Insertion, Care and Removal of a Totally Implanted Vascular Access Device (TIVAD) (Venous Port or Port-a-Cath)

❖ Health Care Professionals: Each individual HCP is accountable for their own practice. HCPs should ensure that they have the underpinning knowledge about the device, can demonstrate the required level of competence in the delivery of care, maintenance, and recognition of potential complications. HCPs should be aware of the need to request expert advice and assistance and know where to access it.

❖ Charge Nurses and Clinical Nurse Managers: They are responsible for overseeing the implementation of the guideline within their area of responsibility and ensuring staff operate within their scope of clinical practice.

❖ Vascular Access Device (VAD) Multi-disciplinary Working Group: It is responsible for communication, monitoring, update and review of the guideline.

❖ The HCPs in both hospital and community settings will work within the requirements and boundaries of their professional regulatory body and NHS Lothian employment policies and procedures.

NHS Borders HCPs involved in the insertion, care and maintenance of any central vascular device including TIVAD device, should complete the NHS Borders TIVAD education programme or equivalent, and a period of supervised clinical practice and competency assessment. Prior to attending the TIVAD training programme, HCP’s must have successfully completed the NHS Borders Intravenous Therapy training programme. The competency assessments for IV therapy and TIVAD should be reviewed every 2 years

 For the purpose of the document only the following terminology will be used:

❖ Totally Implanted Vascular Access Device (TIVAD)

❖ Venous Port

❖ Port-a-Cath

❖ Aseptic Non Touch technique (ANTT)

❖ Central Vascular Access Devices (CVAD)

❖ Health Care Professionals (HCPs)

❖ Huber Needle also referred to as non-coring needle and more commonly known as Gripper Needle (trade name). The term Huber needle will be used throughout this document.

Total Parenteral Nutrition (TPN)

The term Total Parenteral Nutrition (TPN) is used when no significant nutrition is obtained by other routes. The term Parenteral Nutrition is used when nutrition is partially enteric. For the purpose of this document the term Total Parenteral Nutrition (TPN) will be used when referring to the administration of intravenous nutrition.

Chlorhexidine Allergy

Medical devices (central venous catheters) and medical products (antiseptic solutions - ChloraPrep, antimicrobial dressings) containing Chlorhexidine carry a risk of allergy including life-threatening anaphylaxis. If an acute unexplained anaphylactic reaction occurs within one hour of a chlorhexidine impregnated central catheter placement, immediate consideration should be given to the catheter removal.

Pre-Procedure

Check with the patient for allergies or known hypersensitivity to Chlorhexidine products. If a patient is susceptible to skin irritation, an appropriate alternative antiseptic should be considered to clean the insertion site (e.g. povidone iodine in alcohol). Prior to the use of medical products and devices e.g. CVAD’s, labels and instructions should be checked to establish if they contain chlorhexidine. Allergic reactions to products containing chlorhexidine should be reported to the MHRA.

All medical devices and medicinal products containing chlorhexidine - Risk of anaphylactic reaction due to chlorhexidine allergy

Overview

Totally Implanted Vascular Access Device (TIVAD) is a type of central venous catheter device that is surgically implanted subcutaneously under the skin, usually the anterior chest wall, lateral chest wall and less frequently in the upper arm. A TIVAD is a completely closed system with no parts of the device exposed above the skin. The device comprises of a portal body or reservoir with a self sealing septum, connected to a tunnelled radio-opaque central venous catheter. The TIVAD is accessed using a special bevelled non coring point needle know as a Gripper or Huber needle. A standard hypodermic injection needle must never be used to access a TIVAD since it can cause damage to the port septum. TIVADs are designed to provide repeated daily, continuous and intermittent long term central intravenous access. A TIVAD is also known as “Port-a-Cath” or Venous Port and the terms are often used interchangeably.

Figure 1: Position of the TIVAD in the chest and insertion on non-coring Needle

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Product description

A TIVAD compromises of two components:

1 The Portal Body
2 The Catheter which connect to the port reservoir

Figure 1: The Portal Body

Location

TIVAD insertion is a minimally invasive surgical inpatient / day case procedure. The procedure is normally performed in a interventional radiology suite or an operating theatre, where maximal barrier precautions can be maintained. There is also the availability of imaging facilities such as fluoroscopy and ultrasound equipment to provide guidance with TIVAD insertion.

8.2 Pre-Procedure Patient assessment:

❖ A full assessment of the patients past medical history and current medications should be performed to identify factors that could preclude or delay insertion of the device

❖ Pre-procedure blood samples that include electrolytes, full blood count, platelets, and coagulation screen on the day or day before insertion are normally required.

❖ The patient’s lifestyle and sport activities should be established. TIVAD placement should be considered on the non-dominant side for racket sports.

❖ Written informed consent should be obtained by the HCP insertion the TIVAD.

❖ Fasting prior to the procedure: No food for 6 hours (fast from midnight) No fluids for 2 hours.

❖ Check for any allergies including Chlorhexidine.

The following information about the TIVAD should be provided to the patient:

Procedure

❖ The insertion procedure should be in accordance with the specific manufacturer’s instructions

❖ The procedure is generally performed using local anaesthetic infiltration and sedation.

❖ Insertion procedure is performed following the principles of Surgical ANTT - critical aseptic field/maximum barrier precautions (full surgical scrub, theatre cap, surgical mask, sterile gown, sterile gloves, sterile body drapes)

❖ Skin preparation: Single use application 2% chlorhexidine/70%isopropyl alcohol antiseptic agent (Chloraprep) is applied to clean the skin at the catheter and port insertion sites (or povidone iodine in alcohol where chlorhexidine sensitivity is present

❖ Veins: The TIVAD catheter is usually inserted into a large central vein such as the subclavian, internal or external jugular veins. The distal tip of the venous catheter is positioned in the lower third of the superior vena cava (SVC)

❖ The port pocket: An incision is made in the anterior chest wall below the clavicle and a subcutaneous pocket is created for the port. The proximal end of the venous catheter is then tunnelled and connected to the port and secured. The port is anchored in place with absorbable internal sutures to the underlying tissue. The subcutaneous pocket containing the port is sutured closed with non-absorbable or absorbable sutures

❖ Ideally the port should be sited in an anatomical area that provides good port stability for needle insertion and for ease of access (preferable the port lying against bony structure).

8.4 Immediate post TIVAD procedure care

❖ The Huber needle is primed with sodium chloride for injection and inserted into the TIVAD

❖ The TIVAD is bled to confirm patency and position. The TIVAD is then flushed with heparinised saline using push pause technique and locked

❖ The Huber needle maybe removed or left in place for immediate use

❖ The TIVAD catheter tip is verified radiologically either by intra-operative fluoroscopy or a chest X-ray post procedure. Confirm with the medical operator prior to use

❖ The distal end or tip of the catheter should be positioned in the lower third of the superior vena cava above the right atrium (Fig1)

❖ It is recommended that the TIVAD is not accessed for up to two weeks to allow post operative oedema and tenderness around the wound site to resolve. However, occasionally there may be a clinical need to leave Huber needle in place and to access the TIVAD immediately.

8.5 Dressings following TIVAD Placement

A TIVAD dressing should offer; full insertion site visibility, easy application and removal, catheter securement, secure adhesion to the skin, barrier to microorganisms, yet permeable to skin moisture and provide for patient comfort. All dressing should be kept clean dry and intact.

8.5.1 Initial Dressing - First 72 hours

Documentation of Insertion Procedure

                          Entry into medical records should include the following:

TIVAD Insertion Related Complications

Immediate Post TIVAD insertion Care – Ward

Bed Rest: Patient remains on bed rest for 2 hours (following conscious sedation) and thereafter patient can commence to mobilise as clinical condition allows.

Record News2/Observations: Every 30 minutes for the first 2 hours and every 4 hours thereafter.

Wound Sites: Inspect the sites for bleeding, excess swelling every 30 minutes for 2 hours and then every 4 hours thereafter.

Pain Relief: Regular analgesia should be prescribed and monitored.

Discharge: This will be based on the patient’s medical condition, medical operator instructions and the patient’s response to the procedure. If the insertion of a TIVAD is performed as a day case procedure, the patient may be discharged at 4-6 hours provided there are no complex medical problems or complications.

Accessing the TIVAD – General principles

❖ Only appropriately trained HCPs who have been competency assessed can insert the Huber needle.

❖ Huber needle gauge size and length is selected according to the patient’s individual requirements and intravenous therapy to be infused. Standard hypodermic needle must NEVER be inserted into the TIVAD/port septum.

❖ Insertion procedure for Huber needle: This is performed following the principles of Surgical ANTT because the insertion site will need touched (sterile gloves, dressing pack).

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Insertion of the Huber Needle - an overview

❖ TIVAD is assessed in advance of the procedure by locating and palpating the port and identifying the site for the Huber needle insertion

❖ Prescribed Single use Topical local anaesthetic cream may be applied over the port site for at least 30-60 minutes prior to the procedure if required. The skin should be physically cleaned before application of antiseptic solution

❖ Port site is cleaned with single use 2% chlorhexidine/70% isopropyl alcohol e.g. ChloraPrep using a cross hatch method (back and forth strokes with friction) for 30 seconds. The insertion site must be allowed to air dry completely for up to 3 minutes

❖ Huber needle, extension set and needle free connector is primed with sodium chloride 0.9% for injection 2mls in a 10 ml Luer-lock syringe – leave syringe attached if desired.

❖ The port is stabilised between fingers and thumb and the Huber is inserted into the centre of the port at a 90 degree angle as per procedure outline

❖ Huber needle placement is confirmed by checking for the withdrawal of blood

❖ Follow Flushing procedure and technique as outlined in point 9.3

❖ If the Huber needle is to remain in place, it should be secured and covered with a sterile transparent semi-permeable dressing to allow inspection of the needle insertion site

❖ Huber needle should be changed every 7 days whilst treatment is in progress

❖ The TIVAD must never be used unless the device is fully patent e.g. there is withdrawal of blood, the line can be flushed easily without pain, discomfort or oedema

❖ If there is resistance to the withdrawal of blood, refer to trouble shooting guidelines and Persistent Withdrawal Occlusion Policy (PWO). Seek expert medical advice and document clinical decision.

❖ The Huber needle is replaced every 7 days or according to manufacturer’s instructions

Removal of Huber needle – an overview

❖ Only appropriately trained HCPs who have been competency assessed can remove the non -coring needle

❖ Re-confirm that the non-coring needle can be removed and check that further intravenous therapy will not be required

❖ Perform the procedure risk assessment to select aseptic technique. Normally standard ANTT is used to remove the needle

❖ If the TIVAD has been flushed and locked, the Huber needle can be removed without further flushing and locking of the device

❖ If intravenous therapy is discontinued, the procedure for flushing and locking the TIVAD must be followed prior to removal of the Huber needle

❖ The dressing is gentle removed from around the needle (use a stretching method)

❖ The port is stabilised between fingers and thumb and removed according to the procedure outline

❖ A small sterile adhesive pressure dressing is applied over the port; to absorb any oozing from the port site for 1-2 hours and until the site is healed

Maintenance and care of the TIVAD involves the delivery of evidence -based care, at regular intervals, to maintain patency and prevent complications.

       This includes the following considerations:

Syringe Size

A 10 ml Luer-lock size syringe or above (not less than 10 mls) should be used for all access via the Huber needle. A small syringe size of less than 10mls, generate high pressures within the catheter lumen that could potentially lead to catheter fracture or rupture. A Luer-lock syringe prevents accidental disconnection and potential contamination of the syringe tip and needle free connector.

Assessing TIVAD Patency - blood return

❖ The Huber needle must be in place to enable access to the TIVAD

❖ Routine assessment of TIVAD function, involves checking for brisk blood return/flash back to confirm catheter tip placement and patency prior to every access (withdraw 3-5mls blood)

❖ DO NOT USE the TIVAD if resistance is met or if blood return is absent. Follow the protocol for Persistent Withdrawal Occlusion (PWO) and troubleshooting guide to restore patency

❖ If patency problems remain, promptly escalate to medical team to identify appropriate interventions to restore TIVAD patency prior to further use

❖ Aspiration for blood return should be part of the 4-8 weekly maintenance flush when the TIVAD is not in use

Maintenance flushing of a TIVAD

Optimal flushing of a TIVAD is an essential requirement to maintain device function and prevent associated complications such as thrombosis, partial or total obstruction and infection. TIVAD obstruction can result from the precipitation of incompatible medications/solutions, parenteral nutrition and blood clots that adhere to the internal surface of the catheter wall and catheter tip. All of these will shorten the working life of the TIVAD. Effective flushing technique can also minimise the potential risk of intraluminal bacterial adhesion and colonisation that can lead to biofilm formation and catheter related blood stream infection (CRBSI).

Flushing - general principles

❖ Syringe Size: No smaller than a 10mls Luer-lock syringe should be used when accessing the TIVAD. Smaller syringes generate excessive pressures and could lead to catheter fracture.

❖ Flushing Solution and Volume: 10mls sodium chloride 0.9% for injection. An additional 10mls may be required, for example following blood transfusion and Parenteral Nutrition (PN)

❖ Recommended flushing volume should be equal to at least twice the internal volume of the port device and Huber needle and extension set. The flushing volume should be reviewed where there are clinical requirements for a restricted fluid intake e.g. patients with renal disease or chronic heart failure (refer to manufactories instructions for priming volumes).

❖ Maintenance Flushing and Locking of Non-Accessed TIVAD: Follow local protocol which can vary between 4 and up to 8 weeks.

❖ Locking TIVAD: Follow local protocol for the use of heparinised saline if used.

❖ Incompatible medications or infusions: Flush the TIVAD with a minimum of 10mls sodium chloride 0.9% for injection, before and after the medication or infusion to avoid incompatibility and precipitation.

❖ Resistance: never forcibly flush the TIVAD in the presence of resistance. Forceful flushing can cause dislodgement of a thrombusfrom the internal catheter wall into the blood stream or cause catheter fracture. Check for any mechanical related causes including kinked Huber needle, extension set, closed clamps, and consider repositioning patient (follow troubleshooting guide).

❖ Caution: In the presence of a potent medication in the port reservoir and Huber needle e.g. following disconnection of an infusion or bolus injection, withdraw and discard residual 3-5 mls of fluid/blood from the port prior to flushing, to avoid bolus dose injection and possible complications.

❖ If blood is visible in the needle free connector after flushing, replace it (to reduce the risk of microbial contamination).

When to flush TIVAD

❖ Flush after blood withdrawal to confirm TIVAD patency.

❖ Flush prior to infusion and bolus injection to confirm TIVAD patency (pre-flush.

❖ Flush after completion of each infusion and bolus injection to clear the catheter of residual medication and solutions.

❖ Flush in between multiple drug IV bolus injections (to prevent drug incompatibility and precipitation). Flush initially at the same rate of the prescribed medication to avoid the patient receiving a bolus of the drug

❖ Flush at regular intervals to maintain TIVAD patency (maintenance flushing)

Flushing Technique – create a turbulent flow

❖ Use a pulsating movement push –pause / stop- start technique when flushing

❖ Flush the lumen/s briskly by injecting 1ml boluses at time (10 x1mls) pausing briefly (1 second) between two boluses.

❖ Effectively clear the hub of any blood or residue. Use an additional sodium chloride 0.9% flush 10ml as necessary.

❖ Complete the procedure using a “positive pressure” or “locking technique”

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(The “push – pause” technique is designed to create a swirling or turbulent flow and assist with the removal of blood residue, medication precipitate, fibrin from the internal catheter wall and prevent occlusion).

Positive Pressure or Locking Technique

Locking a TIVAD creates a column of fluid inside the port and catheter to maintain patency. Locking involves the mechanical technique of applying positive pressure to the syringe whilst injecting a locking solution (such as sodium chloride 0.9% for injection or heparinised saline) to prevent reflux of blood (port reservoir and catheter) and the formation of a fibrin sheath resulting in TIVAD occlusion.

❖ To Lock the TIVAD, maintain a positive flush pressure on the syringe plunger; clamp the Huber needle extension whilst simultaneously injecting the last 0.5-1ml of flushing solution. Remove the syringe

❖ Locking Solution: Follow local policy for the use of heparinised saline.

Clamping Sequence

❖ Clamp the Huber needle extension before removing the syringe

❖ Unclamp the Huber needle extension after the syringe is attached

❖ Ensure the Huber needle extension is clamped when not in use

Infection Prevention and Management

One of the major complications associated with any central vascular access device is catheter related blood stream infection (CRBSI) which can be life threatening. A key quality care indicator in the management of all CVADs is the measurement of infection rates. The delivery of care is directed towards preventative measures, early recognition and prompt treatment, should an infection occur. Infection rates are reported to be lower with TIVAD, compared to other central vascular access devices.

Preventive strategies

Suspected Infection

Infection of the TIVAD system can be classified as a local port site, systemic and port pocket infection

Local Port Site

Local Port site infection is defined as the presence of local inflammation, redness, pain, exudate, tenderness or oedema around the port site. Management should be as follows:

 − If there is break in the skin overlying the port, obtain a wound swab for culture and sensitivity.

− Escalate to the medical team.

− Peripheral and TIVAD blood cultures should be considered (take peripheral sample first).

− Increase monitoring of NEWS2 and ongoing observations of symptoms.

− Administer prescribed anti-microbial therapy

Systemic Infection/Sepsis

The clinical signs of systemic infection include pyrexia, hypothermia chills/rigors tachycardia, malaise, hypotension raised or low WCC, NEWS2 score greater than 5

Management should be as follows:

− Prompt escalation to the medical team.

 − Follow Sepsis 6 protocol.

− Obtain blood cultures: take peripherally sample first and then from the port (via Huber the needle).

− Increase monitoring of NEWS 2 and ongoing observations of symptoms.

− Administer prescribed anti-microbial therapy.

Port Pocket Infection

This can occur in the vicinity of the subcutaneous port within the port reservoir and catheter. Purulent fluid may be aspirated from the port reservoir, and evidence of systemic signs of infection. Port should not be used until the port infection has resolved. Antibiotic locking solution may be prescribed to treat the infection. TIVAD may require removal despite measures to salvage the device and treat the infection. When the TIVAD is removed the catheter tip and content of port reservoir should be sent to microbiology for culture and sensitivity.

Port erosion

This can occur when the skin overlying, the port septum breaks down, exposing subcutaneous implanted reservoir. Port site ulceration and dehiscence can result from the lack of sufficient subcutaneous fat and tissue when the port is implanted superficially

Catheter related blood stream Infection (CRBSI)

This is defined as bacteraemia in a patient with an intravascular catheter with at least one positive blood culture from a peripheral vein and clinical symptoms of infection.

Cleaning the TIVAD access site

❖ Clean the TIVAD /Port site with single use application of 2% chlorhexidine/70% isopropyl alcohol e.g., Chloraprep using a cross hatch method (up and down back and forth motion) for a timed period of 30 seconds prior to the insertion of the Huber needle.

❖ Clean the area the size of the final dressing around the Huber needle site

❖ Allow the site to air dry completely before the insertion of the Huber needle.

❖ Where there is allergy to chlorhexidine, replace with povidone iodine in alcohol.

❖ Refer to 8.9.1 for an overview of the insertion of the Huber needle. 

Dressing

The TIVAD dressings should offer; visibility of Huber needle insertion site, easy application and removal, Huber needle securement, secure adhesion to the skin, barrier to micro-organisms, yet permeable to skin moisture and patient comfort. All dressing should be kept clean dry and intact. CHG sponge or gel dressings should be avoided in patients susceptible to skin irritation.

Dressing – After 72 hours

Scissors, scalpel or sharp instruments must never be used near the Huber needle/extension set and dressing to prevent the inadvertent damage to the line and the potential risk of air embolus

Needle free connector

Needle free access devices are a self-sealing bung, which are designed to reduce catheter related blood-stream infection and needle stick injuries. All needle-free connectors whether single, double, with or without an extension line must be primed before use with sodium chloride 0.9% for injection. There are a range of needle free devices available and manufacturer`s recommendations should be followed about the number of times they are accessed before replacement and the priming requirements before connection to a vascular access device. Needle-free connectors are recognised as a prime site for microbial contamination and must be thoroughly cleaned (for the recommended period of time) prior to each and every access and allowed to air dry. Needle free access devices must never be pierced with a hypodermic needle as the can cause leakage and potential infection. There are a range of needle free-connectors available and this determine the clamping and disconnection sequence to be used. In NHS Lothian the BD Smart Site needle free connector is used, which is a negative-fluid displacement device that requires positive – pressure flushing and a pre disconnection clamping technique.

Figure 5 Needle free connector decontamination

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Principles of Care

❖ Effective hand hygiene and appropriate PPE should be used prior to all access of the needle-free connector.

❖ Follow the principles of ANTT during all needle-free connector access.

❖ “Scrub the Hub” is the preferred technique or recommended technique for cleaning the needlefree connector.

− Thoroughly clean /scrub the surface connection, tip/septum with friction.

− Use multiple parts of singe use 2% chlorhexidine/70% isopropyl alcohol device wipe

− Clean for 15 seconds and allow to air dry at least 30 seconds before each and every access of a lumen

(A clean swipe of the hub is not sufficient to prevent colonisation by micro-organisms)

Replacement of a Needle Free connector

❖ Clean the outside of the existing needle free connector with a 2% Chlorhexidine/70% isopropyl alcohol device wipe before removing it.

❖ Check the Huber needle is securely clamped before removing an existing needle-free connector.

❖ With a new wipe, thoroughly clean the external threads and groves at the distal end of the Huber extension set for at least 15 seconds and allow it to air dry for at least 30 seconds.

❖ Maintaining an aseptic non touch technique, prime the needle-free connector with sodium chloride 0.9% for injection 1 ml and connect it to the catheter lumen. Follow the procedure for bleeding and flushing as before.

The integrity of the needle-free connector should be examined before and after use and replaced:

• if the needle free connector is removed for any reason (never re-use same connector).
• if there is residual blood or debris within the needle-free connector.
• if an occlusion is suspected.
• if the connector is visible soiled with (debris or blood-stained) the procedure for replacing a new sterile connector should be followed before proceeding with any catheter access.

Frequency of needle-free connector change

The needle free connector should be replaced every 7 days when changing the Huber needle or in accordance with the manufacturer’s instructions.

Intravenous Infusion Administration Sets

❖ A Huber needle must be in place to administer intravenous therapy via the port.

❖ Follow the principles of ANTT during all episodes of care associated with the infusion including. priming, connection, disconnection of intravenous administration and extension sets.

❖ Administration sets are single use and should be discarded when disconnected.

❖ Intravenous administration sets should not be intermittently disconnected including during patient personal care or left hanging unconnected to the non-coring needle since it can increase the potential risk of contamination, the introduction of infection and catheter occlusion.

❖ Any change of administration sets should include a change of add-on devices e.g., extension set.

❖ Follow NHS Borders policy for clearly labelling administration sets and drug additives with date and time when an infusion is started.

❖ Sodium Chloride 0.9% of up to 20mls may be required to optimally flush the port following disconnection of some infusions e.g., PN or blood transfusion.

Total Parenteral Nutrition (TPN)

❖ A larger gauge size non coring needle maybe required for the administration of TPN, glucose or lipid solutions to maximise the flow.

❖ Follow the principles of ANTT during all TPN access procedures.

❖Select Standard or Surgical ANTT according to the risk assessment and technical difficulties in achieving Key Part, Key site asepsis protection, when priming, connecting, flushing and discontinuing a TPN infusion. Surgical ANTT will require sterile gloves /sterile dressing pack.

❖ A single Huber needle with its extension set is only ever used for the administration of TPN to prevent catheter related infection.

❖ The Huber needle/ extension set should be changed every 24 hours or when a new TPN bag is started.

❖ The TIVAD is flushed without delay on completion of the TPN infusion with sodium chloride 0.9% for injection 10mls. An additional 10mls maybe required to fully flush the port.

Administration of Blood and Blood products

❖ TIVAD can be used for the administration of a blood transfusion and blood products.

❖ A larger size non coring needle (19G or 20) maybe be considered to enhance flow rate and avoid the potential risk of haemolysis.

❖ Blood products should be infused using a volumetric pump and a designated administration set incorporating a filter that removes clots and debris that could potentially cause port occlusion.

❖ Sodium Chloride 0.9% of up to 20mls may be required to optimally flush the port following disconnection of the blood administration set.

Blood sampling from a TIVAD – General principles

TIVAD is suitable for safe blood sampling. A range of factors can influence blood sampling including: TIVAD size, rate of blood withdrawal, intravenous therapy in progress and type of blood sampling vacuum system.

❖ Follow the principles of ANTT throughout blood sampling procedure.

❖ A larger size Huber needle (19G or 20G) should be considered to enhance blood flow rate and avoid the potential risk of haemolysis.

❖ Coincide blood collection prior to starting a new intravenous therapy regimen/TPN.

❖ Obtain blood samples using a slow gentle withdrawal technique

❖ Using a 10mls Luer-lock syringe, withdraw 10mls of blood via the Huber needle and discard it prior to taking blood samples (with the exception of blood cultures where the first 10mls of blood is used for analysis). Obtain peripheral blood culture samples first

❖ Immediately flush the TIVAD with at least 10mls sodium chloride 0.9% for injection

❖ Blood for drug analysis should not be taken from the Huber needle that has been used to administer the drug (e.g. antibiotics)

❖ Avoid taking blood samples from a TIVAD used forthe administration of solutions and medication. If the TIVAD is the only option the following guidance should be followed: − Stop the infusion (depending on the patient’s clinical condition).

• Flush the Huber needle/TIVAD with Sodium chloride 0.9% for injection to remove any residual medications and fluids from catheter lumen.
• Wait 10 minutes before taking blood samples.
• Withdraw 10mls of blood and discard. Obtain the requested blood samples

❖ Immediately flush and lock the TIVAD as outlined 9.3.3/4

❖ Do not use vacuum collection bottles directly onto the Huber needle without consulting specific product information and blood sampling kit manufacturer instructions due to the risk of high pressure and catheter rupture.

Blood Cultures - general principles

❖ Blood culture samples should be taken from peripheral vein first and then from the TIVAD

❖ Blood cultures samples are taken from a TIVAD:

• if it is suspected the TIVAD is the source of the infection
• there is no other venous access available

❖ Blood is drawn directly without pre flushing and do not discard the first 10mls of blood

❖ Each anaerobic and aerobic bottle comprises of a set. A total of 20mls of blood is required and 10 mls is placed in each bottle

❖ Other blood samples should be taken after blood cultures have been obtained

The purpose of a daily assessment is to inspect, monitor and evaluate the TIVAD for potential complications including patency, position, function and the ongoing medical requirement for the TIVAD. Assessments may need to be carried out more frequently based on the clinical condition of the patient and the therapeutic interventions.

Daily Assessment should include:

Review and record daily the need for TIVAD access. The Huber needle should be promptly removed by appropriately trained staff when access to the TIVAD is no longer required.

Accessed TIVAD (Huber needle in place)

❖ At every access, check security of Huber needle placement and dressing

❖ Inspect the needle insertion site and surrounding skin over the port through the transparent dressing for signs of needle dislodgement, leakage of fluid around the needle, visible swelling over the port site or evidence of extravasation.

❖ Check with the patient for the presence of pain or tenderness.

❖ Inspect the skin integrity of the surrounding port area for signs of localised infection, redness, swelling or port erosion.

❖ Inspect the integrity of the Huber needle extension set for kinks, cracks or faults.

❖ Ensure the Huber needle securing dressing is dry, clean and intact and replace it if it becomes compromised.

❖ The Huber needle should be replaced every 7 days (or according to manufacturer’s instructions).

MRI and Defibrillation

MRI Scan: Radiographers should be informed in advance of the scan, the presence of the TIVAD.

Defibrillation: If a patient requires defibrillation, do not place paddles directly over the port.

Documentation

In-Patients: The TIVAD maintenance care bundle should be completed and recorded daily in the patient’s medical records as follows:

 Community: The patient held diary should be completed by the registered practitioner at each home visit.

Personal Hygiene

Accessed Port – Huber needle in place

❖ Bath: The Huber needle and dressing (including polyurethane types covering the port site) must not be immersed or submerged in bath water due to the risk of contamination from the water

❖ Showering is preferable to a bath.

Transparent dressing used to secure the Huber needle must be kept dry. If the dressing becomes wet or damp or non-adherent, it must be replaced immediately.

Non-Accessed port/No Huber needle in place:

❖ Patient can have a bath or shower once the initial incision site has healed.

Patient Education

❖ Educate the patient and carer about the TIVAD including its purpose, the aims of treatment, and potential complications that could arise.

❖ Inform the patient and carer about the precautions necessary to prevent infection, including good hand hygiene and refraining from handling or touching the Huber needle/port site.

❖ Advise the patient about the safety the precautions necessary to prevent dislodgement of the Huber needle, the importance of a secure dressing, how to monitor for signs of extravasation and what to do if the Huber needle becomes dislodged or falls out.

❖ Advise the patient and carer of the regular requirement for 4 -8 weekly flushing regimen.

Discharge Planning – Primary Care

If the ongoing care of the TIVAD and delivery of treatment is to be provided by the community team, the referral and relevant documentation must be completed well in advance of the patient discharge and should include:

❖ Patient care plan/guide with information and instructions about care and maintenance procedures that will be required in the community.

❖ Information about contact details, referring hospital, ward, consultant and the process pathway to manage any complications should they arise.

❖ Check list with the relevant equipment required to care for the TIVAD including Huber needles, flushing and locking solutions and dressings.

❖ Discharge letters for GP and nursing team.

Written Information

❖ Supplement patient and carer education with written information/booklet about post discharge care including contact numbers 24/7

❖ Supply the patient with a patient held diary to record the maintenance flushing dates and any problems that may arise.

Hobbies and activities

❖ Patient can return to normal activities, provided the access port is not painful and the patient is advised to start gently.

❖ High level sporting activities should be discussed on an individual basis with the patient’s Consultant e.g. patients should be advised to avoid strenuous activity and contact sports that could displace the device or catheter.

❖ Some regular sporting activities can be built up gradually and practised moderately

❖ Port access should be on the non-dominant side for gentle racket sports.

❖ Swimming and diving is permitted when the device is not being used/accessed.

❖ When sunbathing the port site should be protected with sun cream.

Travelling

❖ There are no restrictions on travelling including the wearing of seat belt

❖ Device can be activated at airports and patient should carry a medical awareness card.

Perform Daily review and record the ongoing requirement for the Huber needle and TIVAD access.

ANTT - Risk assess the difficulties of protecting Key-Parts and Key-Sites asepsis, to determine if Standard or Surgical ANTT should be used. Comply with the principles of ANTT during all access procedures.

Perform effective hand hygiene before and after all contact with the TIVAD.

Non-coring Huber needle (Gripper Needle) should be used at all times for accessing the port. Standard hypodermic needle must never be used. Remove the Huber needle promptly when there is no longer a clinical need.

Replace the Huber needle every 7 days if continuing access is required.

10ml Luer-Lock Syringe: Always use 10 ml Luer-lock size syringe or above (not less than 10 mls).

Flushing a TIVAD – Use a turbulent pulsatile push-pause flushing technique, then lock the TIVAD when disconnecting the syringe at the end of every access. Ensure the Huber needle extension set is left clamped after each access.

De-accessed Port/Not in Use is flushed and locked every 4 up to 8 weeks as per local protocol.

Accessed TIVAD: examine the device for needle dislodgement, leakage of fluid/extravasations, ensure the dressing is intact, dry, clean and secure. Inspect the skin integrity over the port site and for signs infection or erosion.

Clean the needle free connector: “Scrub the HUB” vigorously with 2% Chlorhexidine/70% Isopropyl Alcohol device wipe for 15 seconds, allow to dry for 30 seconds.

Intravenous Administration Sets should NOT be disconnected until it is time to change the administration set and should not be left hanging unconnected. They should be disposed of at disconnection. Comply with the recommended frequency for administration set changes.

Administration of PN: Follow the principles of ANTT during all stages of PN administration procedure and access. Flush the Huber needle immediately following completion of PN infusion to prevent lipid build up in the port reservoir /catheter and TIVAD occlusion.

Administration of Blood Products: Use a volumetric pump with a filtered giving set when administering blood and blood products to avoid occlusion. Flush the TIVAD immediately after the infusion is completed.

Administration of Contrast Medium: Never use a standard port for the administration of IV contrast medium as this may cause the catheter to split. A specially designed Power Injectable TIVAD is required for this purpose.

Frequency of accessing the catheter: Organise care delivery to minimise the number of multiple manipulations of the Huber needle/TIVAD to reduce the potential risk of infection. Where there is a requirement for multiple manipulations/access of the device a continuous infusion should be considered.

Presence of potent medications: If there are potent medication (e.g. sedation) in the Huber needle, portal reservoir, following disconnection of an infusion or administration of a bolus injection, withdraw and discard prior to flushing to avoid bolus injection of the medication.

❖ TIVAD should be removed as soon as it is no longer clinically required.

❖ TIVAD is removed in theatre or radiology by appropriately trained medical staff e.g. surgeon or an Interventional Radiologist.

❖ The procedure is performed in a suitable environment such as theatre or radiology suite

❖ The procedure is undertaken under local anaesthetic and conscious sedation as required.

❖ The procedure involves a minor surgical cut down procedure to remove the portal body and catheter.

❖ If infection of the TIVAD is suspected, the catheter tip and port should be sent for microbiological analysis.

❖ Procedure details are entered in patient’s medical records and patient response to the procedure.

Post Procedure Care

❖ Patient should remain on bed rest post procedure for up to two hours and regular monitoring of observations as per local protocol

❖ A dressing (island dressing) eg 3M Tegaderm transparent film dressing combined with pad is applied to the wound site and observed closely for development of oozing or bleeding

❖ Non absorbable sutures are normally removed around 7-10days and at the instructions of the medical operator