Standard Operating Procedure 6 (SOP 6) Vascuport in Children for Routine Flushing and Administration of Medication Why we have a procedure? This guidance is to assist/ inform healthcare professionals on how to access implantable venous access device (vascuport) in children. The venous access device will ensure reliable vascular access in patients that require regular drug administration, and/or those with poor venous access who need regular treatment. What overarching policy the procedure links to? Children s Community Nursing Team Operational Policy Which services of the trust does this apply to? Where is it in operation? Group Inpatients Community Locations Mental Health Services all Learning Disabilities Services all Children and Young People Services all Who does the procedure apply to? All community health care professionals in CYPF Group. When should the procedure be applied? This Procedure should be applied for all children who require intravenous medication via a Vascuport who receive care from children nurses employed by BCPFT How to carry out this procedure Methodology 1. A vascuport consists of a reservoir with an injectable membrane, which is called the septum. Attached to the vascuport is a central venous catheter. A vascuport may be accessed using a Huber (non-coring) gripper needle, which penetrates the septum and intravenous drugs can be administered along the line attached to the needle. Royal Marsden 2011 Vascuport in Children Page 1 of 9 Version 1.1 June 2018
2. Standard size used is a ¾ inch/19mm/0.75inch x 22 gauge non-coring needle (please check Patient Specific Directive), and if the patient requires ongoing treatment should be changed every 7 days unless otherwise indicated. BCH 2008 3. When not in use a port must be flushed to try and prevent line blockage every 4-5 weeks with 4ml heparinised saline (100iu/ml) (please check Patient Specific Directive) by inserting the needle using aseptic technique. If catheter blockage is suspected advice should be sought from the specialist team at BCH responsible for the child s care BCH 2008 4. It is possible to rupture the catheter by the application of excessive pressure during the drug administration. Such pressures can be minimised by taking the following precautions: The use of sterile intravenous syringes of 10ml capacity Avoid excessive force if catheter blockage is suspected A three stage technique should be used involving: Thorough hand washing using the Ayliffe (1980) technique is essential Identification and non-contamination of key parts. (A key part is any part of equipment that comes into direct contact with the liquid infusion or the patient e.g. needle, syringe tips) Protection of yourself and the service user by wearing sterile gloves, apron and any other protection required When preparing injectable intravenous medicines they should always be administered immediately after preparation. Procedure 1. Ensure correct patient 2. Explain procedure relative to the child s age and cognitive developmentinvolving parent/carer and gain verbal consent from the patient if they are able, or from a parent/guardian 3. Check medication as per NMC Medicine Management 2010 and Medicines Policies 4. Wash hands and dry thoroughly as per Hand Hygiene policy 5. Check site, locate portal septum by palpation 6. Apply prescribed local anaesthetic cream as per instruction over portal septum 7. Remove local anaesthetic after 30 minutes (Ametop) to 1hr (Emla) and inspect the site for signs of redness, irritation or infection before commencing the procedure 8. Thoroughly wash and dry hands, put on apron 9. Prepare sterile field and equipment as per aseptic technique 10. Thoroughly wash and dry hands, put on sterile gloves 11. Draw up 5ml of sodium chloride, using a green needle and then prime port needle-close the clamp leaving the syringe attached 12. Using a filter needle, draw up 4ml Heparin (100 iu/ml) 13. Using a green needle draw up 10ml of sodium chloride 0.9% 14. Dispose of sharps as per policy BCPFT-COI-POL-1112-028 15. Clean the area around the port with Chloroprep 1.5 ml prefilled applicator. Use a zigzag action; begin at the top of the port moving downwards in a quick movement. Not going over the same area twice. N.B. Allow the skin to dry Vascuport in Children Page 2 of 9 Version 1.1 June 2018
16. Relocate the portal septum by palpation using gloved finger 17. Locate the edges of the port and hold firmly between the finger and thumb, pressing down gently 18. Hold the port needle firmly and push it straight at right angles to the skin through the skin into the port septum, until it reaches the bottom of the portal chamber, avoiding any previous injection scars. The needle should fit flush to the skin. 19. Do not use excessive pressure as this may damage the needle tip 20. Release clamp and aspirate to achieve bleed back into the tubing (if this does not occur refer to trouble shooting guidelines 21. Secure clamp and discard this syringe 22. Flush with 5-10 ml 0.9% Sodium Chloride, using a pulsating action 23. Clamp and remove the saline syringe 24. Attach the syringe containing 4ml Heparin and release clamp 25. Flush the system applying positive pressure when inserting last 1ml of heparin and when closing the clamp to prevent reflux up the internal catheter 26. Remove the port needle holding the port firmly with one hand and removing the needle with the other 27. Wipe the port site with the gauze 28. Apply plaster as required 29. Dispose of syringes, needles and ampoules in sharps bin as per policy. Clear away all equipment and dispose of as household waste unless the patient has a known or suspected infection then discard as clinical waste. Remove gloves, wash and dry hands 30. Ensure the child is comfortable, and clothing is replaced 31. Complete nursing documentation and all necessary prescription charts. Plan with the family for the next routine flushing of vascuport or when the next drug dose is due Insertion of a port needle for prescribed medication: Follow procedure for insertion of port needle, numbers 1-18 Flush with 2ml of 0.9% Sodium Chloride Give medication as prescribed If more than one drug is being administered a flush of 3-5ml of 0.9% Sodium Chloride must be given in between When medication is completed: flush the line with 10ml 0.9% Sodium Chloride followed by 4ml Heparin (100iu/ml) maintaining positive pressure when inserting last 1ml and when closing the clamp to prevent reflux up the internal catheter and to prevent clot formation within it. Remove syringe If on multiple doses of antibiotics line to be flushed after each dose as stated above If the line is to remain in situ, secure the port needle (using sterile occulive dressing) and apply a bung Additional Information/ Associated Documents Infection Control Assurance Policy A Guide to the Collection of Microbiological Specimens Nursing and Midwifery Council (2008) The Code: Standards of conduct, performance and ethics for nurses and midwives. NMC: London. Birmingham Children s Hospital NHS Trust (2005) Extravasation Policy BCH Birmingham Vascuport in Children Page 3 of 9 Version 1.1 June 2018
Nursing and Midwifery Council (2010) Standards for Medicines Management. NMC Royal College of Nursing (2010) Standards for Infusion Therapy. RCN: London. Royal Marsden Hospital Manual od Clinical Nursing Procedures(8thEdition), Chapter 18: vascular access devices: insertion and management: Royal Marsden Foundation Trust Equipment and supplies Clean tray/work surface disinfect with 70% Isopropyl alcohol Local anaesthetic cream (Ametop or Emla as prescribed) Non-sterile Gloves Sterile Gloves Sterile Towel Dressing Pack Syringes 10ml x3 Filter needle for glass vials Green needle 0.9% Sodium Chloride 10ml ampoules x2 Heparin 100iu/ml 4ml (depending on PSD) Gripper needle/ Vascuport needle (22g non-coring, consult individual care plan for any deviance) Chloroprep 1.5ml applicator Sterile occlusive film dressing (IV3000) Sterile gauze swabs Drug information sheet and prescription card Sharps bin Bung (if port to remain insitu for administration of medication BCH 2008) Trouble Shooting Infection of port site Cause Prevention Action Port site and skin necrosis may be caused by: Always use strict aseptic technique Swab for culture and sensitivity Extravasations of fluid or drugs, leading to when accessing ports Take peripheral blood culture if the breakdown of the skin over the port Use port needle once only patient is pyrexial (+/- line culture to Not changing the Check dressing is exclude sepsis) needles every 7 days secure and needle Treat infection with Bacterial infection sitting flush to skin appropriate Do not use port if any signs of redness, swelling or lesions to prevent tracking of infection into the blood stream antibiotics or antifungal treatments antibiotics given peripherally as prescribed as per Patient Specific Directive Change port needles according to departmental protocol Vascuport in Children Page 4 of 9 Version 1.1 June 2018 Remove needle (very infrequently it may be decided to keep the needle in
place for cultures and antibiotics if the child has difficult veins to access or is particularly needle phobic) Remove CVAD Infection of a port line Cause Prevention Action Research has shown that Refer to port site infection. Refer to port site infection. most common infection is Staph Epidermis Do not access port if there are signs of local A fibrin sheath at the end of the catheter can harbour infection by sequestering the organism infection Infection can then be pushed into the circulation on flushing the system That may present as a raised temperature and general unwell feeling in the days following port access Potential Problems Problem Mobile Port Sometimes the port may move around on the chest wall leading to difficulty in identifying the lumen Hidden Port Sometimes the port may move around on the chest wall leading to difficulty in identifying the lumen Tilted Port Action Palpate thoroughly for the port before attempting to access Previous scars may not be an indication of the port location Once identified, hold with 2 or 3 fingers (and don t let go until you are in) Try putting the child in a new position: Leaning back with hands holding behind back Sitting with chest out Lying down with arm hanging over bed edge Occasionally the port feels like it has tilted : Re-position as for hidden port Ask the child to move around, swing arms, twist from side to side etc. No Bleed Back on Accessing a Port If the CVAD is new, or usually bleeds back without any problems: Check that the needle is correctly positioned in the port chamber and not lodged in the septum of the port Attempt to re-insert a new needle Ask child to cough, take deep breaths Vascuport in Children Page 5 of 9 Version 1.1 June 2018
Problem Action or change position. This can be undertaken with the syringe still attached to the hub of the insertion needle provided the syringe is held safely to prevent accidental removal BCH 2008 If the CVAD is older or usually presents problems with bleeding back and you are sure you are in the correct place: Attempt to gently flush the system with the sodium chloride If flushing well/patent administer medicines as prescribed, even without bleed back Insert a new needle and try again If you are at all in doubt ask for a medical opinion. (RCN 2005, Royal Marsden 2011) Worn Out Septum Patients will complain over the port site Ports should last for approximately 2000 punctures The site may be red and swollen due to fluid leaking into the tissues (extravasation) When inserting the needle into the septum it won t feel tight around the needle, it will feel wobbly If problems persist then this could indicate that: Blocked port Growth of fibrin sheath in or around the distal end of the catheter The port may require x-ray, radio opaque dye investigation or surgical intervention Removal of port Blocked Ports If unusually high resistance encountered whilst infusing fluid through the port system, this may indicate that the catheter is blocked. Cause Action Incorrectly positioned port needle (the distal Apply firm pressure on the needle to free it end of the needle may be sitting in the port from the port septum (do not press too hard septum) as this may cause the needle to fish hook, Fish hooked needle within the port. If the port needle is pushed too firmly into the port, there is a danger of the needle will bend over where it has hit the base of the port. This hook may then block the needle and restrict the flow of fluid then check again for patency of the port Removal of needle (you will only see the fish hook when the needle has been removed. Removing the needle can be very uncomfortable and likely to cause damage to the port septum and patients skin Vascuport in Children Page 6 of 9 Version 1.1 June 2018
Cause Tubing is clamped, kinked or kinked under the dressing Action Check under dressing Kinking if the catheter internally Ask the patient to change position and/or move upper body and arms. Such movements can free the catheter enough to dislodge its end from the vessel wall or straighten up the kinks If it becomes necessary for the child to do this every time the port is accessed this should be investigated Severe kinks from too much or too little catheter slack or rotation of an inadequately anchored portal may require surgical correction Lodging of the distal end of the catheter against the wall of the blood vessel Occlusion of fibrin sheath around the distal end of the catheter Migration of the internal catheter child may have out grown the catheter therefore the position may have changed and the tube may migrate upwards Gentle, alternating irrigation and aspiration with sodium chloride may clear the obstruction Fibrinolytic agents may be used, under medical direction as per the local departmental protocol Surgical removal of the port Extravasation This is when fluid from the port leaks into the surrounding tissue. Cause Prevention Action Needle dislodgement most frequents cause of extravasation Appropriately trained staff should carry out port access Needle not fully though the septum Inadequate needle stabilisation Blockage Catheter tip displacement Worn out septum Separation of port catheter Verify placement of needle with blood withdrawal 4ml/flush 5-10ml 0.9% sodium chloride before administration of medication Watch for signs of burning, swelling or pain during infusion and administration of drugs per local departmental protocols Secure needle with appropriate dressing Do not access port refer to Birmingham Children s Hospital for advice Vascuport in Children Page 7 of 9 Version 1.1 June 2018
Twiddlers syndrome Cause Prevention Action Patients touching the port Explain to child and parents/.carers the importance of not repeatedly touching the port Cannot access the port refer to Birmingham Children s Hospital for advice Additional Information/ Associated Documents Intravenous Medication administration via a Central Venous Line to Children and Young People within the BCPFT The guidance must be used in conjunction with: Birmingham Children s Hospital NHS Foundation Trust (2008) Policy for the Insertion, Administration, Maintenance and Removal of Intravenous Cannula/Catheters BCH Birmingham Where do I go for further advice or information? Team Leader Training The procedure must only be undertaken by nurses who have received recognised Vascuport and IV training, accessible through external provider (Birmingham Children s Hospital), and maintained competencies in all aspects of the procedure and intravenous drug administration. Visual clinical practice review and clinical supervision for signing off of competency documentation. The Vascuport Competency Document as per Birmingham Children s Hospital 2010 will be utilised. A copy of the Competency documentation to should be kept in the personal file. Discussion regarding competency via Annual appraisal It is the individual s responsibility to ensure this competency is maintained with the support from their line manager. Monitoring / Review of this Procedure In the event of planned change in the process(es) described within this document or an incident involving the described process(es) within the review cycle, this SOP will be reviewed and revised as necessary to maintain its accuracy and effectiveness. Equality Impact Assessment Please refer to overarching policy Data Protection Act and Freedom of Information Act Please refer to overarching policy Vascuport in Children Page 8 of 9 Version 1.1 June 2018
Standard Operating Procedure Details Unique Identifier for this SOP is State if SOP is New or Revised BCPFT-CYPF-SOP-OP-6 Revised Policy Category Executive Director whose portfolio this SOP comes under Policy Lead/Author Job titles only Committee/Group Responsible for Approval of this SOP Month/year consultation process completed Children s Services Director of Nursing, AHPs and Governance Team Leader, Community Paediatric Specialist Team CYPF Quality and Risk Safety Group n/a Month/year SOP was approved June 2018 Next review due June 2021 Disclosure Status Key Words for this SOP B can be disclosed to patients and the public vascuport, venous, implantable device, children, community, see-saw team, palliative, paediatric, administration, medicines, nursing Review and Amendment History Version Date Description of Change 1.1 June 2018 Reviewed, no changes made. 1.0 March 2015 New SOP for BCPFT Vascuport in Children Page 9 of 9 Version 1.1 June 2018