By Derrek Blake, RN, IgCN.

It is essential all nurses know how to properly evaluate, access, and provide proficient central line care. NuFactor provides IVIG therapy to patients in the home and while the majority of these patients receive IVIG via a peripheral IV, there are some patients who receive IVIG via a PICC line or an implanted port (such as Port-a-Cath brand). We as nurses must be competent and comfortable providing care to these patients with a central catheter. While central catheters can be slightly confusing to a nurse who may only see one central catheter a year, this post will help you understand the differences between central catheters used and how to provide the proper care for each.

TYPES OF CENTRAL CATHETERS USED FOR IVIG:

Central catheters can be inserted for many reasons. For instance, if a patient needs to receive a long term IV therapy and they have poor veins, the doctor may order placement of an implanted port. Another common central line is a Peripherally Inserted Central Catheter (PICC) line. If a patient has a PICC line, the patient may also have poor veins or could be receiving another IV medication besides IVIG. The doctor may also place a PICC line if the therapy is short term ranging from one week to one year.

PICC LINES:

PICC lines are typically placed in an outpatient setting by a skilled clinician in a sterile environment but occasionally can be performed in the home. After the PICC line is inserted, there must be confirmation by CT or chest x-ray that the PICC line has been properly placed. The tip of the catheter must be located “central” in either the superior vena cava or cavoatrial junction which leads into the heart. After placement is confirmed, the PICC line can be used. When providing care to a home patient with a PICC line we want to make sure to assess the line and insertion site prior to providing care. Here are a few things to look for upon assessing the site:

• Assess the length of the exposed catheter. You can also ask the patient if the PICC line is longer than usual. If the exposed portion of the catheter has partially come out, the tip of the catheter may have migrated and may not be in the proper place to infuse the medication. If this occurs, do not use and call NuFactor. You can measure the length of the catheter at each visit with the paper tape measure found in the dressing change kit. The practice is to document the exposed length on the nursing note that can be referenced for the following visits.
• Assess for skin integrity around the site. If there is redness, swelling, or discharge present, the patient’s site could be infected. The patient may also show signs of fever if an infection is present. Perform a dressing change to see if it helps with some of the irritation as it may be due to the dressing or needle. If the site is warm, red, swollen or leaking, do not infuse and call NuFactor.
• Assess the extremities. In rare occasions PICC lines cause thrombosis causing swelling to the extremity. If there are signs and symptoms of swelling in the extremity with the PICC line or distended veins in the neck or chest, do not infuse and call NuFactor immediately as this could be due to thrombosis.

Proper assessment and care can prevent many PICC line complications, extremely important since PICC lines can be left in for roughly one year.

PORTS

Ports are fully implanted catheters typically found in patients who are receiving long term infusion therapy, including those with very difficult venous access. Ports are surgically placed in an outpatient setting under the skin on either the right or left side of the chest. The typical port is round and the lumen is composed of a silicone septum that allows a needle to insert through the center of the port. This activates a valve to allow medication to be administered through the port. The majority of patients have single lumen ports; however some may have a double lumen. This may mean the patient was once or could be eventually infusing two medications at once.

Here are a few important tips when assessing a port:

• Visually inspect the port surgical site. If the port was recently placed, 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. The patient may also present with a fever. If there are signs or symptoms of infection, do not access the port and call NuFactor.
• If not a new port, visually inspect the port 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 occurs, do not access the port and call NuFactor.
• Always palpate the surrounding skin for tenderness/pain. If pain/tenderness is noted it can be common for that patient. If it is uncommon for the patient, it may still be ok to use, but use nursing judgment on how to proceed. If you are unsure you can always contact NuFactor.
• Palpate the port dome/lumen to verify the port is in place and it has not migrated or flipped. If the port is moving freely or is flipping, do not access the port and call NuFactor as the port may need to be examined by the surgeon.
• If the port has migrated, assess the patient by monitoring for ear or neck pain on the side of placement and by asking the patient if they hear swishing or gurgling sounds. If this occurs, do not access the port and call NuFactor.

In Part Two of This blog, Central Catheters used for IVIG: Care and Complications of PICC lines and Port-a-Caths we will talk about the care of PICC lines and ports and complications you may run into when accessing and using central catheters.