%PDF-1.4 % 12 0 obj <> endobj 72 0 obj <>stream /Artifact <>BDC q 1 i 0 841.89 595.276 -841.89 re 297.645 420.96 m W n .015015 841.89 595.29 -841.89 re W n .75 .25 0 0 k /GS1 gs .015015 0 595.29 31.48 re f EMC /P <>BDC BT /TT8 1 Tf 36 0 0 36 37.3675 747.9142 Tm .97 .75 .04 0 k -.0103 Tc .0003 Tw (Management of Home)Tj ET EMC /P <>BDC BT 36 0 0 36 406.8752 747.9142 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 36 0 0 36 37.3675 714.9142 Tm -.0109 Tc .0009 Tw [(P)14.1(a)-.9(renteral Support)]TJ ET EMC /P <>BDC BT 36 0 0 36 353.7032 714.9142 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 36 0 0 36 37.3675 681.9142 Tm -.0109 Tc .0009 Tw [(C)9.1(atheter Occlusion)]TJ ET EMC /Figure <>BDC Q q 1 i 496.755 795.282 75.744 -74.544 re W n 492.16 795.282 84.942 -57.667 re 348.555 681.914 m W* n 0 841.89 595.276 -841.89 re 297.645 420.96 m W n .015015 841.89 595.29 -841.89 re W n .97255 .71373 .023529 0 k /GS1 gs q 1 0 0 1 499.837 753.98 cm 0 0 m 5.5545 0 l 7.5996 .0331 9.8448 -.499 9.8448 -2.9767 c 9.8448 -4.0414 9.213 -4.9058 8.2818 -5.3723 c 9.5456 -5.7379 10.327 -6.8356 10.327 -8.1819 c 10.327 -11.009 8.2485 -11.874 5.7042 -11.874 c 0 -11.874 l 0 0 l h 3.093 -4.6738 m 5.4879 -4.6738 l 6.0198 -4.6738 6.7521 -4.3907 6.7521 -3.5425 c 6.7521 -2.6777 6.1364 -2.3947 5.4879 -2.3947 c 3.093 -2.3947 l 3.093 -4.6738 l h 3.093 -9.3963 m 5.5707 -9.3963 l 6.5521 -9.3963 7.234 -9.0474 7.234 -8.066 c 7.234 -7.0176 6.5019 -6.6685 5.5707 -6.6685 c 3.093 -6.6685 l 3.093 -9.3963 l f Q q 1 0 0 1 518.396 753.98 cm 0 0 m 3.1428 0 l 7.5832 -11.874 l 4.3569 -11.874 l 3.6252 -9.7454 l -.5156 -9.7454 l -1.2638 -11.874 l -4.4403 -11.874 l 0 0 l h .1995 -7.4501 m 2.8936 -7.4501 l 1.5798 -3.2931 l 1.5463 -3.2931 l .1995 -7.4501 l f Q q 1 0 0 1 530.203 753.98 cm 0 0 m 5.6375 0 l 7.8495 0 9.928 -1.0146 9.928 -3.8248 c 9.928 -6.7686 8.2487 -7.9164 5.6375 -7.9164 c 3.0932 -7.9164 l 3.0932 -11.874 l 0 -11.874 l 0 0 l h 3.0932 -5.5215 m 5.1719 -5.5215 l 6.1364 -5.5215 6.8348 -5.1225 6.8348 -4.0414 c 6.8348 -2.9268 6.1201 -2.4785 5.1719 -2.4785 c 3.0932 -2.4785 l 3.0932 -5.5215 l f Q q 1 0 0 1 544.92 753.98 cm 0 0 m 9.4625 0 l 9.4625 -2.4785 l 3.0934 -2.4785 l 3.0934 -4.5567 l 8.9136 -4.5567 l 8.9136 -6.9515 l 3.0934 -6.9515 l 3.0934 -9.2134 l 9.629 -9.2134 l 9.629 -11.874 l 0 -11.874 l 0 0 l f Q q 1 0 0 1 559.605 753.98 cm 0 0 m 3.1765 0 l 7.3007 -7.3173 l 7.3338 -7.3173 l 7.3338 0 l 10.244 0 l 10.244 -11.874 l 7.0679 -11.874 l 2.9438 -4.4739 l 2.9105 -4.4739 l 2.9105 -11.874 l 0 -11.874 l 0 0 l f Q 1 .14999 0 0 k q 1 0 0 1 546.25 780.84 cm 0 0 m 0 -6.6269 -5.3719 -11.999 -11.999 -11.999 c -18.625 -11.999 -23.998 -6.6269 -23.998 0 c -23.998 6.6268 -18.625 11.999 -11.999 11.999 c -5.3719 11.999 0 6.6268 0 0 c h -11.999 8.9508 m -16.942 8.9508 -20.95 4.9435 -20.95 0 c -20.95 -4.9434 -16.942 -8.9507 -11.999 -8.9507 c -7.0552 -8.9507 -3.0485 -4.9434 -3.0485 0 c -3.0485 4.9435 -7.0552 8.9508 -11.999 8.9508 c f Q Q q 1 i 496.757 795.282 75.742 -74.542 re W n 496.755 795.282 75.744 -74.544 re W n 492.16 795.282 84.942 -57.667 re 348.555 681.914 m W* n 0 841.89 595.276 -841.89 re 297.645 420.96 m W n .015015 841.89 595.29 -841.89 re W n .97255 .71373 .023529 0 k /GS1 gs q 1 0 0 1 534.324 759.034 cm 0 0 m -1.4904 5.0074 -7.5067 8.5244 y -9.4938 9.8955 -11.646 11.863 y -15.51 15.201 -15.621 21.997 y -15.731 30.045 -8.8313 36.185 y -22.134 35.768 -22.134 22.474 y -22.299 13.83 -14.13 9.5379 y -3.4221 4.888 -2.7048 1.1923 y -6.2923 4.8287 -14.793 7.9279 y -25.335 12.816 -24.71 22.499 y -24.562 31.356 -16.448 36.244 y -31.021 36.483 -31.131 22.235 y -30.902 9.2332 -16.393 5.8416 y -12.695 4.5898 -7.8931 2.742 y -3.6276 .9151 -1.6837 -2.3201 -1.3124 -3.1226 c -.9414 -3.9241 .9764 -3.8447 1.2549 -3.1932 c 1.5333 -2.5418 3.5612 .8863 7.8929 2.742 c 12.696 4.5898 16.394 5.8416 v 30.902 9.2332 31.131 22.235 v 31.021 36.483 16.449 36.244 v 24.563 31.356 24.711 22.499 v 25.336 12.816 14.793 7.9279 v 6.2927 4.8287 2.7048 1.1923 v 3.4225 4.888 14.131 9.5379 v 22.299 13.83 22.134 22.474 v 22.134 35.768 8.8313 36.185 v 15.731 30.045 15.621 21.997 v 15.51 15.201 11.647 11.863 v 9.494 9.8955 7.5071 8.5244 v 1.4904 5.0074 0 0 v f Q EMC /Artifact <>BDC Q q 1 i 0 841.89 595.276 -841.89 re 297.645 420.96 m W n .015015 841.89 595.29 -841.89 re W n .97 .75 .04 0 k /GS1 gs 38.993 385.946 519.699 269.526 re f EMC /P <>BDC BT /TT6 1 Tf 11 0 0 11 60.093 627.1054 Tm 0 0 0 0 k .01 Tc .2033 Tw [(A fully func)10(tioning central v)25(enous ca)10(the)13(t)13(er is essential f)20(or the adminis)19(tra)10(tion of home)]TJ ET EMC /P <>BDC BT 11 0 0 11 538.9953 627.1054 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 544.1134 627.1054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 549.2314 627.1054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 554.3496 627.1054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 559.4677 627.1054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 564.5857 627.1054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 569.7039 627.1054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 574.8219 627.1054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 579.9399 627.1054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 585.058 627.1054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 590.176 627.1054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 595.2942 627.1054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 60.093 611.4054 Tm -.0003 Tc -.0375 Tw [(par)14(ent)13(eral support \(HPS\). Early and ur)12(g)20(ent int)13(erv)25(ention f)20(or ca)10(the)13(t)13(er occlusion is necessary t)13(o)]TJ ET EMC /P <>BDC BT 11 0 0 11 538.9952 611.4054 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 60.093 595.7054 Tm .0127 Tw [(pr)14(eserv)25(e long-t)13(erm v)28(ascular access. Manag)20(ement should be undertak)38(en b)42(y)0( an e)29(xperienced,)]TJ ET EMC /P <>BDC BT 11 0 0 11 538.9946 595.7054 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 60.093 580.0054 Tm .0087 Tc .0543 Tw [(fully trained, multidisciplinary t)13(eam \(MD)31(T\), a nutrition support t)13(eam \(NS)13(T\) within a HPS or)]TJ ET EMC /P <>BDC BT 11 0 0 11 538.9932 580.0054 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 542.4582 580.0054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 545.9232 580.0054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 549.3882 580.0054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 552.8533 580.0054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 556.3182 580.0054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 559.7832 580.0054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 60.093 564.3054 Tm .01 Tc .1623 Tw [(int)13(es)19(tinal f)20(ailur)14(e \(IF\) centr)14(e, or a v)28(ascular access t)13(eam. An intra)17(v)25(enous ca)10(the)13(t)13(er should)]TJ ET EMC /P <>BDC BT 11 0 0 11 538.9951 564.3054 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 543.6622 564.3054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 548.3293 564.3054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 552.9963 564.3054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 557.6633 564.3054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 562.3304 564.3054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 566.9975 564.3054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 571.6645 564.3054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 576.3315 564.3054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 580.9986 564.3054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 60.093 548.6054 Tm .01 Tc .0787 Tw [(ha)17(v)25(e)0( the minimum number of lumens r)14(equir)14(ed t)13(o)0( mee)13(t the v)28(ascular access needs of the)]TJ ET EMC /P <>BDC BT 11 0 0 11 538.995 548.6054 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 542.7424 548.6054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 546.4897 548.6054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 550.2371 548.6054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 553.9844 548.6054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 557.7318 548.6054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 561.4791 548.6054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 565.2264 548.6054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 568.9738 548.6054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 60.093 532.9054 Tm -.0163 Tw [(pa)10(tient)-39(, and ca)10(the)13(t)13(er manipula)10(tions mus)19(t be k)38(e)0(p)20(t)0( t)13(o)0( a minimum. All pr)14(ocedur)14(es in)8(v)25(olving the)]TJ ET EMC /P <>BDC BT 11 0 0 11 538.9949 532.9054 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 60.093 517.2054 Tm -.0031 Tc -.0347 Tw [(ca)10(the)13(t)13(er mus)19(t f)20(ollo)19(w e)20(vidence-based guidelines and an asep)20(tic non-t)13(ouch t)13(echnique \()26(ANTT\).)]TJ ET EMC /P <>BDC BT 11 0 0 11 538.9937 517.2054 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 60.093 501.5054 Tm .01 Tc .063 Tw [(An occlusion can be t)13(o)20(tal wher)14(e no)20(thing can be ins)19(tilled or aspira)10(t)13(ed, partial wher)14(e ther)14(e)]TJ ET EMC /P <>BDC BT 11 0 0 11 538.9949 501.5054 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 542.5693 501.5054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 546.1437 501.5054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 549.7182 501.5054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 553.2928 501.5054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 556.8672 501.5054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 560.4417 501.5054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 564.0161 501.5054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 567.5906 501.5054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 571.165 501.5054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 574.7395 501.5054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 578.314 501.5054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 581.8884 501.5054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 585.4629 501.5054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 60.093 485.8054 Tm .01 Tc .1668 Tw [(is r)14(esis)19(tance on )]TJ /TT9 1 Tf 8.3104 0 TD 0 Tc 0 Tw ()Tj /TT6 1 Tf .597 0 TD .01 Tc .1668 Tw [(ushing, or wher)14(e )]TJ /TT9 1 Tf 8.6074 0 TD 0 Tc 0 Tw ()Tj /TT6 1 Tf .597 0 TD .01 Tc .1668 Tw [(ushing is possible, but aspira)10(tion is no)20(t \(persis)19(t)13(ent)]TJ ET EMC /P <>BDC BT 11 0 0 11 538.9952 485.8054 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 543.712 485.8054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 548.4287 485.8054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 553.1455 485.8054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 557.8623 485.8054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 562.579 485.8054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 567.2958 485.8054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 572.0126 485.8054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 576.7292 485.8054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 581.446 485.8054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 586.1628 485.8054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 60.093 470.1054 Tm .0035 Tc .0595 Tw [(withdra)8(w)22(al occlusion [PW)28(O]\). An occlusion ma)16(y be due t)13(o)0( a )]TJ /TT9 1 Tf 29.0829 0 TD 0 Tc 0 Tw ()Tj /TT6 1 Tf .5895 0 TD .0035 Tc .0595 Tw [(brin shea)10(th co)25(v)25(ering the end)]TJ ET EMC /P <>BDC BT 11 0 0 11 538.9924 470.1054 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 542.4574 470.1054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 545.9225 470.1054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 549.3875 470.1054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 552.8525 470.1054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 556.3175 470.1054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 559.7825 470.1054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 563.2475 470.1054 Tm ( )Tj ET EMC /P <>BDC BT 11 0 0 11 60.093 454.4054 Tm -.0152 Tw [(of the ca)10(the)13(t)13(e)0(r)34(,)0( thr)14(ombus, lipid, particula)10(t)13(e)0( debris \()44(e.g. pr)14(o)20(t)13(ein or drug deposits)7(\) or kinking of)]TJ ET EMC /P <>BDC BT 11 0 0 11 538.9946 454.4054 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 60.093 438.7054 Tm -.0023 Tc -.0355 Tw [(the ca)10(the)13(t)13(er \(including pinch-off s)24(yndr)14(ome\). In clearing an occlusion ther)14(e is a risk of frac)10(tur)14(e)]TJ ET EMC /P <>BDC BT 11 0 0 11 538.9941 438.7054 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 60.093 423.0054 Tm -.0069 Tw [(and/)48(or inf)20(ec)10(tion. It is important f)20(or car)14(ers/pa)10(tients t)13(o)0( pr)14(omp)20(tly escala)10(t)13(e)0( an)16(y concerns about)]TJ ET EMC /P <>BDC BT 11 0 0 11 538.9948 423.0054 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 11 0 0 11 60.093 407.3055 Tm [(ca)10(the)13(t)13(er occlusion.)]TJ ET EMC /P <>BDC BT /TT8 1 Tf 12 0 0 12 38.9931 367.171 Tm .97 .75 .04 0 k [(K)30(e)10(y points)]TJ ET EMC /P <>BDC BT /TT11 1 Tf 8 0 0 8 97.6492 367.171 Tm 0 0 0 .8 k ( )Tj ET EMC /P <>BDC /GS2 gs BT /TT2 1 Tf 8 0 0 8 38.9931 350.0017 Tm 0 0 0 1 k (1.)Tj ET EMC /P <>BDC BT 8 0 0 8 48.2117 350.0017 Tm ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 50.3317 350.0017 Tm (Assessment:)Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 99.9717 350.0017 Tm [( Assessment should include e)23(xploring the e)20(v)25(ents )]TJ ET EMC /P <>BDC BT 8 0 0 8 48.2117 338.5016 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 50.3317 338.5016 Tm [(leading up t)14(o)0( the occlusion, including sudden or gradual onse)17(t)-52(,)0( )]TJ ET EMC /P <>BDC BT 8 0 0 8 48.2117 327.0017 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 50.3317 327.0017 Tm [(r)19(ecent r)19(esis)22(tance t)14(o)0( )]TJ /TT12 1 Tf 9.54 0 TD ()Tj /TT2 1 Tf .555 0 TD [(ushing, chang)20(es in ambula)14(t)14(ory pump )]TJ ET EMC /P <>BDC BT 8 0 0 8 48.2117 315.5017 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 50.3317 315.5017 Tm [(infusion pr)19(essur)19(es or occlusion alarms. It should be no)20(t)14(ed if the )]TJ ET EMC /P <>BDC BT 8 0 0 8 48.2117 304.0016 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 50.3317 304.0016 Tm [(ca)14(the)17(t)14(er is used f)20(or an)15(y purpose o)20(ther than HPS \()41(e.g. blood )]TJ ET EMC /P <>BDC BT 8 0 0 8 48.2117 292.5017 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 50.3317 292.5017 Tm [(sampling or adminis)22(t)14(ering medica)14(tion\) and if ther)19(e ha)19(v)25(e)0( been )]TJ ET EMC /P <>BDC BT 8 0 0 8 48.2117 281.0016 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 50.3317 281.0016 Tm [(dela)15(y)29(s)0( in taking do)19(wn the infusion.)]TJ ET EMC /P <>BDC BT 8 0 0 8 176.5077 281.0016 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 38.9931 266.667 Tm (2.)Tj ET EMC /P <>BDC BT 8 0 0 8 48.2117 266.667 Tm ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 50.3317 266.667 Tm [(Fibrin shea)7(th \()]TJ /TT13 1 Tf 6.946 0 TD ()Tj /TT4 1 Tf .618 0 TD [(ushes but canno)20(t aspira)7(t)13(e\):)]TJ ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 217.1877 266.667 Tm ( A )Tj /TT12 1 Tf 1.194 0 TD ()Tj /TT2 1 Tf .567 0 TD [(brin shea)14(th a)14(t)0( )]TJ ET EMC /P <>BDC BT 8 0 0 8 48.2117 255.167 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 50.3317 255.167 Tm [(the tip of the ca)14(the)17(t)14(er ma)15(y cause an occlusion in which the )]TJ ET EMC /P <>BDC BT 8 0 0 8 48.2117 243.667 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 50.3317 243.667 Tm [(ca)14(the)17(t)14(er ma)15(y s)22(till )]TJ /TT12 1 Tf 8.233 0 TD ()Tj /TT2 1 Tf .555 0 TD [(ush, but aspira)14(tion is dif)]TJ /TT12 1 Tf 10.996 0 TD ()Tj /TT2 1 Tf .567 0 TD (cult or impossible.)Tj ET EMC /P <>BDC BT 8 0 0 8 280.6838 243.667 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 38.9931 229.3324 Tm (3.)Tj ET EMC /P <>BDC BT 8 0 0 8 48.2117 229.3324 Tm ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 50.3317 229.3324 Tm [(Thr)9(ombo)20(tic occlusion:)]TJ ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 136.8437 229.3324 Tm [( An occlusion ma)15(y be caused b)40(y)0( a )]TJ ET EMC /P <>BDC BT 8 0 0 8 48.2117 217.8324 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 50.3317 217.8324 Tm (back)Tj /TT12 1 Tf 2.243 0 TD ()Tj /TT2 1 Tf .555 0 TD [(o)19(w)0( of blood int)14(o the ca)14(the)17(t)14(er lumen. )]TJ ET EMC /P <>BDC BT 8 0 0 8 208.8037 217.8324 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 38.9931 203.4978 Tm (4.)Tj ET EMC /P <>BDC BT 8 0 0 8 48.2117 203.4978 Tm ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 50.3317 203.4978 Tm [(Non-thr)9(ombo)20(tic occlusion:)]TJ ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 155.1797 203.4978 Tm [( An occlusion ma)15(y be due t)14(o)0( lipid )]TJ ET EMC /P <>BDC BT 8 0 0 8 48.2117 191.9978 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 50.3317 191.9978 Tm [(or particula)14(t)14(e)0( debris \()41(e.g. pr)19(o)20(t)14(ein or drug deposits\) f)20(orming within)]TJ ET EMC /P <>BDC BT 8 0 0 8 291.6758 191.9978 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 48.2117 180.4977 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 50.3317 180.4977 Tm (the lumen.)Tj ET EMC /P <>BDC BT 8 0 0 8 88.8757 180.4977 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 38.9931 166.1631 Tm (5.)Tj ET EMC /P <>BDC BT 8 0 0 8 48.2117 166.1631 Tm ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 50.3317 166.1631 Tm [(Mechanical tr)9(oubleshoo)20(ting:)]TJ ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 160.5557 166.1631 Tm [( L)21(ook f)20(or an)15(y compr)19(ession of the )]TJ ET EMC /P <>BDC BT 8 0 0 8 48.2117 154.6631 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 50.3317 154.6631 Tm [(ca)14(the)17(t)14(e)0(r)31(,)0( an)15(y bends, or a closed/partially closed clamp. Kinking )]TJ ET EMC /P <>BDC BT 8 0 0 8 48.2117 143.1631 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 50.3317 143.1631 Tm [(ma)15(y be visible on the ca)14(the)17(t)14(er r)19(einf)20(or)19(cement shea)14(th. Massaging )]TJ ET EMC /P <>BDC BT 8 0 0 8 48.2117 131.6631 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 50.3317 131.6631 Tm [(an)15(y kink)29(s ma)15(y be suf)]TJ /TT12 1 Tf 9.583 0 TD ()Tj /TT2 1 Tf .567 0 TD [(cient t)14(o)0( r)19(elie)20(v)25(e)0( an occlusion. P)23(a)14(tient )]TJ ET EMC /P <>BDC BT 8 0 0 8 48.2117 120.1631 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 50.3317 120.1631 Tm [(r)19(epositioning \()41(e.g. raising arms, coughing\) ma)15(y also r)19(elie)20(v)25(e)0( an )]TJ ET EMC /P <>BDC BT 8 0 0 8 48.2117 108.6631 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 50.3317 108.6631 Tm [(obs)22(truc)14(tion.)]TJ ET EMC /P <>BDC BT 8 0 0 8 94.8197 108.6631 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 38.9931 94.3285 Tm -.049 Tc (6.)Tj ET EMC /P <>BDC BT 8 0 0 8 48.2916 94.3285 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 50.3317 94.3285 Tm -.01 Tc [(Inspec)7(tion of the ca)7(the)9(t)13(er hub:)]TJ ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 167.7411 94.3285 Tm [( Inspec)14(t the hub f)20(or visible debris;)]TJ ET EMC /P <>BDC BT 8 0 0 8 290.2227 94.3285 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 48.2117 82.8285 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 50.3317 82.8285 Tm [(r)19(emo)25(v)25(e)0( the needle fr)19(ee connec)14(t)14(or t)14(o)0( assess and, if necessary)61(, )]TJ ET EMC /P <>BDC BT 8 0 0 8 48.2117 71.3285 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 50.3317 71.3285 Tm [(r)19(emo)25(v)25(e)0( an)15(y no)20(ticeable obs)22(truc)14(tion. )]TJ ET EMC /P <>BDC BT 8 0 0 8 183.0038 71.3285 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 38.9931 56.9938 Tm -.09 Tc (7.)Tj ET EMC /P <>BDC BT 8 0 0 8 48.4517 56.9938 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 50.3317 56.9938 Tm -.03 Tc [(Saline manipula)7(tion t)13(echniques:)]TJ ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 166.7 56.9938 Tm [( Bef)20(or)19(e pharmaceutical int)14(erv)25(ention,)]TJ ET EMC /P <>BDC BT 8 0 0 8 291.7805 56.9938 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 48.2117 45.4938 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 50.3317 45.4938 Tm [(perf)20(orm pulsa)14(tile )]TJ /TT12 1 Tf 8.119 0 TD ()Tj /TT2 1 Tf .555 0 TD [(ushing or the per)19(cussiv)25(e pop t)14(echnique.)]TJ ET EMC /P <>BDC BT 8 0 0 8 267.7958 45.4938 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 304.1843 371.115 Tm -.01 Tc (8.)Tj ET EMC /P <>BDC BT 8 0 0 8 313.4828 371.115 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 315.5229 371.115 Tm -.01 Tc [(Thr)9(ombolytic ag)20(ents \(ur)9(okinase or similar\):)]TJ ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 478.2849 371.115 Tm ( If )Tj /TT12 1 Tf 1.055 0 TD 0 Tc ()Tj /TT2 1 Tf .557 0 TD -.01 Tc [(brin is suspec)14(t)14(ed,)]TJ ET EMC /P <>BDC BT 8 0 0 8 554.8939 371.115 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.4029 359.615 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 315.5229 359.615 Tm -.015 Tc [(ur)19(okinase or a similar ag)20(ent ma)15(y be ins)22(tilled under clinical guidance.)]TJ ET EMC /P <>BDC BT 8 0 0 8 556.9315 359.615 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 304.1843 345.2803 Tm -.03 Tc (9.)Tj ET EMC /P <>BDC BT 8 0 0 8 313.4029 345.2803 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 315.5229 345.2803 Tm [(R)19(adiolo)31(gical imaging: )]TJ ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 398.115 345.2803 Tm [(A ches)22(t radio)21(graph will clarify the ca)14(the)17(t)14(er )]TJ ET EMC /P <>BDC BT 8 0 0 8 313.4029 333.7803 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 315.5229 333.7803 Tm [(tip position. If a partial ca)14(the)17(t)14(er occlusion r)19(emains unr)19(esolv)25(ed, )]TJ ET EMC /P <>BDC BT 8 0 0 8 313.4029 322.2803 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 315.5229 322.2803 Tm [(a lineo)21(gram ma)15(y help de)]TJ /TT12 1 Tf 11.29 0 TD ()Tj /TT2 1 Tf .567 0 TD [(ne the pr)19(oblem. )]TJ ET EMC /P <>BDC BT 8 0 0 8 470.6749 322.2803 Tm ( )Tj ET EMC /P <>BDC /GS1 gs BT /TT8 1 Tf 12 0 0 12 304.1843 301.7264 Tm .97 .75 .04 0 k (Explanations)Tj ET EMC /P <>BDC BT /TT11 1 Tf 8 0 0 8 378.0083 301.7264 Tm 0 0 0 .8 k ( )Tj ET EMC /P <>BDC /GS2 gs BT /TT2 1 Tf 8 0 0 8 304.1843 285.9744 Tm 0 0 0 1 k (1.)Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 313.6189 285.9744 Tm ( )Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 315.5229 285.9744 Tm .0001 Tc -.0001 Tw [(Ques)22.1(tions t)14.1(o).1( ask in assessing a pa)14.1(tient with a t)14.1(o)20.1(tal or partial )]TJ ET EMC /P <>BDC BT 8 0 0 8 313.4029 274.4744 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 8 0 0 8 315.5229 274.4744 Tm [(ca)14(the)17(t)14(er occlusion ar)19(e:)]TJ ET EMC /P <>BDC BT 8 0 0 8 399.7229 274.4744 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.4029 262.9744 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 321.1921 262.9744 Tm -.01 Tc (a.)Tj ET EMC /P <>BDC BT 8 0 0 8 329.6961 262.9744 Tm [(W)49(as the onse)17(t sudden or gradual and has ther)19(e been a chang)20(e)]TJ ET EMC /P <>BDC BT 8 0 0 8 556.0029 262.9744 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.4029 251.4744 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 329.6961 251.4744 Tm -.005 Tc (in )Tj /TT12 1 Tf 1.061 0 TD 0 Tc ()Tj /TT2 1 Tf .55 0 TD -.005 Tc [(ushing beha)19(viour? Ho)19(w long has the ca)14(the)17(t)14(er been in situ?)]TJ ET EMC /P <>BDC BT 8 0 0 8 555.0815 251.4744 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.4029 239.9744 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 321.1921 239.9744 Tm (b.)Tj ET EMC /P <>BDC BT 8 0 0 8 329.6961 239.9744 Tm [(Did it occur aft)14(er a dr)19(essing chang)20(e)20(?)0( If so, is the ca)14(the)17(t)14(er )]TJ ET EMC /P <>BDC BT 8 0 0 8 313.4029 228.4744 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 329.6961 228.4744 Tm [(twis)22(t)14(ed \()41(can occur if a tunnelled Hickman type ca)14(the)17(t)14(er )]TJ ET EMC /P <>BDC BT 8 0 0 8 313.4029 216.9744 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 329.6961 216.9744 Tm [(has been coiled under the dr)19(essing\)? F)21(or pa)14(tients with a )]TJ ET EMC /P <>BDC BT 8 0 0 8 313.4029 205.4744 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 329.6961 205.4744 Tm [(peripherally insert)14(ed central ca)14(the)17(t)14(er \(PICC)30(\), has the )]TJ ET EMC /P <>BDC BT 8 0 0 8 313.4029 193.9744 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 329.6961 193.9744 Tm [(ca)14(the)17(t)14(er been pinched when securing it in a ca)14(the)17(t)14(er )]TJ ET EMC /P <>BDC BT 8 0 0 8 313.4029 182.4744 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 329.6961 182.4744 Tm [(secur)19(ement de)20(vice, f)20(or e)23(x)3(ample Sta)14(tlock or SecurA)27(ca)14(th.)]TJ ET EMC /P <>BDC BT 8 0 0 8 548.5842 182.4744 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.4029 170.9744 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 321.1921 170.9744 Tm (c.)Tj ET EMC /P <>BDC BT 8 0 0 8 329.6961 170.9744 Tm [(Did it occur f)20(ollo)19(wing changing the needle-fr)19(ee connec)14(t)14(or? )]TJ ET EMC /P <>BDC BT 8 0 0 8 313.4029 159.4744 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 329.6961 159.4744 Tm [(Changing the connec)14(t)14(or ma)15(y r)19(esolv)25(e the occlusion.)]TJ ET EMC /P <>BDC BT 8 0 0 8 518.6401 159.4744 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.4029 147.9744 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 321.1921 147.9744 Tm (d.)Tj ET EMC /P <>BDC BT 8 0 0 8 329.6961 147.9744 Tm [(Did it occur f)20(ollo)19(wing a Huber needle \()41(a)0( non-coring needle )]TJ ET EMC /P <>BDC BT 8 0 0 8 313.4029 136.4744 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 329.6961 136.4744 Tm -.005 Tc [(used f)20(or accessing an implant)14(ed port\) chang)20(e)20(?)0( This can occur)]TJ ET EMC /P <>BDC BT 8 0 0 8 557.1375 136.4744 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.4029 124.9744 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 329.6961 124.9744 Tm [(if the Huber needle w)18(as bent when insert)14(ed. Has the right )]TJ ET EMC /P <>BDC BT 8 0 0 8 313.4029 113.4744 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 329.6961 113.4744 Tm [(length of needle been used? The needle needs t)14(o)0( be long )]TJ ET EMC /P <>BDC BT 8 0 0 8 313.4029 101.9744 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 329.6961 101.9744 Tm [(enough t)14(o)0( r)19(each the back of the port.)]TJ ET EMC /P <>BDC BT 8 0 0 8 467.5681 101.9744 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.4029 90.4744 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 321.1921 90.4744 Tm (e.)Tj ET EMC /P <>BDC BT 8 0 0 8 329.6961 90.4744 Tm [(Has blood been tak)36(en thr)19(ough the ca)14(the)17(t)14(er? This is no)20(t )]TJ ET EMC /P <>BDC BT 8 0 0 8 313.4029 78.9744 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 329.6961 78.9744 Tm [(r)19(ecommended as it can cause a thr)19(ombus, especially if the )]TJ ET EMC /P <>BDC BT 8 0 0 8 313.4029 67.4744 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 329.6961 67.4744 Tm [(ca)14(the)17(t)14(er w)18(as no)20(t adequa)14(t)14(ely )]TJ /TT12 1 Tf 13.466 0 TD ()Tj /TT2 1 Tf .555 0 TD [(ushed pos)22(t sampling.)]TJ ET EMC /P <>BDC BT 8 0 0 8 520.2642 67.4744 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.4029 55.9744 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 321.1921 55.9744 Tm -.03 Tc (f.)Tj ET EMC /P <>BDC BT 8 0 0 8 329.6961 55.9744 Tm 0 Tc [(Ar)19(e an)15(y intra)19(v)25(enous therapies being adminis)22(t)14(e)0(r)19(ed thr)19(ough )]TJ ET EMC /P <>BDC BT 8 0 0 8 313.4029 44.4744 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 329.6961 44.4744 Tm [(the ca)14(the)17(t)14(er? This includes pos)22(t-infusion ca)14(the)17(t)14(er lock)29(s. )]TJ ET EMC /P <>BDC /GS1 gs BT /TT4 1 Tf 9 0 0 9 22.6772 811.7886 Tm .97 .75 .04 0 k [(THE BRITISH INTES)9(TINAL F)76(AIL)30(URE ALLIANCE \(BIF)76(A)17(\))0( T)25(OP TIPS ARTICLE SERIES)]TJ ET EMC /Artifact <>BDC .75 .25 0 0 k .015015 806.78 595.29 1.417 re f EMC /P <>BDC BT /TT6 1 Tf 8 0 0 8 22.6772 12.2453 Tm 0 0 0 0 k [(BIF)74(A is a Specialis)19(t Int)13(er)14(es)19(t Gr)14(oup of B)9(APEN www)26(.bapen.or)12(g.uk )]TJ ET EMC /P <>BDC /GS2 gs BT /TT2 1 Tf 8 0 0 8 38.3932 665.4743 Tm 0 0 0 1 k [(Ca)14(th)15(y Ca)10(wle)20(y)61(,)0( Mia Small, Alison Y)87(oung, Br)19(eeg)20(e)0( Kirkham, Jer)19(em)15(y Nightingale and the BIF)71(A Committ)14(ee)]TJ ET EMC /P <>BDC /GS1 gs BT /TT6 1 Tf 7 0 0 7 480.6069 13.2386 Tm 0 0 0 0 k [(F)24(ebruary 2)8(0)8(26 | P)27(a)0(g)20(e)0( 1 of 2)]TJ ET EMC Q endstream endobj 73 0 obj <>/ExtGState<>>> endobj 144 0 obj <>stream /Artifact <>BDC q 1 i 0 841.89 595.276 -841.89 re 297.645 420.96 m W n .015015 841.89 595.29 -841.89 re W n 0 0 0 .08 k /GS1 gs .015015 24.182 595.29 127.464 re f EMC /P <>BDC /GS2 gs BT /TT2 1 Tf 8 0 0 8 46.069 787.9551 Tm 0 0 0 1 k 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 8 0 0 8 62.3622 787.9551 Tm [(Generally)61(, a ca)14(the)17(t)14(er used f)20(or par)19(ent)14(eral support should no)20(t )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 776.4551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 62.3622 776.4551 Tm [(be used f)20(or an)15(y o)20(ther medica)14(tion. Occlusion can occur if )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 764.9551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 62.3622 764.9551 Tm [(multiple medica)14(tions ar)19(e giv)25(en without adequa)14(t)14(ely )]TJ /TT12 1 Tf 23.612 0 TD ()Tj /TT2 1 Tf .555 0 TD (ushing )Tj ET EMC /P <>BDC BT 8 0 0 8 46.069 753.4551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 62.3622 753.4551 Tm [(the ca)14(the)17(t)14(er with 0)40(.)30(9% sodium chloride be)17(tw)19(een each drug )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 741.9551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 62.3622 741.9551 Tm [(adminis)22(t)14(e)0(r)19(ed.)]TJ ET EMC /P <>BDC BT 8 0 0 8 112.5222 741.9551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 46.069 730.5551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 53.8582 730.5551 Tm -.005 Tc (g.)Tj ET EMC /P <>BDC BT 8 0 0 8 62.3622 730.5551 Tm [(Does the pa)14(tient r)19(eceiv)25(e lipid containing HPS and ho)19(w oft)14(en?)]TJ ET EMC /P <>BDC BT 8 0 0 8 285.2275 730.5551 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 46.069 719.1552 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 62.3622 719.1552 Tm [(Lipid containing HPS ma)15(y contribut)14(e t)14(o)0( intraluminal deposits. )]TJ ET EMC /P <>BDC BT 8 0 0 8 290.0502 719.1552 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 46.069 707.7551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 53.8582 707.7551 Tm (h.)Tj ET EMC /P <>BDC BT 8 0 0 8 62.3622 707.7551 Tm [(Has ther)19(e been a dela)15(y in )]TJ /TT12 1 Tf 11.942 0 TD ()Tj /TT2 1 Tf .555 0 TD [(ushing the ca)14(the)17(t)14(er pos)22(t infusion?)]TJ ET EMC /P <>BDC BT 8 0 0 8 288.1623 707.7551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 46.069 696.3551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 62.3622 696.3551 Tm [(The infusion ra)14(t)14(e)0( t)14(o)0( k)36(eep a v)25(ein open \(KV)27(O)67(\) should be 15-2)10(0 )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 684.9551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 62.3622 684.9551 Tm [(ml/hour and ideally no)20(t e)23(x)21(ceed 2 hours. This can r)19(esult in )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 673.5551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 62.3622 673.5551 Tm (blood back)Tj /TT12 1 Tf 5.17 0 TD ()Tj /TT2 1 Tf .555 0 TD [(o)19(w)0( int)14(o the ca)14(the)17(t)14(er and/)47(or the de)20(v)25(elopment of )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 662.1551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 62.3622 662.1551 Tm [(particula)14(t)14(e)0( ma)14(tt)14(er within the ca)14(the)17(t)14(e)0(r)40(.)0( )]TJ ET EMC /P <>BDC BT 8 0 0 8 204.6743 662.1551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 46.069 650.7551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 53.8582 650.7551 Tm (i.)Tj ET EMC /P <>BDC BT 8 0 0 8 62.3622 650.7551 Tm [(Ha)19(v)25(e)0( ther)19(e been an)15(y chang)20(es in the prac)14(titioners/)47(car)19(er)43(s/)]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 639.3551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 62.3622 639.3551 Tm [(pa)14(tient)43(s ability t)14(o)0( adminis)22(t)14(er a )]TJ /TT12 1 Tf 14.519 0 TD ()Tj /TT2 1 Tf .555 0 TD (ush using a push/pause )Tj ET EMC /P <>BDC BT 8 0 0 8 46.069 627.9551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 62.3622 627.9551 Tm -.0001 Tc .0001 Tw [(t)13.9(echnique with positiv)24.9(e pr)18.9(essur)18.9(e \(includes de)22.9(xt)13.9(erity issues\)?)]TJ ET EMC /P <>BDC BT 8 0 0 8 286.7623 627.9551 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 8 0 0 8 46.069 616.5551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 53.8582 616.5551 Tm (j.)Tj ET EMC /P <>BDC BT 8 0 0 8 62.3622 616.5551 Tm [(Ha)19(v)25(e)0( the)20(y had a f)20(e)20(v)25(er aft)14(er s)22(tarting a f)20(eed? Ca)14(the)17(t)14(er-r)19(ela)14(t)14(ed )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 605.1551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 62.3622 605.1551 Tm [(bloods)22(tr)19(eam inf)20(ec)14(tion \()67(CRBSI\) ma)15(y be associa)14(t)14(ed with )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 593.7551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 62.3622 593.7551 Tm [(ca)14(the)17(t)14(er occlusion. )]TJ ET EMC /P <>BDC BT 8 0 0 8 134.8982 593.7551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 46.069 582.3551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 53.8582 582.3551 Tm (k.)Tj ET EMC /P <>BDC BT 8 0 0 8 62.3622 582.3551 Tm [(Has ther)19(e been a his)22(t)14(ory of infusion de)]TJ /TT12 1 Tf 17.809 0 TD ()Tj /TT2 1 Tf .567 0 TD [(cits)29(? If ther)19(e ar)19(e )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 570.9551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 62.3622 570.9551 Tm [(pump pr)19(essur)19(e r)19(eadings, does the e)20(v)25(ent lo)21(g on the infusion )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 559.5551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 62.3622 559.5551 Tm [(pump sho)19(w fr)19(equent int)14(errup)20(tions of the infusion? Has the )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 548.1552 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 62.3622 548.1552 Tm [(pr)19(essur)19(e indica)14(t)14(or on the infusion pump chang)20(ed gradually )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 536.7552 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 62.3622 536.7552 Tm [(o)25(v)25(er a period of time)20(? Ther)19(e needs t)14(o)0( ha)19(v)25(e)0( been clear )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 525.3552 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 62.3622 525.3552 Tm [(e)23(xplana)14(tions about ho)19(w t)14(o)0( identify incr)19(easing pr)19(essur)19(es )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 513.9552 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 62.3622 513.9552 Tm [(on the pump and wha)14(t ac)14(tion t)14(o)0( tak)36(e.)]TJ ET EMC /P <>BDC BT 8 0 0 8 200.4662 513.9552 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 46.069 502.5552 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 48.189 502.5552 Tm [(Ca)14(the)17(t)14(er car)19(e pr)19(o)20(t)14(ocols should emphasise the need t)14(o)0( maintain )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 491.1552 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 48.189 491.1552 Tm [(pa)14(t)14(ency b)40(y)0( using a push-pause )]TJ /TT12 1 Tf 14.835 0 TD ()Tj /TT2 1 Tf .555 0 TD [(ushing t)14(echnique and positiv)25(e )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 479.7552 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 48.189 479.7552 Tm [(pr)19(essur)19(e clamping. )]TJ ET EMC /P <>BDC BT 8 0 0 8 122.069 479.7552 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 36.8503 468.3552 Tm (2.)Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 46.2849 468.3552 Tm ( )Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 48.189 468.3552 Tm (A )Tj /TT12 1 Tf .929 0 TD ()Tj /TT2 1 Tf .567 0 TD [(brin shea)14(th is a la)15(y)47(er of )]TJ /TT12 1 Tf 10.913 0 TD ()Tj /TT2 1 Tf .567 0 TD [(brin and pla)14(t)14(ele)17(ts tha)14(t can f)20(orm )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 456.9552 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 48.189 456.9552 Tm [(ar)19(ound a central v)25(enous ca)14(the)17(t)14(e)0(r)40(.)0( It de)20(v)25(elops fr)19(om the point )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 445.5552 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 48.189 445.5552 Tm [(wher)19(e the ca)14(the)17(t)14(er ent)14(ers the body and gradually e)23(x)0(t)14(ends )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 434.1552 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 48.189 434.1552 Tm [(t)14(o)19(w)18(a)0(r)19(ds the ca)14(the)17(t)14(er tip. Once it fully encases the ca)14(the)17(t)14(er tip, )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 422.7552 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 48.189 422.7552 Tm [(it can func)14(tion lik)36(e a one w)18(a)15(y v)25(alv)25(e. )]TJ ET EMC /P <>BDC BT 8 0 0 8 179.0771 422.7552 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 36.8503 411.3552 Tm (3.)Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 46.2849 411.3552 Tm ( )Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 48.189 411.3552 Tm [(A thr)19(ombus can e)23(x)0(t)14(end fr)19(om the ca)14(the)17(t)14(er t)14(o)0( the central v)25(ein or )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 399.9552 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 48.189 399.9552 Tm [(vice v)25(ersa. A central v)25(ein thr)19(ombosis should be consider)19(ed if the )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 388.5552 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 48.189 388.5552 Tm [(pa)14(tient de)20(v)25(elops ipsila)14(t)14(eral s)19(w)19(elling of the arm, neck, head or )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 377.1552 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 48.189 377.1552 Tm [(f)20(ace, a raised non pulsa)14(tile jugular v)25(enous pr)19(essur)19(e, or dis)22(t)14(ended )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 365.7553 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 48.189 365.7553 Tm [(colla)14(t)14(eral v)25(eins acr)19(oss the ches)22(t w)18(all \()17(typically in chr)19(onic cases\). )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 354.3553 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 48.189 354.3553 Tm [(Other s)21(ymp)20(t)14(oms ma)15(y include ja)10(w or shoulder pain, headaches, )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 342.9553 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 48.189 342.9553 Tm [(or a sensa)14(tion of head fullness. Once suspec)14(t)14(ed ther)19(e should be )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 331.5553 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 48.189 331.5553 Tm [(a lo)19(w thr)19(eshold f)20(or in)10(v)25(e)0(s)22(tiga)14(ting. )]TJ ET EMC /P <>BDC BT 8 0 0 8 168.693 331.5553 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 46.069 320.1553 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 56.6929 320.1553 Tm (Blood back)Tj /TT12 1 Tf 5.144 0 TD ()Tj /TT2 1 Tf .555 0 TD [(o)19(w)0( int)14(o the ca)14(the)17(t)14(er can be r)19(educed b)40(y)0( using a )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 308.7553 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 48.189 308.7553 Tm (brisk push-pause )Tj /TT12 1 Tf 8.359 0 TD ()Tj /TT2 1 Tf .555 0 TD [(ushing t)14(echnique and positiv)25(e pr)19(essur)19(e )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 297.3553 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 48.189 297.3553 Tm [(clamping \()41(open-ended ca)14(the)17(t)14(ers only\). If a pa)14(tient has a v)25(alv)25(ed )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 285.9553 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 48.189 285.9553 Tm -.005 Tc [(ca)14(the)17(t)14(e)0(r)31(,)0( positiv)25(e pr)19(essur)19(e can be achie)20(v)25(ed b)40(y)0( k)36(eeping the thumb)]TJ ET EMC /P <>BDC BT 8 0 0 8 289.5345 285.9553 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 46.069 274.5553 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 48.189 274.5553 Tm [(on the s)21(yring)20(e plung)20(er when r)19(emo)25(ving the s)21(yring)20(e. Using a zer)19(o-)]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 263.1553 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 48.189 263.1553 Tm -.019 Tc (re)Tj /TT12 1 Tf .913 0 TD 0 Tc ()Tj /TT2 1 Tf .555 0 TD [(ux s)21(yring)20(e will also r)19(educe the risk of blood back)]TJ /TT12 1 Tf 22.273 0 TD ()Tj /TT2 1 Tf .555 0 TD [(o)19(w)34(. Mos)22(t )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 251.7553 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 48.189 251.7553 Tm [(commer)19(cially a)19(v)25(ailable pr)19(e)]TJ /TT12 1 Tf 12.266 0 TD ()Tj /TT2 1 Tf .567 0 TD [(lled s)21(yring)20(es with 0)40(.)30(9% sodium )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 240.3553 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 48.189 240.3553 Tm [(chloride f)20(or injec)14(tion ar)19(e zer)19(o-r)19(e)]TJ /TT12 1 Tf 14.888 0 TD ()Tj /TT2 1 Tf .555 0 TD (ux.)Tj ET EMC /P <>BDC BT 8 0 0 8 181.853 240.3553 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 36.8503 228.9554 Tm (4.)Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 46.2849 228.9554 Tm ( )Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 48.189 228.9554 Tm [(A ca)14(the)17(t)14(er ma)15(y also become obs)22(truc)14(t)14(ed b)40(y)0( non-thr)19(ombo)20(tic )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 217.5553 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 48.189 217.5553 Tm -.005 Tc [(ma)14(t)14(erial, such as lipid r)19(esidue, pr)19(o)20(t)14(ein buildup, or drug pr)19(ecipita)14(t)14(e)0(.)]TJ ET EMC /P <>BDC BT 8 0 0 8 288.6227 217.5553 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 46.069 206.1553 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 48.189 206.1553 Tm -.025 Tc [(These subs)22(tances can accumula)14(t)14(e)0( and r)19(e)0(s)22(tric)14(t )]TJ /TT12 1 Tf 20.7101 0 TD 0 Tc ()Tj /TT2 1 Tf .53 0 TD -.025 Tc [(o)19(w)34(. Non-thr)19(ombo)20(tic)]TJ ET EMC /P <>BDC BT 8 0 0 8 288.9522 206.1553 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 46.069 194.7553 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 48.189 194.7553 Tm -.01 Tc [(occlusions ma)15(y de)20(v)25(elop gradually and can be link)36(ed t)14(o)0( inadequa)14(t)14(e)]TJ ET EMC /P <>BDC BT 8 0 0 8 288.4639 194.7553 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 46.069 183.3554 Tm ( )Tj ET EMC /P <>BDC BT /TT12 1 Tf 8 0 0 8 48.189 183.3554 Tm ()Tj /TT2 1 Tf .555 0 TD [(ushing or incompa)14(tible drug combina)14(tions. )]TJ ET EMC /P <>BDC BT 8 0 0 8 212.453 183.3554 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 36.8503 171.9554 Tm (5.)Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 46.2849 171.9554 Tm ( )Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 48.189 171.9554 Tm [(Unders)22(tanding the mechanical causes of ca)14(the)17(t)14(er obs)22(truc)14(tion )]TJ ET EMC /P <>BDC BT 8 0 0 8 46.069 160.5553 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 48.189 160.5553 Tm -.02 Tc [(helps guide saf)20(e manag)20(ement and pr)19(e)20(v)25(ents r)19(ecurr)19(ence. Mechanical)]TJ ET EMC /P <>BDC BT 8 0 0 8 287.4548 160.5553 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.2483 787.9551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 787.9551 Tm [(obs)22(truc)14(tion is usually e)23(x)0(t)14(ernal t)14(o)0( the ca)14(the)17(t)14(er and can occur due )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 776.5551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 776.5551 Tm [(t)14(o)0( r)19(epea)14(t)14(ed s)22(t)0(r)19(ess, s)22(t)0(r)19(e)17(t)14(ching, incorr)19(ec)14(t clamping or e)23(x)0(t)14(ernal )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 765.155 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 765.155 Tm [(compr)19(ession or int)14(ernal obs)22(truc)14(tion due t)14(o)0( debris in the hub. )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 753.7551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 753.7551 Tm -.005 Tc [(P)29(ositional chang)20(es ma)15(y t)14(emporarily r)19(elie)20(v)25(e)0( obs)22(truc)14(tion b)40(y)0( alt)14(ering)]TJ ET EMC /P <>BDC BT 8 0 0 8 553.866 753.7551 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.2883 742.3551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 742.3551 Tm [(ca)14(the)17(t)14(er alignment. Pinch-off s)21(yndr)19(ome wher)19(e the ca)14(the)17(t)14(er )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 730.9551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 730.9551 Tm [(becomes caught be)17(tw)19(een the cla)19(vicle and )]TJ /TT12 1 Tf 19.823 0 TD ()Tj /TT2 1 Tf .567 0 TD [(rs)22(t rib is a rar)19(e cause)]TJ ET EMC /P <>BDC BT 8 0 0 8 553.5444 730.9551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.2483 719.5551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 719.5551 Tm [(of occlusion of a ca)14(the)17(t)14(er ent)14(ering the subcla)19(vian v)25(ein. It can be )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 708.1551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 708.1551 Tm (identi)Tj /TT12 1 Tf 2.634 0 TD ()Tj /TT2 1 Tf .567 0 TD [(ed b)40(y)0( its r)19(esolution when the pa)14(tient r)19(olls their shoulder )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 696.7551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 696.7551 Tm [(on the side of insertion f)20(orw)18(ar)19(d. The ca)14(the)17(t)14(er will need t)14(o)0( be )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 685.3551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 685.3551 Tm [(r)19(emo)25(v)25(ed and r)19(esit)14(ed.)]TJ ET EMC /P <>BDC BT 8 0 0 8 391.4164 685.3551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 302.0297 673.7051 Tm -.039 Tc (6.)Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 311.4643 673.7051 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 313.3683 673.7051 Tm [(Inspec)14(t the ca)14(the)17(t)14(er hub and the opening be)17(tw)19(een the hub )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 662.0551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 662.0551 Tm [(and the ca)14(the)17(t)14(er t)14(o)0( check f)20(or debris or a f)20(o)0(r)19(eign body causing )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 650.4051 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 650.4051 Tm [(obs)22(truc)14(tion. An)15(y visible debris, in a non-v)25(alv)25(ed ca)14(the)17(t)14(er only)61(, )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 638.7551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 638.7551 Tm [(can be r)19(emo)25(v)25(ed asep)20(tically b)40(y)0( using a gr)19(een \(21G\) saf)20(e)17(ty needle. )]TJ ET EMC /P <>BDC BT 8 0 0 8 554.1046 638.7551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 302.0297 627.1051 Tm -.06 Tc (7.)Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 311.4643 627.1051 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 313.3683 627.1051 Tm [(Saline manipula)14(tion can help dissolv)25(e intraluminal debris. A 10 ml )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 615.4551 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 615.4551 Tm [(Luer lock s)21(yring)20(e should be a)14(ttached dir)19(ec)14(tly t)14(o)0( the hub, using )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 603.8051 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 603.8051 Tm -.01 Tc [(g)20(entle back and f)20(orth mo)20(tion without f)20(o)0(r)19(cing the plung)20(er)40(. A smaller)]TJ ET EMC /P <>BDC BT 8 0 0 8 554.1793 603.8051 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.2483 592.1552 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 592.1552 Tm [(s)21(yring)20(e is no)20(t r)19(ecommended as the)20(y g)20(enera)14(t)14(e)0( higher pr)19(essur)19(es )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 580.5052 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 580.5052 Tm [(tha)14(t could burs)22(t the ca)14(the)17(t)14(er and/)47(or cause v)25(essel trauma. The )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 568.8552 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 568.8552 Tm [(per)19(cussiv)25(e pop t)14(echnique ma)15(y also be used. The per)19(cussiv)25(e pop )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 557.2052 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 557.2052 Tm [(t)14(echnique aims t)14(o)0( r)19(emo)25(v)25(e)0( an obs)22(truc)14(tion b)40(y)0( sending shock )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 545.5552 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 545.5552 Tm [(w)18(a)19(v)25(es thr)19(ough the ca)14(the)17(t)14(er ther)19(eb)40(y allo)19(wing the debris t)14(o)0( f)20(all )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 533.9052 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 533.9052 Tm [(back int)14(o the s)21(yring)20(e, as opposed t)14(o)0( being )]TJ /TT12 1 Tf 19.858 0 TD ()Tj /TT2 1 Tf .555 0 TD [(ushed thr)19(ough the )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 522.2552 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 522.2552 Tm [(ca)14(the)17(t)14(e)0(r)40(.)0( It is achie)20(v)25(ed )]TJ ET EMC /P <>BDC BT 8 0 0 8 398.5685 522.2552 Tm -.01 Tc [(b)40(y)0( placing a 10 ml Luer lock s)21(yring)20(e with )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.3282 510.6052 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 510.6052 Tm -.01 Tc [(5 ml 0)40(.)30(9% sodium chloride)]TJ ET EMC /P <>BDC BT 8 0 0 8 408.8975 510.6052 Tm 0 Tc [( f)20(or injec)14(tion dir)19(ec)14(tly ont)14(o the ca)14(the)17(t)14(er )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 498.9552 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 498.9552 Tm [(hub. The s)21(yring)20(e is then in)10(v)25(ert)14(ed with the plung)20(er uppermos)22(t. )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 487.3052 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 487.3052 Tm [(The s)21(yring)20(e plung)20(er is then pulled up and r)19(eleased, continuing )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 475.6552 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 475.6552 Tm [(this until debris fr)19(om within the ca)14(the)17(t)14(er is dra)10(wn back int)14(o the )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 464.0052 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 464.0052 Tm -.0001 Tc .0001 Tw [(s)20.9(yring)19.9(e. These me)16.9(thods pr)18.9(o)24.9(vide inf)19.9(orma)13.9(tion about the degr)18.9(ee )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 452.3552 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 452.3552 Tm [(of occlusion and ma)15(y r)19(e)0(s)22(t)14(or)19(e pa)14(t)14(ency without medica)14(tion.)]TJ ET EMC /P <>BDC BT 8 0 0 8 528.6243 452.3552 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 302.0297 440.7052 Tm (8.)Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 311.4643 440.7052 Tm ( )Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 313.3683 440.7052 Tm [(If mechanical and saline me)17(thods f)20(ail, a thr)19(ombolytic ag)20(ent \()41(e.g. )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 429.0552 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 429.0552 Tm [(ur)19(okinase\) ma)15(y be used accor)19(ding t)14(o)0( local policy)71(. If ca)14(the)17(t)14(er )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 417.4052 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 417.4052 Tm [(func)14(tionality is no)20(t r)19(e)0(s)22(t)14(or)19(ed aft)14(er the )]TJ /TT12 1 Tf 17.232 0 TD ()Tj /TT2 1 Tf .567 0 TD [(rs)22(t dose, then a second )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 405.7553 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 405.7553 Tm [(dose of thr)19(ombolytic ag)20(ent ma)15(y be used. Clinicians mus)22(t monit)14(or)]TJ ET EMC /P <>BDC BT 8 0 0 8 554.9204 405.7553 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.2483 394.1053 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 394.1053 Tm -.0001 Tc .0001 Tw [(f)19.9(or ca)13.9(the)16.9(t)13.9(er ballooning or leakag)19.9(e and ha)18.9(v)24.9(e)-.1( a)13.9(trauma)13.9(tic clamps )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 382.4553 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 382.4553 Tm [(a)19(v)25(ailable. If an ag)20(ent is used, aft)14(er a speci)]TJ /TT12 1 Tf 18.986 0 TD ()Tj /TT2 1 Tf .567 0 TD [(ed dw)19(ell time, the )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 370.8053 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 370.8053 Tm [(solution should be withdra)10(wn, and pa)14(t)14(ency r)19(eassessed. P)23(a)14(tients )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 359.1553 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 359.1553 Tm [(should be monit)14(or)19(ed f)20(or signs of s)21(y)29(s)22(t)14(emic inf)20(ec)14(tion f)20(ollo)19(wing )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 347.5053 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 347.5053 Tm [(r)19(e)0(s)22(t)14(ora)14(tion of )]TJ /TT12 1 Tf 6.491 0 TD ()Tj /TT2 1 Tf .555 0 TD [(o)19(w)34(. Pr)19(e)20(vious me)17(thods of pr)19(e)20(v)25(ention and clearing )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 335.8553 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 335.8553 Tm [(of lipid deposits or particula)14(t)14(e)0( debris included alcohol \(7)14(0%\), )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 324.2053 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 324.2053 Tm [(h)15(y)47(dr)19(ochloric acid and sodium h)15(y)47(dr)19(o)21(xide but these solutions ar)19(e )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 312.5554 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 312.5554 Tm [(no long)20(er \(widely\) a)19(v)25(ailable and ther)19(ef)20(or)19(e no r)19(ecommenda)14(tions/ )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 300.9053 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 300.9053 Tm [(guidance can be made as t)14(o)0( their use. Ins)22(truc)14(tion f)20(or use should )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 289.2553 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 289.2553 Tm [(include dw)19(ell time and initial aspira)14(tion a)14(t)0(t)14(emp)20(t)14(ed aft)14(er this. The )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 277.6053 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 277.6053 Tm -.005 Tc [(v)25(olume t)14(o)0( be ins)22(tilled should ma)14(t)14(ch the )]TJ /TT12 1 Tf 18.27 0 TD 0 Tc ()Tj /TT2 1 Tf .562 0 TD -.005 Tc [(ll v)25(olume of the ca)14(the)17(t)14(er;)]TJ ET EMC /P <>BDC BT 8 0 0 8 554.4979 277.6053 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.2483 265.9554 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 265.9554 Tm [(this will v)25(ary accor)19(ding t)14(o)0( the size \(Fr\) and type of ca)14(the)17(t)14(er \()41(e.g. )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 254.3053 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 254.3053 Tm [(PICC, tunnelled Hickman type or t)14(o)20(tally implant)14(ed port\). The )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 242.6553 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 242.6553 Tm [(solution ma)15(y be )]TJ /TT12 1 Tf 7.645 0 TD ()Tj /TT2 1 Tf .555 0 TD [(ushed thr)19(ough if a PW)25(O persis)22(ts.)]TJ ET EMC /P <>BDC BT 8 0 0 8 499.2404 242.6553 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 302.0297 231.0053 Tm -.03 Tc (9.)Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 311.4643 231.0053 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 313.3683 231.0053 Tm [(A ches)22(t X-ra)15(y can con)]TJ /TT12 1 Tf 10.277 0 TD ()Tj /TT2 1 Tf .567 0 TD [(rm ca)14(the)17(t)14(er tip position, identify an)15(y )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 219.3554 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 219.3554 Tm -.015 Tc [(kinking or looping, and de)17(t)14(e)0(c)14(t)0( some mechanical issues contributing)]TJ ET EMC /P <>BDC BT 8 0 0 8 553.7527 219.3554 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8 0 0 8 311.2483 207.7054 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 207.7054 Tm [(t)14(o)0( occlusion. Imaging )]TJ /TT12 1 Tf 9.967 0 TD ()Tj /TT2 1 Tf .567 0 TD (ndings can guide decisions about )Tj ET EMC /P <>BDC BT 8 0 0 8 311.2483 196.0553 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 196.0553 Tm [(r)19(epositioning, pharmacolo)21(gical int)14(erv)25(ention, or ca)14(the)17(t)14(er )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 184.4054 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 184.4054 Tm [(r)19(eplacement. A lineo)21(gram is useful f)20(or identifying a )]TJ /TT12 1 Tf 23.571 0 TD ()Tj /TT2 1 Tf .567 0 TD [(brin shea)14(th )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 172.7554 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 172.7554 Tm [(and an)15(y associa)14(t)14(ed central v)25(ein thr)19(ombosis. ANTT mus)22(t be )]TJ ET EMC /P <>BDC BT 8 0 0 8 311.2483 161.1054 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 313.3683 161.1054 Tm [(f)20(ollo)19(w)19(ed whene)20(v)25(er accessing the ca)14(the)17(t)14(er t)14(o)0( adminis)22(t)14(er contras)22(t.)]TJ ET EMC /P <>BDC /GS1 gs BT /TT4 1 Tf 9 0 0 9 22.6772 811.7898 Tm .97 .75 .04 0 k [(THE BRITISH INTES)9(TINAL F)76(AIL)30(URE ALLIANCE \(BIF)76(A)17(\))0( T)25(OP TIPS ARTICLE SERIES)]TJ ET EMC /Artifact <>BDC .75 .25 0 0 k .015015 806.781 595.29 1.4171 re f EMC /Artifact <>BDC .015015 0 595.29 31.482 re f EMC /P <>BDC BT /TT6 1 Tf 8 0 0 8 22.6772 12.2466 Tm 0 0 0 0 k [(BIF)74(A is a Specialis)19(t Int)13(er)14(es)19(t Gr)14(oup of B)9(APEN www)26(.bapen.or)12(g.uk )]TJ ET EMC /P <>BDC BT 7 0 0 7 478.3175 13.2386 Tm [(F)24(ebruary 2)8(0)8(26 | P)27(a)0(g)20(e)0( 2 of 2)]TJ ET EMC /P <>BDC BT /TT8 1 Tf 9 0 0 9 21.1732 132.7451 Tm .97 .75 .04 0 k -.0006 Tc .0006 Tw (Suggested reading)Tj ET EMC /P <>BDC BT /TT11 1 Tf 8 0 0 8 129.1732 132.7451 Tm 0 0 0 .8 k 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 7 0 0 7 21.1732 119.9105 Tm .97 .75 .04 0 k ()Tj ET EMC /P <>BDC /GS2 gs BT /TT2 1 Tf 7 0 0 7 29.6772 119.9105 Tm 0 0 0 1 k -.005 Tc [(Ca)10(wle)20(y C, Lal S, Nightingale J, Small M \(2)10(018)41(\). Standar)19(dised par)19(ent)14(eral support ca)14(the)17(t)14(er guidelines. April 2)10(018 \(r)19(e)20(vie)20(w)19(ed April)]TJ 56.547 0 TD [( 2)10(0)10(2)17(4\).)]TJ ET EMC /P <>BDC BT 7 0 0 7 447.9219 119.9105 Tm 0 Tc [( A)27(ccessed online: )]TJ ET EMC /P <>BDC BT 7 0 0 7 29.6772 109.9104 Tm [(www)34(.bapen.or)12(g.uk/pdf)19(s/bif)20(a/)30(s)22(tandar)19(dised-par)19(ent)14(eral-support-ca)14(the)17(t)14(er-guidelines.pdf)]TJ ET EMC /P <>BDC BT 7 0 0 7 310.4753 109.9104 Tm ( )Tj ET EMC /P <>BDC /GS1 gs BT /TT4 1 Tf 7 0 0 7 21.1732 99.9104 Tm .97 .75 .04 0 k ()Tj ET EMC /P <>BDC /GS2 gs BT /TT2 1 Tf 7 0 0 7 29.6772 99.9104 Tm 0 0 0 1 k [(Ca)10(wle)20(y C, Small M \(2)10(0)10(23\). Nursing Car)19(e of P)23(a)14(tients R)30(eceiving Home P)23(a)0(r)19(ent)14(eral Support. In: Nightingale J)20(.M. \()41(eds\) Int)14(es)22(tinal F)34(a)0(i)]TJ 57.409 0 TD [(lur)19(e. Spring)20(er-Na)14(tur)19(e. 2)10(0)10(23; p5)17(7)26(3-618.)]TJ ET EMC /P <>BDC BT 7 0 0 7 554.2715 99.9104 Tm ( )Tj ET EMC /P <>BDC /GS1 gs BT /TT4 1 Tf 7 0 0 7 21.1732 89.9105 Tm .97 .75 .04 0 k ()Tj ET EMC /P <>BDC /GS2 gs BT /TT2 1 Tf 7 0 0 7 29.6772 89.9105 Tm 0 0 0 1 k -.015 Tc [(R)30(o)20(thk)36(opf M, P)23(ant M, Br)19(o)19(wn R, )]TJ ET EMC /P <>BDC BT /TT15 1 Tf 7 0 0 7 120.6213 89.9105 Tm (et al.)Tj ET EMC /P <>BDC BT /TT2 1 Tf 7 0 0 7 135.2654 89.9105 Tm [( \(2)10(0)10(22\). Impac)14(t of a multidisciplinary nutritional support t)14(eam on quality impr)19(o)25(v)25(ement f)20(or pa)14(tients)]TJ ET EMC /P <>BDC BT 7 0 0 7 442.4677 89.9105 Tm 0 Tc [( r)19(eceiving home par)19(ent)14(eral nutrition. )]TJ ET EMC /P <>BDC BT 7 0 0 7 29.6772 79.9104 Tm [(BMJ Nutr Pr)19(e)20(v)0( Health.; 5\(2\): 2)17(86-2)10(96)39(.)]TJ ET EMC /P <>BDC BT 7 0 0 7 149.2234 79.9104 Tm ( )Tj ET EMC /P <>BDC /GS1 gs BT /TT4 1 Tf 7 0 0 7 21.1732 69.9104 Tm .97 .75 .04 0 k ()Tj ET EMC /P <>BDC /GS2 gs BT /TT2 1 Tf 7 0 0 7 29.6772 69.9104 Tm 0 0 0 1 k [(R)30(o)40(y)47(on L, Mer)19(ckx J, Herbaut R, )]TJ ET EMC /P <>BDC BT /TT15 1 Tf 7 0 0 7 124.8772 69.9104 Tm (et al.)Tj ET EMC /P <>BDC BT /TT2 1 Tf 7 0 0 7 140.1512 69.9104 Tm -.0067 Tc .0067 Tw ( \(2020)Tj 3.098 0 TD 0 Tc 0 Tw [(\). Experimental s)22(tudy of the POP t)14(echnique: f)20(ocus on the ph)15(y)29(sical basis of the pr)19(ocess. J V)56(asc A)27(ccess.; 21\()30(6)30(\): 953-958.)]TJ ET EMC /P <>BDC BT 8 0 0 8 543.8483 69.9104 Tm ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 5 0 0 5 21.1732 58.0667 Tm [(Disclaimer)-9(:)]TJ ET EMC /P <>BDC BT /TT2 1 Tf 5 0 0 5 48.1132 58.0667 Tm [( B)12(APEN P)29(osition Sta)14(t)14(ements/)30(Guidelines ha)19(v)25(e)0( been pr)19(epar)19(ed as guidance only t)14(o)0( assis)22(t quali)]TJ /TT12 1 Tf 42.308 0 TD ()Tj /TT2 1 Tf .567 0 TD [(ed healthcar)19(e pr)19(of)20(essionals in the decision-making pr)19(ocesses surr)19(ounding nutritional car)19(e. Users of these ma)14(t)14(erials ma)15(y only do)]TJ 59.161 0 TD ( so on)Tj ET EMC /P <>BDC BT 5 0 0 5 572.2238 58.0667 Tm ( )Tj ET EMC /P <>BDC BT 5 0 0 5 21.1732 52.0667 Tm [(the condition tha)14(t the)20(y e)23(x)21(er)19(cise their o)19(wn pr)19(of)20(essional kno)19(wledg)20(e and skills when applying such guidance t)14(o)0( speci)]TJ /TT12 1 Tf 52.735 0 TD ()Tj /TT2 1 Tf .567 0 TD [(c cir)19(cums)22(tances. An)15(y)47(one without the appr)19(opria)14(t)14(e)0( quali)]TJ /TT12 1 Tf 25.29 0 TD ()Tj /TT2 1 Tf .567 0 TD [(ca)14(tions mus)22(t seek the advice of a quali)]TJ /TT12 1 Tf 17.98 0 TD ()Tj /TT2 1 Tf .567 0 TD [(ed healthcar)19(e pr)19(of)20(essional )]TJ ET EMC /P <>BDC BT 5 0 0 5 21.1732 46.0667 Tm [(bef)20(or)19(e taking, or r)19(efraining fr)19(om, an)15(y ac)14(tion on the basis of the policies or guidance. 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