Original Title: Initier un traitement pharmacologique pour la désobstruction d’un dispositif d’accès veineux central (DAVC)

Authors' objectives: The Ministère de la Santé et des Services sociaux (MSSS) tasked the Institut national d'excellence en santé et en services sociaux (INESSS) with developing, updating and hosting the current national medical protocols and prescription templates. The Direction nationale des soins et services infirmiers (DNSSI) of the MSSS has asked INESSS, in connection with the Québec Cancer Program’s action plan, to develop a national medical protocol on pharmacological treatment to clear a central venous access device (CVAD) occlusion prior to the administration of treatment with an antineoplastic agent or another dug.

Authors' results and conclusions: The data search yielded 1,710 documents, from which we selected six clinical practice guidelines containing clinical practice recommendations concerning pharmacological treatment aimed at CVAD clearance in children or adults. Four of these guidelines (Canadian Vascular Access Association, the Italian Association of Pediatric Hematology and Oncology, the University of Wisconsin Hospitals and Clinics Authority, and the group consisting of the European Society for Paediatric Gastroenterology Hepatology and Nutrition, the European Society for Clinical Nutrition and Metabolism, the European Society of Paediatric Radiology and the Chinese Society of Parenteral and Enteral 2 Nutrition) were considered to be of sufficient methodological quality for use according to the AGREE II instrument. The clinical practice guidelines of the Association for Vascular Access and the Infusion Nurses Society were selected despite their lower methodological quality because they contain recommendations concerning the pediatric population. The national medical protocol (NMP) and collective prescription (CP) template development process involved identifying the best clinical practices for pharmacologically clearing an occluded CVAD. A CVAD occlusion manifests as slow or no blood return, resistance to flushing or the inability to flush. However, pharmacological treatment of an obstruction should be reserved only for thrombotic occlusions. One of the main challenges in managing CVAD occlusions is, therefore, the differential diagnosis that needs be made to ensure that pharmacological treatment is not administered in cases where it would be ineffective. This is because other types of occlusion, notably mechanical and chemical, can sometimes be mistaken for a thrombotic occlusion. It is therefore important to carefully look for signs or symptoms that can serve to distinguish between these clinical situations. This work also revealed that only one thrombolytic agent is available in Québec for the purpose of CVAD clearance, namely, alteplase. Furthermore, the use alteplase for CVAD clearance is relatively safe, given the low doses administered and the fact that alteplase very rarely enters the bloodstream. However, this agent should not be used, without a more thorough medical evaluation, in patients with certain conditions, such as an infection, a thrombosis or active bleeding. In addition, it is used differently in the pediatric and adult populations, mainly because of the lengths of these devices that differs between these two populations. Conclusion: The development of this national medical protocol and the corresponding collective prescription template was based on best clinical practice recommendations, which were enhanced with experiential knowledge provided by different experts and clinicians and with contextual information. Given the analysis involving the triangulation of data from these different sources, the protocol and prescription template should address the issues raised and thus limit the barriers to the use of this treatment while at the same time promoting interprofessional work, which should limit the delays associated with its administration.

Authors' methods: Methodology: A systematic review of clinical practice guidelines (CPGs), expert consensus statements, guidance documents and other publications containing relevant clinical recommendations was carried out in several databases in accordance with INESSS’s standards. The literature search was limited to items published between January 2015 and June 2020. The items selected concern CVAD occlusion in children and adults. The search parameters were the contraindications to pharmacological treatment, the criteria for assessing a patient’s medical condition, physical examinations, medication modalities, the adverse events, precautions and drug interactions that one should be aware of in order to initiate pharmacological treatment, and the necessary post-treatment monitoring. In addition, a manual literature search was performed by consulting the websites of health technology assessment agencies and North American regulatory agencies, and those of government agencies and professional associations or bodies pertaining to the topic of interest. The bibliographies in the selected publications were examined for other relevant items. The data were analyzed from the perspective of contextualizing the practice in Québec, using mainly legislative, regulatory and organizational contextual elements specific to Québec and experiential knowledge provided by the different stakeholders consulted.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/thematiques/medicaments/protocoles-medicaux-nationaux-et-ordonnances-associees/protocoles-medicaux-nationaux-et-ordonnances-associees/davc.html

Year Published: 2021

URL for published report: https://www.inesss.qc.ca/thematiques/medicaments/protocoles-medicaux-nationaux-et-ordonnances-associees/protocoles-medicaux-nationaux-et-ordonnances-associees/davc.html

English language abstract: An English language summary is available

Publication Type: Other

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)