Troubleshooting Implanted Ports
By Candy Finley, RN, IgCN, Clinical Nurse Educator
and Marianna Herrera, RN, BSN, IgCN, Clinical Nurse Educator - March 23, 2023

As a health care provider in the home setting, coming across various types of venous access devices is expected. Access devices can vary from peripherally inserted catheters for short-term or intermittently administered therapies, such as IVIG or infliximab, to centrally placed devices for long-term use, especially if there are venous access problems. A physician and patient should discuss and decide on the most appropriate venous access device while considering the duration of therapy, lifestyle, and history of venous access issues. Nurses are expected to maintain various types of central venous access devices (CVADs), such as peripherally inserted central catheters (PICCs), central venous catheters (CVCs) such as Hickman™ and Broviac™ catheters, and implanted 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.

Nurses are expected to possess proper skill sets while caring for patients with ports. Nurses that lack these skills can put a patient in harm's way by not properly keeping ports free from infections and/or by damaging ports. Understanding that vials must be wiped with alcohol and allowed to completely air dry before being spiked greatly decreases the patient's risk for bloodstream infections. This is especially true when accessing ports to prevent microbes from entering directly into a patient's heart. 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.

Nufactor's CVC kits are used for implanted ports as well as PICC and other central lines. For ports, the nurse will have to drop the sterile saline onto the sterile field as it is not included in the kit. Nufactor will also send extra sterile gloves. Ports are safe to access and use immediately after surgical placement. Visually inspect the port. There may be slight irritation, redness, and swelling over the incision site. These signs should not extend over the chest, and if they do, it may indicate infection. Remind the patient to avoid strenuous activity for at least 7 days after surgical placement. If the patient presents with signs and symptoms of infection, such as fever, 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 occurs, do not access the port and call Nufactor.

The following steps should be performed to attempt to successfully gain access to a port:

• Properly identify the patient
• Set up the sterile field
• Assess and clean the site. Accessing a port must be completed in a sterile manner.
• Using a 10 mL syringe only, flush the port with a minimum of 5 mL of normal saline (NS). According to the Infusion Nurses Society (INS), prefilled flush syringes are associated with disturbances in taste and odor, which have been found to be more prominent when flushing CVADS versus peripheral IVs (PIVs). The cause is thought to be substances leaching from the plastic syringe due to sterilization methods. These sensations may be significant enough to impact appetite and may increase nausea, especially if administered rapidly.
• No more than three attempts should be made to access a port. After access has been achieved, 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 still unable to get blood return, but the port is patent, and there is no resistance or notable infiltration, it is safe to flush the port and proceed with the infusion. The only time it is ill-advised to use a port with no positive blood return is when administering a vesicant, which increases the potential of harming the patient. 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.
• Follow prescriber orders and facility policy when manipulating a port. Nufactor provides the prescriber with the following orders, which the prescriber can accept or decline and provide their own IV access maintenance orders:

• It is very important to notify Nufactor while in the home of issues with access to ensure 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 several issues:
• Thrombotic occlusions - fibrin tail/flap, fibrin sheath, intraluminal thrombus, mural thrombus formation. These types of occlusions may be treated at home with the administration of Cathflo^® Activase^® (alteplase) or might require interventional radiology involvement. Timely notification of issues with access is crucial as it may take several days for the Cathflo^® Activase^® to arrive at the patient's home due to insurance authorization and the need to ship the product.
• Instill Cathflo^® Activase^® in a port for 30 minutes and access the catheter by attempting to aspirate blood. If the catheter is not functional after 30 minutes, allow the Cathflo^® Activase^® to remain for a total of 120 minutes. If catheter function is still not restored, a second dose may be instilled, aspirated, and discarded. It is never flushed into the patient. Always read the Cathflo^® Activase^® package insert and understand how to use it. (www.cathflo.com/dosing-administration/cathflo-preparation-dosing.html)
• Non-occlusive occlusions - mechanical occlusions, lipid formations, etc., will require intervention and must be reported promptly to ensure access can be assessed and returned to a working manner prior to the patient's next infusion.
• Please note: These clots could potentially break loose and travel into a limb, lungs, brain, or heart. Air emboli can occur at any time during the routine use of a port. It is important to have patients perform a Valsalva maneuver and hold their breath during access and catheter changing procedures.
• 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, the infusion can still take place. Place a sterile, folded, 4x4 gauze around the needle to stabilize it and assess the site more frequently. Call Nufactor to request an appropriate length Huber needle for future infusions. When accessed like this, the dressing must be changed every 48 hours to prevent bacterial growth under the occlusive dressing. A Huber needle that is notably too short should not be used to infuse a patient. The potential of causing an infiltration increases significantly and is unsafe for patients. This will be noted when assessing for placement, and resistance is noted, or swelling is noted around the perimeter of the port.
• Note that when locking the port with heparin after an infusion or maintenance, it is unnecessary to check for blood return.
• 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 do not understand that if not maintained, this may lead to clotting of the port, which could lead to permanent damage to the device.

Additional concerns while managing a port in the home:

• Port migration - Ports can migrate out of the superior vena cava and into the axillary vein. Suspect this if the patient is experiencing 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 can slide laterally, flip partially, or completely. If any of these occur or are suspected, do not access the port and call Nufactor immediately.
• Site discomfort - Discomfort could be due to inconvenient placement, bruising at the accessing needle site, poorly applied securement device, or possible infection.
• Skin-related issues - Patients can develop sensitivity or experience an allergic reaction to the occlusive dressings. Patients with thin, fragile skin may experience Medical Adhesive-Related Skin Injury (MARSI), characterized by irritation to the skin at or surrounding the port. Over time, these areas with fragile skin may cause painful redness or skin tears. If this occurs or is suspected, call Nufactor to discuss and determine options to remedy issues, such as trying a different brand of occlusive dressing or skin protectant barrier.
• It is important to document the care of ports. In order to relay important information to the patient's care team, the nurse must include detailed descriptions of what the nurse observes and/or what the patient verbalizes. It is very important to promptly report abnormal findings to the specialty pharmacy and nursing agency so that all information is shared with and acted upon by each member of the care team as needed.
• In summary, it is the nurse's responsibility to ensure that the best care is being provided to the patient. Home infusion nurses are the eyes and ears in the patient's home for the pharmacies and prescribers, and they rely heavily on nursing feedback. Always call Nufactor at 800-323-6832 for all infusion-related issues/concerns, and only call the prescriber directly for life-threatening issues.