By Candy Finley, RN, IgCN, Clinical Nurse Educator
As a health care provider in the home setting, you may come across various types of venous access devices, from peripherally inserted catheters for short term or intermittently administered therapies like IVIG and infliximab to centrally placed devices for long-term use, especially if there are venous access problems. The physician and the patient will decide the type of venous access device while considering the length of time for the therapy and patient lifestyle. Nurses are often expected to maintain various types of central venous access devices (CVADs) such as peripherally-inserted central catheters (PICC), central venous catheters (CVCs) such as Hickman and Broviac catheters, and implant ports. Patients may already have a CVAD when admitted for home infusion therapy services or require placement after admission if they have poor or inaccessible venous access, and the need for long term therapy. This blog will focus on handling and troubleshooting ports.
Some nurses do not possess the proper skillset or have limited experience with caring for ports, which can be harmful to the patient as we need to ensure ports are free from infection and damage caused by a nurse. It is important to understand how to manage or notice when complications arise. If a nurse is unfamiliar with a device, it is best to have the nurse's manager train them on proper care prior to accepting a case or declining it. Remember, it is imperative to report all abnormal findings to Nufactor and our nursing personnel immediately so all information is shared with and acted upon by each member of the clinical team. We will also contact the prescriber to share your findings.
Nufactor's CVC kits are used for implanted ports as well as PICC and other central lines. For ports, the nurse will have to change sterile gloves at least twice for a dressing change. Because CVC kits contain one pair of sterile gloves, Nufactor will send extras gloves. Ports are safe to access and use immediately after placement. Visually inspect the port. There may be slight irritation, redness and swelling over the incision site. These symptoms should not extend over the chest and, if present, may indicate infection. Remind the patient to avoid strenuous activity for at least 7 days. If the patient presents fever or signs and symptoms of infection, do not access the port and call Nufactor. If the port is not new, visually inspect the access area and surrounding skin for redness, swelling, or discharge. If there is swelling and it is not red, the port may have become dislodged. If either of these occur, do not access the port and call Nufactor.
No more than two attempts should be made to access a port. After accessed, check for blood return. Using a 10 mL syringe only, flush the port with a minimum of 5 mL of NS. Note when locking the port with heparin after an infusion or maintenance, it is not necessary to check for blood return. If there is no blood return, ask the patient to cough a few times, and/or raise their arms or change positioning (e.g., from lying to sitting). After this, recheck for blood return. If you are still unable to get blood return but the port is patent and there is no infiltration, it is safe to flush the port and proceed with the infusion. The only time it is ill-advised is if administering a vesicant, which would harm the patient. It is very important to notify Nufactor while in the home so prescriber follow up can occur. The prescriber may advise the patient to be evaluated by the radiologist who placed it. Over time, the tip of any CVAD may become occluded due to fibrin sheath formation and the prescriber may order Cathflo Activase to dissolve the clot. Because of the time needed to obtain insurance authorization and for shipping, it may take 1 - 2 days for the Cathflo Activase to arrive at the patient's home. Cathflo Activase is instilled in a port for a period of time and then removed and discarded. It is never flushed into the patient. Always read the Cathflo Activase package insert and understand how to use it. If the port is accessed while the patient is lying down, once he/she sits upright, visually inspect the IV tubing/extensions and make sure it is still patent and not infiltrated by assessing and palpating the perimeter of the port. When the port is accessed, the dressing must be changed every 7 days. When de-accessed, the port must be flushed and maintained every 30 days. When accessing a port and the Huber needle length is too long, pad a 4x4 gauze around the needle to raise and stabilize it. Request an appropriate length Huber needle from Nufactor. When accessed like this, the dressing must be changed every 48 hours to prevent bacterial growth under the occlusive dressing.
Nufactor sends a back-up kit with peripheral venous access supplies. If the port cannot be used and it is deemed safe and appropriate and the patient agrees, a peripheral line can be inserted and the infusion completed. Depending on whether the patient is an adult or pediatric, peripheral lines may be flushed with a different concentration of heparin and different volume of heparin and saline so always check orders. If a patient is not seen at least monthly (e.g., less often than every 4 weeks), identify who will flush and maintain the port in the interim. This is important as some patients don't understand that if not maintained, this may lead to clotting of the port which could lead to permanent damage to the device.
An additional concern is if a port has migrated into the axillary vein. If suspected, assess the patient by monitoring for ear or neck pain on the side of port placement and ask the patient if they hear swishing or gurgling sounds. Ports are typically held securely in place under the skin with sutures. Very slim patients with less available tissue and those who lose excessive amounts of weight are also at risk for port inversion, where the port slides laterally or flips partially or completely. If any of these occur, do not access the port and call Nufactor immediately.
On occasion, patients experience discomfort from ports. This can be caused by inconvenient placement, bruising at Huber-needle, infection, or poorly applied securement device. Sometimes patients develop sensitivity or experience an allergic reaction to the occlusive dressings. If this is suspected, a different brand can be tried. Patients with thin, fragile skin may experience Medical Adhesive-Related Skin Injury (MARSI), characterized by irritation to the skin at or surrounding the port. An added irritant may be either the antiseptic, adhesive, or dressing components. Over time, these areas with fragile skin may experience painful redness or skin tears. There are now many available products to prevent such injuries.
Ports are at risk for the formation of blood clots along the inside or outside wall of a catheter; these clots could potentially break loose and travel into a limb, lungs, brain, or heart. Air emboli can occur at any time during routine use of a port. It is important to have patients perform a Valsalva maneuver and hold breath during access and tubing change procedures.
It is important to document the specifics of care surrounding ports. Oftentimes, there are many healthcare professionals involved in the care of each individual patient. In order to relay important information to each caregiver, a thorough note must be written, including detailed descriptions of what the nurse sees or what the patient experiences. It is also very important to report abnormal findings to the physician, specialty pharmacy, and nursing personnel so that all information is shared with, and acted upon, by each member of the care team as needed.
In summary, it is your responsibility to make sure you're providing the best care to the patient and alerting the pharmacy once you suspect or detect an issue with the CVAD. This could be a life saver! You are our eyes and ears in the patient's home and we rely on you heavily for critical feedback. Call the prescriber directly for life-threatening issues only and call Nufactor for all other issues.