Background and History of Implanted PortsImplantable ports are implanted subcutaneously to provide access to the peritoneal cavity or thevascular, arterial, or epidural system. This course will deal only with vascular access ports. Itwill 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. Oncologypatients were the first recipients of I.P.s. Acceptance of these devices has grown rapidly withmore than 100,000 ports being implanted each year. More than fourteen different manufacturershave designed their own type of port, yet most are similar in design, function, and application.Design of Implanted PortsThe implantable venous access device consists of the portal body and the catheter. The portalbody is made of either stainless steel, titanium, polysulfone, or a combination thereof with aninner 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 thesurgeon at the time of implantation. Catheters are provided with a catheter lock to insure theintegrity of the attachment. Most catheters are made of silicone, as this material is known toproduce fewer thrombi. The height of the portal body ranges from 9.8 mm to 17.0 mm with awidth at the base of 16.5 mm to 40.0 mm. I.P. weights range from 2.1 gm to 28.8 gm. Thepriming volume of the portal reservoir ranges from 0.2 cc to 1.5 cc. The priming volume of thecatheter 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 PortsThe port is surgically implanted beneath the skin, and generally in the chest region. The incisionis made halfway between the clavicle and nipple on either the left or right side of the chest. Theright side of the chest is generally preferred since the anominate vein curves down more directlyto the superior vena cava (SVC). The surgeon makes the final decision about the site forimplantation based on skin condition, presence of a pacemaker, and taking into account othermedical conditions that would contra-indicate the use of a particular site. An approximate 5-cmincision in the skin is made at the selected site. A “kangaroo” pocket is created approximatelytwo inches away from the incision line and 0.5-cm to 2.0 cm deep into which the portal body isplaced. The pocket is located away from the incision line in order to avoid rupturing the incisionwith subsequent accessing of the port. The I.P. is placed in this pocket and sutured in place to theunderlying tissue.
The suturing should be secure enough so that the I.P. won’t loosen with frequent accessing andmanipulation of the port. The underlying tissue should be firm in order to provide support to theI.P. for accessing and de-accessing. The catheter is connected to the portal body at the shoulderof the I.P. Catheters separate from the portal body are pushed over the barb and the catheterlocked in place with a radiopaque ring. The catheter is then threaded subcutaneously from a pointnear the clavicle to meet with the portal body. The catheter tip is advanced into the subclavianvein and terminated in the SVC/atrial junction. It takes approximately two weeks for the body toestablish 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 thecatheter 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 thandoes the chest location.Types of Implanted PortsCommon 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 uponthe surgeon’s choice or availability within a particular medical facility. Dual ports are preferredfrom a maintenance standpoint because patients often require infusion of non-compatiblemedications and fluids which necessitate another I.V. access. Additional I.V. access increases theprobability of complications such as phlebitis, hematomas, and infiltration. The RN should be thepatient’s advocate by helping the patient make the safest and most appropriate choice for venousaccess devices.Dual I.P.s have separate reservoirs and separate catheters to each reservoir; however thecatheters are generally encased in one sleeve. The catheter end may have staggered tipsterminating 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 ordouble 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. Ifeach port of a dual lumen is accessed properly, two separate external catheters will extend fromthe 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. catheterhas valves typical of the tunneled Groshong catheter. No heparin is required with the Groshongcatheter because of these valves. They are in a closed position when no I.V. fluids are infusing orno blood is being drawn. (NOTE: if there is evidence of a leaking valve [remains open due tofibrin deposit] and blood backup is evident in the catheter, obtain an order for heparin from thepatient’s doctor.)The side access port is accessible from both sides of the port body. A flat butterfly Huber needleis 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 avery small distance in any direction in order to avoid the wire mesh.)Indications for Placement and UseIndications 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 Broviaccatheters extend outside of the body. (This is especially important to active teens and youngadults.)2. Patients with poor venous status, e.g. oncology, fragile diabetic, and/or cystic fibrosis patientshave 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 reliablevenous 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 externalcatheters.8. Patients who need increased mobility (young, active adults).Contra-indications for Placement and Use1. 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 theI.P.3. Severely neutropenic patients should not have an I.P. placed because of their loweredresistance 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 reasonsfor 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 terminalflush (10 cc normal saline and 5 cc heparin [100 units/cc]) of the I.P. was done in O.R. Anocclusion of a newly implanted port has been known to occur due to the non-performance of theterminal flush after implantation.)When receiving report, check that the chest X-ray was done and read. The tip placement shouldbe in SVC/atrial junction. Do not infuse through a central line unless it is certain that the cathetertip is located in the proper position.Dressing changes on the accessed I.P. during the immediate post-operative period must be doneon a daily basis for seven days and/or following the surgeon’s preferences and orders. Dailydressing changes consists of one 4X4 gauze over the folded-up 2X2 gauze around the portneedle. The 4X4 gauze is taped per framed-taping method. This allows daily inspection of theoperative site. This 7-day period of daily changes is followed by the routine dressing changesusing 2X2 gauze and 4X5.5 opsite every three days with needle changes every six days. (Seediagram below.)If the I.P. is not accessed post-operatively, the initial dressing change is typically handled by thesurgeon 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 threeseparate 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 facilitiesrefer to this dressing as tegaderm dressing. (AVOID PLACEMENT OF THE OPSITE TAPEDIRECTLY OVER THE I.P. AND I.P. TUBING BY ASSURING THAT A GAUZE IS INPLACE OVER THE I.P. NEEDLE AND TUBING TO FACILITATE REMOVAL OF THEOPSITE.)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 andadhered to the patient’s skin. This provides additional support for the needle and prevents itsdislodgment 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 theinsertion site and the patient’s reaction to the dressing change.Needle Size and Type DeterminationThe size of the implantable port needle most commonly used is the 1-inch, 19 or 20 gaugeneedle. The needle size least commonly used is the 1 1/2-inch, 19-gauge needle. Other sizesavailable are 3/4 inch and 1 1/4 inch, 19 or 20-gauge needle. Check with the facility’s supplydepartment to determine which sizes are available. The primary factor, which determines choiceof 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-inchlength I.P. needle should be used. (Note: The outline of the I.P. and catheter will be perceivedunder 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 istilted, choose a 1 1/4-inch needle. If the I.P. has been placed deeper under the skin, i.e. breasttissue, 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 isinsufficient space for air circulation. The skin may become necrotic. Plastic surgery and/orremoval of port may then be required.Only non-coring needles should be used when accessing the reservoir of the I.P. Standardhypodermic needles may damage the septum. All I.P. needles have a deflective, non-coring tipthat slices the septum upon entry. The septum reseals itself after being penetrated by a properlydesigned needle. The use of larger gauge I.P. needles will impact the septum’s integrity andshorten 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 cathetersattached. Four types of needles are generally used: gripper needle with Y-set, port-a-cath rightangle 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. Thepatient should be asked whether he/she has an I.P. before placing an angiocath. Duringadmission 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 needleworked best during previous accessing of the port. Ask the patients whether they know the typeof 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 asreducing the discomfort for the patientComplications to Look for Before Accessing Port1. 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 theskin.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 asfollows:1. Opsite (4 X 5.5 inch clear, permeable dressing)2. Appropriate I.P. needle3. Package of alcohol swabs4. Package of betadine swabs5. 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 needle8. 2 or 3-10 or 12 cc syringes9. Package of sterile gloves10. Clean gloves11. 3-Packages of 2X2 sterile gauze12. 1-needleless system access cap (Clave or reflux valve)13. Mask14. 1-Bottle of Lidocaine 1% without epinephrine15. 1-T.B. syringeProcess of Accessing1. 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 thecorner 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 intendedneedle 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 theport.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 orunderneath the needle if there is space. (NOTE: SPACE SHOULD BE NO LARGER THAN0.25 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 closeclamp while flushing.25. Place opsite dressing over accessed port and label with length and gauge of I.P. needle alongwith date and R.N.’s initials.26. A one-inch wide tape should be placed over the catheter, overlapping the opsite dressing andadhered to the patient’s skin. This provides additional support for the needle and prevents itsdislodgment from the port (see diagram).27. Final flush to be done with 10 cc NS and 5 cc heparin (100 units/cc) using an intermittentpositive pressure motion to promote a scrubbing effect in both port and catheter and clear out theresidue that may adhere to the internal lumen of the catheter. The goal of the final flush is toclean out the residue in the system.
28. Document procedure and presence of blood return and also patient’s tolerance of procedure.De-accessing of PortMaterials used in de-accessing the I.P. should be assembled prior to its de-access. The materialsare as follows:1. 2-10 or 12 cc syringes2. 2-18 or 19 gauge needles3. Clean gloves4. 1-Package of 2X2 gauze5. 2-alcohol wipes6. 1-inch tape7. 1-10 cc bottle of NS8. 1-10 cc bottle of heparin (100 units/cc)Process of De-accessing1. 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 intointernal catheter.9. Rest the side of the dominant hand on chest when pulling out the I.P. needle (to avoid reboundof needle) and support the I.P. in place with the index finger and thumb of the non-dominanthand.
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 syringewith 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 contributeto 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 thoroughflush with NS is acceptable when frequent administration of I.V. medicines is required and theI.P. is heplocked.If the I.P. is not being used for infusion of medications or I.V. fluids, the port should be accessedonce 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, heparinwill not dissolve the clot.)Routine Use of PortImplanted Ports are used for blood draws and for I.V. fluid and medication administration oncethe 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, butonly 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.AdvantagesThe 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 externalcomponents.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 5cc heparin [100 units/cc] once a month which can be arranged with a local healthcare provider onan 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.DisadvantagesThe 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 withneedle phobia.2. Displacement of the access needle is possible, particularly if the needle used is too long or tooshort.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 UseA. 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 flushingcatheter).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 slighterythema may not signal infection.2. Immuno-compromised patients may show no external sign of infection while infection couldactually be present.3. The organism that causes infection is believed to colonize the I.P. by two routes: 1) migrationalong 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 theinfection 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 hasoccurred.4. Treatment is to stop infusion, aspirate as much fluid infused as possible, leave the portaccessed 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 andprocedures 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 causedislodgment.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 bloodreturn. Although the presence or absence of blood alone cannot be relied upon, it remains animportant objective signal. When there is no blood return, the catheter may require radiographicevaluation with contrast injection.E. Catheter Malposition1. Projectile vomiting and/or persistent coughing may cause the tip of the I.P. catheter to bespontaneously 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 ofthe 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 radiographicevaluation 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 becomespinched between the clavicle and the first rib. When a patient is upright, the weight of theshoulder narrows the area and pinches off the catheter. The continued pinching action couldeventually wear through and cut the catheter. With an incomplete or complete fracture, infusionis accompanied by swelling and discomfort in the clavicular area. With a complete fracture, thedistal 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 thecatheter through the area furthest removed from the clavicle and first rib location.G. Twiddlers SyndromeThis is also a rare complication. The patient manipulates the in-place I.P. causing the port todislodge 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 thepulmonary system. Signs and symptoms are chest pain, dyspnea, cough, anxiety, and fever.Treatment should be done per doctor’s orders.I. Air EmbolismAn air embolism can occur anytime that a central line is opened to the air. When opening acatheter 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) immediatelybefore and during the time that the catheter is open to the air. Signs and symptoms of airembolism are cyanosis, drop in blood pressure, rapid weak pulse, rise in venous pressure, andloss of consciousness. If an air embolism occurs, the source of air entry must be immediatelyrectified. The patient should be turned on his/her left side with the head down. This causes the airto rise in the right atrium, preventing it from entering the pulmonary artery. Oxygen is thenadministered and the physician notified. Continue treatment as per doctor’s orderJ. OcclusionsCauses of total occlusions (generally indicated by pump readout and/or inability to draw blood orflush 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 accessingport. The I.P. needle could become dislodged from the port reservoir if accidentally pulled outand obstructed by the septum.If portal body has flipped-over underneath the skin due to loosened sutures, the internal cathetermay 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. bagto the insertion site.Chemical precipitates can cause a catheter to occlude. Administration of a medicine with a highpH (e.g. acyclovir has pH of 10.5 to 11.6, dilantin has a pH of 12) can cause catheter occlusion ifthe 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-solutionincompatibilities. Lipid residue also can accumulate in central venous catheters as well asresidual amounts of TPN. Residual amounts of TPN can form a precipitate within twelve hours ifnot flushed correctly.The costs of incompatible medication use are high. Such use can lead to degradation of thedrug’s efficacy with resulting failure in treatment. Clot formation could cause pulmonaryembolism. Rectifying an occlusion causes a waste of valuable time and materials. Clearingagents, such as Streptokinase or TPA, are expensive and administered per facility’s policies andprocedures. The patient and family ultimately pay the cost both in monetary and emotionalterms. AVOID MULTIPLE DRUG INFUSIONS AND ALWAYS FLUSH WITH NSBETWEEN ADMINISTRATION OF DRUGS USING INTERMITTENT POSITIVEPRESSURE. Use a 10-cc syringe to avoid high internal pressure in the catheter/vein and possibleseparation of portal body from catheter.Prevention of drug precipitation requires vigilant flushing between drugs and the ASSUMPTIONTHAT NOTHING IS COMPATIBLE.Be especially aware of “double extension tubing.” It is not to be confused with a double lumenport. Infusion of incompatible medications through a double extension tubing will result inobstruction as these incompatible medicines will meet in the port reservoir potentially causingprecipitate and obstruction.K. Thrombus FormationThe primary cause of a catheter occlusion is the formation of a thrombus within or surroundingthe catheter. Thrombus formation starts initially as a fibrin sleeve/sheath consisting of plateletsand fibrin. This sheath may become seeded with micro-organisms which may disseminate intothe blood stream. The sheath acts as a nidus for bacterial action. It is extremely important to keepthe port catheter and reservoir clear of fibrin formation. Proper flushing and adherence to steriletechniques can reduce or eliminate complications.Sludge is any blood product or drug precipitate that adheres to or resides in the internal path ofthe I.P. reservoir. Each time blood is aspirated from a port, some residual blood can adhere to thecatheter and/or portal reservoir causing fibrin that can lead to infection. Sludge accumulateswithin the reservoir and can obstruct the entrance to the internal catheter. It is the result ofimproper flushing technique between medications, I.V. fluids, and blood sampling.A catheter related venous thrombus is a potentially life-threatening condition. Fibrin depositedon the wall of the vein could eventually result in blood flow obstruction. Septicemia orobstruction of the vein, pulmonary embolism, or chronic venous insufficiency may eventuallyoccur.Obstructions caused by incompatible medications can also become trapped in the Y-injectionport of the I.P. needle tubing. This combined with the blood fibrin or other medicationprecipitates 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 ofcatheter related SVC syndrome are shortness of breath and chest pain. Patients exhibiting thesesymptoms need immediate thrombolytic therapy.Procedures to Clear Obstructions1. The first step in evaluating a total occlusion is to make certain that the port needle has fullytraversed 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 facilitateflushing 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 inreservoir 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 sludgein 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 theuse of Streptokinase, such as fever, chills, hematuria, hypotension, shock, or even death. Takepatient’s vital signs pre and post Streptokinase treatment. Patients who have had Streptokinasetreatments more than twice in one year are more susceptible to developing side-effects. Observepatients carefully.)10. An occluded catheter should NOT be forcefully irrigated because it could result in catheterrupture.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 provento be totally occluded, the removal of the port is indicated.Nurse’s Responsibilities for I.P. Care1. 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.DocumentationAccessing Port Documentation1. 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 Documentation1. 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