Time to Administration, Outcome and Cost Comparison of 2 Different Strategies to Dispense Alteplase in Pediatric Intestinal Failure.

Abstract

Objective: Central venous catheter (CVC) thrombosis is a serious complication in pediatric intestinal failure (IF) patients who require long-term parenteral nutrition. Alteplase is commonly used to restore patency in catheter-related thrombosis. Dispensing practices may vary and include constitution of 2-mg ready-to-use vials by nursing staff or thawing of batched frozen syringes from previously cryopreserved larger alteplase vials, which requires pharmacy involvement. Objectives included comparing time to administration, CVC patency restoration rates, and cost between dispensing methods.

Methods: Single-center retrospective study evaluating patients with IF who presented with catheter-related thrombosis and received alteplase between 2011 and 2017. Patients were consecutively enrolled from the Pediatric Intestinal Rehabilitation program's institutional database. Data included IF-related care during outpatient visits, emergency department (ED) visits, and hospitalizations, including thrombosis events. CVCs were placed by either a pediatric surgeon or the vascular access team, depending on catheter type. Removal occurred if patients were weaned off parenteral nutrition, had an irreparable line break, or a nonsalvageable infection. We reported the efficacy of the intervention in restoring CVC patency using a weight-based alteplase dosing. Cost analysis included assessment of medication cost, pharmacy technician, pharmacist, and nursing time.

Results: We recorded 83 alteplase administrations in 16 patients. Most (81.9%) were instilled in tunneled single-lumen silicon catheters. Alteplase installation was performed in the outpatient clinic (35%), inpatient (59%), and the ED (6%). Ready-to-use 2-mg vials were used in 31% of cases. Median time to administration was significantly shorter with ready-to-use 2-mg vials compared with thawed frozen syringes, at 15 and 71 minutes, respectively (p < 0.0001). The success of restoring patency was noted in 65% and 70% of cases after 1 and 2 doses of alteplase, respectively. Cost was similar between dispensing thawed frozen syringes and ready-to-use 2-mg vials, at $189.0 and $190.4, respectively (based on 2023 expense data).

Conclusions: In this population with long-term CVC dependence, dispensing alteplase using ready-to-use 2-mg vials was associated with a significantly shorter time to administration and comparable cost compared with batching and dispensing thawed frozen syringes.