945

Abstract

Introduction: Alteplase (recombinant tissue plasminogen activator) is the primary therapeutic option to noninvasively salvage an occluded catheter due to thrombus. The use of alteplase as a dwell to clear partially occluded central venous catheters has been well documented; however, the practice of using a low-dose 3-hour infusion has been in place for many years at our institution. The purpose of this study was to evaluate the efficacy and safety of alteplase infusions versus dwells to clear partially occluded central venous catheters in a pediatric intensive care unit (PICU) population over the same period of time. Methods: Medical records of PICU patients who received either an alteplase infusion or dwell as the primary treatment for a partial catheter occlusion from November 2006 through August 2011 were retrospectively reviewed for efficacy and safety. All types of central venous catheters were included. Infusion regimens were typically alteplase 0.1 mg/kg up to 2 mg mixed in 25 mL normal saline and infused over 3 hours; dwells consisted of 1 mg/mL alteplase instilled for up to 2 hours in doses ranging from 0.5 mg to 2 mg based on catheter lumen size per manufacturer recommendations. Efficacy was defined as documentated positive blood return from the catheter at the conclusion of the infusion or dwell. Physician, nursing and radiology documentation and laboratory values were reviewed to assess for bleeding events. Results: Of 346 alteplase orders, 261 were excluded for the following reasons: 2, systemic thrombolysis; 4, chest tube instillations; 19 infusions: dose not given or inadequate documentation to assess outcome; 192 dwells: full occlusion or unknown occlusion type. Eighty-five infusions and 64 dwells occurred during the study period and were included for analysis. Occlusions were cleared after the first alteplase dose in 71 of 85 (84%) of infusions compared to 49 of 64 (77%) of dwells; p=.289, 2-sided Fisher's exact test. In situations where the first dose failed to clear the occlusion, repeat doses were successful in one patient in the infusion group and in two patients in the dwell group, bringing the overall efficacy to 85% for infusions and 80% for dwells; p=.514. No bleeding events were attributed to alteplase. Conclusions: Alteplase low-dose 3-hour infusions were not found to be more effective than dwells for clearing partial central venous catheter occlusions in this retrospective study. The small sample size and the large number of cases with missing or inadequate documentation regarding catheter patency limited the interpretation of efficacy outcomes. Both regimens were associated with an acceptable safety profile.