Intravascular Therapy: Implanted Vascular Access Port

CLINICAL GUIDELINES

Long-term central venous catheters are placed to reduce the trauma of repeated venipuncture. This chapter focuses on implanted vascular access ports (port), which are surgically inserted and removed by a healthcare provider under sterile conditions. Chest placement is most common in children, however they can be placed in the arm. These catheters are used for direct administration of intravenous (IV) fluids; for intermittent use with medications, chemotherapy, blood and blood products, and parenteral nutrition; or for venous blood draws for laboratory analysis. They may be used in the home setting for parenteral therapies, thereby improving the child’s quality of life.
Port access, site care, and infusion may be performed by a validated healthcare provider, or appropriately trained child or family member.
Implanted ports are available in a variety of sizes and may be single or double lumen. In addition some ports are designed to accommodate diagnostic imaging contrast via a power injector (i.e., Power Port, Power Port Needle). It is important to ensure ports with power injector capability are clearly identifiable in the medical record and that the appropriate needle (i.e., Power Port Needle) is selected to access the port. Patients and family must be aware that the child has a power injectable port.
The underlying condition of the child, the indication for use, and the capability of the family or the child to perform self-care for home maintenance help determine which venous access device is appropriate for that child. Ports are better suited for prolonged (3 months or more) intermittent IV therapy. However, because of size restrictions, they may not be available for use in neonates and small infants. Lowprofile devices may be placed in younger children, according to the surgeon’s preference.
Access to a port reservoir is accomplished with a noncoring needle (e.g., Huber) because a standard needle will damage the self-sealing silicone septum. Noncoring needles come in varying lengths and sizes; however, the most commonly used size for children is a 22-gauge right-angle needle with a variable length to accommodate the depth of subcutaneous tissues (Figure 57-1). Select a needle length that will sit flush to the skin. Some needles have an adjustable flange for added stabilization. Safety needles are preferred when available.
Topical anesthetic agents are an option for comfort with needle insertion in nonemergent situations, based on child preference and allergies.
Aseptic technique is used when caring for or using long-term venous access devices to minimize the associated risk for infection.
A 2% chlorhexidine-based preparation is the preferred solution for skin antisepsis. An iodophor (e.g., povidone-iodine), 70% alcohol, or tincture of iodine can be used.
When accessed a transparent dressing should cover the insertion site (Infusions Nurses Society [INS], 2011).
Follow manufacturer’s instructions for the specific venous access devices.
When the port is used daily, the needle remains in place. Insufficient evidence exists to indicate the optimal frequency at which to change the needle (INS, 2011; O’Grady, Alexander, Burns, et al., 2011); common practice is to change the needle every 7 days with the dressing.
Monthly flushes with sterile heparin (recommended concentration of 100 units/ml) are required to maintain patency when the port is not in use and the port reservoir is deaccessed (INS, 2011).
All add-on devices have a Luer Lock design.
Needless neutral or positive pressure caps will be utilized.
IV fluids are administered via a flow-controlled infusion device.
Care and management techniques vary based on the procedure being performed per institutional policies and include:
- Aseptic technique (sterile dressings and sterile gloves)
- Modified clean technique (nonsterile gloves and sterile dressings)

Figure 57-1 Schematic of an implanted port with noncoring needle inserted. Note the difference between a noncoring needle with the lumen on the side versus a standard needle with the lumen at the end. This design avoids shearing of the material of the port septum when accessing the implantable device and maintains integrity of the septum.

EQUIPMENT

For access and administration of solutions through a port:

Sterile drape
Two pairs of sterile gloves
Two sterile 10-mL syringes
Two sterile needleless access devices (per institutional policy)
Appropriate-sized right-angle noncoring needle with attached extension tubing
Sterile needleless neutral or positive pressure catheter cap (to attach to needle extension tubing)
Antiseptic swabs (Table 57-1): 2% chlorhexidine-based preparation is preferred, tincture of iodine, an iodophor (e.g., povidone-iodine), or 70% alcohol can be used
Sterile preservative-free 0.9% sodium chloride (20 mL) for injection
Prescribed fluid for administration, along with administration set
One-inch tape
Sterile closure tape strips
Dressing materials: sterile, semipermeable, transparent dressing, chlorhexidine patch (optional)
Topical anesthetic, if used

For flushing and heparin locking an accessed port:

Nonsterile gloves
Two sterile 10-mL syringes
Sterile needleless system/blunt cannulas (per institutional policy)
Heparin: 10 units/mL (per healthcare prescriber order, usually 5 mL)
Antiseptic swabs: 2% chlorhexidine-based preparation is preferred, tincture of iodine, an iodophor (e.g., povidone-iodine), or 70% alcohol can be used
Sterile needleless connector/catheter cap (to attach to extension tubing of the noncoring needle)
Sterile preservative-free 0.9% sodium chloride (20 mL) for injection
Sterile male catheter cap/adapter (to attach to IV tubing to maintain sterility if disconnecting from an infusion)

For removing the needle from a port:

Nonsterile gloves
Two sterile 10-mL syringes
Sterile needleless access devices (per institutional policy)

Sterile preservative-free 0.9% sodium chloride (20 mL) for injection. Prefilled syringes filled with preservative-free
0.9% sodium chloride may be used for routine flushing

TABLE 57-1 Skin Antisepsis

Age	Solution	Cleansing Method
Older than 2 months	Chlorhexidine gluconate solution (CHG)	Using one applicator, clean with repeated back-and-forth strokes of the sponge: For a dry site (e.g., abdomen, arm), cleanse for 30 seconds and let dry for 30 seconds. For a moist site (e.g., inguinal fold, neck), cleanse for 2 minutes.
Younger than 2 months^a	10% povidone-iodine (PI)	Start at the intended insertion site (e.g., septum of the port) and work outward in a circular pattern to an area at least the size of the dressing (2-4 in [5-10 cm]). Use one swab for 30 seconds. Repeat two more times using a new swab each time. Do not return to cleaned area with the same swab. Remove antiseptic with sterile water or sterile saline.
^a^aNeither the Centers for Disease Control and Prevention (O’Grady, Alexander, Burns, et al., 2011, nor the Infusion Nurses Society (INS), 2011, make a recommendation for the use of chlorhexidine in infants aged <2 months. The Association for Women’s Health, Obstetric and Neonatal Nurses, 2013, neonatal skin care guidelines recommend either CHG or PI. The use of CHG in infants weighing <1,000 g has been associated with contact dermatitis and should be used with caution in this population.

Heparin: 100 units/mL (per healthcare prescriber order, usually 5 mL)
Antiseptic swabs: 2% chlorhexidine-based preparation is preferred, tincture of iodine, an iodophor (e.g., povidone-iodine), or 70% alcohol can be used
Sterile 2 × 2 gauze
Adhesive bandage

For blood withdrawal through a port:

Nonsterile gloves
Sterile needleless system/blunt cannulas (per institutional policy)
Antiseptic swabs: 2% chlorhexidine-based preparation is preferred, tincture of iodine, an iodophor (e.g., povidone-iodine), or 70% alcohol can be used
Sterile male catheter cap/adapter (to attach to IV tubing to maintain sterility if disconnecting from an infusion)
Two 10-mL sterile syringes
Heparin (10 units/mL), if the mixing/push-pull method to obtain sample will be used
Sterile preservative-free 0.9% sodium chloride (20 mL) for injection. Prefilled syringes filled with preservative-free 0.9% sodium chloride may be used for routine flushing
Sterile needleless neutral or positive pressure catheter cap
Sterile syringe of appropriate size to withdraw sufficient blood for ordered tests
Specimen tubes for ordered labs
Biohazard bag
Specimen labels and requisition
Ice, if needed for blood specimen

CHILD AND FAMILY ASSESSMENT AND PREPARATION

Discuss the purpose of a port and the intended reason for its use with the child and the family. Reinforce the purpose, and discuss the risks and benefits of longterm total implanted venous access device. Assess the cognitive level, readiness, and ability to process information by the child and the family. Readiness to learn and process information may be impaired as a result of age, stress, or anxiety.
Explain that the port is completely contained underneath the child’s skin; therefore, when not in use, it is fairly inconspicuous (seen only as a bump under the skin) and has a greatly reduced risk for infection compared with a tunneled catheter.
Explain the procedure, as appropriate, to both the child and the family. To help reduce anxiety, describe the sensations the child can expect: palpation of the site, wetness from the cleansing of the insertion site, pressure, and needle insertion and removal sensation. Explain comfort control with the use of a topical anesthetic agent, such as 4% lidocaine cream or buffered lidocaine injection, before insertion of needle (see Chapter 7).

KidKare Count to three before needle placement and removal so the child can prepare him- or herself and is not surprised. Stress the importance of holding still during the needle placement to facilitate insertion. Children identify needles as the most painful and scariest part of any hospitalization. Involve a child-life specialist, if available, to assist with preparation and distraction techniques.

Assess the skin overlying the port and the tissue surrounding the port. Observe for signs of infection or thrombosis. Insertion of the needle should not be undertaken if any of the following signs are present: erythema, inflammation, exudate, supraclavicular swelling, or venous distention.
Assess the child’s baseline vital signs and observe for changes that may indicate a local or systemic infection (e.g., erythema, fever).
Educate the child and the family about potential complications (infection, mechanical problems, including resistance with flushing, breaks, displaced or accidental needle removal, port extrusion through the skin, partial or total occlusions). This enables both the child and the family to recognize when the port is not functioning properly and to know when to notify the nurse. Provide information to promote developmentally based safety measures of child with accessed or deaccessed port.
Apply topical anesthetic agent or buffered lidocaine injection for needle placement in nonemergent situations, based on child preference (see Chapter 7).

PROCEDURE
Access and Administration of Solutions Through a Port

Steps	Rationale/Points of Emphasis 1
1 Perform hand hygiene and gather all necessary supplies. Involve family in comforting child during procedure.	Reduces the transmission of microorganisms. Promotes efficient time management and provides organized approach to the procedure.
	caREminder
	Obtain the assistance of an additional person as needed to hold child securely to prevent contamination of the sterile field.
2 Remove child’s top/clothing and locate the port by palpating it under the skin.	Verifies proper position of port.
3 Remove topical anesthetic cream, if used.	Allows for evaluation of effectiveness of topical anesthetic and prepares skin for cleansing.
4 Palpate/locate the silicone septum of the port reservoir within the perimeter of the port under the skin.	Establishes landmarks of the septum and identifies where needle will be inserted.
5 Repeat hand hygiene.	Reduces the transmission of microorganisms.
6 Establish a sterile work area with the sterile drape; open supplies aseptically and drop them on the sterile field. Don mask and sterile gloves.	Maintaining sterile precautions decreases the introduction of microorganisms.
7 Draw up 20 mL of sterile preservative-free 0.9% sodium chloride. Attach the needle extension tubing to the needle. Connect the filled syringe to the needle extension tubing/cap and prime the extension tubing and needle. Close the clamp on the extension tubing and return needle with attached syringe to the sterile field.	Prepares syringe for use. Clears the needle and extension tubing of air before port access.
8a Prep the skin over the port septum and surrounding area to the same size of the dressing with appropriate antiseptic (Table 57-1 ). Children with ports placed are typically older; thus the antiseptic of choice is chlorhexidine gluconate.	Cleanses microorganisms from insertion site.
• For chlorhexidine, scrub the site for 30 seconds with a back-and-forth motion to get into the skin crevices.	Antiseptics must be applied with sufficient friction to ensure that the solution reaches into the cracks and fissures of the skin. Chlorhexidine requires 30 seconds with friction scrub for antiseptic effectiveness.
• For povidone-iodine, start at the catheter exit site and work outward in circular pattern for several inches. Repeat two more times with a new swab each time. Use friction to enhance the antifungal and antibacterial effects of the cleansing swab. Do not return to cleaned area with the same antiseptic.	Povidone-iodine must remain on the skin for 2 minutes and dry to be most effective; thus, three swabs are used. It has been thought that working from the center outward moves microorganisms away from the exit site, although there is no research to support this. Working outward allows area to dry, facilitating antiseptic effectiveness.
8b Allow site to air-dry for 30 seconds; allow povidone-iodine to remain on the skin for at least 2 minutes, or longer if it is not yet dry. Do not blot, fan, or blow on site.	Allows antimicrobial action of antiseptic. Drying for 30 seconds decreases the chance of contact dermatitis. Blotting, fanning, or blowing may introduce contaminants and hasten drying, reducing antimicrobial action.
9 If an iodine-based antiseptic was used, remove the solution from the skin using an alcohol swab or pad. Start at the septum of the port and work outward in a circular pattern as the same size of the dressing. Repeat two more times with a new alcohol swab each time.	Removes povidone-iodine solution from the skin. Some children have sensitivity to iodine products; do not allow it to remain on the skin.
10 Don a new pair of sterile gloves, if nonsterile items were handled.	Maintains sterile technique.
11 With the nondominant hand, stabilize the port reservoir between the thumb and the forefinger on the overlying skin.	Stabilizes the port from moving or slippage due to the firm pressure required to access the silicone septum.
12 Grasp the needle with the dominant hand, using the forefinger to support the needle or the butterfly wing set. Insert the needle directly perpendicular to the septum of the port; continuously apply steady pressure until you feel the needle touch the back base of the reservoir.	Prevents deflection of the needle into outlying skin. First step of confirming correct needle placement. Do not access the port septum through the same needle site that was previously used because of the potential for skin breakdown and potential abscess formation. The septum can typically withstand approximately 2,000 needle insertions.
13 Pull back on syringe plunger until blood is aspirated.	Second step of confirming correct needle placement into port reservoir.
	caREminder
	Blood return may be brown with fibrin clots when the catheter has not been in use for some time. If this is the case, continue to aspirate blood until it is bright red, and then detach the syringe in use and replace with a new 20-mL saline-filled syringe. If no blood return is obtained and needle placement is correct, do not proceed with fluid administration and notify the healthcare prescriber immediately to ensure prompt intervention to reduce complications.
14 Using small pulses of fluid, infuse the 20 mL of sterile preservative-free 0.9% sodium chloride and clamp when completed.	Flushing is the third step in confirming correct needle placement. Flushes any blood from the port reservoir/catheter and prevents occlusion. Children who require fluid restriction (e.g., those with renal or cardiac conditions) may not tolerate 20 mL. Less flush volumes may be determined in conjunction with the healthcare prescriber (i.e., use 10 mL if it clears the line). Observe for signs of infiltration, such as swelling in the reservoir pocket, or complaints of discomfort/pain, which indicate incorrect noncoring needle placement.
15 Remove the syringe and apply the primed sterile needleless connector/catheter cap. Maintaining sterility, connect prescribed fluid by connecting the IV infusion directly to the needleless connector/catheter cap of the needle extension tubing. Open clamp and begin IV fluids as prescribed or place catheter to “heparin lock” for intermittent infusions by administering the prescribed heparin flush. Close clamp on extension tubing when system is heparin locked.	Provides fluid delivery as prescribed or maintains patent system for use. A closed clamp is a backup to prevent inadvertent communication into the vascular system.
16 Apply sterile closure tape strips over needle, chlorhexidine patch around needle (optional), and a semipermeable sterile transparent dressing over the port, needle, and the upper portion of the extension tubing. May place sterile gauze under device wings to prevent rocking motion of needle within the port. If available, the needle flange may be used to further stabilize the needle.	Maintains sterility of system and allows for assessment of needle position and skin. Stabilizes needle in position. Use of a 2 × 2 gauze to stabilize the needle does not constitute a gauze dressing if the insertion site is visible (INS, 2011).
17 Remove sterile gloves and secure the line with additional tape or sterile closure tape strips.	Prevents accidental dislodgment, tugging, or pulling at the needle site.
18 Replace the child’s clothing over port.	Maintains body image.
19 Dispose of equipment and waste in appropriate receptacle.	Standard precautions.
20 Perform hand hygiene.	Reduces transmission of microorganisms.
21 Ensure that fluid is infused via a flow-control infusion device and that no more than 4 hours worth of IV fluid for an infant, 8 hours for older child (or refer to organizational policy) is allowed to hang at any one time.	Infusing using a flow-control infusion device and limiting amount of fluid hanging can prevent potential accidental fluid overload and complications from IV infiltration.
22 Change IV tubing using aseptic technique no more frequently than every 72 to 96 hours except for tubing used to administer fat emulsions or blood or blood products, which should be changed within 24 hours of infusion initiation. (O’Grady et al., 2011). Label the IV tubing with time, date, and initials when hung.	Changing tubing at routine intervals reduces risk of microorganisms from growing in IV tubing. Labeling tubing aids in identifying proper change times.