Oncology Nurse Basics: Port-a-Caths!

I asked on Instagram what post you wanted to see next and it was a very overwhelming response for a post on port access. 



It warmed my heart that so many of you want to know all about the little thing that changes my patients' lives! Plus, they are one of my favorite nursing tasks! (One of my sweet patients even offered to be a model, but HIPAA)



First, let’s start with the basics:

What is a port-a-cath?!

In short, a port is an implanted device that allows for a trained medical professional (or the patient) to easily have access to the vein for medication administration, fluids, and blood products. The device is placed under the patient's skin while a thin tube is tunneled into a large blood vessel (superior vena cava) leading directly to the heart. Ports must be placed surgically under local anesthesia and typically take anywhere from half an hour to one and a half hour. 

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Are there different kinds of ports?

Of course! But they all work about the same. The only difference is what pressure and osmolarity of medication are safe to be injected. (Not all ports can have CT contrast placed in them.) Ports can be single lumen or double lumen. Typically they have a round shape or can be a triangle in nature. I have never encountered a double lumen port. I have heard that they can be tricky to access because of the division and double needle. To be honest, I am not even sure how many people have a double lumen port. I have, however, accessed a port in the brachial vein, meaning the port was on the patient's forearm. It was interesting and done in Germany. 

Similarly, there are different types of needles and sizes for ports. Most patients require a non-anchoring needle that is 3/4inch. You will know because of the port's visibility under the skin and slight protrusion. A 22G needle can withstand 312 mL/hour, whereas a 20G needle can handle up to 960mL/hour. Choose appropriately for what you will be administering. Too much pressure can damage the port.

[[I interrupt for story time!]] So, on the floor, we had triangle power ports. These babies were small and easy to grasp. The triangle gave you the perfect bullseye too because they had 3 raised dots at each corner and you simply aimed for the middle! These things were really a beauty!! When I switched to outpatient infusion (and a different state), I no longer had these beauties. Instead, I had more traditional ports that are round. Like the one in the diagram above. I've accessed circle ones before, but sometimes the grasp can be a bit more challenging. I find that I am sometimes too close to an edge now. And one time I almost missed the center all together because I was about to go for that flat base around it. It could have been bad! One of my biggest tips with ports is to get your bearing before putting on sterile gloves. Initially, I palpate the top of the port to get a feel for the diameter and depth and then I will grasp around the edges to understand where I am going to hold. I sort of make a "n" with my nondominant thumb on one side and my nondominant index finger on the other side and insert in the middle. 

Important tips to remember:

Each port is unique. One patient may experience little pain during access whereas others may feel excruciating pain. Pain is a subjective feeling and I never challenge it! As a nurse, you can make the recommendation to the doctor for a prescription for EMLA cream. It is a topical numbing cream that patients can put a dollop size amount over their port and use press and seal to keep it in place. Our recommendations are to apply one hour before coming to their appointment. If your patient forgot, a glove of ice over the area for at least 5 minutes can help decrease the sensation. There is also a spray that you can use, but it really compromises your sterile field since its onset of action is mere seconds and would need to be sprayed right before inserting the needle (breaking sterile field). 

Continuing on with the uniqueness, ports can have strange orientations. I have run across ports that are tilted downwards and you have to adjust your angle. Similar to IV placement, you always assess your point of access and stabilize. Most patients are able to tell their nurse if they know of any strange phenomenons with their port.

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Now to the good stuff:

Steps to accessing/deaccessing a port: (Please always refer to your facilities policies and procedures)

One\\ Obtain a physician's order for accessing the port. Note that you may also need a separate order to obtain labs from the port.

Two\\ Explain the procedure to the patient. Assess the site to help determine the appropriate Huber needle.

Three\\ Gather all necessary supplies. Most facilities have a central line kit. My kit includes mask, sterile gloves, cleanser, Tegaderm, alcohol swabs, and a sterile saline syringe. I just have to drop the needle onto my sterile field.

Four\\ Put on mask. Wash hands (duh)! Some patients do not like to wear masks and know to look to the opposite side and remain still during the procedure. 

Five\\ Open central line kit while maintaining sterile field. If need be, drop appropriate needle on to sterile field. Make sure all necessary supplies are available.

Six\\ Don sterile gloves.

Seven\\ Grap chlorhexidine swab and with friction clean port site for 30 seconds. Some facilities use a hatch/patch cleaning technique, while some may use a circular motion. Nonetheless, just make sure it is as clean as possible. Allow site to dry completely before accessing.

Eight\\ While the site is drying and maintaining the sterile field, attach 10mL NS syringe (ideally sterile) to the connector on the needle. Hold needle by wings or top with your dominant hand. Some individuals prefer to coil the extension tubing in their hand. I, on the other hand, prefer to let the syringe dangle, acknowledging that it no longer remains sterile and my hand will become "clean". 

Nine\\ Once dry, grasp the edge of the port with your dominant thumb and index finger. (Sort of like a "n" shape) With your dominant hand, use a smooth, but firm motion to pierce the sputum using a 90-degree angle. (Ask your patient to take a deep breath and hold while you are accessing.) With your first access, you will realize the small force you need to push through. If I had to compare it to something, it is almost like piercing the plunger of a solumedrol vial. It is at this point (while both hands are still "sterile") I would place a biopatch if the patient is staying accessed for longer than 24 hours.

Ten\\ Check your blood return! I use my non-dominant hand to grasp the NS flush and check blood return. Flush using pulsating pressure. Clamp. (Since I use my non-dominant hand, I am able to adjust the biopatch or apply the Tegaderm as sterile as possible)

Eleven\\ Apply Tegaderm. My hospital uses Tegaderm with CHG pads instead of biopatches. So, I would apply it at this point.

Tweleve\\ Secure your line. Check on your patient. Document.

I think the thought of accessing a port is a lot more terrifying than doing the task. The task is pretty straightforward.

Now for deaccessing:

I use clean gloves for deaccessing and only gather 2-10mL NS flushes, 1-5mL 100usp Heparin flush, sterile 2x2 gauze, and a bandaid. Prior to removing my needle, flush with 2-10mL NS flushes followed by the Heparin flush. Clamp. Carefully remove the dressing. If a patient has fragile skin, obtain adhesive remover pads. Once the dressing is removed and you can adequately get to the needle, then securely hold the port in your non-dominant hand and remove your needle with dominant. With the triangle ports, we used these winged butterfly needles in which you would have to hold the base of the needle with your port and pull up using the butterfly wings until the needle clicks into safety. With the circle ports now, I have to hold the base of the needle with the port, and pull up on a clear tab at the top of my needle as it clicks back into a hold. The needle should pull straight up. Place gauze over insertion site in case of a little bleeding and apply bandaid as needed.

Maintenance of implanted ports

Ports are not only used for administration of medications but can also be used for lab draws! Typically patients who have implanted ports, have terrible venous access and this saves them from multiple pokes. I beg of you to adequately flush your ports after blood draws to ensure patency. Additionally, PT and PTT should not be drawn from ports as their results may be inaccurate.

If IV fluids are not infusing through an implanted port, flush implanted ports with 10 mL NS and 5 mL Heparin every 24hours to maintain patency. If IV fluids are infusing, ensure that the minimum rate is greater than 5mL/hour.

Implanted ports should be flushed every 6-8 weeks when not in use to help maintain patency. Port flushes consist of 10-20mL NS followed by 5mL Heparin. Heparin should not be instilled in ports less than eight hours apart.

A failure to draw blood from an implanted port can come from a variety of complications: fibrin sheath, sludge build up, tumor growth, catheter malposition, etc.

Tips for troubleshooting:

In order to use a port, you must have brisk blood return. This is defined as 3mL of blood in 3 seconds. If you are not obtaining blood return, then do not immediately deaccess. Instead, try pulling back a little on the needle to see if you are too far against the backboard of the port. Have the patient give you a big cough as you try to aspirate for blood return. Or you can also ask the patient to raise their right arm (if the port is on the right).

[[I interrupt for another story]] I would consider myself an expert at accessing ports, but even I can get caught up when I am not obtaining blood return. It is even more stressful that I do not have a poker face and my patients know when something is not going as I planned it. I was accessing a patient for his second time and did not receive that beautiful pull back of blood. I was 100% positive that I was correctly positioned in the port and have tried all the previously mentioned tricks. Then, I remembered that unlike those beautiful triangle ports that I love, these ports sometimes require a few extra flushes to obtain blood return. And there you have it, friends! All I had to do was flush with 30mL of NS!

If none of these weird tricks work, then ask the provider for an order for Cathflo Activase (alteplase). Please only use cathflo if you are positive that you are in the port. Cathflo is a plasminogen activator and works to degrade clot-bound fibrin in as little as 30 minutes. And oh boy does this stuff work really well!

So there you have it! I really wish I was able to record a port access or have a demonstration, but unfortunately, I do not! Hopefully, this was enough!

Megan

*please note that my patient population is adults

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