catheters
(attachment B)
4. Algorithm for the use of Alteplase in occluded HD CVCs must be followed (attachment 
c) to evaluate the need for declotting agent, t‐PA. 
5. Only Hemodialysis Nurses previously trained and competent regarding the care of
implanted vascular access devices will perform this procedure.
6. Tissue Plasminogen Activator (t-PA) for catheter clearance will be administered
taking into consideration following guidelines (attachment A)
Title: Management of clotted access / extra corporeal circuit
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IV. PROCEDURES AND RESPONSIBILITIES:
Item Responsible
PROCEDURE SEQUENCE
No Person/s
ALTEPLASE USE FOR OCCLUDED HEMODIALYSIS
A
CATHETERS
1. Follow NSP/HM 039.06 for the initiation of the dialysis
2 Verify catheter occlusion.
3. Obtain physician’s order for use of t-PA for catheter clearance.
Determine internal volume of catheter lumen using manufacturer’s
4.
information.
5. Obtain t-PA from pharmacy.
Attach syringe of t-PA directly to end of catheter. Slowly instill drug
6. and re clamp catheter. (Dosage of the drug to be instilled should be the
amount that is identified in the catheter that is used).
FOR SHORT (PRE- DIALYSIS )DWELLS:
a. Leave t-PA in catheter at least 30 minutes and up to 60 minutes;
unless otherwise ordered by the physician
b. Withdraw the Alteplase solution and residual clot from both
7. lumens and discard. If unable to withdraw Alteplase solution, try
to reposition the catheter or patient to aid in the withdrawal.
c. Attempt to flush the CVC with NS using maximum force.
d. If one or both lumens are still “sticky” or blocked, repeat Nephrologists /
administration of Alteplase 2nd dose. Hemodialysis Nurse
FOR LONG (OVERNIGHT )DWELLS:
Remove the emptied 3ml Alteplase syringe from each lumen and secure
a luer lock cap.
8. If unsuccessful, after a total of 60 minutes, administer a second dose of
t-PA with physician’s order. Note that remaining t-PA in the syringe
should not be used after 8 hours.
FOR PUSH / PAUSE METHOD:
• Clamp both lumens and then attach the 3 mL syringe(s) filled
with Alteplase to the occluded CVC port(s)
• Instill Alteplase as per order into each catheter lumen then add
NS 0.9% without preservative to fill the internal volume of each
lumen plus 0.1 mL overfill.
• Attach a 3 mL syringe filled with NS 0.9% without preservative
9.
to each lumen.
• Wait 10 minutes, then gently push NS 0.9% 0.3 mL
Wait another Wait 10 minutes, then gently push NS 0.9% 0.3 mL into
each lumen. Wait another 10 minutes, and then repeat NS 0.9% 0.3 mL
push. Wait another 10 minutes, than aspirate clots using a 10 mL
syringe and discard. May push remaining Alteplase if unable to
withdraw. Forcefully flush each catheter lumen.

Title: Management of clotted access / extra corporeal circuit

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 Item Responsible
PROCEDURE SEQUENCE
No Person/s
10. The Hemodialysis Nurse who suspects a drug reaction, inform the
Nephrologists immediately and record the following in the Nurse’s
Progress Notes. As well as fill up the Adverse Drug Reaction Form
• The medication administered (drug, dose, date, time and route)
• The effect on the patient.
• The patient’s vital signs.
Any other pertinent signs and symptoms. Inform the Nephrologists
immediately.
11. Start dialysis treatment and continue monitoring patient till procedure is
finished.
12. Obtain order from the Nephrologists if t-PA lock is needed to lock the
catheter after dialysis treatment and if necessary repeat procedure
number 6.
13. Although the drug (t-PA) is very minimal which act in the lumen of the
catheter only it is very important that upon patient’s discharge he/she
shall be reminded to monitor at home the signs of drug reaction and
report at once.
B HOW TO CHANGE THE CLOTTED EXTRA CORPORIAL CIRCUIT
1. During dialysis assess the patient for signs of clotting extreme dark
colored blood with black steaks in the dialyzer, clots in the blood
chambers & rapid refilling of the transducer.
Once clotting is occurred or cracks or defect is observed during dialysis: Hemodialysis Nurse
• explain the procedure to the patient
• Wash hands
• Wear PPE plastic apron, mask, face shield and a clean gloves.
• Stop the blood pump, clamp the arterial blood line open the iv
line and flush with 200 ml of NS to visualize the blood chambers
and dialyzer for clotting, if moderate or large amount of clotting
is evident the blood line and dialyzer has to be changed.
• Turn off the blood pump clamp the arterial blood line and arterial
fistula needle tubing. Disconnect the blood lines.
• Unclamp and irrigate needle tubing with 10 ml of NS. Re- clamp
needle tubing and leave the syringe in place.
• Turn blood pump speed down to 100 ml/ minute. and release
arterial line clamp.
• After termination of dialysis each catheter lumen is flushed with
NS and locked with heparin 5000 units per ml with additional
NS according to the lumen volume.
• Inform the treating physician for the adjustment of heparin dose.
2. Document all observation and the action taken in the nurses progress
notes

Title: Management of clotted access / extra corporeal circuit

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 Item Responsible
PROCEDURE SEQUENCE
No Person/s
C NON FUNCTIONING AVF / AVG
1 Regular HD patients presenting to the unit follow the NSP HN 001 Nephrologists
2 • Make initial assessment as per NSP HM 002, Hemodialysis Nurse
• If AVF / AVG no bruit and thrill:
• Inform the Nephrologists
• Check the vitals including weight, Bp, TPR and pain score.
• Obtain the blood sample for CBC, RFT, Na, K & coagulation
profile
• The physician will assess and request for Doppler ultrasound and
patient then will be referred to the vascular surgeon
3 • Document all the finding in the nurse’s progress notes.

V. REFERENCES:

1. Manual of Nursing Policies and Procedure 2nd edition 2011, Hemodialysis –

MOH – KSA – SRN:HN -012
2. NSP/HM # 039.15, Declotting of Vascular Access by using Tissue
Plasminogen Activator (t-PA), 4th Edition, October 2015 (Deleted)
3. www.kidney.org

VI. ATTACHMENTS:

A. Special Considerations in the Administration of Tissue Plasminogen Activator (t-PA)

B. Guidelines for the use of Alteplase for the occluded Hemodialysis catheters
C. Algorithm for the use of Alteplase in occluded HD CVCs
 

VII. DISTRIBUTIONS:

1. Hemodialysis Unit
2. Central Nursing Office

Title: Management of clotted access / extra corporeal circuit

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NSP/HM # 039.14 06 August 2018 August 2018 August 2021 4 of 5
 SPECIAL CONSIDERATION IN THE ADMINISTRATION OF TISSUE
PLASMINOGEN ACTIVATOR (t-PA)

The guidelines apply to the following types of catheters and ports:

1. Tunneled
2. Central Venous
3. Subclavian

Equipment/Supplies:
1. Sterile water for injection
2. Tissue Plasminogen Activator (t-PA)
3. Two syringes (10ml)
4. Alcohol swabs

A. The following reactions have been associated with t-PA in doses recommended for lysis of
pulmonary embolism. Possible adverse reactions include:
• Bleeding
• Allergies (Bronchospasm, skin rash, and fever)
• Anaphylaxis
• Nausea and vomiting, fever and chills, shaking chills (rigors), transient hypotension or
hypertension, dyspea, tachycardia, cyanosis, back pain, hypoxemia, acidosis.

B. NOTE: Because thrombolytic therapy increases the risk of bleeding, t-PA is

contraindicated in the following situations.

1. Active internal bleeding.

2. History of cerebral vascular bleeding.
3. Recent (within 2 months) intracranial or intraspinal surgery.
4. Recent trauma including cardiopulmonary resuscitation.
5. Intracranial neoplasm, arteriovenous malformation, or aneurysm.
6. Known predisposition toward bleeding.
7. Severe uncontrolled hypertension.

Patient/Family Education:
The patient and family/significant other(s) should be educated at their level of understanding of the
following:
a) The purpose of t-PA.
b) Potential adverse reactions of t-PA.

Documentation:
a) When using t-PA, document verification of occlusion, volume of t-PA instilled, number of
attempts required, result of instillation, and patient response in the medical record. Document
dosage of t-PA on Medication Administration Record (MAR) Outpatient Assessment Form.
b) Any adversity caused by t-PA should promptly be reported as an adverse drug.
c) Document patient/family education in the Patient Family Education Form.

ATTACHMENT - A
NSP/HM - 039.14
 ALMANA GENERAL HOSPITAL – HEMODIALYSIS UNIT AL AHSA
GUIDELINES FOR THE USE OF ALTEPLASE FOR THE OCCLUDED
HEMODIALYSIS CATHETERS
 

A well functioning vascular access is a prerequisite for Hemodialysis (HD). To be consistent with
national and international standards, the preferred form of HD vascular access as the native arterio
venous fistula (AVF), followed by the artificial Arteriovenous graft (AVG) and lastly the central
venous catheter (CVC).

Despite all best efforts for patients undergoing HD to have an AVF (preferred) or AVG (2nd choice),
there will always be patients that receive HD by CVC on a temporary or permanent basis. The most
common complications of the CVC are thrombosis and infection (Develter, 2005 and Little, 2001).
Even with care, fewer than half the catheters placed as “long-term accesses” are in use a year after
placement (Ponikvar, 2005)and about a third are remove d because they fail to deliver adequate blood
flow (K/DOQI 2006)

The initial approach for the treatment of a dysfunctional or blocked catheter is conservative – rule out
mechanical issues such as machine problems or kinks in the catheter and forcefully flush the lines with
normal saline. If conservative measures fail, the administration of thrombolytic agents may be
required.

Prevent and / or reduced incidences of CVC-related thrombosis by:

Regularly assessing dialysis performance and early recognition of problems.

Forceful flushing with normal saline pre and post dialysis and capping the CVC pre-and post dialysis
with heparin
Using the newer catheters that are capable of achieving rates of ≥400 ml/min when properly placed.

Signs of CVC dysfunction include (KDOQI, 2006)

Blood flow rate < 300 ml/min

Arterial pressure (< -250 mm Hg)or Venous pressure (>250 mm Hg)
Urea reduction ratio (URR) progressively < 65%
Unable to aspirate blood freely
Frequent pressure alarms – not responsive to patient repositioning or catheter flushing.

If CVC dysfunction is identified, rule out causes other than thrombosis as the source of the
dysfunction.

Causes of CVC dysfunction other than thrombosis is included mechanical reasons, kinks, misplaced
sutures, catheter migration, drug precipitation, hypovolemia, patient position, catheter integrity, holes
and cracks (KDOQI;2006)such causes need to be ruled out prior to the use of thrombolytics.

Use of recombinant tissue plasminogen activators (TPA) (Alteplase)

ALTEPLASE USE FOR OCCLUDED HD CATHETERS
If CVC dysfunction is related to thrombosis, administer Alteplase as per physicians order.
ATTACHMENT – B
NSP / HM – 039.14
After mechanical reasons, thrombotic occlusion (partial or total) is the most common cause of catheter
dysfunction and / or occlusion. Common sites of thrombus formation are the catheter lumen, the site
where the catheter enters the vein, the catheter tip and along the external surface of the catheter.

Alteplase is the thrombolytic agent of choice for treating occlude HD CVCs. Alteplase works by
binding to fibrin in a thrombus, then converting the entrapped plasminogen to plasmin which results in
local fibrinolysis (i.e. digests fibrin and dissolves blood clot).

While Alteplase has proven to be useful in the management of catheter related thrombotic occlusion.

Two methods used in AGH HD unit Al Ahsa are:

Push/ Pause,
Dwell (short and long)

Selection of method will depend on individual circumstances including the severity of the occlusion
and the timing and urgency of the need for dialysis.

Chronic use of Alteplase is strongly discouraged other than in exceptional circumstances (i.e., resistant
CVCs and :
CVC is the last option for HD access AND the patient is unable to tolerate further CVC replacements;
ORA maturing AVF or AVG is imminent.

IF NO FLOW OR BLOOD PUMP SPEED IS LESS THAN 200 ML/MIN 

PUSH / PAUSE METHOD: 
• Instill Alteplase 1mg per mL into each catheter lumen then add NS 0.9% without preservative to fill the 
internal volume of each lumen plus 0.1mL overfill 
• Attach syringe filled with NS 0.9% to each lumen. Wait 10 minutes, then gently push NS 0.9% 0.3 mL 
into each lumen. Wait another 10 minutes, and then repeat NS 0.9% 0.3 mL push. Wait another 10 
minutes, than aspirate clots using a 10 mL syringe and discard. May push remaining Alteplase if unable 
to withdraw. Forcefully flush each catheter lumen. 
 

SHORT DWELL METHOD: 
• Instill Alteplase 1mg per mL into each lumen then add NS0.9% without preservative to fill the internal 
volume of each lumen plus 0.1 mL overfill. 
• Leave Alteplase solution in situ for 60 minutes, then withdraw the solution and clot(s); May push 
remaining if unable to withdraw. Forcefully flush each catheter lumen. 
 
OVERNIGHT DWELL METHOD: 
• Instill Alteplase 1mg per mL into each catheter lumen then add NS 0.9% without preservative to fill the 
internal volume of each lumen plus 0.1mL overfill 
• Leave Alteplase solution in situ until next Hemodialysis treatment. Prior to start of next treatment, 
withdraw the solution and clot(s); May push remaining if unable to withdraw. Forcefully flush each 
catheter lumen. 
ATTACHMENT – B
NSP / HM – 039.14
 
 ALMANA GENERAL HOSPITAL – HEMODIALYSIS UNIT‐ AL AHSA 

ALGORITHM FOR THE USE OF ALTEPLASE IN OCCLUDED HD CVCs 
Difficulty instilling or aspirating catheter lumens, blood pump speed < 250ml/min or decrease in blood flow of 20% during HD
 
↓ 
• Rule out machine problems   
  • Check for kinks beneath catheter clamps or at exit site 
• Change patient position 
• Confirm the HD catheter has not been used for non‐HD uses (e.g. TPN) 
  • Flush lines forcefully with 20 ml NS into each lumen 
• Reverse lumens & increase BPS as high as possible 
  • If a maturing peripheral access, is it ready to be cannulated? 
• If catheter inserted < 1 week, obtain order for CXR to rule out catheter position problem 
 
                                       ↓ 
  Adequate flow?  → Yes →  Adequate blood flow established; proceed with HD; continue to observe & monitor; 
lock catheter with heparin
                                                   ↓ 
                                NO 
                ↓ 
               As per physician orders, instill Alteplase using one of the following methods:
  1. If no flow or blood pump speed < 200 ml/min, instill 1‐2mg/ lumen using: 
a. Push / pause method; or 
b. Short dwell method (60 minutes); or 
  c. Long dwell method (over night) 
2. If blood pump speed is ≥ 200 ml/ min and ≥ 300 ml / min: 
  a. Instill 1‐2mg / lumen using the long dwell method (overnight) 

                                         ↓ 
 
        YES     Adequate Flow?                 
                                           ↓ No 
Repeat instillation of Alteplase using one of the 
                             
                                     ↓      No 
                        
                                                                  YES                                           
Adequate Flow?
                                                                                                                       NO 
                                                                                                                ↓ 
  Contact treating physician to investigate and INTERVENE:
• Chest X‐ray PA & Lateral 
• CVC Exchange 
  • Creation of AVF or AVG (if feasible) 

                
Under the exceptional circumstances,
Adequate Flow? 
                                                                            ↓ YES                                  YES  NO 
Treating physician may consider 
implementing the protocol for 
                                                                           ↓ 
                                                                           YES  resistant CVC (Alteplase to cap off 
                                                                            ↓  CVC post‐ dialysis 1‐3 x/wk 
   
Adequate blood flow is established; proceed with HD; continue 
    to observe & monitor; lock catheter with heparin 

ATTACHMENT – C
NSP / HM – 039.14