Purpose: To access and deaccess implanted vascular port devices for the purpose of transfusing blood and blood components safely to patients in skilled nursing and long-term care facilities.

Policy: Directions for safe accessing and deaccessing implant vascular access ports for the purpose of the transfusion of blood and blood components are established in the following policy with procedures and practice guidelines.

Supplies:

  1. Port Access
    1. Central vasulcar access device (CVAD) dressing kit (preferred)
    2. If no dressing kit:
      1. Mask
      2. Sterile gloves
  • Sterile gauze
  1. Sterile barrier tape
  2. Antiseptic solution
  3. Transparent semipermeable (TSM) dressing that covers the noncoring needle and access site when the port is accessed
  • Sterile tape
  • Noncoring needle and extension set with clamp
    1. Access the port with the smallest-gauge noncoring needle to accommodate the prescribed therapy.
      1. Reduce the risk for dislodgement after access; use a noncoring needle of length that allows the external components (e.g. wings) to sit level with the skin and securely within the port (needle touches bottom of port upon insertion).
    2. Sterile gauze or foam pad as needed
    3. Needless connector
    4. Package sterile, prefilled 10 mL syringe of preservative-free 0.9% sodium chloride (package should indicate sterile and able to drop onto sterile field); alternative is a vial of 0.9% sodium chloride with vial adaptor and sterile packaged 10 mL syringe
  • Local anesthetic, if applicable
  • Additional sterile gloves if packaged sterile sodium chloride syringe not available
  1. Port Deaccess
    1. Nonsterile gloves
    2. Prefilled syringe preservative-free 0.9% sodium chloride flush
  • Prescribed locking solution
  1. Dressing as indicated

 

Special Consideration in the Older Adult:

  1. Decreases in tissue turgor, changes in nerve conduction contributing to hypersensitive or delayed response to pain, and delayed wound healing will contribute to changes in skin integrity, bruising and hematoma development, skin tearing, and infectious processes.
  2. The older adult may be anxious or fearful about accessing the implanted port. As with every patient, assessment of pain and fear about infusion-related procedures should be incorporated into the plan of care.

 

Other Considerations:

  1. Use a patient’s port, unless contraindicated (e.g., existing complication with the device) as the preferred intravenous (IV) route in preference to insertion of another vascular access device (VAD).
  2. Facility administrator approval MUST be obtained prior to accessing a patient’s port.
  3. Facility to provide supplies necessary to access/deaccess patient’s port.

PROCEDURE

  1. ASSESSSMENT
    1. Assess patient’s pain tolerance and preferences regarding use of local anesthetic prior to port access.
    2. Assess port site for redness, tenderness, swelling, and drainage or leakage of infusing or injected fluids, also dehiscence of surgical incision or erosion of port body through the skin by visual inspection and palpation.
    3. Assess for presence of venous collaterals on the chest wall that may signal occlusion; erosion of the portal body through the skin; or signs of catheter-associated deep vein thrombosis.
    4. Assess for swelling or pain near the clavicle or subclavian insertion sites. This could indicate pinch-off syndrome; notify provider if pain or swelling is present.
  2. PATIENT EDUCATION
    1. Prior to insertion: place procedure, type of port, routine care expectations (frequency of flushing, expectations of aseptic non touch technique (ANTT) during access, use for power injection, if indicated) and identification of potential complications and interventions.
    2. Importance of carrying port identification card.
    3. Report any signs or symptoms of pain, burning, stinging, or soreness at the site.
    4. Potential complications and interventions, and how/whom to report.
    5. How to protect accessed port and avoid pulling at the noncoring needle during activities of daily living (e.g., use of seatbelts, when dressing/undressing, bathing).
  • PORT ACCESS
    1. Verify with facility administrator and/or director of nursing that it is okay to access the patient’s port for the purpose of blood/blood component transfusion.
    2. Gather Supplies from the facility. Individual facility to provide supplies necessary to access port.
    3. Perform hand hygiene before direct contact with the patient and subsequently as required through the procedural steps.
    4. Verify patient’s identity using 2 independent identifiers according to organizational policy (e.g., name and date of birth).
    5. Obtain and review the provider’s order for implanted port access or organizational protocol.
    6. Obtained informed consent according to organizational policy OR patient assent.
    7. Disinfect work area (i.e., overbed table) with antimicrobial solution; allow to dry completely.
    8. Prepare for port access, collect necessary supplies, and set up sterile field.
    9. Administer local anesthetic, as indicated.
    10. Place patient in a comfortable position with head turned away from implanted port.
    11. Assess skin over and around implanted port; palpate port to locate septum.
    12. Perform hand hygiene.
    13. Don mask and sterile gloves.
    14. Attach needleless connector to hub of extension set on noncoring needle with extension set, and prime set with preservative-free 0.9% sodium chloride.
      1. Alternative procedure if packaged sterile sodium chloride syringe not available.
        1. Don mask.
        2. Scrub (disinfect) top of vial and allow to dry.
        3. Don sterile gloves.
        4. Assemble vial adapter and sterile syringe.
        5. Draw up 10 mL 0.9% sodium chloride from vial. Use nondominant hand to hold nonsterile vial. Maintain sterility of syringe in dominant hand while drawing from vial.
        6. Place sterile syringe of sodium chloride on sterile field.
        7. Remove gloves and perform hand hygiene.
        8. Don new sterile gloves.
      2. Prep the skin in the entire area where the dressing will cover. Cleanse insertion site using the preferred skin antiseptic agent of alcohol-based chlorhexidine solution according to manufacturer’s directions for use; allow to dry completely.
        1. Use an iodophor (e.g., providone-iodine) or 70% alcohol if chlorhexidine solution is contraindicated.
        2. Use aqueous chlorhexidine if there is a contraindication to alcohol-based chlorhexidine.
      3. With nondominant hand, stabilize implanted port.
      4. Insert noncoring needle perpendicular to the skin, through the septum of the port, until the needle tip comes in contact with the back of the port.
        1. Orient the bevel of the noncoring needle in the opposite direction from the outflow channel where the catheter is attached to the port body. *In vitro testing demonstrates that a greater amount of protein is removed when flushing with this bevel orientation.
      5. Slowly inject preservative-free 0.9% sodium chloride into implanted port, noting any resistance or sluggishness of flow; slowly aspirate for blood return and note the color and consistency of whole blood; then complete the 0.9% sodium chloride flush.
        1. ALERT: If an antimicrobial locking solution was used, withdraw solution from the port prior to flushing and discard. Flushing the lock solution into the patient’s bloodstream could increase development of antibiotic resistance and other adverse effects.
        2. Never inject against resistance.
  • Inability to flush or absence of blood return requires further investigation about the cause (e.g., mechanical problem, fibrin/thrombosis over VAD tip, extravascular tip location).
  1. A pulsatile flushing technique may be effective at removing solid deposits.
  1. Place sterile gauze or foam pad to support wings of noncoring needle, if needed, making sure gauze does not obscure needle insertion site.
  2. Cover with TSM dressing.
    1. Change the TSM dressing at least every 7 days; if gauze is needed over the noncoring needle and access site, change the dressing every 2 days.
    2. When gauze is used under the TSM dressing to solely support the wings of the noncoring needle, does not obscure the access site, and its integrity is not compromised (e.g., not visibly soiled and remains free of moisture, drainage, or blood), change the TSM dressing at least every 7 days.
  3. Initiate infusion therapy as prescribed.
  4. Discard supplies in appropriate receptable(s).
  5. Remove gloves and perform hand hygiene.
  1. PORT DEACCESS
    1. Perform hand hygiene.
    2. Gather supplies. Individual facility to provide supplies for deaccess of port.
    3. Verify the patient’s identity using 2 independent identifiers, according to organizational policy (e.g., name and date of birth).
    4. Explain procedure to patient.
    5. Apply nonsterile gloves.
    6. Flush port with 5-10 mL of preservative-free 0.9% sodium chloride, and lock port with prescribed locking solution (e.g. sodium chloride, heparin, antimicrobial solution).
    7. Remove dressing, noting any drainage, and discard.
    8. Stabilize port using thumb and forefinger of nondominant hand.
    9. Grasp needle with dominant hand and remove device, engage safety mechanism according to manufacturer’s directions for use, and discard into sharps container.
    10. Apply dressing to site if bleeding occurs.
    11. Discard materials in appropriate receptacles.
    12. Remove gloves and perform hand hygiene.
  2. DOCUMENTATION
    1. Facility approval for access/deaccess of port
    2. Appearance of port site
    3. Performance of procedure
    4. Noncoring needle gauge/length
    5. Medication/solution administration
    6. Pain management interventions
    7. Flush/lock solution and volume
    8. Patient’s response to the procedure
    9. Patient education