Broviac, Hickman, Port-a-cath Access Review
In-dwelling venous catheters come in a variety of configurations but they share some common characteristics…
- They have a catheter that is placed in the superior vena cava to provide central circulation access.
- They can be accesses by using an external port or in the case of a port-a-cath, a port placed just beneath the skin.
- Accessing the indwelling the catheter is less traumatic and for the most part painless for the patient.
- Aseptic technique is required when utilizing them. EMS can access indwelling ports and lines to give meds just like a peripheral IV line.
Broviac, Hickman, Leonard
These catheters have an external hub or hubs connected to a surgically implanted or placed catheter. The hubs usually exit the skin in the anterior thoracic region or upper arm. Most utilize a special material to prevent infection where the catheter enters the skin. All of them end up in the central circulation, usually the superior vena cava. The lines can have one, two or three hubs; one hub per lumen of the tubing. They may be color coded red, blue, green, etc or numbered for reference. All the lumens end up in the same place. It’s a common misconception that one tube is venous and another is arterial; that isn’t correct, they all end up in venous central circulation and you can use any of the hubs for the same purpose. Multi-lumen lines are used when incompatible substances need to be administered simultaneously. Fortunately we don’t have to worry about that with our stuff, so we can use any of the line’s lumens.
Port-a-caths, Bard Ports, other brands of implanted ports
These catheters have a large port implanted just beneath the patient’s skin and the catheter is routed into the superior vena cava. A special non-coring needle is used to pierce the skin and the port. With the needle in place it works just like any other implanted central line device. Since a special needle is required, and the skin covers the port, the procedure is a little different.
Accessing Broviac, Hickman and Leonard Lines
The patient and their family will likely have extensive knowledge about the line and how to properly care for it. In fact, there are some videos on “YouTube” showing proper care by family members. The lines are heparinized to prevent clotting of the end of the catheter in the blood stream.
You will need an empty 10ml syringe, alcohol preps, INT hub, a saline flush and a primed an ready saline IV setup.
- To access the line first clamp off the hub line you intend to use. It’s important to clamp off the line to prevent air from being sucked in to the line and blood stream. Any of the hub lines can be used, they all go to the same place and work the same way.
- Once you have the line clamped off, expose the end of the hub (it may have a cap or be taped over) clean it well with an alcohol prep and put an INT hub on it.
- With the INT hub in place you can unclamp the tubing and let the INT hub seal out air; this makes it a little less complicated than dealing with the clamp.
- Clean the INT hub and attach an empty 10 cc syringe to the INT hub and aspirate about 5ml of blood and heparin to confirm the line is in place, discard the syringe and contents as biohazard waste. There should be no resistance to aspiration. If there is resistance, don’t force it. It’s possible that the line is pinched off internally. The patient and the family will likely be familiar with the situation and will know how to move the arm around to reduce the pinch. Talk to the patient and family! They know about this thing!
- Attach a saline flush syringe to INT hub and flush it gently.
- Attach a flushed 60 drop set (or blood set if you think you need volume replacement) and saline bag and run it into the line at a KVO rate. We use the saline at KVO to prevent clotting off since we don’t have heparin available.
- Use the y-sites on the IV tubing to give meds as needed; make sure to clean the y-site correctly and flush with the saline IV line after each med.
Accessing Port-a-caths and Bard Ports
Like the other lines, the patient and family are likely to have extensive knowledge; don’t be afraid to ask questions!
You will need a special “Huber” needle, an empty 10ml syringe, alcohol preps, INT hub, a saline flush and a primed an ready saline IV setup.
Locate the port beneath the patient’s skin. It’s often just inferior one of the clavicles. The soft dome is about the size of a quarter and easily penetrated with one of the special needles. The back of the port is titanium so you don’t need to worry about putting the needle in too far.
Once you have located the port site, clean the skin with LOTS of betadine, giving yourself plenty of sterile field to work in. Mark the port location with betadine so you won’t have to feel around there again after you cleaned it. If you do re-palpate the port location, betadine your glove fingers to prevent re-introducing gremage.
You must use a non-coring Huber needle. There are several varieties; all of them are slightly curved with a gentle bevel, some have folding wings and others have a removable gripper. The ones we use most often have small wings that fold up so you can hold it and fold down on to the skin once it’s in place.
Before insertion, remove the plug from the hub of the line and replace it with an INT hub. The INT port will seal out air and make it less complicated than messing with the clamp all the time.
Hold the wings of the needle over your index finger to provide you the most control. The needle goes into the skin at a 90 degree angle; straight in, not at an angle. Penetrate the skin and port in one motion, you can’t go in too far. Flatten out the wings so they lay on the skin.
Clean the INT hub with an alcohol prep and attach an empty 10ml syringe. Aspirate about 5 ml of blood and heparin from the port and line to confirm that you are in the port and that the port is functioning properly; discard the syringe and contents as biohazard waste.
If it’s working right, put a tegaderm over the wings of the needle to keep it sterile. If it’s not working and you intend to remove the needle, see the removal info below.
Clean the INT hub again and attach a saline flush, flush the line and port gently.
Assemble a saline IV set and after cleaning the INT hub again, connect the IV set and bag and run it at KVO. We use the KVO IV line to prevent clotting of the port line since we don’t have heparin available.
Use the y-sites on the IV line or the port line to administer meds as needed; remember to clean it properly first!
Removal of the Needle
Don't remove the needle unless you have to because the line must be heparinzed to prevent clotting. The port-a-cath is not held in place with screws or nails so you have to hold it in place when you remove the needle. Place a finger on two sides of the port, hold it down as you remove the needle. As the needle is removed, inject about 0.5 ml of fluid to prevent pulling blood into the end of the catheter. (We use a needle attached to a short line set, not a syringe as shown here).