Research in practice

Effectiveness of urokinase for salvaging occluded central venous access devices

A literature review explores the effectiveness of urokinase in salvaging occluded central venous access devices.

It is estimated 20,000 central venous access devices (CVADs) are inserted each year in the UK (Flood and Flood 2016). Occlusion is a complication occurring in up to 50% of children with long-term CVADs (Verso and Agnelli 2003). An occluded device prevents crucial treatments being delivered.

Picture: Alamy

Fibrinolytic drugs, such as urokinase, are used as a first line of action to clear the blockage, yet the effectiveness of fibrinolytic drugs is uncertain. Salvaging occluded CVADs prevents the patient needing a replacement, which would be inserted as a surgical procedure. Side effects and costs associated with inserting a new CVAD are higher than those for instilling urokinase.

Aim

The aim of this literature review was to explore the effectiveness of urokinase in salvaging occluded CVADs.

Methods

A literature review using a systematic approach was undertaken. EMBASE and MEDLINE databases were searched as they index patient treatments widely. Reference lists of relevant papers were reviewed. Selection criteria included the fact that participants must include children and urokinase as the intervention. Studies were assessed using critical appraisal tools appropriate to the research method (Critical Appraisals Skills Programme 2017).

Findings

Five quantitative studies were included in the review (Table 1). Application of CASP tools suggested the studies' methods were appropriate and results valid and reliable, although the number of child participants was small.

Conclusion

The review found that urokinase is effective in salvaging occluded CVADs. However, further research - such as a large, randomised controlled trial of other fibrinolytic drugs - needs to be undertaken as one study found alteplase was superior in restoring patency than urokinase (Bussiéres et al 2001).

Table 1. Summary of studies reviewed

Reference Main findings
Bussiéres JF, Therrien R, David M et al (2001) Efficacy of urokinase and alteplase to reopen occluded central venous catheters in children. Journal of Pharmacy Technology. 17, 3, 95-98. Urokinase successful in 54.4% of cases. Alteplase successful in 93.2% of cases.
Svoboda P, Barton RP,Barbarash OL et al (2004) Recombinant urokinase is safe and effective in restoring patency to occluded central venous access devices: a multiple-center, international trial. Critical Care Medicine Journal. 32, 10, 1990-1996. Urokinase is safe and effective to use, creating total catheter patency in 75% of central venous access devices (CVADs).
Haire W, Deitcher SR,Mullane KM et al (2004) Recombinant urokinase for restoration of patency in occluded central venous access devices. Journal of Thrombosis and Haemostasis. 92, 3, 575-582. Urokinase more successful than placebo in restoring catheter function (54% versus 30%).
Deitcher S, Fraschini G,Himmelfarb J et al (2004) Dose-ranging trial with a recombinant urokinase (urokinase alfa) for occluded central venous catheter in oncology. Journal of Vascular and Interventional Radiology. 15, 6, 575-580. For all three concentrations of urokinase used, all three were superior to placebo to restore total patency.
Kalmanti M,Germanakis J,Stiakaki E et al (2002) Propylaxis with urokinase in pediatric oncology patients with central venous catheters. Journal of Pediatric Hematology and Oncology. 19, 3, 173-179. Thrombopropylaxis led to lower incidence of CVAD dysfunction and higher salvage rate of CVADs.

Reflections

With the support of a supervisor, I am confident the search was extensive and that relevant papers were selected to review. The experience was valuable, as there is a need to ensure the care provided to children is evidence based.

Implications for practice

As the risks and costs associated with catheter replacement are considerable, the use of intracatheter thrombolysis remains the treatment choice for CVAD occlusions.

The review found 5000IU/mL strength of urokinase was effective and safe to use as a prophylactic measure or to manage CVAD occlusions.

References

  • Bussiéres JF, Therrien R, David M et al (2001) Efficiacy of urokinase and alteplase to reopen occluded central venous catheters in children. Journal of Pharmacy Technology. 17, 3, 95-98.
  • Critical Appraisals Skills Programme (2017) Appraising the Evidence.
  • Flood S, Flood K (2016) Central venous catheters – staying safe at the sharp end. Journal of the Intensive Care Society. 17, 4, 277- 279.
  • Verso M, Agnelli G (2003) Venous thromboembolism associated with long-term use of central venous catheters in cancer patients. Journal of Clinical Oncology. 21, 19, 3665-75.

Kelsey Dyson-Fleming was a nursing student at the time of writing and is now a staff nurse at Royal Manchester Children’s Hospital. Written on behalf of the RCN’s Research in Child Health community

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