Suwannee Sirilerttrakul, APN (Oncology nursing)
November 8
th, 2018
Implanted port: maintenance,
complication, and management
Topics
Overview types of CVADs& implanted port
CVADs maintenance
Complication & management
Colon cancer and H&N cancer, controlled co-morbidity
Regimens; mFOLFOX / mFOLFIRI (5-FU continue infusion)
On CVADs ; PORT & PICC etc.
Good compliance
Sign consent ; Home chemo consent form
Eligibility criteria
CVADs
• Percutaneous
placement of IV catheter
• Threaded into Subclavian V.
Jugular V. etc.
• Tip location Cavoatrial
junction(CAJ) & : Lower 1/3 SVC
CAJ
Type of CVADs
2 1
Tunneled catheters; Hickman catheters
(single-lumen, double-lumen and triple-lumen)
Tip catheter: The open-ended
The catheter is opened at the distal tip
The catheter required clamping before entry into the system
Clamps are usually built into the catheter
Require flushing
Tip of the open-ended catheters
• A valve is located at the tip or hub of catheter
• Opens with infusion or aspiration
• Remains sealed at other times
• Normal saline flush only, Heparinization is not required
The closed-ended tip catheter (Valved cath)
PowerPort
NON-CORING NEEDLE
NON-CORING NEEDLE
Flushing and Locking Central Venous Catheter Devices @ Ramathibodi Hospital
Not use Cont infusion Intermittent; within 1 day
Flushing Locking
Flush volume/
frequency
Flushing Locking
NSS volume
Heparin concentration
Heparin volume
Heparin frequency
NSS volume Heparin conc.
Heparin volume Frequency
Non-tunnel central catheter and PICC
Adult 10 ml 10 unit/mL 2.5 mL q 24 hr. NSS 10 mL q 24hr 10 mL - - Administration
time Pediatric 10 ml 10 unit/mL 1.5 mL q 24 hr. NSS 10 mL q 24hr 10 mL 10 unit/mL 1.5 mL Administration
time Tunnel central venous catheter
Adult 10 ml 10 unit/mL 2.5 mL q 1-2 week NSS 10 mL q 24hr 10 mL - - Administration
time Pediatric 10 ml 10 unit/mL 1.5 mL q 1-2 week NSS 10 mL q 24hr 10 mL 10 unit/mL 1.5 mL Administration
time Implanted port
Adult 10 ml 100 unit/mL 3.5 mL q 4-8 week NSS 10 mL q 24hr 10 mL - - Administration
time
Pediatric 10 ml 100 unit/mL 3 mL q 4-8 week NSS 10 mL q 24hr KVO at least 10 ml/hr.
CVADs CNPG_Ramathibodi,18
Flushing: Push-pause technique
Turbulent
Laminar
Locking: positive pressure
1technique
• Forward pressure creates turbulent flow
• Clamp line while injecting
• Maintain forward pressure;
flush as withdrawing if no clamp
1
2
Complications
Type of Occlusions
- Thrombotic occlusion
- Nonthrombotic occlusion - Mechanical occlusion
Infection
Hypercoagulability
Endothelial injury
Stasis of blood flow
Virchow’s Triad
Adapted from Virchow (1863)
Sousa et al., 2015
ESMO clinical practice guideline
Central veins position Right Left
Table : Relationship between catheter tip position and frequency of thrombosis
Position No. of Catheters No of thromboses
1. Right atrium 31 0
2. Low SVC 19 0
3. High SVC 44 2
4. Above SVC 19 6
Case scenario 1: Mr. PW 39 Yo HN 538-3858
Jan 18 : Dx colon cancer with liver metastasis
9Mar-20Jul 18 : mFOLFOX6 + Bevacizumab x 10 C(port insertion APR,18) (home chemo C8) Imaging CT show PD
9Aug18-2Nov18 : mFOLFIRI + Bevacizumab ( Home chemo x 7C)
5Nov18 : Take device off (FOLFIRI + Bevacizumab C7)
Signs& symptoms
Rt arm swelling
face, neck& chest normal
Port: flush free-flow
T= 36.4c, BP= 115/72mmHg, P=61 BPM
Q2:What should we do next?
Q1:What do you think about it?
5Nov18 Emergency US dropper
Acute DVT at the right subclavian v. with total flow obstruction
Vascular Sx : Enoxaparin 0.8 mg SC OD x2 wk with FU
Management
Should port be removed?
ESMO clinical practice guideline Sousa et al., 2015
Sousa et al., 2015
ESMO clinical practice guideline
Complication: post implanted port insertion
Case scenario
Post Docetaxel 37 days
Post Docetaxel 63 days
Implanted port function :
Flush with normal saline was free
Flow without blood return
(fibrin tail/ vessel wall sucking?)
No declotting intervention
Case scenario
Q& A
• What is the real cause of this event?
• Could chemotherapy was administered via implanted port?
• Should it be removed?
• Is it possible to be an reaction of catheter material
(Polyurethane ) and Docetaxel ?
Case scenario
Post Docetaxel 37 days
Post Docetaxel 63 days
Catheter occlusion and thrombosis
Imaging Techniques
A. Extraluminal pericatheter thrombus B. Post-lytic Therapy
®
Characteristics of Thrombolytic Agents
Baskin JL. et al., 2012
®
Characteristics of Thrombolytic Agents
Baskin JL. et al., 2012
Mechanism of Action : Thrombolytic agents
Baskin JL. et al., 2012
negative pressure technique
catheter
empty 10 cc syringe
(aspirate syringe until plunger reach 8-9 cc ) t-PA in 5 cc syringe ( 1 mg/cc)
1 2 3
direction into body
t-PA indwelling procedure by 3-way stopcock
Extravasation : Vinorelbine leak via implanted port
2 days 11 days
17 days 30 days
Extravasation : Doxorubicin leak via implanted port
Extravasation : Doxorubicin leak via implanted port
Non-thrombotic occlusion
Precipitation
- TPN ; Calcium-phosphate precipitation - Drug to drug incompatibilities
- Drug to solution incompatibilities
e.g. Oxaliplatin in NSS, Bevacizumab in D/W
Drug to heparin incompatibilities
1. Amikacin sulfate 2. Codeine phosphate 3. Cytarabine 4. Daunorubicin HCl 5. Gentamicin sulfate 6. Hyaluronidase
7. Kanamycin sulfate 8. Levorphanol bitartrate 9. Meperdine HCl 10. Methadone HCl
11. Morphine sulfate 12. Polymyxin B sulfate 13. Promethazine HCl 14. Streptomycin sulfate
15. Dobutamine 16. Erythormycin lactobionate
Trissel LA, 1992
Treatment strategies for nonthrombotic occlusions:
Precipitate Treatment solution to Instill
Calcium phosphate - Hydrochloric acid (0.1 N) or
- L-cysteine hydrochloride (not FDA approved) Low-pH drug (pH 1-5) - Hydrochloric acid (0.1 N)
High-pH drug (pH 9-12) - Sodium bicarbonate (8.4%) or - Sodium hydroxide(0.1)
Lipid residual - Ethanol 70% or
- Sodium hydroxide (0.1 N) for lipid & protien
INS, 2014
**May combine both agents**
Mechanical occlusion/complications:
Pinch-off syndrome Catheter kink
Port and catheter rupture
Catheter tip migration/ malposition
Broken/damaged catheter
CVADS complication
Mechanical occlusion : catheter kink
Implanted port erosion
Inappropriate tip position
Clinical lesson : Pinch- off syndrome
A port was implanted for chemo in 56 yrs woman with CRC
The catheter was inserted through Rt. Subclavian vein by centesis technique Q : Fluoroscopy?
1st-3rd cycle of chemo administration were not trouble
However, the occlusion was suspected 2 mth after Sx, but she had no any symptom
Case presentation :
BMJ Case Reports, 2012
Investigations
Figure 2 The lateral chest x-ray showed that the catheter fragment was located in the cardiac shadow (above the dashed line). The catheter shadow could have been easily missed because it was behind the cardiac shadow.
Figure 1 : Posteroanterior chest x-ray revealed a shortened catheter. The arrow showed the end of the catheter.
BMJ Case Reports, 2012
Treatment :
The remaining catheter was removed
It was transected at 7 cm, the tip was clean cut and smooth
The fragment catheter in the heart was removed through the rt femoral vein
Out come and F/U :
New port was implanted and catheter was inserted through Rt jugular V. , The patient has taken chemo via the device
BMJ Case Reports, 2012
DISCUSSION:
Q1 : What is the main cause of catheter transection ? A1: Chronic compression btw clavicle & 1st rib
Q2 : How to prevent this pinch off syndrome?
A2: Theoretically, A catheter must inserted into subclavian v. laterally A2: Consider new insertion sites such as Int. Jugular v. and Ext.
Jugular v.
BMJ Case Reports, 2012
Schema : Pinch-off syndrome
Types of infection
1. Localized entrance or exit-site infection 2. Tunnel and/or port pocket infection 3. Catheter associated BSIs
ASCO. 2013
Sousa,2015
In US, cancer patient
=1.5/1000CVC days with mortality rate12-25%
Gram –positive bacteria 60%
Gram- negative 25%
Fungus 10%
Most common are coagulase-negative staphylococci, gram-negative bacilli, staphylococcus aureus, pseudomonas aeruginosa, and candica species
Prevention
Sterile technique strictly; insertion, scrub skin /hub
Use CVADs as needed
CHG was shown superior than providone iodine
Antibiotic coated catheter show to prevent infection in short-term catheter
Tabatabaie O et al, 2017
Schiffer., 2013
ASCO guideline,2013
with friction
How to minimize CLABSI
How to minimize CLABSI: How long time to s
crub the hub?Lockman, JL et al., 2011
