Occlusion Assessment & Management

What is the optimal management of partial and complete occlusions of central venous access devices (CVADs) and occluded peripheral intravenous cannulas (PIVCs) for adult and paediatric patients with cancer?

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TERMINOLOGY

Common language facilitates communication between professional and organisations, the translation of evidence into clinical practice, data sharing, and research. CNSA, eviQ and eviQ Education are leading vascular access management and education in cancer care in Australia utilizing common, contemporary terminology (Table 1).

Table 1: CVAD terminology

INTRODUCTION

Occlusion is one of the most frequent Central venous access device (CVAD)complication, occurring in 14-36% of patients (1-14). Occlusions are associated with interruption of therapies, increased risk and cost of occlusion reversal therapies and potential complications related to CVAD reinsertion (15). In the paediatric patient population, overall survival is negatively impacted by CVAD occlusion (16).

Standardised, evidence based clinical guidelines for the prevention, diagnosis, and management of occlusion are lacking (15). Implementation of an algorithm to guide clinical practice in the assessment and appropriate management based on the infusate, CVAD, patient age and catheter material has the potential to improve compliance with evidence based recommendations (17). Furthermore, it is recommended occlusion management is performed by skilled practitioners (4).

Comparatively, in 2021 the Australian Commission on Quality and Safety in Healthcare published the first clinical care standard for the management of peripheral cannulas (18). The aim of this document is to promote standardised, evidence-based clinical care of PIVCs and details ten quality statements or areas of care to reduce PIVC complications. One area of care is regular observation and assessment for signs of complications, for example occlusion (18). Prevention of PIVC occlusion is key as the most efficient use of resources for PIVC occlusion is removal (19).

SUMMARY OF RECOMMENDATIONS

CENTRAL VENOUS ACCESS DEVICES

CNSA recommends the implementation of standardised, evidence based clinical guidelines e.g. a patency management algorithm for the assessment and management of partial and complete occlusions of central venous access device for adult and paediatric patients with cancer (15,17).

CNSA recommends that educated and competent clinicians are involved with occlusion management of central venous access device occlusion for paediatric and adult patients with cancer (4).

PERIPHERAL INTRAVENOUS CANNULA (PIVC)

CNSA recommends that occluded peripheral intravenous cannulas for paediatric and adult patients with cancer are removed (19).

Prevention of PIVC occlusion is key. Recommendations for clinical practices to optimise PIVC patency include: (18,20,21)

  • educated and competent clinicians insert and maintain PIVCs
  • selection of smallest gauge for the prescribed therapy
  • appropriate size and length of cannula for the vein e.g. 20-24 gauge
  • infuse peripherally compatible medications and solutions e.g. osmolarity < 600 Osm/L, avoid extremes in pH
  • stable insertion site: forearm and avoid areas of flexion, chest wall, breast, digits, lower extremities, abdomen veins that are compromised (e.g. bruised, hard)
  • use of vein visualisation technology e.g. near-infrared or ultrasound
  • adequate securement and application of dressing to prevent micromotion and migration e.g. tissue adhesive, bordered dressings, securement device
  • attach short extension tubing with bonded needleless connector to cannula to prevent micromotion
  • refer to flush and lock question

Paediatric patients:

  • avoid fingers, thumbs, hand used for sucking
  • consider forearm, hand, upper arm below axilla, scalp for under 18 months of age, foot if not walking 

SECTION A: CENTRAL VENOUS ACCESS DEVICES

1. Summary of Evidence

Patency assessment includes the aspiration AND the injection ability of a CVAD (22).

Investigate any deviance from easy aspiration and injection to assess the potential different types of occlusion including:

  1. Mechanical (3,19,23-29)
  2. Venous thrombosis (24)
  3. Chemical (8,9,19,25,26,28,30-32)
  4. Thrombotic _1-4,6-9,15,19,23-26,28,29,32-50)

Radiological studies: investigate if thrombolytics are not successful (25,26,33,39,45,49-52)

Final step: exchange or removal if previous interventions are not successful (9,25,28-32,49)

Implement a patency algorithm for standardised, evidence based prevention, assessment, and management (17).

Refer to Patency Management Algorithm For Central Venous Access Devices (CVADS)

Refer to Summary of Evidence: Occlusions for a detailed summary of evidence

SECTION B: PERIPHERAL INTRAVENOUS CANNULA (PIVC)

Patency assessment includes the aspiration AND the injection ability of a CVAD (22).

There is no evidence regarding the management of occluded PIVCs. Expert opinion is to remove occluded PIVCs as the most efficient for resource management (19).

Vascular access evidence and recommendations for all patient populations identify that prevention of occlusion is key. Recommendations for clinical practices to optimise PIVC patency include: (18,20,21)

  • educated and competent clinicians insert and maintain PIVCs
  • selection of smallest gauge for the prescribed therapy
  • appropriate size and length of cannula for the vein e.g. 20-24 gauge
  • infuse peripherally compatible medications and solutions e.g. osmolarity < 600 Osm/L, avoid extremes in pH
  • stable insertion site: forearm and avoid areas of flexion, chest wall, breast, digits, lower extremities, abdomen veins that are compromised (e.g. bruised, hard)
  • use of vein visualisation technology e.g. near-infrared or ultrasound
  • adequate securement and application of dressing to prevent micromotion and migration e.g. tissue adhesive, bordered dressings, securement device
  • attach short extension tubing with bonded needleless connector to cannula to prevent micromotion
  • refer to flush and lock question

Paediatric patients:

  • avoid fingers, thumbs, hand used for sucking
  • consider forearm, hand, upper arm below axilla, scalp for under 18 months of age, foot if not walking

Refer to Patency Management Algorithm For Central Venous Access Devices (CVADS).

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