• What are the risks to care workers when the needle is withdrawn from the implantable port septum?  

Procedures on implantable ports are the most dangerous nursing procedures (Lamontagne et al., 2003). The incidence of accidental needlestick injury when handling this type of equipment is 24.9 needlestick injuries per 100,000 procedures, i.e. an incidence five times higher than that of a ‘conventional’ nursing procedure which has an incidence of 4.7 needlestick injuries per 100,000 procedures.

References:

Lamontagne F., Lolom I., Tarantola A., et al. Évolution de l’incidence des accidents exposant au sang chez le personnel infirmier hospitalier en France métropolitaine de 1990 à 2000. Hygiènes 2003; volume XI no 2: 113-119.


 

• Use of non-heparinised saline solution to maintain implantable ports?

Maintenance (usual) after chemotherapy:
The device must always be rinsed with physiological saline through a syringe after any injection or infusion, between the two infusions and at the end of treatment (cf. ANAES Recommendations, December 2000)
Many studies (Hamilton 1988, Epperson 1984) have shown that a 0.9% sodium solution is as effective as heparinised saline solutions in preventing catheter obstruction. These findings were recalled at the last congress on long term intravenous devices in 2004 by E. Pierre, Toulouse University Hospital pharmacist.
In addition, the ANAES recommendations stipulate that to prevent IP obstructions, rinsing with physiological saline each time after usual use (particularly chemotherapy) is as effective and more straightforward than heparinised saline (Théard JL. 1995).


Maintenance after the blood sampling, transfusion or venesection:
The device must be rinsed with physiological saline through a syringe. Heparinisation may be used in this case.


Maintenance between two chemotherapies:
No specific maintenance is recommended. POLYSITE® integrity is ensured by the membrane (silicone septum) which prevents any change in pressure or blood rising into the distal end of the catheter. It is recommended that patients check their skin regularly for any redness, pain or weeping, discharge or oedema (for all implanted ports regardless of manufacturer). Alert the patient of the need to seek advice promptly if any of these signs develop.


Maintenance after parenteral nutrition:
It is recommended after parenteral nutrition that a glucose solution (20 ml of 5% glucose solution) be injected through a syringe first before rinsing with physiological saline.


Long term maintenance (6 months to 1 year; outside of courses):
There is currently no consensus apart from checking the skin (for any redness, pain, discharge or oedema) every 2 to 3 months. No specific maintenance is recommended, although regardless of the type of port and particularly catheter, some hospitals also recommend injecting physiological saline (10 ml by positive pressure through a syringe) every 2 to 3 months without initially checking for venous return.
In addition, the POLYSITE® implantable ports allow high flow rates to be administered at the same time reducing the external catheter diameter which has been designed in order to minimise the risk of venous thrombosis which is occasionally caused by the large external diameter of high flow catheters. In addition, a catheter which allows high flow rates (and is not bulky) carries fewer risks of becoming blocked or obstructed by deposits and therefore offers better patency over time.


References:

Epperson EL. Efficacy 0.9% sodium chloride injection without heparin for maintaining indwelling intermittent injection sites.  Clinical pharmacy Vol 3 Nov-Dec 1984: 626-629.

Hamilton RA. Heparin sodium versus 0.9% sodium chloride injection for maintaining patency of indwelling intermittent infusion devices.  Clinical pharmacy 1988; 7(6) : 439-443.

Di Costanzo J, Sastre B, Choux R, Kasparian M. Mechanism of thrombogenesis during total parenteral nutrition: role of catheter composition. Journal of parenteral and Enteral Nutrition 1988; 12(2): 190-194.

Eastridge BJ, Lefor AT. Complications of indwelling venous access devices in cancer patients. Journal of Clinical Oncology 1995; 13(1):233-235.

Theard JL, Robard S. Evolution des protocoles d’utilisation des chambres implantables. Ann Fr Anesth Rean 1995; 14:534-5.


 

• What is a Huber needle?

Huber needles are specific needles intended for injection into implantable infusion ports. They have a tangential cutting edge in order not to damage the silicone membrane (septum) of the implantable port. They are made of a straight or 90o elbow bend, generally stainless steel, tube, which may or may not be covered with silicone oil. They end in a cutting edge with a specific geometry designed to allow multiple perforations of a synthetic polymer membrane without damaging it.
 

The manufacturer of HUBER needles is not covered by any Standard.
They are available in 20 to 64 mm lengths and in diameters ranging from 0.55 to 1.1 mm.
They may have synthetic polypropylene fixing wings and a polyvinyl chloride or polyurethane extension piece.
They are sterilised with ethylene oxide and disposable

• What is the use of positive pressure when a Huber needle is withdrawn from an IP septum?

Removing an infusion needle from an implantable port generates pressure changes. The magnitude of the fall in pressure caused when the needle is withdrawn without precaution, which is a potential source of complications (increased risk of obstructing the catheter with a blood clot), was measured by a nursing team from the Saint Nazaire Hospital (ANNFAR 2005). These measurements showed a large aspiration effect (maximum fall: Dmax = -21.6 mm Hg + 4.1 mm Hg), due to the elastic nature of the implantable port membrane which buckles when the needle is withdrawn.

The ANAES recommendations which were based on the same findings are to withdraw the infusion needle from the implantable port under positive pressure (ANAES 2000): ‘V.4.6 needle removal – the needle must be withdrawn applying positive pressure’.

This phenomenon of reflux at the distal end of the catheter without positive pressure was also demonstrated by J. Lapalu in a double-blind randomised experimental study on more than 800 needle insertions/removals (JVA, March 2009). This study confirmed the benefits of removing the Huber needle applying continuous pressure to the syringe plunger, counteracting the large aspiration effect produced by mobilising the septum when the needle was moved.

‘This aspiration has harmful consequences as a result of reflux of very small volumes of blood which lodge on the internal lining of the catheter lumen causing progressive thickening wall lining leading to malfunctioning or even complete obstruction of the catheter’ (ANNFAR 2005).

References:

Annales Françaises d’Anesthésie et de Réanimation 24 (2005) 1117-1120, R299 Variations de pression induites par le retrait de l’aiguille sur une chamber àcatheter implantable.
ANAES Evaluation de la qualité de l’utilisation des chambers à cathéter implantables Déc 2000.
Totally implantable port management:  impact of positive pressure during needle withdrawal on catheter tip occlusion (an experimental study), J Lapalu et al., Journal of Vascular Access, March 2009.

 

• What to do in an ABE (Accidental Blood Exposure)?

1)    Urgent first care:

Needlestick injuries and wounds:

- Do not encourage bleeding
- Clean the area of damaged skin immediately with soap and water and then rinse
- Apply antisepsis with a chlorinated compound (Dakin or 9% chlorometric bleach diluted 1/5), failing that an iodinated product (polyvidone iodine in dermal solution etc) 70o alcohol, alcoholic dermal chlorhexidine (for at least 5 minutes).

Direct contact between biological fluid and broken skin:

- Use the same cleaning and aseptic protocols for the affected area as above.
Spraying on to eye and mucosal membranes:
- Rinse thoroughly with physiological saline or water (for at least 5 minutes).


2)    Contact the doctor responsible immediately

Who will assess the risk of infection:

- HIV, hepatitis B and C infections and other infections
Who will tell you what to do:
- You may be offered prophylaxis (chemo and anti-retroviral chemoprophylaxis, specific anti-HBV gamma Globulins +/- vaccination). Before this is given you will be informed about its effects and the process and you will need to give your consent. The treatment must be started within hours of the accident (within 48 hours for hepatitis B).


3) Then contact the occupational physicians

To declare the work accident:

- Practical details vary between establishments and social organisations. Inform the occupational physician, nurse manager or personnel office.

For appropriate clinical and serological follow-up (HIV, HCV, HBV)

Always examine the circumstances of the accident with the occupational physician to avoid it happening again.

References:

GERES (Groupe d’Etude des Risques d’Exposition des Soignants aux agents infectieux), Guide des matériels de santé, Édition 2004.