Portacath

The Portacath may be used after 7-14 days depending on healing. However, it can be used immediately if necessary but this will depend on the inflammation and pain around the site. Advice must be sought from the child or young person’s Consultant.

There is usually a tunnel site post-insertion which will be covered with steri-strips and the port site will have a dry dressing in place. These dressings/steri-strips should be assessed within 24 hours and can be left intact for 1 week or until the wound is healed.

The position of the port should be identified prior to accessing the port by palpating the port and checking the contour. If there is no contour and the surface is flat, it is possible the port has flipped or become displaced. If there is any doubt about the correct placement of the Portacath, discuss with senior medical staff and specialist staff. A decision will be made about continuing with, or abandoning, the procedure.

Portacath access is performed by percutaneous needle insertion using a Gripper needle. Choose a needle length based on reservoir depth and tissue thickness. Check the child and young person’s notes to see if the patient requires a specific size of needle. Do not use a syringe smaller than 10ml in size for flushing procedures to prevent damage from increased pressure on the lumen from the use of smaller syringe.

Please refer to Table 1 below for recommended flushing instructions for particular procedures.

Table 1: Recommended flushing volumes for Portacath

Site preparation: Always inspect the injection site prior to accessing the port and undertake all procedures using an aseptic technique.

Prescribed topical anaesthesia (i.e. Emla or Ametop cream) used to anaesthetise the surface area of the skin. This is applied at least 60 minutes prior to having the procedure performed if the patient wishes.

Equipment required:

• 1 pair sterile gloves;
• sterile dressing pack;
• 2% chlorhexidine skin cleanser (Chloraprep) Note: Chloraprep cannot be used in infants under 8 weeks;
• correct size gripper needle (specific needle for accessing ports);
• 3 sterile 10ml luer lock syringes (extra10ml luer lock syringes required if blood investigations are requested) Note: no syringe smaller than a 10ml luer lock should be used;
• 2 x sterile needles;
• filter straw;
• 10ml 0.9% sodium chloride for injection;
• 5ml heparinised 0.9% sodium chloride (100iu/ml) or 3ml heparinised 0.9% sodium chloride (100iu/ml) for mini ports. This is for monthly flushing;
• sharps container;
• disposal bag;
• semi permeable dressing (optional);

Procedure

1. Explain the procedure to the child or young person and obtain verbal consent. Ensure that the child is aware of the procedure and they are sitting in a comfortable position. A play leader and/or distraction therapy may assist the child to cope more easily with this procedure.
2. Read the child or young person’s notes to find out what size of gripper needle is required. Look for documentation regarding whether the line is known to bleed back. There are some Portacaths that do not bleed back. This must be documented.
3. Put on an apron and perform hand hygiene as per the WHO 5 moments for hand hygiene.
4. Wipe away surface anaesthesia at needle insertion site prior to the procedure and dispose of wipe.
5. Perform hand hygiene as per the WHO 5 moments for hand hygiene. Put on sterile gloves.
6. Using aseptic technique draw up 10ml 0.9% sodium chloride for flushing into one luer lock syringe. Again draw up 5ml (or 3mls for a mini port) 100iu/ml heparinised 0.9% sodium chloride for locking the port. This is only for monthly flushing.
7. Prime the needle and infusion set with approximately 2mls of the 10mls of sterile 0.9% sodium chloride and close the clamp on the set. Leave on the sterile field.
8. Cleanse the child or young person’s skin (at least 10-13cm in diameter) around and across port site using Chlorprep (0.5% chlorhexadine and 70% isopropyl alcohol in infants under 8 weeks of age) use repeated back and forth strokes for 30 seconds. Allow to dry for 30 seconds. Discard applicator after use.
9. Feel the site of the port to identify its centre and stretch the child or young people’s skin between first two fingers of non dominant hand.
10. Insert needle and infusion set into the centre of the port septum. Advance needle through the skin and septum until reaching bottom of the reservoir (see figure 4). If the infusion set is to stay in the Portocath for IV infusion purposes then a transparent dressing must be applied e.g. (IV3000).
11. Confirm correct position of the needle within the port reservoir by obtaining a flashback of blood. .If you cannot obtain a flashback then ask the parent/patient if the Portacath usually bleeds back and read the child or young person’s notes for information. If the Portacath usually bleeds back but you cannot obtain flashback then it could be positioned incorrectly. Seek advice from a Registrar/Advanced Paediatric Nurse Practitioner, Specialist Nurse or nurse in charge.
12. If laboratory blood specimens are required they can be taken next with a 10ml sterile luer lock syringe. Set to the side of sterile area.
13. Insert the syringe containing the sterile 0.9% sodium chloride for flushing into the end of the infusion set. Open the clamp. Flush the Portacath using a push/pause technique until the last 1ml and close the clamp on the last push. This technique is used to reduce the potential for blood backflow into the catheter tip which would encourage blood clotting in the catheter or the formation of blood clots.
14. Insert the syringe containing the sterile 0.9% sodium chloride for locking the port to the end of the infusion set. Monthly maintenance flushes need 100iu/ml of heparinised sodium chloride. Open the clamp. Flush the port using a push/pause technique until the last 1ml and close the clamp as the remaining fluid is pushed in.
15. De-access the port by removing the needle from the centre of the port. If a period of IV administration is required the gripper needle must be secured with a semi permeable dressing.
16. Oncology patients only: Curos port protector for each lumen (not sterile, therefore do not place this onto sterile area)
17. Remove personal protective equipment and perform hand hygiene as per the WHO 5 moments for hand hygiene
18. Dispose of all waste management appropriately as per Waste Management Procedure. 
19. Document procedure, review date, any problems and action taken in the child or young person’s notes.

An aseptic technique must be adhered to when commencing an infusion. The giving set should be primed using an aseptic technique. The fluid must not be run over a sink to prevent spillage because this would significantly increase the risk of infection from the splash back of organisms within the sink. The giving set must only be primed immediately prior to the start of the infusion procedure.

Follow steps 1 to 13 of the flushing procedure prior to connecting any product to the patient. Clean the end of the line thoroughly with a chlorhexidine gluconate BP 2% & isopropyl alcohol 70% wipe and allow to dry for at least 30 seconds.

Aseptic technique must be used when connecting any product to the infusion set. Sterile swabs are used to hold the line and the infusion set for extra protection when connecting to chemotherapy agents.

All equipment should be appropriately disposed of after connection. The contents of the sterile dressing pack should never be kept for disconnecting the infusion, no matter how short the duration of the infusion as this significantly increases the risk of infection.

When disconnecting an infusion pump a strict aseptic technique must be followed.
A trolley should be set up the same as directed in the Removal of CVAD section of this guideline.
Steps 12-18 of care and maintenance of a port should then be followed.