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17.12 Implanted arm PORT insertion using modified Seldinger technique (MST) with ultrasound guidance and ECG technology

It is helpful to have an assistant when performing this procedure, if possible.

Essential equipment

  • Personal protective equipment
  • One or two pairs of sterile gloves (according to practitioner preference)
  • Sterile pack containing sterile gown, mask with visor, theatre cap, sterile drapes and scissors
  • Sterile minor operation pack containing a variety of forceps and a needle holder
  • Alcohol‐based skin‐cleaning preparation, e.g. 2% chlorhexidine gluconate in 70% alcohol
  • 10 mL syringes × 2–3
  • 5 mL syringes × 2
  • MST kit (containing needle, guidewire, 5 mL syringe, dilator/introducer/peel‐away sheath, safety scalpel, and 22 or 20 G cannula)
  • Arm PORT kit (containing catheter, PORT and tunneller)
  • Sutures
  • Surgical glue
  • Padded semi‐permeable IV film dressing
  • Small transparent semi‐permeable IV film dressing
  • 25 G safety needle
  • 23 G safety needle
  • Blunt drawing‐up needles
  • Tape measure
  • Disposable tourniquet
  • Sharps container
  • Ultrasound machine, sterile gel and sterile probe cover
  • ECG leads, electrodes and monitor
  • Labels

Medicinal products

  • Sterile pre‐filled 10 mL syringes of 0.9% sodium chloride × 2–3
  • 1% lidocaine with adrenaline

Pre‐procedure

ActionRationale

  1. 1.
    Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
    To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [356], C).
  2. 2.
    Assess the patient's medical and intravenous device history. Assess the patient's arms for suitability of port implantation.
    To ensure the patient has no underlying medical problems such as taking anticoagulants or previous surgery to the arm or chest and so is suitable to undergo the procedure (Hamilton [198], E; Moureau [329], E). To ensure suitability for an implanted arm port (Goltz et al. [173], E; Shiono et al. [413], E).
  3. 3.
    Draw screens and assist the patient into a (semi)supine position, with their arm at a 90° angle to their torso.
    To ensure privacy. To aid insertion of the introducer and then advancement of the catheter (Gabriel [161], E; Moureau [329], E). To help in creating a subcutaneous pocket and insertion of the port (Shiono et al. [413], E).
  4. 4.
    Take the ultrasound equipment to the patient. Apply a tourniquet and gel and assess venous access using ultrasound, assessing both extremities. Locate and select the most suitable vein.
    To ensure the patient has adequate venous access and to select the vein for catheterization (Gabriel [161], E; Goltz et al. [173], E; Krieger and Burbridge [249], E; Moureau [329], E; Shiono et al. [413], E).
  5. 5.
    Where required, apply local anaesthetic cream or gel to the chosen venepuncture site and leave for the allotted time.
    To minimize the pain of insertion (BNF [42], C).
  6. 6.
    Take the equipment required to the patient's bedside. Open the outer pack.
    To ensure the appropriate equipment is available for the procedure. E
  7. 7.
    Attach ECG leads to electrodes and monitor, and apply to the patient as per the manufacturer's instructions.
    To ensure an ECG tracing can be obtained and used as a comparison once the catheter has been inserted (La Greca [256], E; manufacturer's instructions, C; Oliver and Jones [364], E; Oliver and Jones [365], E).
  8. 8.
    If using a tracking device, attach it to the patient's chest area.
    To track the tip of the catheter as it advances into the venous system (La Greca [256], E; manufacturer's instructions, C; Oliver and Jones [364], E; Oliver and Jones [365], E).
  9. 9.
    Apply a theatre cap and face‐mask with visor.
    To minimize the risk of infection during the procedure and to protect the practitioner from blood splash contamination (Loveday et al. [278], C, E).

Procedure

  1. 10.
    Wash hands with soap and water, or an alcohol‐based handrub. Dry hands using sterile paper towels from the pack.
    To minimize the risk of infection (Fraise and Bradley [156], E; Loveday et al. [278], C).
  2. 11.
    Put on sterile gown and sterile gloves; open the inner pack, arranging the contents as required.
    To prevent contamination (Elliott [139], E; Loveday et al. [278], C). To have medications prepared for use. E
  3. 12.
    If not using pre‐filled syringes then draw up 0.9% sodium chloride into a 10 mL syringe (provided by assistant if possible). Label the syringe.
    To prevent contamination (Elliott [139], E; Loveday et al. [278], C). To have medications prepared for use. E
  4. 13.
    Draw up 1% lidocaine with adrenaline into two 5 mL syringes (provided by assistant if possible) and attach 25 G safety needles. Label the syringes.
    To have medications prepared for use and avoid confusion and medication errors. E
  5. 14.
    Remove the cap from the extension set and attach the syringe containing 0.9% sodium chloride; gently flush to the end of the catheter lumen and leave the syringe attached. Prepare the port as per the manufacturer's guidelines.
    To check that the catheter is patent and to enable easy removal of the guidewire (Krieger and Burbridge [249], E; manufacturer's instructions, C; Shiono et al. [413], E).
  6. 15.
    Place a sterile towel under the patient's arm.
    To provide a sterile field to work on. E
  7. 16.
    Clean the skin at the selected site with 2% chlorhexidine gluconate in 70% alcohol, with backwards and forwards movements and friction, for 30 seconds, and prepare an area of 15–25 cm2.
    To ensure the removal of skin flora and to minimize the risk of infection (Fraise and Bradley [156], E; Loveday et al. [278], C).
  8. 17.
    Allow the solution to dry thoroughly.
    To ensure coagulation of bacteria and disinfection (Loveday et al. [278], C).
  9. 18.
    Drape the patient with a full‐body sterile fenestrated drape.
    To provide a sterile field (Loveday et al. [278], C).
  10. 19.
    Apply sterile gel to the ultrasound probe cover. Then apply the sterile ultrasound probe cover over the probe head and pull down along the cable.
    To ensure all equipment that is in contact with the patient is sterile (Loveday et al. [278], C).
  11. 20.
    Retighten the disposable tourniquet through the sterile drapes or ask assistant to do this.
    To aid venous distension (Dougherty [124], E).
  12. 21.
    Apply sterile gel to the skin and scan to find the chosen vein.
    To identify the most suitable vein. E
  13. 22.
    Keeping the probe in position, inject local anaesthetic intradermally using a 25 G needle and wait for it to take effect.
    To provide adequate anaesthesia (BNF [42], C).
  14. 23.
    While visualizing the vein under ultrasound, perform venepuncture with a needle or cannula. (If using a cannula, when flashback is seen, advance the cannula into the vein.)
    To gain venous access (Gabriel [161], E; Goltz et al. [173], E; Moureau [329], E; Shiono et al. [413], E). To prevent blood loss and through‐puncture, and enable advancement of the catheter (Gabriel [161], E).
  15. 24.
    Remove the stylet and advance the guidewire through the needle (or cannula) until there is 10–15 cm of wire in the vein.
    To maintain venous access (Goltz et al. [173], E; Krieger and Burbridge [249], E; Shiono et al. [413], E)
  16. 25.
    Release the tourniquet and remove the probe.
    To contain flashback, prevent contamination of the area with blood and minimize the amount of blood loss from the patient (Gabriel [161], E).
  17. 26.
    Reinfiltrate over the puncture site with 1% lidocaine with adrenaline (intrademally) if necessary.
    To achieve anaesthesia and minimize patient discomfort. E
  18. 27.
    Inject 1% lidocaine with adrenaline intradermally using a 23 G needle and making an L‐shape in a fanning motion to a lateral and distal area approximately 4 cm away from the cannulation site until a bleb is observed.
    To allow for subcutaneous pocket formation (Goltz et al. [173], E; Krieger and Burbridge [249], E; Shiono et al. [413], E).
  19. 28.
    Further inject 1% lidocaine with adrenaline intradermally between the cannulation site and the subcutaneous pocket area.
    To create a subcutaneous tunnel between the puncture site and subcutaneous pocket (Krieger and Burbridge [249], E; Shiono et al. [413], E).
  20. 29.
    Check the patient has no sharp sensations at the anaesthetized areas
    To ensure area is anaesthetized before proceeding. E
  21. 30.
    Make a small incision by sliding the tip of the scalpel blade along the top of the wire.
    To ensure that connective tissues between the skin and guidewire are free with the purpose of facilitating the introduction of the dilator/peel‐away sheath and to place the catheter route deeper to reduce the risk of catheter erosion (Shiono et al. [413], E).
  22. 31.
    With the scalpel at 60–90° to the skin, make a 2–3 cm incision perpendicular to the long axis of the arm to the previously anaesthetized L‐shaped area.
    To facilitate entrance and to allow for subcutaneous pocket formation (Goltz et al. [173], E; Krieger and Burbridge [249], E; Shiono et al. [413], E).
  23. 32.
    Activate the safety function on the scalpel and replace it onto the sterile field.
    To minimize the risk of sharp stick injury (HSE [217], C; NHS Employers [347], C).
  24. 33.
    Grip the dilator/peel‐away introducer firmly and advance it over and along the guidewire.
    To enable advancement of the introducer/peel‐away sheath (Goltz et al. [173], E; Shiono et al. [413], E).
  25. 34.
    Withdraw the guidewire and dilator and leave the peel‐away introducer in situ.
    To enable catheter insertion (Goltz et al. [173], E; Krieger and Burbridge [249], E; Shiono et al. [413], E).
  26. 35.
    Grip the catheter a few centimetres from the tip and thread through the peel‐away introducer sheath.
    To facilitate catheter insertion. E
  27. 36.
    Continue slow advancement of the catheter and aspirate (if possible) and flush to check for blood return or resistance.
    To minimize damage to the tunica intima of the vein (Gabriel [161], E). To check there is no obstruction and that the catheter advances into the correct location. E
  28. 37.
    Ask the patient to turn their head towards the arm of insertion and place their chin on their shoulder if possible.
    To prevent the catheter entering the jugular vein and to ensure correct advancement of the catheter downwards to the superior vena cava (Gabriel [161], E).
  29. 38.
    Ask the patient whether they have any aural (behind the ear) sensations on the side of catheter insertion. If using a tracking device, observe the direction of the catheter on the screen.
    This could indicate that the catheter has advanced along the internal jugular vein and needs to be withdrawn and readvanced (Dougherty [123], E; manufacturer's instructions, C).
  30. 39.
    Using the ECG technology, gently manipulate the catheter, observing the ECG trace for changes in the P wave. When the highest P wave without deflection is observed, the catheter tip is in the correct position (cavo‐atrial junction). If using a tracking device, track to see the catheter heading down and then verify the exact position using ECG technology.
    To ascertain tip position (La Greca [256], E; manufacturer's instructions, C; Moureau et al. [331], E; Oliver and Jones [364], E; Pittiruti et al. [375], E).
    To track the tip of the catheter as it advances into the venous system (La Greca [256], E; manufacturer's instructions, C; Oliver and Jones [364], E; Oliver and Jones [365], E).
  31. 40.
    Carefully withdraw the peel‐away/ introducer sheath and peel apart.
    To ensure there is minimal movement of the catheter. To remove the peel‐away introducer (Gabriel [161], E; Goltz et al. [173], E; Moureau [329], E; Shiono et al. [413], E).
  32. 41.
    Aspirate for blood return and flush the catheter with 0.9% sodium chloride.
    To check the patency of the device and ensure continued patency (Gabriel [161], E; Loveday et al. [278], C).
  33. 42.
    Using the ECG technology, gently manipulate the catheter, observing the ECG trace for changes in the P wave. Ensure the highest P wave without deflection is observed.
    To ensure that the catheter tip remains in the correct position (cavo‐atrial junction) (La Greca [256], E; manufacturer's instructions, C; Moureau et al. [331], E; Oliver and Jones [364], E; Pittiruti et al. [375], E).
  34. 43.
    Acknowledge the catheter's length (from the cannulation site to the cavo‐atrial junction) by looking at the catheter markings.
    To determine catheter length when the tip is positioned at the cavo‐atrial junction. E
  35. 44.
    Make a subcutaneous pocket through the incision made to the anaesthetized L‐shaped area by blunt dissecting using forceps. The pocket needs to accommodate a snug implantation of the port.
    To facilitate the port implantation (Goltz et al. [173], E; Krieger and Burbridge [249], E; Shiono et al. [413], E).
  36. 45.
    Apply gentle pressure on the catheter and slowly withdraw the stylet.
    To ensure there is no withdrawal of the catheter (Gabriel [161], E).
  37. 46.
    Attach the distal end of the catheter to the tunneller and tunnel under the subcutaneous tissue from the venotomy (cannulation) site to the already formed subcutaneous pocket. The tunneller will come out at the pocket incision.
    To make a subcutaneous tunnel between the venotomy site and the subcutaneous port pocket (Goltz et al. [173], E; Krieger and Burbridge [249], E).
    To minimize infection risk as the tunnel increases the distance from the venotomy site to the implantation site (Singh Vats [417], E).
  38. 47.
    Remove the tunneller and trim the distal catheter end accordingly.
    To ensure correct catheter length and appropriate assembly of parts (Goltz et al. [173], E; Krieger and Burbridge [249], E; manufacturer's instructions, C; Shiono et al. [413], E).
  39. 48.
    Connect the catheter to the port as per the manufacturer's instructions.
    To ensure correct assembly of the catheter and reservoir (manufacturer's instructions, C).
  40. 49.
    Place the port into the subcutaneous pocket (suturing of the port to the connective tissue through the suture hole is optional).
    To implant the port into the subcutaneous pocket and ensure the stability of the device (Goltz et al. [173], E; Krieger and Burbridge [249], E; manufacturer's instructions, C; Shiono et al. [413], E).
  41. 50.
    After percutaneously accessing the port with a non‐coring needle, aspirate and flush with at least 10 mL of 0.9% sodium chloride.
    To ascertain device function and to ensure continued patency (Gabriel [161], E; Loveday et al. [278], C).
  42. 51.
    Remove the non‐coring needle and activate its safety mechanism.
    To minimize the risk of sharp stick injury (HSE [217], C; NHS Employers [347], C).
  43. 52.
    Suture the port insertion site with a curved needle. Use 2‐0 vicryl to close the subcutaneous pocket and 4‐0 monocryl to close the skin subcuticularly. (Refer to the section on suturing in Chapter c18: Wound management.)
    To ensure the stability of the device (Gabriel [161], E; Hughes [219], E; Moureau and Iannucci [334], E; NICE [353], C; RCN [381], C).
  44. 53.
    Clean the area with 2% chlorhexidine gluconate in 70% alcohol and leave to air dry.
    To minimize the risk of infection (Fraise and Bradley [156], E; Loveday et al. [278], C).
  45. 54.
    Apply a small amount of surgical glue to both the small venotomy incision and the subcutaneous pocket exit site, and leave to air dry.
    To minimize bleeding at the implantation site and reduce extraluminal contamination (Corley et al. [88], E; Jeanes and Martinez‐Garcia [229], E; Scoppettuolo et al. [407], E; Simonova et al. [415], E).
  46. 55.
    If the patient needed the device for immediate use, insert a safety non‐coring needle and fix it to the patient using an appropriate dressing.
    To minimize pain and discomfort and to decrease the risk of infection from early manipulation of the implantation site (Krieger and Burbridge [249], E; Wilkes [472], E).
  47. 56.
    Apply a semi‐permeable transparent IV film dressing (using a padded semi‐permeable IV film dressing is optional). Date the dressing.
    To ensure protection of the site (Loveday et al. [278], C; RCN [381], C). To see when the dressing is due for changing if appropriate. E

Post‐procedure

  1. 57.
    Dispose of sharps and clinical waste. Remove gloves, gown, mask and theatre cap and dispose of equipment appropriately.
    To prevent sharps injury (HSE [217], C; NHS Employers [347], C).
  2. 58.
    If necessary, send the patient for a chest X‐ray. The position of the catheter should be assessed and documented by an appropriate healthcare professional (see Figure 17.5).
    To ensure that the catheter tip is in the correct position (Wise et al. [474], E).
  3. 59.
    If ECG tip positioning technology was used during catheter insertion (recommended), a chest X‐ray is not required provided that a good ECG tracing is obtained showing maximal P wave elevation. This must be verified by the operator, who should be proficient in the use of this type of technology.
    To ensure correct tip position and minimize unnecessary patient exposure to radiation (La Greca [256], E; NICE [353], C; Oliver and Jones [365], E; Pittiruti et al. [375], E; RCN [381], C).
  4. 60.
    Document the procedure in the patient's notes:
    • size and type of port
    • depth and size of needle used to access or left in situ (as appropriate)
    • where the port was inserted
    • tip confirmation by ECG and/or chest X‐ray
    • batch number of catheter and lot number of sterile packs
    • ECG trace
    • any problems
    • how the port was secured
    • patient education/booklets given.
    To ensure adequate records are maintained and enable continued care of the patient and device (NMC [356], C; RCN [381], C). To enable any faulty equipment to be traced back to the manufacturer (MHRA [312], C).
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