I have a patient that had a port in the past. It was removed, according to him, because nobody could access it. It was deep and tilted. If I remember correctly it was deep enough that a 1 1/2 in needle was barely long enough to reach adequately. He was hospitalized again on Friday for his chronic condition. I was called in to start a PIV on him. I was able to place a 24G catheter in the inner aspect of his wrist after he had 7 attempts by other nurses. His previous line was his opposite thumb. He is hospitalized every 2 - 6 weeks for hydration and anti-emetics, occasionally antibiotics. He and I discussed the fact that the line I put in wasn't in a good spot, and we discussed him having another port. The location of the port seems to be the key. Anyhow... On most people if you have them sitting up you can feel bony structure in their upper chest area. On this gentleman I was not able to feel the bony structure easily. He has a thickish layer of soft fat throughout the chest area. I am afraid that a port placed in this fatty area will continue to be difficult to access. He is in his late 20's, about 6 feet tall and overweight. Any thoughts of places to place the port to minimize tilting and not place it too deep? Is it possible to put the port above the clavicle? Any other ideas about chronic access for this gentleman?
From time to time I have seen ports placed in the upper arm and the forearm just distal to the antecubital fossa. This may provide a solution for you and your patient as the other normal areas of the chest and the hip area will have the excess adipose tissue that makes maintaining a “traditionally” placed port difficult (if not impossible). Smiths Medical makes the P.A.S. Port (just for an example, not an endorsement). Hope this helps as an alternative.
Lynda
http://www.smiths-medical.com/Upload/products/product_relateddocs/access/PAS-PORT-Peripheral-Access-Systems/19406.pdf
A peripheral arm port could be an option. Just remember it is smaller than a chest port and will accept about 700 punctures whereas a chest port will accept about 2000. It could be a good choice for this patient. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Almost all port companies have a smaller "Arm" model.....
Newest on the market is by MedComp 5FR (5cc/sec...300psi) "Dignity Mini" (I'm not an employee...just new on the market)
Thanks for the ideas. I have found an interventional radiologist who does the arm ports and said he often can find an acceptable chest location.
The next question - if my patient shows up with a port in his arm it is going to be my responsibility to do some education and any updating on the policies needed. I have some real good resources, but what I need to know is information from people who have used them before. Are there any particular pitfalls or tricks that we should know about? There are very few arm ports in our area, and we have not seen any in our hospital yet.
Gail
Gail McCarter, BSN,CRNI
Franklin, NH
They are much smaller and will feel very different becauses of the smaller size of the port body and septum. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Keep in mind you have the median nerve running along the middle of the forearm. If your physician places the reservoir for the port over this nerve you will give your patient a "zinger" (sorry, I have never found a correct medical term for this) each time you manipulate the port. In an ideal world you would be able to discuss the placement of the reservoir that is a compromise for the patient, the physician and you, the clinician. Optimally you would like to have the reservoir either between the radial and median or between the ulnar and median nerves.
The term is paresthesias and includes anything that indicates a nerve has been damaged. Tingling, electrical shock feelings in any direction from the puncture site, numbness, "pins and needles" feelings are included in this category. It can be caused by transection of the nerve by the needle or compression of the nerve from excess fluids in the tissue such as infiltration. This is a major cause of complex regional pain syndrome and often leads to malpractice lawsuits. The patient should be told to let you know if these symptoms occur and there must be immediate intervention by the nurse to limit these possibility for these bad outcomes. This means immediate withdrawal of the needle and another attempt at a different location. If this is always caused each time you access an implanted port, you are setting this patient up for a lifelong course of physical and occupational therapy and narcotics to manage this permanent pain syndrome. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
This is why the Vascular Access Nurses should be directly placing the arm port or very active in assisting the MD....Arm ports are truely a PICC placement with an addition step added! (a step that can be learned!)