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Wed, 03/04/2009 - 12:12

carrie12

Increased risk for infections with PAC accessed from OR?

IÂ currently work at South Shore Hospital in Weymouth, MA and we are looking into a new process for our surgeons practice. They surgically place a port-a-cath and access it to check placement and flush, then the surgeons deaccess the port in the OR right away. The pt leaves the OR and some return to the floor for further treatment due to medical or oncological reasons. The floor RN's are accessing these PAC's so they can utilize them for treatment and it can be quite a challenge for 2 reasons.

1. The area is tender due to just having surgery for a port-a-cath placement and pt is in pain during access

2. The area is swollen due to having surgery and may be difficult to access.

We would love for our surgeons to leave the ports accessed for those patients who will continue to need treatment during their hospital stay. My questions for you all are

1. Is there evidence based practice (EBP) stating there is a higher risk of infection for those ports that are utilized right after surgery?

2. Does the port site need to heal a certain number of days prior to accessing the port for use?

3. Is keeping a newly accessed port from surgery a way of practice for other facilities or is it contraindicated for some reason?

Thanks so much in advance for your feedback!

Fri, 03/06/2009 - 11:27

Juline

I have previously discussed

I have previously discussed this with one of our surgeons- He said that they access and flush the port in the OR prior to closing the skin (not through the skin). We can use the port at anytime post-op. The patient is given a local anesthetic in the OR for insertion. I try to evaluate the pt preop to see if the patient will need further IV access post-op and if needed I have the nurse call me as soon as the pt returns to access it before the local wears off. I try to use a needle that will leave a little length to allow for some local post-op swelling to help prevent the needle from dislodging due to swelling.

Juline DiSilvestro BSN, RN, CRNI, VA-BC, CPUI
Central Access Team Nurse
Inspira Medical Center- Woodbury,NJ

Sat, 03/07/2009 - 19:27

Terry Hall

During the AIDS epidemic, I

During the AIDS epidemic, I often accessed Ports immediately after their placement with no adverse affects. I believe it is a sound practice to have the surgeons access the ports intra operatively if possible, particularly if the pt. may not have infusion nurses managing the VAD after placement. There can be bleeding around the Port site and the nurse or other CG may think they have successfully accessed the port when in reality what has happened, is the needle has penetrated a hematoma near or over the VAD. A "blood return" seems apparent, however, it is aspirate from a hematoma created during the operative period.

Sat, 07/18/2009 - 10:24

momdogz

What type of post-procedure

What type of post-procedure site care do the MDs order/your facilities provide?

Mari Cordes, BS RN

Nurse Educator IV Therapy

Fletcher Allen Health Care, Burlington VT

Educator, Bard Access Systems

Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center

Mon, 07/20/2009 - 08:52

Donna Fritz

We also had the same

We also had the same issue. Unless you get into the patient's room upon return from the OR while the local anesthetic is still in effect, it can be quite painful. Another issue is that the port pocket incision, with subcuticular sutures or "glue" was covered with a tegaderm that also covered the port access site. Try taking THAT off immediately post-op! I would usually end up cutting the tegaderm around that incision and leaving that part on. I worked with the OR staff manager/educator/gen surg team leader to get a safety Huber into the OR stock and made a specific request each time a patient went down from our inpt oncology unit. We finally had processes in place, but it happened about half the time that the patient returned accessed. In one case, the surgeon had inserted the needle THROUGH the tegaderm! From an infection control perspective, I would think that inserting a needle under sterile conditions in the OR would be preferable to on the nursing unit. But no evidence that I know of to compare . . . NOR evidence on using initially and how that might affect infection rates.

Mon, 07/20/2009 - 09:10

(Reply to #5) #6

momdogz

Donna: what are your

Donna: what are your post-procedure site care patient instructions? Assuming that it is accessed in the OR - leave everything alone for 7 days? I'm looking at our policy and can see it needs clarifying.

If not accessed and patient sent home - when do you/MDs instruct that dressing be removed? If it's transparent semipermeable membrane (TSM) with steri strips, you can see the site and it doesn't need to be accessed immediately - seems like a good idea to leave dressing in place at least 5 days to allow for wound healing.

Our current policy recommends that the first postop dressing change be done after 24-48 hours, but doesn't clarify whether that first dressing should be gauze or TSM, and then goes on to say that TSMs can stay in place for 7 days if intact etc....and gauze changes done every 24-48.

If gauze, it would be a different story.

Usually we follow the MD's orders for post care, and agree that it's better to access while in OR.

I'd be interested to hear comments from any/all.

Mari Cordes, BS RN

Nurse Educator IV Therapy

Fletcher Allen Health Care, Burlington VT

Educator, Bard Access Systems

Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center

Mon, 07/20/2009 - 16:39

carrie12

Carrie Sanger RN, BSN, OCN,

Carrie Sanger RN, BSN, OCN, CNE

Thanks for all the feedback so far.

I think it would be best if pt's PAC was accessed in the OR if they were to return to the inpt unit, of course bearing in mind a larger length needle would be necessary to allot for swelling. Our hopes is that the pt can be comfortable during access- so why not do it when they still are under anethesia or local. Post procedure site care would be 24 hour drsg change, observe site for s/s of infection.

Carrie Sanger RN, BSN, OCN, CNE

Mon, 07/20/2009 - 16:39

carrie12

Carrie Sanger RN, BSN, OCN,

Carrie Sanger RN, BSN, OCN, CNE

Thanks for all the feedback so far.

Carrie Sanger RN, BSN, OCN, CNE

Thu, 07/23/2009 - 08:47

Donna Fritz

Mari, Seems like you're

Mari,

Seems like you're asking about outpatients, which I was not involved in. I would agree that leaving the tegaderm dressing on for several days would be preferable; however, one cannot predict if there will be bleeding/oozing. In that case dressing should be changed or reinforced to put some pressure on the site. Would not be a bad idea to phone pt in about 24-48 hrs to ask about visible bleeding under dressing and to have pt come to inf ctr if needs changing. The other wild care is that sometimes, the surgeons would put gauze UNDER the tegaderm.

Our post-care instructions were for patients to leave it alone until they came to the onc office/inf ctr to have the dressing changed. Unfortunately, some pts fall through the cracks and their appt is 2-3 wks (for chemo) from placement. Communication seems inconsistent between surgeons/peri-op dept and the med/onc offices about when ports are placed and the necessity to have pts see SOMEONE within a week. (Would be nice to at least get a phone call from the surgeon's office or peri-op.) Peri-op would tell pts to call the hem/onc office . . . but it was very loose instruction and some patients wouldn't. I think the med oncs assume surgeons will follow-up with immed post-op issues (like evaluating the site, dressing changes) and surgeons think they're done when the dressing is placed.

I was looking on the web for some port illustrations and found a pic someone had posted on their own blog that had a huge hematoma and bleeding oozing through the port pocket incision--still covered with many steri-strips. Maybe I'll try to find it and have Sarah post in the gallery. The largest hematoma I've seen . . .

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