Alteplase use for prevention of central line occlusion in a preterm infant

OBJECTIVE: To report the use of alteplase for catheter clearance in a neonate of 27 weeks' gestation at day 50 of life. SETTING: Neonatal Intensive Care Unit, Naval Medical Center. CASE SUMMARY: At day 50 of life, a neonate boy of 27 weeks' gestation had a clotted peripherally inserted central catheter line. He required central access to complete a 28-day course of amphotericin B. An alteplase dose of 0.3 mg/0.3 mL was instilled into the catheter, for an indwelling time of 1 hour. The initial attempt was successful, and the patient was able to finish the course of amphotericin B. DISCUSSION: When a catheter becomes occluded, the cause must be determined initially; then an appropriate treatment option can be initiated. Hydrochloric acid and ethanol are some of the pharmacologic agents available, with their use dependent on the precipitating cause of the occlusion. Thrombolytic agents, such as streptokinase and urokinase, have also been used in catheter clearance. The potential risk of anaphylactic reactions with streptokinase and the unavailability of urokinase have clinicians searching for other pharmacologic alternatives. Alteplase, a synthetic tissue plasminogen activator, has been shown to be a promising alternative agent. There are various reports of alteplase use in pediatric patients for catheter clearance, with different suggested doses ranging from 0.25 to 2 mg. To minimize the risk of bleeding events, initiation with low doses from the suggested range is recommended. CONCLUSIONS: Alteplase was shown to be safe and effective for clearance of an occluded central line in a preterm infant.