NOTTINGHAM CHILDREN S HOSPITAL Nursing Guideline P07 Care and Management of Children with a Totally Implantable Venous Access Device (Portacath). Introduction A Portacath is a central venous access device system that can be used for the delivery of both IV medications and fluids. Once accessed, it can usually be used for the collection of blood specimens without venepuncture. It is particularly useful in patients that have poor vascular access or who require frequent intravenous medication for various reasons such as regular long term antibiotics or chemotherapy. A Portacath must be flushed regularly in order to minimize complications. Once needled the Portacath can be accessed like any other central venous access device using ANTT. However, needling requires additional training and assessment. Standard statement A Registered Nurse (Child), who has been appropriately trained and has completed the IV and Portacath Working in New Ways Expansion to Practice Packages, will be able to safely access a Portacath. A parent or carer who has been appropriately trained and assessed competent may access a Portacath that has been inserted in the child in their care. Structure Where possible this procedure should be a two person technique, however, in the community setting a parent carer of a co-operative child or a community nurse may do the procedure alone. Needling a portacath is done using a traditional aseptic technique, however once needled then an aseptic non-touch technique (ANTT) can be used for all access to the line. Syringes of less than 10mls should be avoided as they exert too much pressure. Flushing a portacath (which requires needling using an aseptic technique) Portacaths should be routinely flushed every 4-6 weeks. Equipment Prescription card/ Patient Group Directive Tray or trolley Dressing Pack Sterile gloves Chloraprep 2% 3ml (Chlorhexidine gluconate applicator) or Sterexidine 200 if baby under 3 months. Gripper needle of the appropriate size 2 x 10mls syringes of 0.9% Sodium Chloride 2-4mls Heparinised Saline (100 units/ml) 2 x Blue needles 10 ml syringe for withdrawing Alcohol hand rub P07 Page 1 of 7
Local anaesthetic cream if required Procedure ACTION 1. Explain the process to the child and parent 2. Apply local anaesthetic cream if required 3. Wash hands and then use alcohol hand rub. Clean trolley or tray, prepare equipment, gel hands and apply sterile gloves. 4. Prepare additional equipment, this includes: drawing up 10mls 0.9% sodium chloride x 2 and 2-4mls heparinised saline (100 units/ml) using an aseptic technique. 5. Prime gripper needle with one syringe of 0.9% sodium chloride and close clamp. Remove the syringe. 6. Expose and clean around port area with chloraprep or Sterexidine 200 applicator in a circular motion, working from inside out for 30 seconds, and leave to dry 7. Immobilise port with fingers and insert needle into port at a 90-degree angle until the base of the port is felt. 8. Withdraw a small amount of blood into a clean 10ml syringe to ensure correct position then attach other syringe and instil 10mls of sodium chloride, observing for localised swelling. RATIONALE To ensure they are fully aware of what the process will entail Minimise pain on needle insertion. To reduce risk of infection To ensure preparation prior to procedure To clear dead space and reduce risk of embolism. To minimise introduction of infection and ensure effectiveness of cleaning agent. To ensure correct position To confirm correct position and patency of portacath 10ml syringe or larger should be used to prevent damage to the catheter through pressure (Smiths Medical International Ltd. 2005) P07 Page 2 of 7
9. If in doubt remove the needle To prevent infiltration of medication into subcutaneous tissue. 10. If it is positioned correctly, To prevent port and line occlusion flush line with 4mls of heparinised saline (2mls for (NUH CF guidelines 2012) children under the age of 5 years) under positive pressure then clamp the line. 11. Remove needle, pushing down To minimise risk of damage on the portacath with two fingers. If continuing on regular prescribed IV medication do not remove needle. 12. If there is any bleeding, apply To stop the bleeding a clean piece of gauze or plaster. 13. Dispose of all equipment according to trust policy. Wash hands. 14. Sign for heparinised saline and To keep record of medication given sodium chloride on prescription and any problems encountered. card and report any problems encountered to hospital or community staff. Document as appropriate. IF BLOOD SAMPLING IS REQUIRED: Extra Equipment needed 5mls of 0.9% sodium chloride in a 10ml syringe 3 x 10 ml syringes (will need more if more than 10mls blood required) Blood bottles, labels and request cards Procedure ACTION Follow steps 1-7 in guideline for needling portacath. 7. Withdraw 3 mls of waste blood. If unable to withdraw blood immediately then instil 5mls of 0.9% sodium chloride then withdraw 5mls of waste blood and discard. Clamp line. Change syringe and withdraw sample of blood required. RATIONALE P07 Page 3 of 7
Clamp the line and remove syringe. 8. Flush line with 20mls sodium chloride 0.9% and clamp line using positive pressure. (Smiths Medical International Ltd. 2005). 9. Flush line with 2-4mls of heparinised saline under positive pressure and clamp line. 10. Remove needle, pushing down on the Portacath with two fingers If continuing on regular prescribed IV medication do not remove needle. 11. If there is any bleeding, apply clean piece of gauze or plaster. 12. Decant blood samples into appropriate bottles and label correctly. Send to lab. 13. Dispose of all equipment according to the trust waste management policy. Wash hands. 14. Sign for heparinised saline and sodium chloride on prescription card and report any problems encountered to hospital or community staff. Document as appropriate. To further help disperse blood in the line. To prevent port and line occlusion and create a lock (Babu and Spicer, 2002) To minimise risk of damage To allow IV medication to continue to be given as prescribed. To stop the bleeding To ensure specimens are correctly processed. To keep record of medication given and any problems encountered. P07 Page 4 of 7
Administration of Medication via a Portacath using an ANTT Equipment Prescription card Sodium Chloride 0.9% 2-4mls Heparin (100 units in 1 ml) 10 ml syringes Blue needles Green needles Tray Bionector Alcowipe Non sterile gloves Appropriate drugs Procedure Action 1. Wash hands with soap and water and then use alcohol hand rub. Clean tray as per ANTT guidelines and apply non sterile gloves. 2. Prepare and check prescribed medications in accordance with Trust s Medicines Management Policy using ANTT. Only use syringes of 10mls or greater. 3. Clean Bionector cap with alcowipe and leave to dry. 4. Attach the syringe and flush with 5mls of sodium chloride 0.9% using a 10ml syringe. Clamp using positive pressure. 5. Administer prescribed medications using positive pressure. Ensure bolus drugs are given first. Flush with 5mls of sodium chloride 0.9% between each drug using 10ml syringes. 6. The tissue surrounding the site should be monitored throughout the procedure for: Rationale To minimise risk of infection. To ensure patient s safety. To minimise the risk of line sepsis. To ensure patency of the line and the positioning of the needle. To ensure that the medications do not mix in the line. To ensure that appropriate steps are taken to prevent port infection and any other problems associated with P07 Page 5 of 7
Redness Swelling Discomfort surrounding the port It is inadvisable to use the port in these circumstances inform medical staff and document. 8. On completion of the administration of medications, flush with 5mls sodium chloride 0.9% and clamp the line. 9. Attach the syringe containing 2-4mls of heparinised saline (100u/ml), flush and clamp the line using positive pressure. 10. Dispose of all equipment according to trust policy. Wash hands. 11. Sign the drug prescription card to denote that they have been administered. 12. Report any problems encountered and record in nursing notes. the Portacath. To ensure all medication is infused. To prevent port and line occlusion. To maintain an accurate record of medications given. To maintain an accurate record of any change P07 Page 6 of 7
References Babu, R. and Spicer, RD. (2002) Implanted vascular access devices (Ports) in children: complications & their prevention. Pediatric Surgical International 18: 50-53. Nottingham University Hospital NHS Trust (2012) Cystic Fibrosis management guidelines section 5.8 heparin and sodium chloride flushes page 49, unpublished. Smiths Medical International Ltd. (2005) Port-a-cath and Port-a-cath II Vascular access systems, instructions for use. Veal G (2007) A study to determine the minimum volume of blood necessary to be discarded from a central venous catheter before a valid sample is obtained in children with cancer. Pediatric Blood and Cancer, 48(7) :687 695 Authors: Janice Mighten, Debra Forster and Amanda Ward Date : June 2014 Review Date: June 2019 Ratified by: Nottingham Children s Hospital Clinical Educators Group (RK, KW, LH, MF, AK, SC, LB, GB ) Signed off by: Jamie Crew, Kerry Webb and Rachel Keay P07 Page 7 of 7