The Use and Maintenance of Implanted Port Vascular Access Devices
This course covers the history, required skills, and proper techniques of accessing and maintaining an implantable port in a clinical setting. The pros and cons of implantable ports versus other central lines are described and troubleshooting techniques are detailed. The importance of patient education is emphasized.
The course work is intended for nurses, medical technicians, and physician assistants who are required to maintain the efficacy of implantable ports and central lines.
Background and History of Implanted Ports
Implantable ports are implanted subcutaneously to provide access to the peritoneal cavity or the vascular, arterial, or epidural system. This course will deal only with vascular access ports. It will cover accessing, de-accessing, and care of the implantable port (I.P.)
The use of implantable ports has grown tremendously since their first use in 1981. Oncology patients were the first recipients of I.P.s. Acceptance of these devices has grown rapidly with more than 100,000 ports being implanted each year. More than fourteen different manufacturers have designed their own type of port, yet most are similar in design, function, and application.
Design of Implanted Ports
The implantable venous access device consists of the portal body and the catheter. The portal body is made of either stainless steel, titanium, polysulfone, or a combination thereof with an inner center space called a reservoir. The three principal outside features of the I.P. are the base, the shoulder, and the barb. A self-sealing, compressed silicone septum overlays the portal body. The septum is designed for either top and/or side access. This access is done by an I.P. needle, Huber needle, or a needle with a deflective, non-coring tip.
Several commercially made ports are available in single or double lumen designs. Lower profile (thinner) designs are available for smaller patients.
A catheter is either integral with the portal body or separate from the body to be attached by the surgeon at the time of implantation. Catheters are provided with a catheter lock to insure the integrity of the attachment. Most catheters are made of silicone, as this material is known to produce fewer thrombi. The height of the portal body ranges from 9.8 mm to 17.0 mm with a width at the base of 16.5 mm to 40.0 mm. I.P. weights range from 2.1 gm to 28.8 gm. The priming volume of the portal reservoir ranges from 0.2 cc to 1.5 cc. The priming volume of the catheter is 0.5 cc. Four to eight suture holes are located on the outside base of the portal body. These are used to suture the port to the underlying tissue intra-operatively.
Placement of Implanted Ports
The port is surgically implanted beneath the skin, and generally in the chest region. The incision is made halfway between the clavicle and nipple on either the left or right side of the chest. The right side of the chest is generally preferred since the anominate vein curves down more directly to the superior vena cava (SVC). The surgeon makes the final decision about the site for implantation based on skin condition, presence of a pacemaker, and taking into account other medical conditions that would contra-indicate the use of a particular site. An approximate 5-cm incision in the skin is made at the selected site. A “kangaroo” pocket is created approximately two inches away from the incision line and 0.5-cm to 2.0 cm deep into which the portal body is placed. The pocket is located away from the incision line in order to avoid rupturing the incision with subsequent accessing of the port. The I.P. is placed in this pocket and sutured in place to the underlying tissue.
The suturing should be secure enough so that the I.P. won’t loosen with frequent accessing and manipulation of the port. The underlying tissue should be firm in order to provide support to the I.P. for accessing and de-accessing. The catheter is connected to the portal body at the shoulder of the I.P. Catheters separate from the portal body are pushed over the barb and the catheter locked in place with a radiopaque ring. The catheter is then threaded subcutaneously from a point near the clavicle to meet with the portal body. The catheter tip is advanced into the subclavian vein and terminated in the SVC/atrial junction. It takes approximately two weeks for the body to establish a “healed in tract” for the tunneled catheter.
This procedure takes from one-half to one-hour and generally a local anesthesia is used. Placement of the smaller P.A.S. port in the arm can be done in a doctor’s office.
Other sites used for the placement of an I.P. are in the abdominal cavity with the tip of the catheter tunneled into the inferior vena cave (IVC). The breast may also be used for I.P. placement in female patients. These sites provide less stability to the port when accessed than does the chest location.
Types of Implanted Ports
Common types of I.P. are the single and double lumen ports, the P.A.S. port, the Groshong port, the side-access port, and the dome (or Omega) port. The port used is primarily dependent upon the surgeon’s choice or availability within a particular medical facility. Dual ports are preferred from a maintenance standpoint because patients often require infusion of non-compatible medications and fluids which necessitate another I.V. access. Additional I.V. access increases the probability of complications such as phlebitis, hematomas, and infiltration. The RN should be the patient’s advocate by helping the patient make the safest and most appropriate choice for venous access devices.
Dual I.P.s have separate reservoirs and separate catheters to each reservoir; however the catheters are generally encased in one sleeve. The catheter end may have staggered tips terminating in the SVC/atrial junction or in the IVC if the I.P. was placed in the abdominal wall. Each port requires individual care. (NOTE: if it is not clear whether a patient has a single or double port, feel the skin over the port. A double lumen will be rectangular with two septums [surface gives slightly upon palpation]; a single lumen port will be round with one septum. If each port of a dual lumen is accessed properly, two separate external catheters will extend from the dressing site. Label distal and proximal catheters appropriately.)
The Groshong port is manufactured as a single or dual port. The tip of the Groshong I.P. catheter has valves typical of the tunneled Groshong catheter. No heparin is required with the Groshong catheter because of these valves. They are in a closed position when no I.V. fluids are infusing or no blood is being drawn. (NOTE: if there is evidence of a leaking valve [remains open due to fibrin deposit] and blood backup is evident in the catheter, obtain an order for heparin from the patient’s doctor.)
The side access port is accessible from both sides of the port body. A flat butterfly Huber needle is used to access these ports.
The Omega (or dome) port is shaped like a dome with a steel mesh encasing the dome. (NOTE: the base is steel. If, upon accessing, the needle will not penetrate the septum, move the needle a very small distance in any direction in order to avoid the wire mesh.)
Indications for Placement and Use
Indications for use of the implantable ports over use of other central lines are:
1. There is no external component to break. (Tunneled Groshong, Hickman, and Broviac catheters extend outside of the body. (This is especially important to active teens and young adults.)
2. Patients with poor venous status, e.g. oncology, fragile diabetic, and/or cystic fibrosis patients have fragile veins which are difficult to access.
3. Patients with need for long term (>3 to 10 years) venous access.
4. Patients who need total parenteral nutrition (TPN), vesicant drugs, chemotherapy, and anti-biotics.
5. Administration of pain medicines which are delivered by PCA or CADD pumps needs reliable venous access.
6. Administration of blood products and need for blood draws are facilitated by use of an I.P.
7. Patients with body image concerns; i.e. their body image is not threatened by external catheters.
8. Patients who need increased mobility (young, active adults).
Contra-indications for Placement and Use
1. I.P.s should not be used when a known infection is present.
2. A patient with too adequate or inadequate body tissue will present a challenge to the use of the I.P.
3. Severely neutropenic patients should not have an I.P. placed because of their lowered resistance to infection.
4. Patients with low platelet count are at risk for bleeding during and after operative procedures.
Care and Use of I.P. after Initial Surgical Implantation
Doctors have individual preferences as to when the port should be used after surgical placement; therefore the nurse must check with the physician or the doctor’s order. The two primary reasons for waiting for use after implantation are the following:
1. Reduction of swelling post-operatively.
2. Restricted access for I.V. infusion by doctor’s orders.
(NOTE TO NURSES: When receiving report from the O.R. nurse, check whether a terminal flush (10 cc normal saline and 5 cc heparin [100 units/cc]) of the I.P. was done in O.R. An occlusion of a newly implanted port has been known to occur due to the non-performance of the terminal flush after implantation.)
When receiving report, check that the chest X-ray was done and read. The tip placement should be in SVC/atrial junction. Do not infuse through a central line unless it is certain that the catheter tip is located in the proper position.
Dressing changes on the accessed I.P. during the immediate post-operative period must be done on a daily basis for seven days and/or following the surgeon’s preferences and orders. Daily dressing changes consists of one 4X4 gauze over the folded-up 2X2 gauze around the port needle. The 4X4 gauze is taped per framed-taping method. This allows daily inspection of the operative site. This 7-day period of daily changes is followed by the routine dressing changes using 2X2 gauze and 4X5.5 opsite every three days with needle changes every six days. (See diagram below.)
If the I.P. is not accessed post-operatively, the initial dressing change is typically handled by the surgeon or as per surgeon’s orders.
Dressing changes are done as follows:
1. Remove the old dressing carefully (DO NOT PULL BACK ON I.P. NEEDLE).
2. Cleanse skin under and/or around the I.P. needle with alcohol swabs. This is done three separate times (X3) using a circular motion with friction.
3. Allow alcohol to dry.
4. Use Betadine swabs X3 using circular motion from center to the periphery.
5. Allow to dry.
6. Apply dressing of singularly folded 2X2 gauze around or on the sides of the I.P. needle.
7. Place one 2X2 gauze over the I.P. needle and over the tubing of the I.P. needle.
8. Apply opsite dressing (a clear, permeable membrane typically 4 X 5.5 inches). Some facilities refer to this dressing as tegaderm dressing. (AVOID PLACEMENT OF THE OPSITE TAPE DIRECTLY OVER THE I.P. AND I.P. TUBING BY ASSURING THAT A GAUZE IS IN PLACE OVER THE I.P. NEEDLE AND TUBING TO FACILITATE REMOVAL OF THE OPSITE.)
9. Assure that the entire dressing is occlusively sealed, i.e. no gauze should be exposed to the air.
10. A one-inch wide tape should be placed over the catheter, overlapping the opsite dressing and adhered to the patient’s skin. This provides additional support for the needle and prevents its dislodgment from the port.
11. Label site with gauge, length of I.P. needle, day, time, and the R.N.’s initials.
12. Document on intravenous administration record (IVAR) the appearance of skin around the insertion site and the patient’s reaction to the dressing change.
Needle Size and Type Determination
The size of the implantable port needle most commonly used is the 1-inch, 19 or 20 gauge needle. The needle size least commonly used is the 1 1/2-inch, 19-gauge needle. Other sizes available are 3/4 inch and 1 1/4 inch, 19 or 20-gauge needle. Check with the facility’s supply department to determine which sizes are available. The primary factor, which determines choice of I.P. needle size, is the amount of the patient’s adipose tissue.
1.) If the port is easily visible under the skin and protruding slightly from the chest, a 3/4-inch length I.P. needle should be used. (Note: The outline of the I.P. and catheter will be perceived under the skin only in emaciated patients.)
2.) If the top of the port is flush with the skin (of average thickness) use a 1-inch long I.P. needle. (In most cases, the I.P. and/or catheter will not be seen.)
3.) If the I.P. is not visible, but can be felt deeper under the skin with adipose tissue or if port is tilted, choose a 1 1/4-inch needle. If the I.P. has been placed deeper under the skin, i.e. breast tissue, a 1 1/2-inch needle should be selected.
Needle wings or gripper needle pads should not be placed so tightly onto the skin that there is insufficient space for air circulation. The skin may become necrotic. Plastic surgery and/or removal of port may then be required.
Only non-coring needles should be used when accessing the reservoir of the I.P. Standard hypodermic needles may damage the septum. All I.P. needles have a deflective, non-coring tip that slices the septum upon entry. The septum reseals itself after being penetrated by a properly designed needle. The use of larger gauge I.P. needles will impact the septum’s integrity and shorten its effective life. In general, the septum can withstand 1000 to 2000 punctures.
The type of I.P. needle used differs with each facility. Needles come with and without catheters attached. Four types of needles are generally used: gripper needle with Y-set, port-a-cath right angle winged infusion needle, port-a-cath 90° needle, and the port-a-cath straight needle.
Part of the preparation of accessing a port is conversing with the patient and/or family. The patient should be asked whether he/she has an I.P. before placing an angiocath. During admission patients often forget to tell the R.N. about the presence of a central line. An I.P. hidden under the skin is easily overlooked. Sometimes patients will know what size needle worked best during previous accessing of the port. Ask the patients whether they know the type of port implanted. On rare occasions they may have information or even literature about the port. A simple question asked at the appropriate time can save time and material costs as well as reducing the discomfort for the patient.
Complications to Look for Before Accessing Port
1. Assess chest wall for swelling.
2. Check lateral circulation.
3. Check for distended neck veins.
4. Gently palpate catheter tract for kinking or coiling, but only if catheter is visible under the skin.
5. Palpate I.P. under skin and check for flipped-over portal body.
6. Ask patient whether he/she has experienced pain in shoulder on side where I.P. is located (e.g. chest tightness) or swelling in arms and fingers.
7. Assess condition of skin over and around I.P.
8. Report complications to doctor.
Materials used in accessing the I.P. should be assembled prior to its access. The materials are as follows:
1. Opsite (4 X 5.5 inch clear, permeable dressing)
2. Appropriate I.P. needle
3. Package of alcohol swabs
4. Package of betadine swabs
5. 1-10 cc bottle of normal saline (NS)
6. 1-10 cc bottle of heparin (100 units/cc)
7. 1-18 or 19 gauge straight needle
8. 2 or 3-10 or 12 cc syringes
9. Package of sterile gloves
10. Clean gloves
11. 3-Packages of 2X2 sterile gauze
12. 1-needleless system access cap (Clave or reflux valve)
14. 1-Bottle of Lidocaine 1% without epinephrine
15. 1-T.B. syringe
Process of Accessing
1. Put on mask.
2. Wash hands; put on clean gloves.
3. Open the corner of the I.P. needle package and pull out the end of the tubing through the corner opening and attach the access cap.
4. Attach filled 10-cc syringe with NS and prime I.P. needle.
5. Open the I.P. needle package entirely, keeping it sterile.
6. Open the package with the opsite.
7. Open the three packages of sterile 2X2 gauze and drop onto the opsite, maintaining sterility.
8. Position patient in supine position; provide privacy, expose I.P. site.
9. Palpate area of port prior to site prep to determine the precise location of port septum.
10. Prep site with two alcohol swabs using friction in a circular motion.
11. Allow alcohol to dry.
12. If Lidocaine is used, inject at a 5º angle, 0.05 to 0.10 cc 1% intradermally, at the intended needle injection site. (The site will remain numbed up to 15 minutes.)
13. Clean site with a third alcohol swab.
14. Allow alcohol to dry.
15. Prep site with three betadine swab sticks using circular motion from inside to outside.
16. Put on sterile gloves.
17. Place sterile paper from opened glove package on patient’s chest, just below the I.P.
18. Pick up the sterile I.P. needle by its wings or top, and let the syringe at the end of the needle-tubing lie on the sterile paper.
19. Support I.P. with the non-dominant hand, using both thumb and index finger to stabilize the port.
20. With dominant hand, using a firm, smooth motion at the point numbed by the Lidocaine, penetrate the center of the septum at a 90º angle until the needle hits the bottom of the reservoir.
21. Remove gripper tab before applying gauze and transparent dressing.
22. Place the contents of two packages of folded 2 X 2 gauze on each side of the I.P. needle or underneath the needle if there is space. (NOTE: SPACE SHOULD BE NO LARGER THAN 0.25 CM) A single 2 X 2 gauze should be placed on top of the I.P. and one on top of the I.P. tubing. This will facilitate easier removal of dressing.
23. Do not allow the needle to be pulled back when placing the gauze.
24. Check for blood return; flush port with NS using intermittent positive pressure and close clamp while flushing.
25. Place opsite dressing over accessed port and label with length and gauge of I.P. needle along with date and R.N.’s initials.
26. A one-inch wide tape should be placed over the catheter, overlapping the opsite dressing and adhered to the patient’s skin. This provides additional support for the needle and prevents its dislodgment from the port (see diagram).
27. Final flush to be done with 10 cc NS and 5 cc heparin (100 units/cc) using an intermittent positive pressure motion to promote a scrubbing effect in both port and catheter and clear out the residue that may adhere to the internal lumen of the catheter. The goal of the final flush is to clean out the residue in the system.
28. Document procedure and presence of blood return and also patient’s tolerance of procedure.
De-accessing of Port
Materials used in de-accessing the I.P. should be assembled prior to its de-access. The materials are as follows:
1. 2-10 or 12 cc syringes
2. 2-18 or 19 gauge needles
3. Clean gloves
4. 1-Package of 2X2 gauze
5. 2-alcohol wipes
6. 1-inch tape
7. 1-10 cc bottle of NS
8. 1-10 cc bottle of heparin (100 units/cc)
Process of De-accessing
1. Gather supplies.
2. Wash hands.
3. Put on clean gloves.
4. Draw-up one syringe with 10 cc of NS.
5. Draw-up one syringe with 5 cc heparin (100 units/cc).
6. Check I.P. for blood return.
7. Flush I.P. with 10 cc NS and 5 cc heparin (100 units/cc), using intermittent positive pressure.
8. While infusing the last 1 cc of heparin, close clamp on tubing to prevent blood reflux into internal catheter.
9. Rest the side of the dominant hand on chest when pulling out the I.P. needle (to avoid rebound of needle) and support the I.P. in place with the index finger and thumb of the non-dominant hand.
10. Clean site with alcohol wipe and apply gauze dressing.
Process of Re-accessing (changing I.P. needle)
1. Gather supplies as in port access plus one additional bottle of 10 cc NS and one 10 cc syringe with an 18 or 19 gauge needle.
2. Put on mask.
3. Wash hands.
4. Put on clean gloves.
5. Flush I.P. with 10 cc of NS and clamp I.P. needle tubing.
6. Cap end of I.V. tubing to maintain sterility.
7. De-access as per procedure above.
8. Follow I.P. access procedure.
Maintenance of I.P.
If no I.V. fluids are infusing through I.P., flush with 10 cc NS and 5 cc heparin (100 units/cc) once every 24 hours. Follow facility’s policies and procedures.
If I.V. fluids are infusing, avoid a very slow infusion rate (i.e.<5 cc/hour) as this could contribute to the development of clots at the end of the internal catheter.
Do not flush I.P. with heparin 500 units more often than once every eight hours. A thorough flush with NS is acceptable when frequent administration of I.V. medicines is required and the I.P. is heplocked.
If the I.P. is not being used for infusion of medications or I.V. fluids, the port should be accessed once per month for a terminal flush with 10 cc NS and 5 cc heparin (100 units/cc); see access/de-access procedure above.
(Note: Heparin is used to keep blood from clotting in the catheter. Once a clot forms, heparin will not dissolve the clot.)
Routine Use of Port
Implanted Ports are used for blood draws and for I.V. fluid and medication administration once the tip is determined to be located in the SVC or IVC.
PT and PTT draws SHOULD NOT BE TAKEN from an I.P. (exception: a Groshong Port, but only when NS has been used for flushing) because laboratory results may be inaccurate. Experienced personnel should obtain PT and PTT draws via a peripheral draw.
The advantages of I.P.s versus tunneled centrally placed catheters are the following:
1. Decreased risk of infection of site as the port is sealed under the skin.
2. Decreased interference with activities of daily living (ADL) because there are no external components.
3. There is less concern about body image (an important factor in teenage use).
4. Relatively low maintenance cost (I.P.s require a terminal flush consisting of 10 cc NS with 5 cc heparin [100 units/cc] once a month which can be arranged with a local healthcare provider on an outpatient basis).
5. Long usable life. I.P.s may be used for up to ten years if properly maintained compared to <one year for a PICC.
The disadvantages to the use of an I.P. are as follows:
1. Needle access is required; this is an especially important consideration for a patient with needle phobia.
2. Displacement of the access needle is possible, particularly if the needle used is too long or too short.
3. I.P.s are the most expensive vascular access devices (VAD) to place.
4. I.P.s require a minor surgical procedure to both place and remove.
5. I.P.s are difficult for patients to maintain.
Complications of Use
A. Failure to draw blood from port could possibly be due to:
1. the presence of a fibrin sheath.
2. tumor growth at catheter site.
3. slush inside port.
4. vessel wall drawn up into the catheter tip.
B. Failure to draw blood and infuse fluids could be caused by:
1. A1, A2, A3, and A4 (above).
2. a thrombus formation as a result of damage to the venous intima by the catheter.
3. inadequate flushing technique (intermittent positive pressure should be applied when flushing catheter).
4. catheter malposition.
5. mechanical failure of catheter.
6. accumulation of fibrin tail or sheath at internal catheter tip.
C. Infection along catheter tract or in port pocket requires astute assessment skills, e.g.:
1. Redness or exudate along catheter tract need to be evaluated; however, evidence of slight erythema may not signal infection.
2. Immuno-compromised patients may show no external sign of infection while infection could actually be present.
3. The organism that causes infection is believed to colonize the I.P. by two routes: 1) migration along the catheter tunnel 2) being introduced upon port access.
4. If a port pocket infection is suspected, the nurse should not access port as this can track the infection into the blood stream. However, if the port is already accessed, obtain blood cultures. Eventually, the port may need to be removed.
D. Extravasation is a potentially serious consequence of I.P. use.
1. Signs and symptoms of extravasation are: stinging, burning and pain in infusion site.
2. Fluid palpable under skin.
3. Ulceration develops insidiously, usually 48 to 96 hours after extravasation into tissues has occurred.
4. Treatment is to stop infusion, aspirate as much fluid infused as possible, leave the port accessed as an anti-body may need to be administered via external catheter to allow it to dwell in extravasated site. Call the pharmacy and notify the doctor. Follow the facility’s policies and procedures re: extravasation.
5. Needle dislodgment is the most frequent cause of extravasation, but thrombotic events, catheter tip displacement, inadequate needle stabilization, and catheter damage can also cause dislodgment.
6. Assess skin frequently for signs and symptoms of extravasation when a vesicant is infusing. Also check for blood return during infusion.
7. Before administering a vesicant, the port should be flushed and checked for positive blood return. Although the presence or absence of blood alone cannot be relied upon, it remains an important objective signal. When there is no blood return, the catheter may require radiographic evaluation with contrast injection.
E. Catheter Malposition
1. Projectile vomiting and/or persistent coughing may cause the tip of the I.P. catheter to be spontaneously migrated up into the internal jugular vein (IJ).
2. If the patient complains of “the sound of a waterfall or rushing water” in the ear on the side of the I.P., the tip may have moved up the I.J.
3. Follow up care as per MD’s order. In this situation the catheter may require radiographic evaluation with contrast injection to ascertain the location of the catheter tip.
4. The catheter tip positioned deeply in the SVC/atrial junction is less likely to migrate.
F. Pinch-off Syndrome This is a rare complication and occurs when the catheter becomes pinched between the clavicle and the first rib. When a patient is upright, the weight of the shoulder narrows the area and pinches off the catheter. The continued pinching action could eventually wear through and cut the catheter. With an incomplete or complete fracture, infusion is accompanied by swelling and discomfort in the clavicular area. With a complete fracture, the distal catheter tip may migrate to the right side of the heart with a sudden onset of chest pain. The pinch-off syndrome can be avoided by the surgeon during the procedure by placing the catheter through the area furthest removed from the clavicle and first rib location.
G. Twiddlers Syndrome
This is also a rare complication. The patient manipulates the in-place I.P. causing the port to dislodge in the subcutaneous pocket by loosening the sutures.
H. Pulmonary Embolism
This complication is a result of the inadvertent loosening and lodging of a thrombus in the pulmonary system. Signs and symptoms are chest pain, dyspnea, cough, anxiety, and fever. Treatment should be done per doctor’s orders.
I. Air Embolism
An air embolism can occur anytime that a central line is opened to the air. When opening a catheter to the air (e.g. when changing clave), instruct the patient to use the valsalva maneuver, i.e. the patient is to breath out and bear down (forced expiration with mouth closed) immediately before and during the time that the catheter is open to the air. Signs and symptoms of air embolism are cyanosis, drop in blood pressure, rapid weak pulse, rise in venous pressure, and loss of consciousness. If an air embolism occurs, the source of air entry must be immediately rectified. The patient should be turned on his/her left side with the head down. This causes the air to rise in the right atrium, preventing it from entering the pulmonary artery. Oxygen is then administered and the physician notified. Continue treatment as per doctor’s order.
Causes of total occlusions (generally indicated by pump readout and/or inability to draw blood or flush catheter) are:
1. dislodgment of port and/or needle.
2. kinking or coiling of external catheter.
3. kinking or coiling of internal catheter.
4. precipitation of a drug within the length of a catheter.
5. presence of a fibrin tail or sheath at catheter tip.
6. thrombus formation.
Port dislodgment occurs as a result of twiddlers syndrome and/or rough handling when accessing port. The I.P. needle could become dislodged from the port reservoir if accidentally pulled out and obstructed by the septum.
If portal body has flipped-over underneath the skin due to loosened sutures, the internal catheter may become kinked. (Correction of this situation requires surgical procedure.)
Check tubing and external catheter for kinking or coiling by following the line from the I.V. bag to the insertion site.
Chemical precipitates can cause a catheter to occlude. Administration of a medicine with a high pH (e.g. acyclovir has pH of 10.5 to 11.6, dilantin has a pH of 12) can cause catheter occlusion if the medicine has not been flushed out properly with normal saline. Precipitates can form as a result of a drug crystallization, drug-to-drug incompatibilities, or drug-to-solution incompatibilities. Lipid residue also can accumulate in central venous catheters as well as residual amounts of TPN. Residual amounts of TPN can form a precipitate within twelve hours if not flushed correctly.
The costs of incompatible medication use are high. Such use can lead to degradation of the drug’s efficacy with resulting failure in treatment. Clot formation could cause pulmonary embolism. Rectifying an occlusion causes a waste of valuable time and materials. Clearing agents, such as Streptokinase or TPA, are expensive and administered per facility’s policies and procedures. The patient and family ultimately pay the cost both in monetary and emotional terms. AVOID MULTIPLE DRUG INFUSIONS AND ALWAYS FLUSH WITH NS BETWEEN ADMINISTRATION OF DRUGS USING INTERMITTENT POSITIVE PRESSURE. Use a 10-cc syringe to avoid high internal pressure in the catheter/vein and possible separation of portal body from catheter.
Prevention of drug precipitation requires vigilant flushing between drugs and the ASSUMPTION THAT NOTHING IS COMPATIBLE.
Be especially aware of “double extension tubing.” It is not to be confused with a double lumen port. Infusion of incompatible medications through a double extension tubing will result in obstruction as these incompatible medicines will meet in the port reservoir potentially causing precipitate and obstruction.
K. Thrombus Formation
The primary cause of a catheter occlusion is the formation of a thrombus within or surrounding the catheter. Thrombus formation starts initially as a fibrin sleeve/sheath consisting of platelets and fibrin. This sheath may become seeded with micro-organisms which may disseminate into the blood stream. The sheath acts as a nidus for bacterial action. It is extremely important to keep the port catheter and reservoir clear of fibrin formation. Proper flushing and adherence to sterile techniques can reduce or eliminate complications.
Sludge is any blood product or drug precipitate that adheres to or resides in the internal path of the I.P. reservoir. Each time blood is aspirated from a port, some residual blood can adhere to the catheter and/or portal reservoir causing fibrin that can lead to infection. Sludge accumulates within the reservoir and can obstruct the entrance to the internal catheter. It is the result of improper flushing technique between medications, I.V. fluids, and blood sampling.
A catheter related venous thrombus is a potentially life-threatening condition. Fibrin deposited on the wall of the vein could eventually result in blood flow obstruction. Septicemia or obstruction of the vein, pulmonary embolism, or chronic venous insufficiency may eventually occur.
Obstructions caused by incompatible medications can also become trapped in the Y-injection port of the I.P. needle tubing. This combined with the blood fibrin or other medication precipitates can cause a clump/clot to form and later be pushed into the circulation system.
Catheter related venous thrombosis can progress to SVC syndrome. Signs and symptoms of catheter related SVC syndrome are shortness of breath and chest pain. Patients exhibiting these symptoms need immediate thrombolytic therapy.
Procedures to Clear Obstructions
1. The first step in evaluating a total occlusion is to make certain that the port needle has fully traversed the septum and is not occluded by the silicone.
2. Check external tubing for kinks and straighten them, if found.
3. Listen to patients—they may have developed their own, successful methods to facilitate flushing process.
4. Change the patient’s position in bed or chair (raise arms, turn head, cough, etc.)
5. Ambulate patient, if possible, and try again to obtain blood after one hour.
6. Valsalva maneuver (ask patient to breath deeply and bear down)
7. Try to loosen and aspirate clot with 20 cc NS and allow 5 cc heparin (100 units/cc) to dwell in reservoir for at least one hour. After dwell time, attempt to aspirate the clot or thrombus.
8. The next step is to re-access the port as the needle may be lodged in an accumulation of sludge in the reservoir. Reposition the needle slightly before re-accessing to avoid the sludge.
9. If not successful, use a fibrinolytic agent (e.g. streptokinase or TPA should be considered.) Follow facility’s policies and procedures. (NOTE: Some patients may show side effects to the use of Streptokinase, such as fever, chills, hematuria, hypotension, shock, or even death. Take patient’s vital signs pre and post Streptokinase treatment. Patients who have had Streptokinase treatments more than twice in one year are more susceptible to developing side-effects. Observe patients carefully.)
10. An occluded catheter should NOT be forcefully irrigated because it could result in catheter rupture.
11. Imaging study, with dye, will determine position of fibrin sleeve.
12. If none of the above methods are effective in restoring patency and the port has been proven to be totally occluded, the removal of the port is indicated.
Nurse’s Responsibilities for I.P. Care
1. Maintaining the function of the I.P. is a critically important task.
2. Access/de-access/re-access I.P.
3. Perform proper flushing technique.
4. Flush by creating a turbulent flow/scrubbing action thereby clearing out residue.
5. Clamp tubing toward the end of the flushing action.
6. Withdrawal of blood:
a. Flush with 10 cc NS and withdraw 3 cc to 5 cc of waste and discard.Use the facility’s procedure for drawing blood from a line with continuous TPN infusion.
c. Draw blood sample.
d. Flush with 10 cc NS using proper flushing technique.
e. Continue I.V. fluids as ordered or, if heplocked, flush with 5 cc heparin (100 units/cc).
f.Send blood sample per policy and procedure of facility.
7. Troubleshoot problems such as: 1) causes of occlusions 2) tipped I.P. 3) edema around I.P. and catheter, and other situations encountered.
8. Assessment of skin integrity at the I.P. site.
9. When port is accessed, change dressing every 3 days (or follow your facility’s procedure.)
10. Change I.P. needle every 6 days when port is accessed (or follow your facility’s procedure.)
11. Perform terminal flush once per month, when the port is not accessed.
12. Clear I.P. with heparin or Streptokinase or TPA (R.N. should be proficient in this technique.)
13. Instruct patients regarding all aspects of I.P. and its care.
14. Have patient report swelling, redness, and soreness at site.
15. Make patient familiar with design and function of port.
Accessing Port Documentation
1. Date and time accessed.
2. Indicate single or dual lumen port.
3. Appearance of skin over and surrounding port.
4. Gauge and length of I.P. needle used.
5. Type and amount of priming solution used.
6. Ease of access.
7. Whether blood return was positive or negative.
8. Action initiated if blood return was negative.
9. Indicate if blood work done using the I.P. or a peripheral draw.
10. If PT/PTT was ordered, indicate that it was drawn peripherally.
11. Type of dressing used (4X4s or 2X2s, and opsite).
12. Indicate if catheter is heplocked or if I.V. fluid/medication is infused.
13. Indicate universal precautions and sterile technique used.
14. Record comments made by patient re: insertion.
De-Accessing Port Documentation
1. Blood return prior to de-accessing, either positive or negative.
2. The ease of which I.P. was flushed.
3. Terminal flush done: 10 cc NS, 5 cc heparin (100 units/cc).
4. Record comments patient made about procedure.
5. Skin condition.
6. Information provided to patient.