Vascular Access

 

Vascular Access

 

What is Vascular Access?

 

Vascular Access is simply the ability to enter the veins to administer therapy or take blood samples. When frequent access is necessary, a vascular access device, such as an implantable port, PICC or dialysis catheter, is surgically implanted and can stay in place for weeks, months or even years. A vascular access device can be used to administer chemotherapy, draw blood, deliver antibiotics and nutrition,

and perform blood transfusions.

 

Implantable Ports

 

Why do I need an implantable port?

 

Your doctor may determine that as part of your treatment, you will need to receive your medications by intravenous (IV) injection. This method of drug delivery involves infusion of your medication into a large vein, a blood chest wall or the upper arm. The smallest ports are often placed just under the skin on the arm. Your doctor may also decide that your treatment will need to continue over a period of months. Insertion of an implantable port is intended to make this possible.

 

An implantable port consists of a small, hollow chamber (the port) and a catheter. The area of self-sealing silicone rubber in the center of the port is called the septum. The catheter is a long, soft, hollow tube. One end of the catheter is securely connected to the port, and the other end is placed into a large vein.

 

There are a variety of port systems available. Some have a valve that may be located in the area where the catheter joins the port, while others do not have a valve. Your physician will determine which is best for you. Both valved and non-valved ports can deliver the medications that you need. However, the care that each requires is different. Your physician or nurse will discuss the care of your specific port with you.           

 

How is an implantable port inserted?

 

Insertion of an implantable port is a brief procedure done under local or general anesthesia.

 

First, the skin on your chest and neck or arm is cleaned to remove germs.

 

Then, a small incision is made on your chest or arm to create a space or “pocket” for the port and a “tunnel” for the catheter. The port is inserted under the skin and into the pocket. One end of the catheter is threaded through the tunnel and connected to the port.

 

The other end of the catheter is inserted into a vein in your shoulder or your neck, or your arm. The tip is positioned near your heart to help dilute and distribute your medications.

 

Usually, X-rays are taken during the procedure to make sure the catheter is in the best position.

 

Finally, your incision is stitched closed and covered with a dressing until it heals, a process that takes a few days.

 

How is an implantable port used?

 

Once your Implantable port is in place, you can begin your treatments right away.

 

Each time you receive a treatment, the skin over your port is cleaned. A special needle is then inserted through both your skin and the septum of the port. This small needle allows fluid to be delivered into the port chamber. From there, the fluid flows through the catheter into your bloodstream.

 

After the needle is in place, the nurse will first inject a solution to flush your port. Then, you will receive the fluid that contains your medication. In some cases, the medication can be delivered over a few minutes. In other cases, it must be delivered over a period of hours or days.

                       

How do I care for my implantable port?

 

Your doctor or nurse will give you specific instructions about how to care for your bandage while your incision heals. In addition, you should follow some important general rules:

 

• Avoid heavy exertion or strenuous activities for the first few days after port insertion.

 

• Avoid touching the port site as much as possible.

 

 • Carry your implantable port travel card and/or wear your implantable port ID bracelet at all times and for as long as the port in inserted.

 

Also...

 

Check your skin around the port and tunnel site every day. If you notice redness, tenderness, irritation, swelling or any unusual symptom, call your doctor or nurse immediately.

 

Check the port site while you have a needle in place for delivery of your medication. Immediately notify your doctor or nurse if you experience discomfort or swelling in the area around the port. You should also notify them if you notice any fluid leaking in the area.

                  

Note:

If you have a port in your arm:

• Do not allow a blood pressure test to be taken on that arm.

 

• Do not allow a blood sample to be taken from that arm unless it is done through the port using a specially   designed, “non-coring” needle which will not damage the port.

 

Commonly asked questions

 

Q. How long will I have my implantable port?

A. Your doctor or nurse can answer that question. Some people may need it for only a few weeks, others for several months. As long as the system is periodically flushed to keep the catheter from becoming blocked, the port can remain under the skin indefinitely.

 

Q. Will my port cause any pain?

A. You may feel some soreness for a day or two after your port is inserted. This is normal. Once healed, there should be minimal pain associated with the device.

 

Q. Will my insurance company cover the cost of my port?

A. Because coverage varies, you should check with your insurance company to be sure they cover your port and treatment.

 

Q. Are there any activities that I shouldn’t do with the port in place?

A. You should check with your doctor or nurse about any activity restrictions that they recommend for you. However, because the port is completely internal, you should be able to resume most of your normal activities between treatments.

 

 Q. What happens if my implantable port stops working properly?

A. There are ways to treat problems that may occur. Your doctor will first determine the cause of the problem and what should be done to correct it. If the problem cannot be corrected, the port can be replaced.

 

Q. Can my port be used immediately after it is inserted?

A. Your healthcare provider will give you specific instructions about when the port can be used after placement.

 

 

PICC Lines

 

What is a PICC (Peripherally-Inserted Central Catheter)?

 

A PICC is a long, thin tube that is placed into a vein and threaded until the tip is in a very large vein in your chest. The PICC may be used to deliver medicines and other fluids, such as nutrition and blood products, into the vein. This is called IV or intravenous delivery.

 

Unlike the short IV lines you may have had placed in your hand or arm, a PICC may remain in your arm for many weeks or months. It may also be possible to take blood samples from your PICC to be used for special tests.

 

There are a variety of PICCs available. Some have a valve located in an area at the end of the catheter called the hub, while others do not.

 

Valved catheters generally do not have clamps like non-valved catheters. Your physician will determine which type of PICC is best for you.

 

How is a PICC placed?

 

Your PICC will be placed by a trained healthcare provider. This may be done in your room in the hospital, a clinic, the X-ray department or other locations.

 

Your arm will be cleaned and you will be covered with special cloths to keep the area as clean as possible — this is called sterile technique. The person placing your PICC will wear a mask, gown, gloves and hat. This is to protect you and keep the area clean during the procedure.

 

A numbing medicine may be given at the place where the catheter will enter your arm. This is done through a very small needle and may sting. In some cases, an ultrasound machine or X-ray machine, may be used to look at your veins. The PICC is threaded into the vein during this visualization process. After the PICC is in place, a sterile dressing will be put over the insertion site (the place on your arm where the PICC enters the vein). An X-ray image may be taken to make sure the PICC tip is in the right position in a vein in your chest.

 

How do I care for my PICC?

 

Your PICC will need to be cared for and kept clean. Care will include changing the dressing any time it becomes loose, soiled or wet and at least once per week. This may be done by a healthcare provider, by you, a family member or friend that has been taught how the dressing is changed.

 

A sterile end cap will be placed on the end of the catheter that is called the hub. This keeps the catheter closed when not being used. Certain end caps allow access to the catheter without removing it from the hub. Some PICCs have one opening (lumen) and others have multiple lumens. Notify your healthcare provider if your end cap(s) becomes loose, comes off or is leaking. The end caps should be changed at least once per week, or as often as your healthcare provider otherwise suggests.

 

Before any medicine or fluid is given, or blood is drawn, the end cap and/or hub should be cleaned with a special cleaning solution. This is done to prevent germs from getting into your catheter. Your healthcare provider will teach you how to clean the end cap.

 

Should I limit my activities while I have this PICC?

 

Generally, bending your arm, reaching and doing everyday activities will not harm your PICC. You should not lift heavy objects or carry objects held in the bend of your arm that may put strain on the PICC or the dressing.

 

If your healthcare provider approves, you may take a shower or bath with the PICC in place as long as you cover the PICC and dressing with plastic wrap, a plastic bag or material that will keep it from getting wet. You should NOT do other activities, like swimming, that may get the catheter or dressing wet. A wet dressing or catheter may put you at risk for infection.

 

Notify your healthcare provider and seek medical attention if you have:

 

• Redness, soreness or swelling at the PICC insertion site or on your arm

 

• Fever, chills or vomiting

 

• Any problems with your catheter while caring for it

 

• Difficulty giving medications, or being able to draw blood

 

• A catheter that becomes damaged in any way, leaks, is torn or broken

 

 

Commonly asked questions

 

What is a PICC? 
A PICC is a long, soft, flexible catheter that is placed by specially trained nurses. The catheter starts in a vein between the elbow and the shoulder and then follows that vein to a large vessel in the chest called the superior vena cava. You will have a sterile dressing on your arm and one or two short extensions where your nurse will infuse your medication and/or draw blood.

 

Why do I need a PICC?
 The small veins in your arms and hands are good for short-term, mild medications and fluids. Your physician may have determined that you need a PICC because of the strength of the medication prescribed, the length of time you will need the medication, the availability of veins in your arms and hands, the need for frequent blood samples or a combination of these things.

 

Where will this procedure happen?
 Most likely the entire procedure will take place in your hospital room. Your infusion nurse will assess your veins either by palpation (touch) or by ultrasound. The ultrasound is a painless device that helps locate veins that are deeper in your arm using sound waves. If the infusion nurse feels that the PICC cannot be placed in your room, he or she will make arrangements for the procedure to take place in Interventional Radiology.

 

Will I be awake for this? Yes. The procedure takes between 30 and 45 minutes. The only discomfort you will feel is the numbing of the site with lidocaine. Lidocaine is injected into the skin using a very small needle. This will numb the tissue so you won't feel the IV catheter being inserted.

 

Will I feel the long catheter as it travels into my vein?
 No. The inner layer of your vein does not have nerves, so the small soft catheter just floats along with the blood back towards the heart. Your infusion nurse will measure and cut the catheter prior to insertion so that it stops in the right place.

 

How will the nurse know it is in the right place? 
Your infusion nurse has been trained to measure from the point where he or she plans to insert the PICC to the area on your chest that lies over the superior vena cava. The target area is approximately 3 inches (7 cm) long. To confirm where the tip is located, an X-ray will be taken in your room or in the radiology department. If you are pregnant, please inform the X-ray technician to cover your abdomen.

 

What are the risks of getting a PICC placed? 
Any time you have a needle inserted into your skin there is a risk of infection. This is why your infusion nurse will take time setting up a sterile area and cleansing your skin. After the PICC is placed, we encourage you to use that arm as you normally would. This will help decrease the chance of a blood clot forming in the vein by increasing the blood flow around the catheter.

 

Most people will have a little bleeding at the insertion site, so your infusion nurse will place a small piece of gauze under the clear dressing for 24 hours. Some people have more significant bleeding and may need the dressing changed a few times. Unsuccessful insertions do happen occasionally. Due to your unique situation, the soft, flexible catheter may not be able to reach its destination. On extremely rare occasions there could be an equipment failure that makes first attempts at insertion unsuccessful. Your physician, primary nurse and infusion nurse will be monitoring your PICC for any complications.

 

Will my arm hurt tomorrow? 
Probably not. Most people do not have arm pain after placement of a PICC. Few people, maybe one in twenty, experience mild-to-moderate soreness in their upper arm. This is most likely caused by venospasm. This is when the muscle layer of your vein tightens around the catheter. It is most often relieved by applying warm compresses around your upper arm to relax the vein. It feels like a muscle that has had a workout. This can happen anytime from 12 hours after insertion to a week later. Usually applying warmth to the area relieves the spasm and the soreness goes away.

 

Can I go home with a PICC line in place?
 Yes. If your physician decides you need to receive IV medication at home, you can go home with your PICC line. A nurse called a Discharge Planner will assist with setting up healthcare services to care for your PICC after you leave the hospital. Most patients have it taken out before they leave the hospital.

 

Can I take a shower with the PICC in place?
 Yes. If you have no other restrictions for taking a shower or bath, your PICC will not prevent you from bathing. You will need to be careful not to soak the dressing with water. Ask your nurse for assistance with how to cover the dressing to minimize exposure to water. If moisture gets under the dressing let your nurse know so it can be changed quickly.

 

Will I have the PICC for a long time? How do you take it out? 
Most people have their PICC between one to four weeks, depending on the therapy. When your physician determines that it is no longer needed, a trained nurse will remove the PICC. Removing your PICC is a simple, quick procedure performed in your room. The most uncomfortable part of removing a PICC is taking off the dressing. It usually slides out without your knowledge.

 

Dialysis Catheters

 

Why do I need a dialysis catheter?

 

Normally, our kidneys filter waste from our blood. When your kidneys are not functioning properly, these harmful wastes build up. A dialysis machine can be used to cleanse these wastes from your blood. Your catheter is used to connect you to this dialysis machine.

 

The catheter is a hollow, soft tube that has two openings or lumens—one lumen to send your blood to the dialysis machine and the other to return the cleansed blood back to your body. Each lumen has a clamp and a cap. The clamp is kept closed and the cap is on whenever the catheter is not being used.

 

How is a dialysis catheter inserted?

 

The catheter is inserted into a blood vessel called a vein that directs blood back to your heart. Most often, a vein in the neck or chest is chosen, but your doctor will decide what is best for you.

 

After your skin has been cleaned to remove germs, an anesthetic will be used to numb the area where the catheter will be inserted. You may be given other anesthesia or medicine to help you relax.

 

One end of the catheter will be inserted through your skin into the vein. The rest of the catheter will be formed into a curve and placed under your skin in what is called the tunnel. Where the catheter comes out of your skin is called the exit site. A dressing will be placed over this area and an x-ray will be taken to make sure the catheter is in the best position.

 

Under your skin near the exit site, you may feel a small bump on the catheter in the tunnel. This is called the catheter cuff, which helps to hold your catheter in place.

 

How is the dialysis catheter used?

 

Once your catheter is in place, you can begin dialysis treatments right away.

 

Each time you go for your dialysis treatments, the nurse will clean the end (called the hub) of both catheter lumens. Your nurse will inject a solution to flush your catheter and then will connect each lumen to the dialysis machine. One lumen will send your blood to the machine and the other will return it to your body

 

How do I care for my dialysis catheter?

 

Your doctor or nurse will give you specific instructions about how to care for your catheter, but you should follow some important general rules:

 

• Do not swim or shower

 

• Do not soak your dressing while bathing

 

• If your dressing becomes wet or loose, change it; if you cannot change it or need assistance, then notify your healthcare provider immediately

 

• To clean the skin around your exit site, use either 70% isopropyl alcohol-based solution or aqueous-based povidone iodine solution; be sure to let the area dry before you apply dressing

 

• Do NOT use acetone on any part of the catheter tubing; exposure to this agent may cause catheter damage

 

• Carry your catheter travel card with you at all times

 

 Also...

 

Check your catheter and exit site every day. Your exit site should heal in about a week and you should not notice any oozing or drainage from this area. If you do, call your doctor or nurse. You should also call if you notice any redness, swelling, irritation or soreness at the exit site or along the tunnel.

 

It is important to keep the clamps closed and the caps on at all times. If you notice a leak in your catheter, check that your clamps are closed and your caps are on tightly. Call your doctor or nurse right away.

 

Be careful not to damage your catheter. Don’t use scissors to remove your old dressing and make sure

it is always securely fastened to your skin. Call your doctor or nurse immediately if your catheter does get damaged.

 

Commonly asked questions

 

Q. How long will I have a dialysis catheter?

A. Your doctor or nurse can answer that question. Some people may need it for only a few days, others for several years.

                           

Q. Will my body reject the catheter?

A. That is not likely. Your dialysis catheter is made of materials that are not likely to cause any reaction.

 

Q. Will my catheter cause any pain?

A. You may feel some soreness for a day or two after your catheter is inserted. This is normal. However, after that, the catheter should cause you no pain.

 

Q. Will my insurance company cover the cost of my catheter?

A. Because coverage varies, you should check with your insurance company to be sure they cover your catheter and treatment.

 

Q. Can the catheter be removed if I don’t need it anymore?

A. Yes, it can be removed by your doctor. It is often done in the out-patient department, using only local anesthesia.

                           

Q. Are there any activities that I shouldn’t do with the catheter in place?

A. You should check with your doctor or nurse about any activity restrictions that they recommend for you.

 

Q. What happens if my catheter stops working properly?

A. There are ways to treat problems that may occur. Your doctor will first determine the cause of the problem and what should be done to correct it. If the problem cannot be corrected, the catheter can be replaced.

 

Q. I’ve heard doctors and nurses refer to my catheter as a “Hickman” Catheter or “PermCath” Catheter. What does this mean?

A. Hickman and PermCath are brand names of other dialysis catheters and some people refer to all dialysis catheters by those names.