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## Complete Summary

#### GUIDELINE TITLE

Access device guidelines: recommendations for nursing practice and
education.

#### BIBLIOGRAPHIC SOURCE(S)

Oncology Nursing Society (ONS). Access device guidelines:
recommendations for nursing practice and education. 2nd ed. Pittsburgh
(PA): Oncology Nursing Society (ONS); 2004. 141 p. \[433 references\]

#### GUIDELINE STATUS

This is the current release of this guideline.

This guideline updates a previous version: Oncology Nursing Society
(ONS). Access device guidelines: recommendations for nursing practice
and education. Pittsburgh (PA): Oncology Nursing Society; 1996. 83 p.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory and/or
warning information has been released.

-   [February 28, 2008, Heparin Sodium
    Injection](http://www.fda.gov/medwatch/safety/2008/safety08.htm#HeparinInj2):
    The U.S. Food and Drug Administration (FDA) informed the public that
    Baxter Healthcare Corporation has voluntarily recalled all of their
    multi-dose and single-use vials of heparin sodium for injection and
    their heparin lock flush solutions. Alternate heparin manufacturers
    are expected to be able to increase heparin production sufficiently
    to supply the U.S. market. There have been reports of serious
    adverse events including allergic or hypersensitivity-type
    reactions, with symptoms of oral swelling, nausea, vomiting,
    sweating, shortness of breath, and cases of severe hypotension.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   General:

> Cancer and other diseases or conditions associated with the use of
> devices to access the venous, arterial, peritoneal, or
> intraventricular/epidural body system

-   Specific:

> Thromboembolic disease, diabetes mellitus, chronic osteomyelitis,
> severe spasticity, renal disease, and Parkinson\'s disease

#### GUIDELINE CATEGORY

Management\
Treatment

#### CLINICAL SPECIALTY

Nursing\
Oncology\
Pediatrics

#### INTENDED USERS

Advanced Practice Nurses\
Nurses

#### GUIDELINE OBJECTIVE(S)

-   To describe the different types of access devices available, their
    advantages and disadvantages, patient selection criteria, the use of
    access devices, and techniques of insertion

-   To describe the special features, maintenance, and care of each type
    of access device

-   To describe potential complications associated with each type of
    access device

-   To list nursing interventions for monitoring and treating access
    device complications

-   To identify the learning needs of and resources for patients and
    care providers related to each type of access device

-   To describe controversial issues associated with access devices

-   To describe documentation procedures recommended for access devices

-   To describe educational needs and clinical competency for RNs
    providing care to patients with an access device

-   To describe anatomic and physiologic parameters influencing
    placement and management of access devices

-   To describe the significance of vein selection and catheter
    size/catheter material used in relation to complications

#### TARGET POPULATION

Adult and pediatric patients with cancer

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  The use of access devices, including vascular access devices,
    arterial access devices, intraventricular access devices, epidural
    and intrathecal access devices, intraperitoneal catheters, and
    implantable pumps

2.  Patient selection criteria and techniques of insertion

3.  Removal techniques

4.  Maintenance and care of each type of access device

5.  Nursing interventions for monitoring for and treating access device
    complications

6.  Identifying the learning needs of and resources for the patient and
    care provider related to each type of access device

#### MAJOR OUTCOMES CONSIDERED

-   Quality of life

-   Complication rates and types associated with the use of access
    devices

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The guideline developer performed literature searches using Medline,
CINAHL (Cumulative Index to Nursing and Allied Health), and Index
Medicus.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

Cost overviews are provided for each of the access devices.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The current document was written and edited by experts in the field. The
content/field review was done by seven additional reviewers.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

For an overview of vascular access devices (VADs) including materials,
costs, usages, maintenance and care, removal, and complications, see the
original guideline document.

**Vascular Access Devices**

**Peripheral Intravenous (IV) Catheters**

1.  Description and types of catheters (See the original guideline
    document for full details.)

2.  Advantages and disadvantages of using a peripheral IV (See Table 6
    in the original guideline document for full details.)

3.  Patient selection criteria

    a.  Patient\'s age, in general, does not restrict use of peripheral
        IV.

    b.  Indications for peripheral IV include the following.

        1.  With adequate vascular integrity, peripheral IVs are
            recommended for short-duration, nonirritating infusions of
            less than seven days, which may include antimicrobials,
            analgesics, blood components, fluid and electrolyte
            replacement, and nonvesicant chemotherapy (Barton et al.,
            1998).

        2.  Peripheral IVs are best used for simple, one-time-use IV
            therapies, such as administering an IV push of a vesicant or
            nonvesicant chemo-therapy, because the IV is inserted only
            at the time of therapy and usually is discontinued
            immediately after the procedure is complete.

        3.  Patients with a short life expectancy are candidates for
            peripheral IVs.

        4.  Peripheral IVs are not indicated for continuous vesicant
            therapy or highly concentrated solutions.

        5.  Using peripheral IVs for blood specimens has mixed
            recommendations.

            a.  They are not to be used for routine blood drawing
                (Intravenous Nurses Society \[INS\], 2000).

            b.  Within certain limitations of infusate, peripheral IVs
                can be used for blood sampling for many routine tests,
                including coagulation studies, with reliable results
                (Arrants et al., 1999; Himberger & Himberger, 2001;
                Mohler et al., 1998; Powers, 1999).

            c.  There are no definitive guidelines on blood sampling
                from peripheral IVs; research still needs to be done in
                this area. Additionally, weighing the benefits and risks
                of safety, costs, and comfort to the patient may aid in
                decision making.

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    c.  Vein selection

        1.  The vein selected should be based on the type of fluid to be
            infused and the rate and duration of infusion. Ideally, it
            should not interfere with the patient\'s comfort or
            mobility.

        2.  Preferred sites

            a.  Upper extremity veins in adults; these may include the
                superficial dorsal and metacarpal veins on the dorsum of
                the hand as well as the cephalic and basilic veins, and
                cephalic, basilic, and median veins on the upper arm
                (see Figure 1 in the original guideline document).

            b.  Hand veins have a lower risk of phlebitis than veins on
                the wrist or upper arm (O\'Grady et al., 2002; Perry &
                Potter, \"Intravenous and vascular access\", 2002;
                Weinstein, \"Anatomy and physiology,\" 2001).

            c.  Select the most distant site possible, but proximal to
                previous venipuncture.

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        3.  Sites to avoid

            a.  Avoid extremities/sites that have impaired circulation
                or injury, such as lymphedema, postoperative swelling,
                recent trauma, hematoma, axillary lymph node dissection,
                local infection, phlebitis, or open wounds; also avoid
                extremities where venipuncture has been performed within
                the last 24 hours, if possible (Fischer, Knobf, &
                Durivage, 1997).

            b.  Lower extremities are associated with higher risk of
                infection than are upper extremities (O\'Grady et al.,
                2002; Weinstein, \"Anatomy and physiology,\" 2001) and
                more likely to develop thrombophlebitis. Physician order
                is recommended when using a lower extremity, but more
                importantly, nurses should consult with physician
                regarding central line placement or other alternatives
                prior to using the lower extremity (Weinstein, \"Anatomy
                and physiology,\" 2001). Replace lower-extremity IV
                catheter as soon as it is feasible (O\'Grady et al.,
                2002).

            c.  Skin changes and changes in the integrity of the vein
                lumen associated with radiation, prior chemotherapy, or
                prior IV therapy can make catheter insertion or site
                care difficult.

            d.  Antecubital veins are not recommended because of the
                difficulty of detecting infiltration and because they
                are located on an area of flexion (Ellenberger, 1999).

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    d.  Catheter or device selection

        1.  Use the smallest-gauge device that will successfully deliver
            the prescribed therapy at the desired rate.

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        1.  Select catheter based on intended purpose, expected length
            of therapy, viscosity of fluid, fluid components, and
            condition of vein.

        2.  Avoid use of steel needles for administration of fluids and
            medications that may cause tissue necrosis if extravasation
            occurs (O\'Grady et al., 2002); limit steel needles to
            short-term or single dose administration (INS, 2000) or
            one-time infusion and IV push only (Perry & Potter,
            \"Intravenous and vascular access,\" 2002, \"Parenteral
            medications,\" 2002).

        3.  Considerations for gauge selection include the following.

            a.  16-18 gauge for major surgery

            b.  18-20 gauge for rapid infusion of IV fluids, blood
                components, or viscous medications (Perry & Potter,
                \"Intravenous and vascular access, 2002, \"Parenteral
                medications,\" 2002)

            c.  20 gauge for most IV applications and for blood products

            d.  22-24 gauge with ¾-inch catheter for elderly patients:
                Short length and small gauge is less traumatizing,
                reduces irritation, and permits better blood flow
                (Weinstein, \"Intravenous therapy,\" 2001; Whitson,
                1996); 24 gauge can infuse up to 250 ml of fluid per
                hour (Masoorli, 1997).

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        5.  Obese patients with veins deep in the subcutaneous (SC)
            tissue may need slightly longer peripheral IV catheters, or
            consider a peripherally inserted central catheter (PICC) as
            the catheter of choice (Gallagher, 1999).

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4.  Overview of insertion techniques (Perry & Potter, \"Intravenous and
    vascular access,\" 2002)

    a.  Conduct preplacement assessment to determine if peripheral IV
        access is appropriate.

    b.  Perform patient assessment and preparation before the procedure;
        consider any special needs regarding age, physical condition, or
        type of fluid being infused. Explain the insertion procedure to
        the patient, and answer any questions the patient and/or
        significant others may have.

        1.  Older patients have fragile veins and less SC support tissue
            because of thinning of the skin (Weinstein, \"Intravenous
            therapy,\" 2001).

        2.  Use minimal tourniquet pressure over clothing or no
            tourniquet with older adults. Venous distention may take
            longer because of slower venous return.

        3.  Approach the skin with the catheter almost parallel for
            insertion (Weinstein, \"Anatomy and physiology,\" 2001,
            \"Principles and use,\" 2001; Whitson, 1996).

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    c.  Interventions to reduce the pain of IV insertion should be
        considered, especially if they increase the chance of success
        (Moureau & Zonderman, 2000). Interventions include topical
        anesthetics, injections, and nonpharmacologic techniques.

        1.  Physician order or an order from an individual with
            prescriptive authority is needed for any pharmacologic
            interventions.

        2.  Topical anesthetics include creams, patches, gels, and
            sprays (Moureau & Zonderman, 2000).

            a.  A meta-analysis of 20 studies found that EMLA®
                (lidocaine 2.5% and prilocaine 2.5%) cream (Astra
                Pharmaceuticals, LP, Wayne, PA) and ELA-Max® (Ferndale
                Labs, Ferndale, MI) significantly decreases pain from
                venipuncture and IV insertion in 85% of both pediatric
                and adult patients (Fetzer, 2002). Other topical creams
                are being tested (Browne et al., 1999).

            b.  Numby Stuff® (IOMED Clinical Systems, Salt Lake City,
                UT) is a topical, noninvasive delivery system with
                results found to be superior to other agents (Miller et
                al., 2001; Moureau & Zonderman, 2000; Squire, Kirchhoff,
                & Hissong, 2000).

                i.  Apply topical anesthetic according to directions
                    (e.g., EMLA cream: apply 2.5 g to 4 x 4 cm area for
                    puncture, cover with semipermeable transparent
                    dressing for one hour, wipe off, and cleanse site as
                    usual) (Weinstein, \"Intravenous therapy,\" 2001).

                ii. Cream may cause hypersensitivity, inadvertent
                    systemic absorption after prolonged application, and
                    erythema at site. Anesthetic also may obscure the
                    vein, and vasoconstriction and vasospasm have been
                    associated with topical application (Bahruth, 1996).

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            c.  Ethyl chloride spray is a topical anesthetic skin
                refrigerant causing numbness and lasting only seconds
                (Moureau & Zonderman, 2000). It may cause frostbite or
                skin ulceration as well as being very flammable
                (Weinstein, \"Intravenous therapy,\" 2001).

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        3.  Intradermal lidocaine injection has been found to be
            effective (Brown & Larson, 1999), although it may cause
            erythema at site, inadvertent intravascular injection, pain
            with injection, or hypersensitivity (Weinstein,
            \"Intravenous therapy,\" 2001). One study found that it did
            not diminish the success rate of cannulation (Holdgate &
            Wong, 1999).

        4.  One study found that the use of ice did not decrease pain on
            insertion (Richman et al., 1999); intradermal saline has
            mixed results, with no decrease in pain in one study
            (Jacobson, 1999) or results similar to intradermal lidocaine
            (McNelis, 1998).

        5.  Using music as a distraction was found to reduce the pain
            associated with insertion (Jacobson, 1999). Other
            complementary therapy methods, such as acupuncture and
            hypnosis, also have been suggested (Moreau & Zonderman,
            2000).

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    d.  Wash hands: Good hand hygiene and standard precautions are used
        for insertion and IV maintenance; a new pair of disposable
        nonsterile gloves may be used in conjunction with a \"no-touch\"
        technique for peripheral IV insertion. With \"no-touch\"
        technique, the planned IV insertion site is not palpated after
        skin cleansing, unless sterile gloves are worn. Wash hands
        before and after IV catheter insertion and dressing change
        (O\'Grady et al., 2002).

    e.  Organize equipment (see Appendix 2, page 120, in the original
        guideline document for clinical practicum).

        1.  Prepare IV fluid, attach administration set, and purge if
            peripheral IV is to be connected to continuous fluids.

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        1.  If using peripheral IV for bolus medication administration,
            prepare IV medication and check for accuracy.

        2.  If using peripheral IV as a saline lock, obtain protective
            cap and normal saline flush.

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    f.  Examine veins on both extremities by visual inspection and
        palpation, keeping in mind the purpose of the IV therapy and any
        physical limitations of the patient, such as stroke-limiting use
        of arm or side of an axillary node dissection. Assess distal
        veins, then move proximally.

    g.  Place tourniquet 5-6 inches above insertion site. Tourniquet
        should obstruct the venous flow, not the arterial flow. Check
        presence of distal pulse, and if not felt, loosen tourniquet.

        1.  Select site (Masoorli, 1997).

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        1.  Remove tourniquet for patient\'s comfort.

        2.  If large amounts of body hair are present at the insertion
            site, clip the area. Avoid shaving, which can increase
            irritation and risk of infection.

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    h.  Select appropriate IV needle or catheter.

    i.  Cleanse site and allow it to dry before inserting catheter.
        Agents for skin antisepsis include, in preferred order, 2%
        chlorhexidine gluconate (CHG) or 0.5% CHG in 70% isopropyl
        alcohol, 10% povidone-iodine, or 70% alcohol (O\'Grady et al.,
        2002). Do not apply alcohol after povidone-iodine because
        alcohol negates the effect of povidone-iodine (INS, 2000). Do
        not use acetone or ether to cleanse skin because these agents
        are not effective skin cleansers and have a drying effect
        (LeBlanc & Cobbett, 2000).

    j.  Reapply tourniquet and put on disposable gloves.

    k.  Perform venipuncture. Insert needle at 15-degree to 30-degree
        angle with bevel up distal to actual site of venipuncture.

    l.  Look for blood return through tubing of butterfly needle or
        catheter, which indicates that needle has entered the vein.
        Butterfly needle may be taped in place at this time or threaded
        into the vein. An IV catheter should be threaded in its entirety
        into the vein and the stylet removed.

    m.  Release tourniquet and attach catheter to infusion set or
        syringe.

    n.  Flush the catheter free of blood while holding the IV catheter
        or needle in place. Watch insertion site during initial flush to
        assess the integrity of the vein. Edema and/or pain/discomfort
        at the site indicates an infiltration or ruptured vein. If this
        occurs, the IV will need to be removed and restarted elsewhere.

        1.  If the IV must be restarted, use the other extremity or
            select a site proximal to the previous venipuncture.

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        1.  When administering a vesicant chemotherapy agent, select a
            site on the opposite extremity, if at all possible.

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    o.  Secure IV catheter or needle with tape or an immobilization
        device and apply occlusive dressing over insertion site. Do not
        put tape directly over the insertion site.

        1.  Use of transparent, semipermeable dressings is recommended
            and results in significantly fewer dislodged catheters, with
            a trend toward reduced phlebitis and infiltration than with
            gauze dressings (Palmer, 1998; Tripepi-Bova, Woods, & Loach,
            1997).

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        1.  StatLock® (Venetec International, Mission Viejo, CA), a
            securement device, significantly reduced dislodgment
            episodes and increased dwell times up to 3.95 days (Sheppard
            et al., 1999; Wood, 1997). Other securement devices are
            available (Weinstein, \"Intravenous therapy,\" 2001).

        2.  For extremely short dwell times, less than 30 minutes during
            a procedure, micropore tape could be used, but it should be
            clean and not in contact with the insertion site (Campbell &
            Carrington, 1999).

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    p.  No more than two attempts at cannulation per nurse per patient
        should be done to avoid unnecessary trauma to the patient
        (Fischer, Knob, & Durivage, 1997; INS, 2000).

    q.  Document number of attempts, locations, dressing type,
        securement, and patient\'s response after procedure is
        completed.

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5.  Removal technique

    a.  Verify order for removal and indication.

    b.  Note length of catheter on insertion.

    c.  Explain procedure to patient.

    d.  Place patient in chair or bed to stabilize extremity.

    e.  Inspect general condition of catheter pathway.

    f.  Discontinue all infusions into device.

    g.  Put on gloves; remove dressing; and observe site for any pain,
        edema, redness, or discharge.

    h.  Change gloves; pull catheter out in the same angle of insertion
        while stabilizing the skin and vein with a sterile gauze.

    i.  If removal of catheter is indicated for infection, send catheter
        tip for culture (INS, 2000).

    j.  Apply constant, firm pressure to exit site until bleeding stops
        (longer in patients with coagulopathies or on anticoagulants).
        Apply dressing or adhesive bandage, and monitor as necessary.

    k.  Instruct patient/caregiver to report any discomfort or signs of
        bleeding, bruising, redness, swelling, or drainage.

    l.  Inspect device for appropriate length and for defects. Report
        any defects to the manufacturer and regulatory agencies. Examine
        distal tip for signs of jagged, uneven edges, suggestive of
        breakage.

    m.  Document observations and actions.

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6.  Maintenance and care (\"ASHP therapeutic position statement,\" 1994;
    O\'Grady et al., 2002; Goode et al., 1991, 1993; INS, 2000; Peterson
    & Kirchhoff, 1991; Randolph et al., 1998) (see Section II-A, page 3,
    for an overview and Table 2 in the original guideline document for
    Common Maintenance Procedures.)

    a.  Inspect catheter insertion site and palpate for tenderness daily
        through the intact dressing (O\'Grady et al., 2002; INS, 2000).

    b.  All catheters inserted under emergency conditions are replaced
        within 48 hours when adherence to aseptic technique cannot be
        ensured (O\'Grady et al., 2002).

    c.  Routine replacement of catheters: The old catheter is removed
        and a new catheter is placed in another site.

        1.  Replacement of peripheral IV catheters every 72-96 hours is
            strongly recommended to prevent phlebitis and
            catheter-related infections, as well as patient discomfort.
            This recommendation is based on experimental, clinical, or
            epidemiologic studies with a strong theoretical rationale
            (O\'Grady et al., 2002).

        2.  Although it has been reported that the incidence of
            thrombophlebitis and bacterial colonization of catheters
            increases when catheters are left in place more than 72
            hours (O\'Grady et al., 2002), several studies have shown no
            difference in complication rates with extended dwell times.

            a.  In a study of the use of 665 catheters in 451 patients,
                the rate of phlebitis was 19.7% without a demonstrated
                increased risk for catheters remaining in place after
                three days (Bregenzer et al., 1998).

            b.  In a study of 722 patients, restarting the IV after 72
                hours did not reduce the risk of complications when
                compared to continuing the original catheter (Homer &
                Holmes, 1998).

            c.  No difference in phlebitis rates was shown for dwell
                times of 72 hours versus 96 hours in a study involving
                2,503 catheters (3.3% and 2.6%, respectively) (Lai,
                1998).

            d.  When 34 catheters were left in place over 72 hours
                (73-120 hours), no phlebitis was detected (White, 2001).

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    d.  Routine replacement of administration sets (Weinstein,
        \"Principles and use,\" 2001)

        1.  Replace IV administration sets every 96 hours or with
            catheter change, except for fluids that enhance microbial
            growth (i.e., blood products, lipids, total parenteral
            nutrition (TPN), which should be changed daily); this
            practice is strongly recommended unless catheter-related
            infection is suspected (O\'Grady et al., 2002; Lai, 1998).

        2.  IV administration sets changed at three days versus four to
            seven days in 428 low-risk patients (i.e., those not
            receiving total parenteral nutrition, blood products, or
            interleukin-2) had no difference in colonization rates (0.4%
            versus 0.5%) or catheter- or infusion-related bloodstream
            infections (Raad et al., 2001).

        3.  The only study found to address neutropenic patients
            reported no difference between IV administration sets
            changed at 48 versus 24 hours in terms of incidence of
            colonization or infusion-related septicemia (deMoissac &
            Jensen, 1998).

        4.  Tubing used to administer blood, blood products, lipids, or
            total parenteral nutrition is replaced every 24 hours after
            initiation of therapy (O\'Grady et al., 2002).

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7.  Complications (See the \"Potential Harms\" field for a summary of
    complications or the original guideline document for full details.)

**SC Infusion Devices**

1.  Description of SC infusion therapy and types of devices (See the
    original guideline document for full details.)

2.  Advantages and disadvantages of SC infusions (see Table 6 in the
    original guideline document for full details)

3.  Patient selection

    a.  Patient age: Generally not restrictive

    b.  Indications for SC infusion

        1.  When an oral or transdermal route is inappropriate or
            ineffective (e.g., bowel obstruction, intractable nausea
            and/or vomiting, dysphagia, malabsorption, inadequate oral
            fluid intake secondary to confusion or infection in the
            elderly) (Brown & Worobec, 2000; Coyle & Adelhardt, 1996;
            Pasero, 2002)

        2.  If the patient has poor peripheral veins (e.g., obese,
            elderly, or very young patients, those whose veins have been
            overused)

        3.  When a single-lumen, long-term vascular access device is
            being used for other incompatible IV therapy

        4.  For patients with delirium, confusion, stupor, or other
            mental status changes for which oral administration is
            contraindicated because of aspiration risk (Agency for
            Health Care Policy and Research (AHCPR), 1994)

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    c.  Purpose of the SC infusion

        1.  Pain management

            a.  For acute pain management when vascular access is
                difficult (e.g., patients with sickle cell disease who
                are in pain crisis) (American Pain Society, 1999)

            b.  For chronic pain management when oral or transdermal
                route is not available, transdermal route is not
                tolerated, and there are no other indications for IV
                therapy

            c.  Short-term, self-limiting SC infusion system with a
                local anesthetic directly into the incision site for
                operative and postoperative pain (available but beyond
                the scope of these guidelines) (Pasero, 2000)

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        2.  Reduction or alleviation of intractable nausea and vomiting

        3.  Hypercalcemia treatment

        4.  Iron chelation: For iron removal from transfusional iron
            overload

        5.  Fluid replacement (hypodermoclysis): For short-term,
            reversible fluid deficits when fluid replacement is not an
            emergency and is less than 3,000 ml/24 hours (Brown &
            Worobec, 2000)

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4.  Contraindications (See the \"Contraindications\" field for a summary
    of contraindications or the original guideline document for full
    details.)

5.  Patient setting

    a.  Patients may receive SC infusions in any setting---acute care,
        home care, long-term care, intermediate care, or hospice
        (Herndon & Fike, 2001; Smeets, Beusmans, & Weber, 1999).

    b.  SC infusions are particularly well suited for non-acute care
        sites because of the ease of maintenance and restarts, low
        probability of systemic complications, reduced pain on
        insertion, and decreased number of injections required.

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6.  Insertion procedure (see Appendix 3, page 121 in the original
    guideline document, for clinical practicum)

    a.  Infusion sites include anterior chest wall, upper abdomen,
        anterior or lateral aspects of thighs, above the scapula on the
        back, and outer upper arm.

        1.  For ambulatory patients, the upper chest area (subclavicular
            area) is recommended because it allows full range of
            movement (Coyle & Adelhardt, 1996).

        2.  The upper abdomen is best for patients with little
            peripheral SC tissue (Perry & Potter, \"Intravenous and
            vascular access,\" 2002). One recommendation was made for
            sole use of the abdomen because a pneumothorax occurred from
            needle migration when the anterior chest wall was used in
            cachectic patients (Sheard, 1997).

        3.  Locate access site away from bony prominence and patient\'s
            waistline (INS, 2000).

        4.  Rotate sites when changing needle, although it may remain in
            the same region.

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    b.  Procedure

        1.  Explain purpose of infusion, rationale for type of infusion,
            and procedure to patient and family/significant others.

        2.  Select site.

        3.  Prep site with cleansing agent, using circular motion and
            working from center out. Excess solution may be removed with
            sterile gauze. Allow to dry.

        4.  Use smallest gauge needle/catheter available (e.g., 25 or 27
            gauge).

        5.  Attach tubing and infusion bag with fluids or medication;
            prime set. A secondary bag of normal saline is not needed
            because this infusion does not directly enter the vascular
            system.

        6.  Put on gloves. Stabilize tissue with free hand, holding hand
            flat in a natural position, or pinch skin slightly. Local
            anesthetic may be used (see page 26 in the original
            guideline document).

        7.  Insert needle with bevel down at about a 20-degree to
            30-degree angle almost up to hub.

            a.  Other authors have recommended a 30-degree to 45-degree
                insertion angle (Coyle & Adelhardt, 1996; Obenour, 1998;
                Pasero, 2002).

            b.  The angle of the needle is dependent on the amount of
                fatty tissue and SC tissue available and whether the
                tissue is held flat or pinched. When minimal SC tissue
                is available, the smaller angle is recommended to ensure
                correct placement.

            c.  When the needle is beveled, it is placed bevel down so
                the fluid is infused into the SC tissue and to promote
                absorption.

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        8.  Secure wings or hub with tape.

        9.  Check for blood return (i.e., lower unclamped solution bag
            or pull back on syringe). There should be *no* blood return,
            although an air bubble may be seen.

            a.  If blood is seen in tubing, clamp tubing and remove
                needle.

            b.  Repeat procedure using new needle and an adjacent site.

            c.  If no blood is seen, clamp tubing.

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        10. Attach tubing to pump, set correct rate, unclamp tubing, and
            turn pump on.

        11. Cover with semipermeable, transparent dressing. Secure
            tubing to either dressing or skin.

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7.  Maintenance

    1.  Observe site every eight hours for local irritation or leakage,
        and assess patient\'s comfort with infusion placement and
        infusion rate (Obenour, 1998).

    2.  Recommendations for catheter or needle replacement vary.
        Catheters and needles may be replaced every three days (INS,
        2000); every five days (Smeets, Beusmans, & Weber, 1999); weekly
        (Coyle & Adelhardt, 1996; Obenour, 1998); if bruising, erythema,
        or other signs of local irritation or infection appear; or if
        the site is painful to the patient.

    3.  Transparent dressings may be left in place for up to a week and
        changed with insertion of a new catheter or needle (O\'Grady et
        al., 2002).

    4.  Clients, families and significant others, and assistive
        personnel should be instructed to report any leakage, erythema,
        edema, or pain at injection site as soon as possible.

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8.  Removal

    a.  Verify order or indication for removal.

    b.  Explain procedure to patient.

    c.  Place patient in chair or bed for stabilization.

    d.  Discontinue all infusions.

    e.  Put on gloves, remove dressing, and observe site for edema,
        erythema, or discharge. Remove gloves and replace.

    f.  Pull catheter/needle out in the same angle as insertion while
        stabilizing the skin with a sterile gauze.

    g.  Apply constant firm pressure to exit site if there is bleeding.
        Apply small bandage.

    h.  Instruct patient/caregiver to report any discomfort or signs of
        bleeding, bruising, erythema, edema, or drainage.

    i.  Document observations and actions.

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9.  Administration of medications and fluids

    a.  Medications and fluids should be isotonic, nonirritating,
        nonviscous, and water soluble (Perry & Potter, \"Parenteral
        medications,\" 2002).

    b.  Medications

        1.  Any analgesic available for parenteral use is acceptable for
            SC infusion except meperidine hydrochloride, which causes
            tissue necrosis (DHHS, 1994).

            a.  Morphine or hydromorphone are the preferred analgesics
                for home administration (DHHS, 1994).

            b.  Hydromorphone is recommended as the most cost-effective
                analgesic because it is very potent and high doses can
                be delivered in small amounts. Stability was found to be
                28 days (Fudin et al., 2000). Hydromorphone is at least
                as effective as morphine using the SC infusion route
                (Miller et al., 1999).

            c.  Morphine was found to be equianalgesic for IV and SC
                routes when administered as a continuous infusion
                (Nelson et al., 1997). In normal circumstances, morphine
                is measured in the plasma within 15 minutes of SC
                injection, and peak concentration occurs at 30 minutes.
                Pasero (2002) recommended an equivalency ratio of 3:1
                when converting from oral morphine to SC morphine.

            d.  Other commonly used opioids include oxymorphone,
                levorphanol (Coyle & Adelhardt, 1996), methadone, and
                fentanyl (Polomano, McGuire, & Sheidler, 2000; Watanabe
                et al., 1998).

            e.  Methadone does cause skin irritation with infusion
                (erythema and induration), but several authors have
                proposed successful interventions. These include the use
                of dexamethasone in the infusion (Mathew & Storey,
                1999), the use of hyaluronidase in the infusion, and
                site rotation every 24 hours (Makin, 2000). Currently,
                hyaluronidase is not available from the manufacturer.

            f.  The IV opioid dose is considered clinically equivalent
                for SC use (Coyle & Adelhardt, 1996; DHHS, 1994).

            g.  The PCA mode allows for rapid individual dose titration
                and provides sense of control for the patient. This can
                be done both in the hospital and in the home (DHHS,
                1994).

            h.  Ketamine also has been used for cancer pain (Bell, 1999;
                Fine, 1999; Lloyd-Williams, 2000).

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        2.  Other symptom management

            a.  Octreotide, scopolamine, and phenobarbital have been
                used for symptom management (Ripamonti et al., 2000;
                Stirling, Kurowska, & Tookman, 1999).

            b.  Metoclopramide has been used for intractable nausea and
                vomiting in SC infusions (Bruera et al., 1996).

            c.  Hypercalcemia may be treated with SC infusion of
                clodronate (Body, 2000).

            d.  Drugs used for iron overload include deferoxamine and
                deferiprone (Kontoghiorghes et al., 2000).

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    c.  Fluids

        1.  Solutions include 0.9% sodium chloride or a mixture of 0.9%
            sodium chloride and 5% dextrose; dextrose alone cannot be
            used because although it is isotonic, in the body it becomes
            hypotonic because of rapid metabolism (Brown & Worobec,
            2000). Potassium has been added without local irritation
            (Steiner & Bruera, 1998).

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        1.  The use of the enzyme hyaluronidase has been debated because
            of its effectiveness and potential systemic reaction. It
            facilitates fluid absorption from the tissue, especially
            when the fluid is infused rapidly or in large quantities.
            When used, the dose ranges from 150 units to 600 units per
            1,000 ml of infusate; it only is used when absorption is
            poor (Brown & Worobec, 2000; Centeno & Bruera, 1999; Ferry,
            Dardaine, & Constans, 1999). It may cause a systemic
            reaction, so a test dose may be considered. Currently,
            hyaluronidase is not available from the manufacturer.

        2.  Fluid replacement using SC infusion has been shown to be as
            effective as IV therapy with decreased cost and a trend
            toward fewer fluid therapy-related complications (Dasgupta,
            Binns, & Rochon, 2000).

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    d.  Rate of infusions

        1.  Recommended maximum infusion rate for medications is 3
            ml/hour (INS, 2000). Researchers in one study used 5--7
            ml/hour with minimum skin irritation (Nelson et al., 1997).
            Faster infusion rates result in tissue irritation and
            sloughing unless other measures are taken, such as using
            hyaluronidase in the infusate.

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        1.  Concentrate the drug dose to ensure maximum flow rate of 3-5
            ml/hour or less, taking bolus dosing into consideration
            (Wall & Melzack, 1999).

        2.  Rates for fluid replacement depend on how quickly the
            replacement must be achieved but range from 20-80 ml/hour
            and can safely be as high as 300 ml/hour (Brown & Worobec,
            2000; Centeno & Bruera, 1999; Dasgupta et al., 2000). Fluid
            replacement for some patients has been done at night only
            (Dasgupta et al., 2000).

        3.  An electronic infusion device should be used to deliver the
            infusion (INS, 2000). Several portable electric and
            nonelectric infusion devices were compared and showed
            similar reliability of infusion rates (Capes, Martin, &
            Underwood, 1997). Examples include electronic syringe
            driver, and elastomeric, balloon, or peristaltic pumps.

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2.  Complications (See the \"Potential Harms\" field in this summary for
    a summary of potential harms or the original guideline document for
    full details.)

**Midline Catheters**

1.  Description and types (See the original guideline document for full
    details.)

2.  Advantages and disadvantages (see Table 6 in the original guideline
    document for full details)

3.  Patient selection criteria

    a.  Patients with limited peripheral veins for venous access

    b.  Patients with need for venous access for a limited length of
        time (several weeks)

    c.  Patient or caregiver is willing and able to understand and
        follow instructions on how to properly care for the device in
        the home setting.

    d.  Intravenous therapy planned appropriate for midline catheter.
        Contraindicated intravenous fluids include

        1.  Continuous infusion of vesicants

        2.  Solutions with glucose concentration \>10%

        3.  Solutions with protein concentration \>5%

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    e.  Patient preference for this type of device over more permanent
        devices

    f.  Life expectancy of patient

    g.  For patients scheduled to receive IV therapy for more than a
        week, a plan should be followed to maximize comfort and preserve
        the integrity of the veins.

    h.  Inappropriate patients include patients with lymphedema of the
        arm or those who will need to do heavy lifting with the arm used
        (Greene, 2000).

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4.  Insertion technique

    a.  Insert in an antecubital vein terminating in the upper arm or
        axilla (see Figures 1 and 2 in the original guideline document).
        Appropriate veins include

        3.  Basilic

        4.  Cephalic

        5.  Median cubital

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    b.  Determine if the patient is a suitable candidate for a midline
        catheter based on patient selection criteria and patient
        willingness to care for and protect a catheter.

    c.  Explain the procedure to the patient and answer any questions
        the patient and/or significant others may have.

    d.  Organize equipment and wash hands.

    e.  Examine veins on both extremities, taking into account the
        purpose of the IV therapy, the most comfortable exit site for
        the patient, and any physical limitations the patient may have,
        such as stroke or lymphedema, that could limit the use of one
        arm.

    f.  Use a measuring tape to determine the proper length from the
        insertion site to the axilla.

    g.  Use local anesthetic (topical, injectable) per institutional
        policy and patient preference. Be aware that anesthetic may
        obscure the vein secondary to vasoconstriction and vasospasm. An
        order from a healthcare provider with prescriptive authority is
        needed (see page 26 in the original guideline document).

    h.  Place the line, per manufacturer\'s guidelines, for the type of
        catheter being used; the nurse inserting should be trained for
        the individual product. Prior to insertion, the line should be
        cut based on the measurement from the insertion site to the
        axilla. Insertion techniques include the following.

        1.  Through the peel-away sheath

        2.  Over-the-wire method

        3.  Modified Seldinger technique

        4.  Through the peel-away needle

        5.  Catheter pre-inserted through a peelaway needle

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    i.  Place tourniquet five to six inches above insertion site.
        Tourniquet should obstruct venous, not arterial flow. Check
        presence of distal pulse.

    j.  Clip the area if a large amount of body hair is present at
        insertion site. Avoid shaving, which can cause increased
        irritation and risk of infection. Remove tourniquet for
        patient\'s comfort.

    k.  Cleanse site and allow to dry. Reapply tourniquet. Apply gloves.

    l.  Perform venipuncture by inserting needle at a 15-degree to
        30-degree angle with bevel up distal to actual venipuncture
        site.

    m.  Look for blood return through tubing of catheter, which
        indicates that the needle has entered the vein. Advance to
        length of needle and remove tourniquet.

    n.  Once venipuncture is complete, retract the needle into the
        needle safety tube on the external end of the catheter. The tip
        of the catheter is advanced for several inches to the proximal
        end of the upper extremity, with the tip located just short of
        the axilla (Larouere, 2000).

    o.  Secure IV catheter with tape and apply dressing over insertion
        site.

    p.  The dressing should be changed 24 hours after insertion to
        assess for complications, then as per protocol for transparent
        film or gauze dressing.

    q.  As a midline catheter is not considered a central catheter,
        x-ray verification of tip placement is not indicated.

    r.  Document insertion, including type of line used and length of
        catheter.

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5.  Removal technique

    a.  Verify order for removal and indication.

    b.  Explain the procedure to the patient and answer questions.

    c.  Place the patient in a reclining position.

    d.  Inspect the general condition of the catheter.

    e.  Discontinue all infusions into the device.

    f.  Put on gloves, remove dressing, and observe site for redness,
        swelling, bruising, or drainage.

    g.  If drainage is present, send swabs for culture.

    h.  Change gloves.

    i.  Grasping device by hub, pull slowly and steadily until
        completely removed.

    j.  If infection is suspected, send catheter tip for culture.

    k.  Apply constant firm pressure to the exit site until the bleeding
        has stopped (longer in patients with coagulopathies or decreased
        platelet count). Apply sterile occlusive dressing and monitor
        for bleeding or drainage.

    l.  Measure catheter for appropriate length and catheter integrity.
        Examine distal tip for jagged edges that would suggest breakage.
        If found, report to physician.

    m.  Document length of catheter on removal, action, and patient
        response.

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6.  Maintenance and care (see Section II, B-6, page 28 in the original
    guideline document for full details)

7.  Complications (See the \"Potential Harms\" field for a summary of
    complications or the original guideline document for full details.)

**Peripherally Inserted Central Catheters (PICC)**

1.  Description and types (See the original guideline document for full
    details.)

2.  Catheter tip location

    a.  Appropriate tip location of a PICC is the distal third of the
        superior vena cava (Hadaway, 1999).

    b.  A catheter that is trimmed so the tip falls in the axillary or
        subclavicular junction is termed midclavicular (midline
        catheter) and should be used only for drugs safely administered
        via peripheral veins (Macklin, 1997).

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3.  Patient selection criteria (Hadaway, 1990; Merrell et al., 1994)

    a.  Patients without accessible peripheral vessels or with a minimal
        number of adequate vessels available for use in the
        administration of therapy for moderate duration (less than six
        months)

    b.  Patients who are in need of the infusion of vesicant or
        irritating medications

    c.  Patients who are in need of hyperosmolar solution, such as total
        parenteral nutrition

    d.  Patient preference for this type of device or other vascular
        access devices, which may be equally appropriate for the
        situation

    e.  In the home setting, availability of family member/significant
        other who can properly care for the device

    f.  For patients scheduled to receive IV therapy for more than five
        days, a plan should be followed to maximize comfort and preserve
        the integrity of the veins.

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4.  Advantages and disadvantages (see Table 6 in the original guideline
    document for full details)

5.  Insertion techniques (Goodwin & Carlson, 1993; James, Bledsoe, &
    Hadaway, 1993; La Fortune, 1993)

    a.  Insert PICCs via the vein (Ryder, 1993) (see Figure 3 in the
        original guideline document).

        1.  Cephalic

        2.  Accessory cephalic

        3.  Basilic

        4.  Median cubital

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    b.  Perform a preplacement assessment of the patient to determine if
        a PICC is appropriate.

    c.  Choose appropriate PICC size (diameter) for solution to be
        administered. Use the smallest acceptable catheter diameter to
        decrease incidence of thrombophlebitis (Grove & Pevec, 2000).

    d.  Explain the insertion procedure to the patient and answer any
        questions the patient and/or significant other may have. Ensure
        that informed consent is obtained.

    e.  Gather all necessary supplies, including any IV administration
        set and medications/IV fluids to be used.

    f.  Wash hands with a cleansing agent.

    g.  Examine arms and select the best vein for cannulation.

        1.  Avoid veins that are sclerotic on inspection and palpation.

        2.  Select patient\'s nondominant arm, if possible.

        3.  Avoid extremities that may have compromised circulation,
            such as the presence of lymphedema or venous congestion
            secondary to superior vena cava syndrome.

        4.  If possible, the basilic vein would be the best choice, as
            it is the straightest and has the most direct route to the
            central venous system (Timmis, 1998).

        5.  The cephalic vein is the second choice because its abrupt
            angle that joins to the axillary vein makes the advancement
            of the line more difficult. Position the arm at a right
            angle to the body to assist with insertion (Timmis, 1998).

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    h.  Consider the use of a local anesthetic (topical cream or
        intradermal injection) to reduce the pain associated with
        insertion (Ahrens, Wiersema, & Weilitz, 1991; Harrison, Langham,
        & Bogod, 1992; Kano et al., 1992).

        1.  An order is needed from a healthcare provider with
            prescriptive authority.

        2.  Apply topical anesthetic according to directions (see page
            26 in the original guideline document) (Joyce, 1993;
            McPhail, 1992; Smith et al., 1990; Steward, 1993).

        3.  Cream may cause hypersensitivity, inadvertent systemic
            absorption after prolonged application, and erythema at the
            site.

        4.  Intradermal injection may cause erythema at site,
            inadvertent intravascular injection, pain with injection, or
            hypersensitivity.

        5.  Anesthetic may obscure the vein. Reports of vasoconstriction
            and vasospasm have been associated with topical application
            (Bahruth, 1996).

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    i.  Use a measuring tape to determine appropriate catheter length by
        measuring from the point of venipuncture, over the course of the
        selected venous pathway, across the shoulder to the right side
        of the sternal notch, and down to the third intercostal space.
        The tip of the catheter should rest in the superior vena cava
        (see Figure 3 in the original guideline document). Add 2.5 cm (1
        inch) onto this measurement to account for the length of the
        catheter outside of the insertion site.

    j.  Open the chosen PICC tray and, following sterile technique, add
        additional supplies. The general insertion procedure may vary
        according to the type of PICC being used. The RN needs to be
        familiar with the product selected and to follow manufacturer\'s
        directions.

    k.  Position the patient\'s arm at a 45-degree to 90-degree angle
        from the body, below heart level, to aid in vein engorgement.

    l.  Perform catheterization with full aseptic technique, including
        surgical hand scrub, mask, sterile gown, gloves, drapes, and
        appropriate cleansing agents (INS, 2000; Masoorli & Angeles,
        1990; Timmis, 1998).

    m.  Place sterile waterproof drape under patient\'s arm.

    n.  Cleanse the area, and allow the area to air dry before
        initiating cannulation.

    o.  Fill two syringes with normal saline. Use one syringe to prime
        extension tubing that may be needed during the procedure.

    p.  Place fenestrated sterile drape (a sterile drape with an opened
        center) over the arm, leaving the insertion site exposed.

    q.  Prepare the catheter.

        1.  Measure the length of catheter needed, using the sterile
            measuring tape.

        2.  Pull the guidewire back ½ inch from this distance.

        3.  Trim the catheter with sterile scissors according to the
            manufacturer\'s recommendation. Some PICC manufacturers do
            not recommend trimming the catheter. Others recommend
            trimming at a 45-degree or 90-degree angle. Groshong PICCs
            are trimmed proximal and not at the distal tip.

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    r.  Apply tourniquet approximately four inches above selected site.
        Check distal pulse to ensure that arterial circulation has not
        been compromised. Change sterile gloves.

    s.  While stabilizing the vein, perform venipuncture. Note blood
        return, which indicates introducer location inside vein.

    t.  Release tourniquet and continue to advance the catheter
        according to the PICC insertion technique used (Goodwin &
        Carlson, 1993; Hadaway, 1995; Loughran & Borzatta, 1995).

        1.  Breakaway needle technique: Venipuncture is made with a
            specially designed split introducer needle. After needle
            insertion, the catheter is threaded into place. The
            introducer needle is removed and slid down to the catheter
            hub. The needle is broken apart and peeled away from the
            catheter.

            a.  Advantages: Uses familiar and simple needle insertion,
                requires insertion of only one device, and is available
                in a variety of gauge sizes.

            b.  Disadvantages: The potential exists for catheter damage
                and embolus if catheter is inadvertently drawn back
                through the introducer needle; the steel introducer
                needle may cause vascular damage; and a slight increase
                in blood spillage occurs.

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        2.  Through the intact cannula technique: Venipuncture is made
            with a short-term peripheral introducer cannula with a
            stylet. The stylet is removed, and the catheter is threaded
            into the vein. The short catheter is removed by pulling it
            over the external end of the PICC.

            a.  Advantages: Risk of catheter damage is greatly reduced;
                it entails a familiar initial venipuncture technique;
                minimal blood loss occurs; and trimming of catheter is
                done on the external portion.

            b.  Disadvantages: It is a slightly more complicated
                procedure; careful monitoring of the length of the
                catheter is required because the catheter is trimmed
                after insertion; and a larger introducer unit is needed
                for venipuncture. Only used for catheters with
                unattached hubs (e.g., Groshong).

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        3.  Peel-away sheath technique: Venipuncture is made with a
            needle/sheath device. After the stylet is removed, the
            catheter is threaded into the vein, and the sheath/cannula
            is removed down to the hub of the catheter. Wings of the
            sheath/cannula are cracked, and the two sections are pulled
            apart and away.

            a.  Advantages: Risk of catheter damage is low; a variety of
                gauge sizes is available; and it can be performed
                virtually without blood spills.

            b.  Disadvantages: A larger introducer unit is required, as
                is the acquisition of a new skill (peeling away a
                sheath). It may cause more bleeding around exit site
                during first few hours after insertion.

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        4.  Over-wire Seldinger method: Venipuncture is made with a
            smaller gauge steel needle. Blood is obtained in the
            attached syringe. The syringe is removed, and a guidewire is
            threaded through the needle into the vein. The needle and
            cannula are removed, and a peel-away sheath is threaded down
            to the skin over the guidewire introducer. The guidewire is
            removed and the catheter is advanced, stabilized, and the
            sheath removed and torn away.

            a.  Advantages: Requires smaller venipuncture; a variety of
                gauge sizes is available; and the risk of catheter
                damage is eliminated.

            b.  Disadvantages: It is a more complex technique; the need
                for a minor surgical incision may limit its insertion in
                particular settings and by certain clinicians; and
                insertion costs more than other methods.

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    u.  Attach prefilled syringe and flush with normal saline. Ensure
        adequate blood return. A primed extension tubing may be attached
        at this time.

    v.  After securing the catheter with tape, SteriStrips, or StatLock,
        flush with heparin solution (Andersen & Holland, 1992).

    w.  Some PICCs may be best secured into place with sutures. Refer to
        the State Board of Nursing Practice Act regarding the insertion
        of sutures by an RN.

    x.  Apply dry, sterile gauze above insertion site and place an
        occlusive dressing over the insertion site and external part of
        the catheter up to the hub. Change dressing 24 hours after
        initial insertion (likely to have bloody drainage), and apply
        only a transparent dressing (Sansivero, 1997; Timmis, 1998).
        Several manufacturers have developed PICC line securing devices
        (Macklin, 1997).

    y.  Radiographic confirmation must be performed to ensure correct
        placement.

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6.  Removal technique (Macklin, 2000)

    a.  Verify order for removal of catheter.

    b.  Gather materials you will need: measuring tape, alcohol pad,
        gauze, and tape.

    c.  Wash hands and don nonsterile gloves.

    d.  Remove existing dressing. Remove contaminated gloves and replace
        gloves.

    e.  Grasp PICC at the insertion site and slowly pull outward, about
        one inch, pulling parallel to the skin.

    f.  Release it and grasp again at insertion site, continuing to pull
        the PICC out in short increments.

    g.  When PICC is completely removed, place gauze over the site and
        apply light pressure until bleeding stops, then apply tape.

    h.  Observe catheter tip for integrity, and measure length and
        compare it to the length documented at insertion.

    i.  Problems with removal (Macklin, 2000)

        1.  Venospasm

            a.  If you sense resistance during removal, stop. Reposition
                the arm and attempt to remove it again.

            b.  If resistance continues, apply warm compress to upper
                arm for 15-20 minutes and attempt gentle removal again.

            c.  If the catheter has been removed far enough so that you
                can apply a tourniquet above the area containing the
                catheter, apply the tourniquet to the arm, and attempt
                removal again.

            d.  If resistance is still present, apply dressing to
                insertion site and leave alone for 12-24 hours and
                attempt removal again.

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        2.  Thrombosis

            a.  Will cause the PICC to eventually lodge in the lumen of
                the vessel as you attempt removal

            b.  If during removal you are only able to pull the PICC out
                four inches or less, stop.

            c.  Because you do not know whether this is caused by
                venospasm or thrombosis, use interventions recommended
                for venospasm.

            d.  If these attempts fail, notify physician for possible
                radiologic studies, to rule out thrombus.

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        3.  Catheter fracture

            a.  Catheters already may be damaged prior to removal or may
                become damaged if excessive force is applied during the
                removal process.

            b.  If the catheter breaks during removal but is still long
                enough to be pulled, clamp the catheter and continue
                removal.

            c.  If the catheter breaks at the insertion site, clamp it
                and apply a tourniquet around the upper arm in an
                attempt to prevent migration of the fragment. The
                tourniquet should not impede the arterial flow; check
                radial pulse.

            d.  Notify the physician immediately, as a cutdown procedure
                will be needed to extract the catheter.

            e.  If a complete fracture occurs within the vein above the
                insertion site, immediately apply the tourniquet at the
                highest point on the arm.

            f.  The fragment can become an embolus. Observe for
                shortness of breath, tachycardia, confusion, pallor, or
                hypotension. Place patient in Trendelenburg position,
                and contact the physician immediately. The fragment will
                need to be removed by an interventional radiologist,
                thoracic surgeon, or vascular surgeon.

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7.  Maintenance and care (see Section II, A-4, page 5, on vascular
    access devices and Tables 2 and 3 in the original guideline
    document)

8.  Complications (See the \"Potential Harms\" field for a summary of
    complications or Section II, A-6, page 12, on vascular access
    devices and Tables 4 and 5 in the original guideline document for
    full details.)

**Central Venous Lines (Nontunneled)**

1.  Description and types (See the original guideline document for full
    details.)

2.  Insertion of catheters with a percutaneous technique using a
    guidewire or stylet.

3.  Advantages and disadvantages (see Table 6 in the original guideline
    document for full details)

4.  Patient selection criteria

    a.  Size of patient/vein may determine the gauge of catheter and the
        number of lumens used. Smaller catheters decrease the incidence
        of venous thrombosis (Dooley et al., 1995). Adequate venous flow
        around the catheter also ensures appropriate dilution of
        medications (Greene, 2000).

    b.  Short-term treatment (up to six weeks), with no need for
        extended therapy anticipated

    c.  Patients with poor peripheral venous access

    d.  Patient who needs frequent venous access requirements for
        infusion or blood specimens

    e.  Poor surgical candidate for long-term catheter placement

    f.  Short life expectancy

    g.  Critically ill patients requiring multilumen access (Fischer,
        Knobf, & Durivage, 1997)

    h.  When choosing the type of line for the patient, consider that
        infection rates rise exponentially with the addition of each
        subsequent lumen (Dooley et al., 1995).

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5.  Insertion location

    a.  Preferentially use the right internal jugular vein as the entry
        site because it follows a fairly straight course to the
        subclavian. A triangle of landmarks (clavicle and the two heads
        of the sternocleidomastoid muscle) identifies the insertion
        site.

    b.  Cannulate the subclavian vein on the left side, if possible,
        because it has a smooth curve to the superior vena cava without
        an acute turn.

    c.  If the right internal jugular is not available, the left
        internal jugular, the external jugular, or the subclavian veins
        may be used (Webster, 2001) (see Figure 2 in the original
        guideline document). In patients with chest pathology, a femoral
        attempt with the tip in the inferior vena cava is possible but
        has an increased risk of infection and other side effects,
        including thrombotic complications and complete venous
        thrombosis (Goodman, 2000; Merrer et al., 2001).

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6.  Insertion techniques

    a.  Perform a preplacement assessment of the patient to determine if
        a nontunneled catheter is appropriate, based on patient
        selection criteria.

    b.  Explain the insertion procedure to the patient and answer any
        questions the patient and/or significant others may have. Ensure
        that informed consent is obtained. Determine if the patient has
        allergies to iodine or tape products, and inform the
        practitioner placing the line.

    c.  Position the patient (Dooley et al., 1995; Masoorli & Angeles,
        2002).

        1.  Usually, the patient is placed in a 15-degree Trendelenburg
            position, which distends the vein selected for venipuncture
            and decreases the risk of air embolism.

        2.  If the internal jugular is to be used, the patient\'s head
            should be turned to the opposite side of the catheterization
            to decrease contamination and make the site more accessible.

        3.  A rolled towel may be placed beneath the neck and shoulders
            to increase venous distention.

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    d.  Prep the insertion site with a cleansing agent. If necessary,
        clip (do not shave) long hair to decrease contamination.

    e.  Use local anesthetic to decrease insertion discomfort.

    f.  Insert needle percutaneously into the vein, using the clavicle
        as a guide (Masoorli & Angeles, 2002).

        1.  When a flashback is observed in the syringe, the syringe is
            removed, and a guidewire is advanced into the vein. The
            guidewire should not be advanced farther than 18 cm in order
            to minimize complications (Andrews, Bova, & Venbrux, 2000).

        2.  The catheter is advanced over the guidewire into the
            subclavian vein until it reaches the superior vena cava. Use
            of a peel-away sheath protects the catheter until it is
            inserted and decreases the risk of infection.

        3.  The guidewire is removed.

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    g.  Flush each lumen with heparinized saline. Flush closed-valve
        lumens with saline.

    h.  Suture the catheter to the skin or secure it with tape, and then
        apply an occlusive dressing over the exit site.

    i.  Obtain a chest x-ray before therapy is initiated to determine
        proper placement, location of the tip, and to detect
        pneumothorax, although there is a low incidence of complication
        following subclavian or nontunnelled central line placement
        (Burn, Skewes, & King, 2001). Tip placement in the right atrium
        is unacceptable, as the tip could trigger arrhythmias if it
        comes in contact with the sinoatrial node (Masoorli & Angeles,
        2002).

    j.  Allow a physician, nurse practitioner, or radiologist to verify
        the proper position in the superior vena cava; then the line may
        be used immediately for infusion.

    k.  Document length of catheter, presence of blood return, and
        condition of patient.

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7.  Nontunneled lines are removed when therapy is completed, when the
    line is no longer functional because of thrombus or mechanical
    failures or when the line is infected.

    a.  Potential complications related to central line removal include
        venous air embolism, dyspnea, pain, bleeding from the insertion
        site, and arrhythmias (Dumont, 2001).

    b.  Routine replacement of a nontunneled central catheter should not
        be performed (O\'Grady et al., 2002; Timsit, 2000).

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8.  Removal technique

    a.  Verify order for removal and indication.

    b.  Note the length of the catheter on insertion.

    c.  Explain the procedure to the patient.

    d.  Place patient in a reclining position.

    e.  Inspect the general condition of the catheter.

    f.  Discontinue all infusions into the device.

    g.  Put on gloves, remove dressing, and inspect exit site for
        redness, pain, swelling, exudate, or other problems.

    h.  Change gloves and remove sutures, if present.

    i.  Have patient perform Valsalva maneuver (Masoorli & Angeles,
        2002). Performing the Valsalva maneuver decreases the risk of
        air embolism during catheter removal. The maneuver is
        contraindicated in patients with increased intracranial pressure
        or if intubated.

        1.  Instruct the patient to take a deep breath and hold it.

        2.  Patient should \"bear down\" for 10 seconds.

        3.  Patient then exhales.

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    j.  Grasp hub of nontunneled catheter and gently and steadily
        retract catheter until completely removed.

    k.  Apply constant, firm pressure to the exit site until bleeding
        stops (longer in patients with coagulopathies or decreased
        platelet count). Apply sterile, occlusive dressing and monitor
        patient for discomfort, bleeding, bruising, redness, swelling,
        or drainage. Advise patient/family to report above signs.

    l.  Visually inspect the VAD for appropriate length and defects,
        such as holes, tears, or jagged edges suggesting breakage. If
        length is shorter than expected or the edges appear broken,
        notify the physician.

    m.  Document observations, actions, and patient teaching.

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9.  Maintenance and care (see Section II, A-4, page 5, and Tables 2 and
    3 in the original guideline document for full details)

10. Complications (see the \"Potential Harms\" field for a summary of
    complications or see Section II, A-6, page 12, and Table 4 in the
    original guideline document)

11. Education and documentation (see Section VIII, page 80 in the
    original guideline document)

**Tunneled Central Venous Catheters (CVCs)**

1.  Description and types (See the original guideline document for full
    details.)

2.  Advantages and disadvantages (see Table 6 in the original guideline
    document for full details)

3.  Patient selection criteria: May be used in any patient population
    that requires longterm IV access, such as bone marrow
    transplantation, hematologic disease, or malignant diseases that
    will result in a prolonged nadir of blood counts after therapy.

4.  Insertion technique: Surgical procedure by surgeon or interventional
    radiologist after informed consent is obtained (Alexander, 1994)

    a.  Select the vein according to the individual patient\'s
        anatomical structure, type and purpose of catheter, and the
        vessel used. The most common veins used for insertion include
        the following (see Figure 2 in the original guideline document).

        1.  Subclavian vein

        2.  Internal or external jugular vein

        3.  Cephalic vein

        4.  Femoral vein (Note: If the subclavian, cephalic, or external
            jugular veins are unable to be cannulated because of
            superior vena cava syndrome, obstruction of the subclavian
            vein, tumor blockage, bilateral radical neck dissection, or
            trauma to the upper torso, the saphenous vein can be
            cannulated with the catheter advanced into the inferior vena
            cava \[Wickham, 1990\].)

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    b.  Perform percutaneous insertion using the Seldinger method
        (Baranowski, 1993; Silberman, Berne, & Escandon, 1992).

        1.  It is the most common insertion technique using the
            subclavian or internal jugular vein. Once the vein is
            cannulated, the guidewire is advanced into the vein.

            a.  A pull-apart sheath introducer is threaded over the
                guidewire.

            b.  The guidewire is removed, and the catheter is advanced
                through the introducer into the vein.

            c.  The catheter is tunneled through the SC tissue. The
                tunnel is created from the vein entry site to the exit
                site. With the antegrade technique, the catheter is
                pulled from the exit site through the tunnel to the vein
                entry site and trimmed. With the retrograde technique,
                the catheter is pulled from the vein entry site to the
                exit site and trimmed.

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        2.  The exit site depends on male and female anatomy; however,
            usually it is above the nipple line midway between the
            sternum and clavicle.

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    c.  Perform the cut-down insertion (Hadaway, 1995).

        1.  The procedure greatly reduces risk of hemothorax or
            pneumothorax.

        2.  This technique is more time-consuming and difficult to
            perform than other methods.

        3.  The procedure requires more manipulation of the skin and SC
            tissue, thereby increasing the infection rate.

        4.  The veins used include the axillary, external jugular,
            internal jugular, cephalic, and subclavian.

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    d.  Verify catheter position by radiographic imaging (Guth, 2001).

    e.  Secure catheter with sutures.

        1.  Exit site sutures remain in place until healing occurs,
            which can range from 10 days to 6 weeks or longer if
            immunosuppression is present.

        2.  Sutures are removed after healing to prevent irritation at
            the exit site.

        3.  In some cases (e.g., the use of apheresis catheters),
            sutures are left in place until the catheter is removed
            because of the risk of catheter dislodgment caused by the
            external weight of the catheter.

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5.  Removal technique: RNs may be able to remove tunnel catheter,
    depending on their specific State Board of Nursing Practice Act.

    a.  Verify order for removal and indication.

    b.  Note length of catheter on insertion.

    c.  Explain procedure to patient.

    d.  Place patient in reclining position.

    e.  Inspect general condition of catheter and tunneled pathway.

    f.  Discontinue all infusions into device.

    g.  Put on gloves, remove dressing, and observe site for edema,
        erythema, or other problems.

    h.  Change gloves and remove sutures as needed.

    i.  Have the patient perform Valsalva maneuver (Thielen & Nyquist,
        1991). Grasp hub of VAD and gently and steadily retract catheter
        until completely removed.

    j.  Send catheter tip for culture, if removal of VAD is indicated
        for infection (Hadaway, 1995; Windmer et al, 1992).

    k.  Apply constant firm pressure to exit site until bleeding stops
        (longer in patients with coagulopathies or patients on
        anticoagulant therapy). Apply sterile occlusive dressing and
        monitor as necessary. Some institutions use triple-antibiotic
        gauze or petroleum jelly gauze when dressing is applied to
        prevent air from entering SC space.

    l.  Instruct patient/caregiver to report any discomfort or signs of
        bleeding, bruising, erythema, edema, and drainage.

    m.  Inspect device for appropriate length and for defects. Report
        any defects to the manufacturer and regulatory agencies. Examine
        distal tip for signs of jagged, uneven edges suggestive of
        breakage.

    n.  Document observations and actions.

    o.  Contact a physician immediately if difficulty occurs in
        retrieving the cuff or with removal of catheter.

    p.  If tunnel infection is suspected, a cutdown procedure may be
        performed to remove the cuff, based on physician preference.

    q.  If there is a question of incomplete catheter removal, call the
        physician immediately. A chest x-ray or cathetergram is
        recommended.

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6.  Maintenance and care (see Section II, A-4, page 5, and Tables 2 and
    3 in the original guideline document)

7.  Complications (see the \"Potential Harms\" field for a summary of
    complications or see Section II, A-6, page 12, and Tables 4 and 5 in
    the original guideline document)

8.  Education and documentation (see Section VIII, page 80 in the
    original guideline document)

**Implanted Venous Ports (see Figure 4 in the original guideline
document)**

1.  Description and types (See the original guideline document for full
    details.)

2.  Advantages and disadvantages (see Table 6 in the original guideline
    document for full details)

3.  Patient selection criteria

    a.  Patients who require intermittent intravenous therapy

    b.  Patients who are unwilling to care for an external line

    c.  Patients who are unable to care for an external line because of
        poor vision, poor dexterity, an inability to comprehend, or who
        do not have a caregiver

    d.  Patients with a very active lifestyle, including swimming and
        outdoor activities

    e.  Patients who are not extremely obese, because the port must be
        sutured to the muscle and under the adipose layer, making it
        difficult to locate and access the port septum. Also, the port
        can migrate further in SC tissue.

    f.  Patients who find needle sticks extremely traumatic may not be
        good candidates for a totally implanted device.

    g.  Patients with poor peripheral access and ongoing IV needs

    h.  Ample chest area is required, so patients with open chest
        wounds, tumor involvement of the chest wall, or radiation
        fibrosis are poor candidates (Camp-Sorrell, 1992).

    i.  Peripherally placed ports are an option in patients with chest
        pathology or those patients in whom obesity would make it
        difficult to access a chest-placed port.

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4.  Insertion techniques

    a.  Ideally, the nurse should assist in determining the optimum
        location for the portal body (Goodman, 2000).

        1.  The portal body should be located over a rib for stability.

        2.  Placing the port over the sternum in obese patients assists
            in locating and accessing the port.

        3.  In women, the port should not lie under a bra strap or edge,
            therefore the woman should be sitting and clothed when
            placement is determined.

        4.  Consider the activity level of the patient.

        5.  Avoid placement in the axilla, breast tissue, or soft tissue
            of the abdomen to avoid access problems.

        6.  A preferred site and an alternate site should be marked for
            the surgeon.

        7.  A peripheral port is placed below or above the antecubital
            fossa, to minimize range of motion impairment.

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    b.  After obtaining consent, the patient is taken to the operating
        room or interventional radiology. The procedure may be performed
        under straight local anesthesia, a local with the addition of
        sedation, or general anesthesia. Insertion may be performed
        under fluoroscopy to facilitate correct tip placement.

    c.  The most common veins used include the following (see Figure 2
        in the original guideline document).

        1.  Subclavian

        2.  Internal or external jugular

        3.  Cephalic, basilic, or axillary (peripheral port)

        4.  Femoral

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    d.  The catheter is placed using the cut-down technique or the
        percutaneous method.

        1.  Pre-attached catheters are measured and cut from the distal
            end.

        2.  Separate catheters are inserted, and then may be cut at the
            proximal (portal body) end.

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    e.  If portal body is separate, the catheter is connected per
        manufacturer\'s instructions based on the type of locking
        mechanism.

    f.  An incision is made to create a port \"pocket,\" preferably in a
        previously determined location.

        1.  The portal body is placed over a bony area for
            stabilization, under the adipose layer, and sutured to the
            fascia layer.

        2.  The suture line should not be over the top of the port
            septum to maintain the integrity of the suture line
            (Goodman, 2000).

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    g.  Following closure of the port pocket, the port is accessed using
        a noncoring needle, and the system is flushed to ensure patency
        and blood return.

        1.  If the port is to be used immediately, the needle should be
            left in place and dressed occlusively, as postoperative
            edema and tenderness of the incision make postsurgical
            access more difficult.

        2.  If the port is not used immediately, the needle is removed,
            and a dressing applied over the port pocket incision and the
            catheter entry site.

        3.  Ideally, the port should not be accessed for several days to
            allow edema and tenderness to resolve. If it needs to be
            used sooner, instruct the patient to apply an ice pack to
            minimize edema.

        4.  When a peripheral port is placed, that arm should not be
            used to obtain blood pressure and should not be used for
            peripheral blood drawing or infusions of IV solutions except
            through the port (Sims Deltec, 2000).

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    h.  Radiographic imaging is obtained following insertion to
        determine tip placement and to assess for complications of
        insertion.

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5.  Access and de-access procedures (see Appendix 6, page 125 in the
    original guideline document)

    a.  Implanted ports must be accessed with a special noncoring needle
        (see Figure 4 in the original guideline document).

        1.  A specially designed needle tip separates the silicone
            septum, preventing \"coring\" of the diaphragm, which could
            lead to debris in the reservoir and ultimate degradation of
            the integrity of the septum.

        2.  An offset bevel allows the tip of the needle to be flush
            with the bottom of the reservoir without impeding the flow
            of solution.

        3.  Noncoring needles are available in a variety of sizes and
            configurations.

            a.  Length varies from 0.5-1.5 inches

            b.  Most commonly used gauge is 19-22.

            c.  Straight needles are available for flushing with
                immediate deaccessing or bent at a 90-degree angle for
                continuous infusions.

            d.  Needles are available as the needle alone or attached to
                a short piece of tubing.

            e.  The system has extension tubing with a clamp.

                i.  Wings may or may not be attached to the hub for
                    easier access and stabilization of the needle to the
                    chest.

                ii. The extension tubing also may have a Y-site.

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    b.  To decrease the discomfort during needle access, the patient may
        be offered topical anesthetic with a physician\'s order (see
        Section II, B-4, c)-(1), page 26 in the original guideline
        document).

    c.  When not in use, implanted ports must be accessed and flushed
        every 4-6 weeks to maintain patency.

    d.  Positive pressure technique is extremely important in preventing
        the development of fibrin sheaths, leading to withdrawal or
        infusion occlusions and contributing to the development of
        venous thrombosis. The following procedures prevent the slight
        negative pressure on the end of the catheter that results in
        pulling a small amount of blood into the end of the catheter,
        where it becomes a fibrin sheath.

        1.  Positive pressure is maintained while flushing an accessed
            port by clamping the port tubing while still flushing the
            line.

        2.  Port access devices that do not have a clamp may be flushed
            with positive pressure by withdrawing the syringe from the
            injection cap while continuing to push fluid through the
            needle.

        3.  Positive pressure is maintained while deaccessing a port by
            flushing the catheter while withdrawing the needle from the
            septum.

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    e.  Prior to each access, the site should be examined for
        complications, including examination of the veins of the
        ipsilateral chest and neck, which might be indicative of venous
        thrombosis (Brown et al., 2001).

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6.  Removal technique

    a.  Procedure usually is performed in the operating room; however,
        may be performed in an outpatient setting.

    b.  A cut-down procedure is used to remove the port from the port
        pocket.

    c.  The catheter is removed as described previously and the port
        incision reclosed.

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7.  Maintenance and care (see Section II, A-4, page 5, and Tables 2 and
    3 in the original guideline document)

8.  Complications (see the \"Potential Harms\" field for a summary of
    complications or see Section II, A-6, page 12 in the original
    guideline document)

9.  Education and documentation (see Section VIII, page 80, and Tables 4
    and 5 in the original guideline document)

**Apheresis/Hemodialysis Catheters**

1.  Description and types (See the original guideline document for full
    details.)

2.  Advantages and disadvantages (see Table 6 in the original guideline
    document for full details)

3.  Patient selection criteria are based on type of therapy or
    indications for use.

    a.  Patients who require apheresis of blood components, including
        stem cells, to be used with peripheral blood stem cell
        transplant. A temporary catheter may be used for collection of
        stem cells from allogeneic donors who have poor peripheral
        venous access.

    b.  Patients who require leukopheresis of white blood cells

    c.  Patients who require plasmapheresis of plasma

    d.  Patients who require hemodialysis for management of acute and
        chronic renal failure

    e.  Patients who may need venous access for continuous arterial
        venous hemodialysis (CAVHD), ultrafiltration, or continuous
        veno-venous hemodialysis (CVVHD).

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4.  Insertion techniques (see Section II, F-5, page 41, on nontunneled
    catheters or Section II, G-4, page 44, on tunneled catheters in the
    original guideline document)

5.  Removal techniques (see Section II, F-7, page 42, on nontunneled
    catheters or Section II, G-5, page 44, on tunneled catheters in the
    original guideline document)

6.  Maintenance and care (see Section II, A-4, page 5, and Tables 2 and
    3 in the original guideline document)

7.  Complications (see the \"Potential Harms\" field for a summary of
    complications or see Section II, A-6, page 12 in the original
    guideline document)

8.  Education and documentation (see Section VIII, page 80 in the
    original guideline document)

**Arterial Access Devices**

1.  Description and types of devices (See the original guideline
    document for full details.)

2.  Advantages and disadvantages of arterial therapy

    a.  Advantages

        1.  Regional perfusion is useful only when the entire tumor is
            perfused and infusate can be confined to a specific area
            (Weinstein, \"(Intravenous therapy,\" 2001). Efforts are
            being made to further restrict systemic circulation of
            infusate using techniques such as arterial, mechanical, or
            chemical embolization (Alsowmely & Hodgson, 2002).

        2.  Only in the case of hepatic perfusion may access be achieved
            through the hepatic artery, as well as through the portal
            vein, and consideration is being given to use both accesses
            for drug delivery to the tumor (Paku et al., 1998).

        3.  Increased exposure of tumor to drug increases tumor
            response, whereas less systemic circulation and exposure to
            infusate decreases risk of systemic side effects (Dizon &
            Kemeny, 2002; Goodman, 2000; Haller, 2000; Kemeny, 2000).

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    b.  Disadvantages

        1.  Less systemic circulation and exposure to infusate increases
            the risk for distant metastasis.

        2.  Positive outcomes from arterial therapy, such as improved
            survival and quality of life, remain under continued
            investigation (Haller, 2000; Kemeny, 2000).

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3.  Patient selection criteria

    a.  Devices are available for children and adults.

    b.  Assess patient condition, venous and arterial infusion device
        history, and type and duration of all antitumor therapy (INS,
        2000).

    c.  Consider any age-related factors and comorbidities for the
        procedure, surgery, or drug administration.

    d.  Indications for arterial access device placement are as follows.

        1.  Regional perfusions for adjuvant, cure, control, and
            palliative therapies

        2.  Accessible artery supplying entire tumor

        3.  Indications for long-term catheter placement

            a.  Disease is confined to area of perfusion.

            b.  Patient has adequate performance status and ability to
                tolerate surgical procedure.

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        4.  Percutaneous hepatic artery temporary catheter placement
            (Habbe et al., 1998)

            a.  The liver is the focal point of disease, although
                extrahepatic metastatic disease may be present
                (Bergsland & Venook, 2000).

            b.  Patient\'s clinical status precludes undergoing surgery.

            c.  Evaluate tumor response before placing a permanent
                device.

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    e.  Check for sites of organ or regional perfusion for malignant
        disease with arterial access (see Table 8 in the original
        guideline document).

    f.  Consider contraindications for arterial access.

        1.  Acute infection, prolonged fever, and absolute neutrophil
            count \<1,500 mm^3^

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        1.  Severe coagulopathy

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4.  Patient setting

    a.  Percutaneous placements and infusions usually are performed as
        an inpatient procedure, but they may be performed as an
        outpatient procedure.

    b.  Bolus injections/infusions through a longterm catheter or port
        may be performed in an ambulatory setting, including the home,
        if nursing support is provided.

    c.  Homecare and visiting nurses must be knowledgeable about the
        following.

        1.  Arterial infusions and administration techniques

        2.  Chemotherapy and side effects

        3.  Safe handling of cytotoxic drugs by family and healthcare
            professionals

        4.  Twenty-four-hour on-call assistance for pump failure or
            complications

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5.  Insertion procedures and perfusion checks (Arru et al., 2000)

    a.  Direct arterial access can be performed at the time of initial
        tumor resection or during a second surgical procedure. Although
        commonly viewed as a permanent catheter, it may be removed if a
        specific surgical technique is used (Maruyama et al., 1999).

        1.  Advantages of catheter placement during the initial surgery
            include the following.

            a.  Catheter can be sutured in place, reducing the risk of
                catheter migration and displacement.

            b.  Vessels can be viewed directly.

            c.  Accessory vessels can be ligated (i.e., during hepatic
                perfusion, the right gastric artery is ligated to
                prevent perfusion of cytotoxic drugs to the stomach with
                resultant erosion).

            d.  Gallbladder can be removed before hepatic arterial
                perfusion to prevent biliary sclerosis and cholangitis.

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        2.  Disadvantages of surgical catheter placement involve the
            stress and recovery period because of surgery.

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    b.  Percutaneous access with a local anesthetic is accomplished in
        the radiology department.

        1.  Percutaneous access provides the advantage of excluding a
            surgical procedure and its cost and potential postoperative
            complications.

        2.  Accessory vessels also can be ligated successfully (Habbe et
            al., 1998).

        3.  A newer technique uses a fixed-tip catheter, reducing
            migration (Irie, 2001; Seki et al., 1999). In the fixed-tip
            catheter placement, the open end of the catheter is attached
            to the gastroduodenal artery with microcoils that also
            discontinue blood flow to this artery and occlude the open
            end of the catheter. A side hole in this catheter is located
            in the hepatic artery, which is the desired location for
            drug administration.

        4.  Catheter may be inserted percutaneously and connected to an
            SC port (Seki et al., 1999).

        5.  Disadvantages to percutaneous access include the following.

            a.  An inability to suture the catheter to the vessel
                exists, increasing the potential for catheter migration.

            b.  Catheter is not long-term, so percutaneous access may
                require repeated catheter insertions for subsequent
                treatment.

            c.  It possibly precludes ability to ligate other vessels.

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    c.  Port placement (see Section II-H-4, page 46 in the original
        guideline document)

        1.  Port is attached or preconnected to a long-term catheter.

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        1.  Port is placed in SC pocket and sutured to underlying
            fascia.

        2.  The port pocket usually is placed over a bony prominence in
            the upper chest wall area or in the lower abdomen, but it
            can be placed anywhere on the trunk.

        3.  Pocket incision should not transverse the septum.

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    d.  Perfusion check

        1.  Intraoperatively, adequacy of hepatic perfusion is checked
            to ensure absence of extrahepatic or accessory organ
            perfusion using intra-arterial injection of fluorescein dye
            and Woods lamp (Curley et al., 1993).

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        1.  Perfusion checks confirm permanent catheter patency and
            extent of perfusion. Checks are performed postoperatively,
            before cytotoxic therapy and every three months (Martin,
            2002).

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6.  Postoperative care

    a.  Surgically placed external catheter

        1.  Assess exit site for drainage, edema, erythema, and catheter
            connections. Assess patient for pain.

        2.  Measure external catheter length to obtain baseline
            measurement. This measurement is used to determine if the
            catheter is becoming dislodged.

        3.  Ensure catheter connections or cap are Luer-locked and
            firmly connected.

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    b.  Surgically placed internal catheter connected to port or
        implanted pump

        1.  Assess port or pump site for drainage, edema, and erythema.
            Assess patient for pain.

        2.  Antibiotics are given intravenously, prophylactically before
            and after surgery.

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    c.  Percutaneous arterial catheter insertion

        1.  Heparin may be continuously infused to maintain artery
            patency. Blood coagulation values, such as partial
            thromboplastin time (PTT), should be monitored closely.

        2.  Catheter migration or dislodgment may impede blood supply to
            the limb. Assessment is made of the limb, which is supplied
            by the artery used for the catheter insertion, such as the
            leg if the femoral artery is used.

            a.  The involved limb is assessed for pulse, color,
                temperature, capillary refill, numbness or tingling,
                edema, or hematoma. The specific insertion site
                determines any additional observations (i.e., a carotid
                artery insertion indicates the patient\'s neurologic
                signs are monitored for potential seizures) (West,
                1998).

            b.  Assess the catheter and exit site for catheter kinking,
                leaking, or migration; site bleeding; or hematoma.

            c.  Frequency of assessment varies, and further research is
                warranted. Assessment frequency ranges from every four
                hours to every 15 minutes for one hour, every 30 minutes
                for 3 hours, every one hour for four hours, and then
                every four hours (Almadrones, Campana, & Dantis, 1995;
                Lynes, 1993).

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    d.  Dressing: If oozing, use gauze and change every 24 hours or more
        frequently. If dry, use transparent semipermeable dressing. No
        ointments are applied to the site (O\'Grady et al., 2002).

    e.  Brachial access-arm is secured in sling

    f.  Femoral artery access

        1.  To decrease the chance of dislodgment, patient may be
            required to lie flat with a pressure dressing over insertion
            site. Use a loose restraint around ankle to remind patient
            not to move leg, and provide appropriate care for
            immobilization. Careful ambulation may be permitted in some
            settings (Habbe et al., 1998).

        2.  Antiembolic stockings are recommended to decrease risk of
            thrombus (West, 1998).

        3.  Hemodynamic monitoring and venipuncture should not be
            performed on the involved extremity except with physician
            order (INS, 2000).

        4.  Ensure catheter connections or cap are Luer-locked and
            firmly connected.

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7.  Removal

    a.  Long-term external catheter: May be in place indefinitely. The
        catheter may be removed by a surgeon. The catheter is tied off
        and buried SC by surgeon (Maruyama et al., 1999).

    b.  Port: May be in place indefinitely. The port may be removed
        using a local anesthetic, and the catheter is tied off and
        buried subcutaneously by a surgeon.

    c.  Percutaneous catheter: The catheter is removed in radiology or
        at the bedside with close observation by a surgeon. It is
        usually removed after four days or, at the maximum, seven days.

        1.  Apply pressure for 10 minutes over exit site or until
            bleeding stops.

        2.  Apply povidone-iodine ointment or a triple-antibiotic
            ointment to the site, cover with gauze, and apply an
            adhesive, occlusive pressure dressing.

        3.  Place a small sandbag over the site for eight hours.

        4.  Monitor for bleeding or edema at site, and check extremity
            pulse, skin color, and temperature changes every 10 minutes
            six times, then every 30 minutes two times, and then hourly
            six times. After eight hours, change the pressure dressing
            to an occlusive bandage (INS, 2000).

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8.  Drug delivery with arterial access

    a.  Determine catheter placement and perfusion area.

        1.  If sutured, perform perfusion check every three months or
            more frequently if regional side effects exist, suggesting
            catheter migration.

        2.  If not sutured, perform perfusion check every course or
            every other course unless regional side effects exist,
            suggesting catheter migration.

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    b.  Laboratory studies are conducted to monitor regional and
        systemic side effects of the infused drug.

        1.  Area of perfusion and drugs used dictate type of studies
            that need to be conducted to monitor regional side effects
            (e.g., liver function tests for hepatic artery infusion).

        2.  Monitoring for systemic side effects follows a similar
            pattern as if the drug was given systemically; thus
            assessment depends on the drug given.

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    c.  Infusates used in regional therapy include cytotoxic agents,
        lymphocytes, and tumor necrosis factor. Any drug can be
        delivered through an implanted port without concerns about
        drug-device biocompatibility because of the limited time of
        contact with the drug and port (Graham & Holohan, 1994).

    d.  Administration schedule depends on specific protocol.

        1.  Drugs may be given as a bolus, intermittent, or continuous
            long-term infusion using either external or implanted pumps.
            The drug administration may continue for a specified number
            of cycles or indefinitely until there is response or disease
            progression (Lorenz & Muller, 2000).

        2.  Hepatic arterial infusions through a temporary percutaneous
            catheter often are for four days, then the catheter is
            pulled. The cycle is frequently repeated for several months
            (Copur et al., 2001).

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    e.  A pump is required for arterial infusions; this may be an
        implantable pump or an external pump (see Section VII, page 73
        in the original guideline document).

    f.  Arterial access devices are not to be used for other therapies
        (e.g., total parenteral nutrition, lipid administration).

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9.  Access, flushing, and dressing (see Table 9 and Appendix 7, page
    127, in the original guideline document for an example of a
    practicum.)

    a.  For proper use of these devices, the nurse should be familiar
        with the device, its features, patient- and drug-related
        considerations, and precautions provided by the manufacturer.

    b.  Use aseptic technique for all care provided.

    c.  Catheter access is at the hub.

        1.  Clean catheter connection with 70% alcohol or
            povidone-iodine.

        2.  Clamp catheter during tubing or cap changes.

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    d.  Port access

        1.  See Section II-H-5, page 47 in the original guideline
            document, on accessing a port.

        2.  Flush port to verify patency. The port should have a brisk
            blood return, allow easy flow of fluids, and cause no edema,
            pain, or erythema.

        3.  Clinicians are divided on the practice of aspirating blood
            to verify needle placement because of the risk of occlusion
            after repeated aspirations. Research is needed in this area.

        4.  Blood cannot be aspirated from catheters with a one-way
            valve design.

        5.  When administering vesicants through a port: If no blood
            return or perfusion, radiographic check needs to be obtained
            to verify catheter placement.

        6.  Interventions for painful needle sticks during port access
            are described previously (see Section II-B-4-c), page 26, in
            the original guideline document on peripheral IVs).

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    e.  Flushing to maintain patency

        1.  Controversy exists related to the type, amount, and
            concentration of final flush solutions.

        2.  For information on port flushing, see Table 9 in the
            original guideline document.

        3.  Flushing for external catheters (see Table 9 in the original
            guideline document)

            a.  Post-surgery: Usually instilled with 1,000 units of
                heparin/ml using 2 ml.

            b.  During continuous drug infusions or for \"keep open\"
                purposes when drug infusion is completed, the type and
                amount of solution and rate may be the following.

                i.  Use continuous normal saline.

                ii. Flush with heparin solution as ordered by physician
                    to maintain catheter patency (Martin, 2002).

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10. General practice issues

    a.  Use pressure tubing, positive pressure pumps, and stopcocks with
        Luer locks.

    b.  Always use positive pressure when withdrawing needle or clamp
        before withdrawing needle from injection cap.

    c.  Never leave open to air; maintain a closed system.

    d.  If external catheter is capped, keep clamped to avoid retrograde
        blood flow.

    e.  Make sure dressing is secure. Loop catheter to dressing, and
        tape securely so catheter loop is not exposed to accidental
        pulling.

    f.  Arterial access devices for regional cytotoxic therapy are not
        used for blood sampling. Other arterial catheters (pulmonary
        artery catheter or radial artery catheter) often are used for
        blood sampling using specific techniques (Schallom, Bisch &
        Intravenous Nursing Society (INS), 2001).

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11. Complications (see the \"Potential Harms\" field for a summary of
    complications or see the original guideline document for full
    details)

12. Education and documentation (see Section VIII, page 80 in the
    original guideline document)

**Intraventricular Access Devices**

1.  Description of devices (See the original guideline document for full
    details.)

2.  Advantages and disadvantages of intraventricular reservoir:

    a.  Advantages

        1.  Provides relatively painless access to the cerebrospinal
            fluid (CSF)

        2.  Obviates the need for repeated spinal taps

        3.  Permits consistent and predictable drug delivery through the
            CSF (Kosier & Minkler, 1999)

        4.  Allows for measurement of intracranial pressure

        5.  Can be used for multiple therapies, such as chemotherapy,
            antibiotics, antifungals, and pain medication

        6.  Allows for sampling of CSF

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    b.  Disadvantages

        1.  Requires surgical insertion

        2.  Catheter may migrate.

        3.  Expensive to implant

        4.  May become infected

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3.  Patient selection criteria (West, 1998)

    a.  Patients with malignant CSF leukemias or lymphomas, meningeal
        carcinomatosis, CSF infections, or chronic pain

    b.  Patients who require intermittent administration of
        chemotherapy, antibiotics, antifungals, and/or analgesics into
        the CSF

    c.  Patients who do not wish to undergo repeated spinal tap for CSF
        access

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4.  Insertion procedures

    a.  The procedure is explained to the patient and/or significant
        others, and informed consent is obtained.

    b.  The device is inserted while the patient is under local or
        general anesthesia (Berweiler, Krone, & Tonn, 1998).

        1.  The patient is placed in a supine position and the area is
            cleaned and shaved.

        2.  A burr hole in made in the scalp, and the catheter is fed
            into the lateral ventricle of the brain.

        3.  The reservoir is surgically implanted subcutaneously under
            the scalp above the frontal lobe (Kosier & Minkler, 1999).

        4.  The skin over the reservoir is sutured. Care should be taken
            that the suture line does not cross the port of the device
            (Berweiler, Krone, & Tonn, 1998).

        5.  Usually, the surgeon accesses the reservoir intraoperatively
            to confirm the free flow of CSF (Kosier & Minkler, 1999).

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    c.  Confirmation of placement is confirmed with x-ray, CT scan, or
        MRI. The tip of the catheter should be located in the frontal
        horn of the lateral ventricle or close to the foramen of Monro
        (Berweiler, Krone, & Tonn, 1998).

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5.  Postoperative care

    a.  A pressure dressing is placed over the operative site in surgery
        and should remain in place for at least 24 hours; afterward a
        gauze and tape dressing is applied for several days, then the
        wound left open to the air.

    b.  The site should be monitored for bleeding, leakage of CSF, and
        excessive edema.

    c.  Monitor and notify the physician for neurologic changes, such as
        headache, vomiting, cognitive changes, blurred vision,
        increasing lethargy, changes in neurologic signs, or speech
        difficulties.

    d.  Monitor and notify the physician for signs of infection,
        including fever, stiff neck, or headache. Some physicians may
        order prophylactic antibiotics to prevent infection prior to
        insertion and for several days afterward (Webster, 2001).

    e.  The reservoir can be used 48 hours following insertion (Fischer,
        Knobf, & Durivage, 1997).

    f.  Sutures will need to be removed in 7-10 days (Fischer, Knobf,&
        Durivage, 1997).

    g.  The patient may shower prior to the sutures being removed, if
        the area is kept covered (Kosier & Minkler, 1999).

    h.  The patient should be advised to avoid trauma to the area in
        order to prevent damage to the reservoir.

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6.  Removal of device

    a.  An intraventricular reservoir is rarely removed once implanted
        unless the device malfunctions or the body develops an infection
        that cannot be resolved with the device in place.

    b.  Intraventricular reservoirs must be removed in surgery.

    c.  Intraventricular reservoirs may be removed if implanted for the
        purpose of delivering prophylactic therapy only.

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7.  Access, dressing, and flushing procedures

    a.  The physician generally accesses the intraventricular
        reservoirs. In some states, specially trained RNs may access the
        device in accordance with the individual\'s State Board of
        Nursing Practice Act.

    b.  Access is a sterile procedure to reduce the risk of CSF
        infection (Kosier & Minkler, 1999).

    c.  Preservative-free drugs and diluent must be used at all times to
        prevent meningeal irritation (Kosier & Minkler, 1999).

    d.  Use of a 25-gauge or smaller needle will preserve the integrity
        of the dome.

    e.  Although intraventricular administration of the drug minimizes
        systemic side effects, some patients may require an antiemetic
        prior to the procedure if antineoplastics are to be given.

        1.  Explain the procedure to the patient.

        2.  Assess the patient\'s vital signs and neurologic status.

        3.  Wash hands and assemble all equipment for drug injection
            and/or CSF sampling.

            a.  Sterile field

            b.  25-gauge butterfly needle with attached extension tubing

            c.  Sterile 2 x 2 gauze

            d.  Syringe with medication to be infused

            e.  Three alcohol swab sticks

            f.  Three povidone-iodine swab sticks

            g.  Sterile gloves

            h.  CSF sample containers

            i.  Syringe for withdrawing CSF

            j.  Razor to shave area, if necessary

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        ```
        4.  Ensure that patient is comfortable.

            a.  Place patient in a supine or semirecumbent position.

            b.  The patient may be positioned in a sitting position if
                more comfortable (Goodman, 2000).

            c.  Support head of patient on pillow.

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        ```
        5.  Shave area over reservoir, if necessary (Goodman, 2000).

        6.  Prepare a sterile field and open equipment.

        7.  Examine area over reservoir for signs of infection or
            trauma.

        8.  Gently palpate the reservoir. It should be possible to feel
            the reservoir filling with CSF when gently depressed and the
            fingers left in place. If the reservoir does not refill or
            refills very slowly when depressed, notify the physician.
            X-ray may be indicated to evaluate position of dome or
            catheter (Kosier & Minkler, 1999).

        9.  Using three alcohol swabs, cleanse the area over the site in
            a circular motion, beginning with the center and moving
            outward, and avoid covering the same area twice with the
            same swab.

        10. Repeat with the three povidone-iodine swab sticks.

        11. Allow povidone-iodine to air dry for 30 seconds.

        12. Insert the butterfly needle at a 45° angle into the
            reservoir.

        13. Attach a syringe to the extension tubing. CSF should flow
            freely into the syringe. Withdraw CSF equal to the amount of
            drug to be infused\--reserving 3 ml to use as flush
            following the procedure\--and set aside on a sterile field,
            maintaining the sterility of the syringe. Never forcibly
            aspirate, although gentle aspiration is not contraindicated
            (Goodman, 2000).

            a.  If CSF is bloody or cloudy: Preserve the specimen,
                notify the doctor, and stop the procedure.

            b.  If CSF is clear, attach syringe with medication. Slowly
                and gently infuse medication over 5-10 minutes.

            c.  Following medication, flush with reserved CSF (Kosier &
                Minkler, 1999).

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        ```
        14. Remove needle, and apply gentle pressure with a sterile 2 x
            2 gauze.

        15. Gently pump the reservoir 3-5 times to help distribute the
            drug. When CSF flow is adequate, the half-time of drug from
            the reservoir to the cisterna magnum is 60 minutes. Slowing
            of central nervous system (CNS) fluid because of device
            malfunction can lead to decreased distribution of drug and
            increased CNS toxicity (Levin, Leibel, & Gutin, 1997).

            a.  The patient may hear a whooshing or squishing sound when
                the reservoir is pumped (Goodman, 2000).

            b.  The patient may experience headache, nausea, and
                dizziness.

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        16. Instruct the patient to remain supine or semi-recumbent for
            30 minutes following the procedure.

        17. Obtain vital signs, and assess neurologic status following
            the procedure.

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    ```
    f.  No heparinization or flushing is necessary, as there is no blood
        in the system and the free-flow of CSF through the system should
        keep the catheter patent (Webster, 2001).

    g.  No dressing is required over the reservoir after the immediate
        postoperative period.

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8.  Complications (see the \"Potential Harms\" field for a summary of
    complications or see the original guideline document for full
    details)

9.  Patient education

    a.  Care of device

        1.  Avoid getting incision wet while sutures are present.

        2.  No care is required once sutures are removed.

        3.  Hair is allowed to grow back, except for a small 2-3 cm area
            over the device.

        4.  Avoid trauma to the device to prevent damage to reservoir.

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    ```
    b.  Signs and symptoms of infection (Fischer, Knobf, & Durivage,
        1997; Goodman, 2000)

        1.  Site tenderness, warmth, erythema, or drainage

        2.  Fever

        3.  Headache with or without vomiting, neck stiffness

        4.  Bloody or purulent CSF from reservoir

        5.  Blurred vision

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    c.  Signs and symptoms of catheter malfunction

        1.  Nausea and vomiting

        2.  Ataxia or slurred speech

        3.  Change in mentation or level of consciousness

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10. Education and documentation (see Section VIII, page 80 in the
    original guideline document)

**Epidural and Intrathecal Access Devices**

1.  Purpose (See the original guideline document for full details)

2.  Description of access devices (See the original guideline document
    for full details.)

3.  Placement

    a.  Patient preparation: Preplacement assessment of the patient. The
        procedure is explained to the patient and informed consent is
        obtained.

    b.  Area of insertion is cleaned.

        1.  Ten percent povidone-iodine and 0.5% chlorhexidine have been
            shown to be effective as cleansing agents.

            a.  In 96 temporary epidural catheter insertions,
                chlorhexidine was found to have reduced risk of
                infection when compared to povidone-iodine (Kinirons et
                al., 2001).

            b.  In 62 temporary epidural catheters, no difference was
                found between 0.5% solution of chlorhexidine and 10%
                povidone-iodine in reducing temporary catheter infection
                from insertion (Kasuda et al., 2002).

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        ```
        2.  Ten percent povidone-iodine, chlorhexidine, and alcohol all
            have the potential to be toxic to the CNS if introduced
            during access.

        3.  Protocols need to emphasize vigorous scrubbing techniques
            and to decrease the amount of solution at the insertion
            site. Commercially available pledgets impregnated with
            povidone-iodine have been found to introduce the least
            amount of disinfectant into the epidural space when compared
            with povidone-iodine-soaked gauze and swab sticks (Paice,
            DuPen, & Schwertz, 1999).

        4.  Sterile water can be used after povidone-iodine dries to
            decrease the introduction of cleansing solution into the
            epidural space (Paice, DuPen, & Schwertz, 1999).

    ```{=html}
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    ```
    c.  Epidural and intrathecal port placement

        1.  Placement is performed in the operating room with the
            patient under local anesthesia.

        2.  Patient is placed in a lateral decubitus position.

        3.  Catheter is inserted percutaneously into the epidural space
            approximately 4 cm, usually through the second and third
            lumbar interspace (Kasuda et al., 2002; Kinirons et al.,
            2001; Smitt et al., 1998).

            a.  Dura mater is the most exterior membrane covering the
                spinal cord, which forms the inner border of the
                epidural space. The ligamentum flavum and periosteum of
                the vertebral column form the outer border. The epidural
                space is a potential space between these boundaries.

            b.  Epidural space extends from the foramen magnum to the
                sacral hiatus.

            c.  Contents of the epidural space are composed of adipose
                and connective tissue, as well as blood vessels.

            d.  For intrathecal administration, the catheter is advanced
                below the dura where cerebral spinal fluid circulates.

            e.  The route of delivery into the subarachnoid space is
                termed intrathecal administration (Mercadante, 1999).

            f.  The potency of opioid is approximately 10 times greater
                when injected into the intrathecal space as compared to
                the epidural space (Mercandante, 1999).

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        ```
        4.  The proximal end of the catheter is subcutaneously tunneled
            around the flank to the abdomen or anterior chest wall and
            connected to the portal body.

        5.  The portal body is sutured to the fascia over a bony
            prominence, such as the lower rib.

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    d.  A temporary catheter may be placed for up to seven days.

        1.  It may be inserted at the bedside or in the operating room
            using local anesthesia and placed into the epidural space or
            intrathecal space of the spine.

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        ```
        1.  External portion is taped up the patient\'s back to the
            anterior chest wall or around the flank and taped to the
            abdomen.

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    ```
    e.  Tunneled catheter

        1.  Catheter is inserted in the operating room using local
            anesthesia, with the distal tip of the catheter inserted
            into the epidural or intrathecal space.

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        ```
        1.  Proximal tip is tunneled under the SC tissue, exiting at the
            waist or side of the abdomen.

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    ```
    f.  SC implantable pump

        1.  Pump is inserted in the operating room while the patient is
            under local anesthesia.

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        ```
        1.  Pump is implanted into a created SC pocket, and the catheter
            is tunneled and threaded into the intrathecal space

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    g.  Immediate postoperative care

        1.  Check dressing for bleeding or drainage.

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        ```
        1.  Assess site for hematoma or excessive postoperative edema.

        2.  Change dressing daily until site is healed.

        3.  Assess for paresthesia, which may result from contact of the
            catheter with neural tissue, neurotoxic drug administration,
            or spinal cord compression (Mercadante, 1999).

        4.  Monitor blood pressure and pulse per postoperative routine
            and then every four hours until they are stable.

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```
4.  Advantages and disadvantages of epidural/intrathecal access devices
    (see Table 12 in the original guideline document for full details)

5.  Patient selection for epidural and intrathecal access devices

    a.  Patient has chronic intractable cancer pain.

    b.  Temporary catheter: Selected for short-term use for
        approximately seven days postoperatively or to administer test
        doses of epidural narcotics to evaluate if pain can be
        controlled by this route prior to implanting a long-term access.

    c.  Tunneled catheters, ports, or pumps: Selected for long-term use
        for patients with a life expectancy of months.

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6.  Nursing management (West, 1998)

    a.  Specially trained nurses may administer epidural and intrathecal
        medications, as directed by the individual\'s State Board of
        Nursing Practice Act (Goodman, 2000).

    b.  Nurses must be knowledgeable of the principles of epidural drug
        administration.

        1.  Patients will be monitored and managed with the initial dose
            of opiate and with each subsequent increase in dose.

        2.  Patients need to be weaned off other opioids while receiving
            epidural analgesia.

        3.  Notify physician immediately for signs of systemic or local
            inflammation; tenderness or edema; leakage; bleeding; loss
            of skin integrity; change in neurologic status; unusual
            resistance upon infusion of fluids; or alteration of
            circulation, sensation, or mobility in lower extremities and
            complaints of paresthesia.

        4.  Always use Luer-lock connections. Avoid tubing with
            injection ports, or place tape over any injection ports to
            prevent inadvertent administration of other drugs into the
            epidural/intrathecal catheter.

        5.  With continuous infusion administration of medication, tape
            a tension loop of tubing to the patient\'s body to prevent
            accidental dislodgment.

        6.  Only preservative-free normal saline or Elliott\'s B™
            (Orphan Medical, Minnetonka, MN) solution may be
            administered. (Elliott\'s B solution is an artificial fluid
            that approximates the normal ionic composition of CSF.)

        7.  Placement should be checked prior to drug administration by
            gently aspirating. If clear fluid is greater than 0.5 ml or
            if blood is obtained, notify physician and do not administer
            drug. The presence of CSF indicates that the catheter has
            punctured the dura, and the presence of blood may indicate
            that the catheter has punctured the vasculature.

        8.  Patient should be assessed for symptoms of respiratory and
            CNS depression by monitoring the following.

            a.  Quality and rate of respirations

            b.  Breath sounds

            c.  Color of lips and nail beds

            d.  Level of consciousness, sensorium, and arousability

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        9.  Use of an apnea monitor or pulse oximeter is recommended for
            the first 24 hours because the risk of respiratory
            depression is highest during this period. Respiratory
            depression may not occur in patients who have been taking an
            opiate on a long-term basis.

            a.  Delayed respiratory depression usually occurs 3-12 hours
                after administration, but it can occur after as long as
                24 hours.

            b.  Have an oral airway, Ambu bag, and naloxone
                hydrochloride at the bedside for management of
                respiratory depression.

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        10. All patients must have an IV line or Heplock in place for at
            least 24 hours for administration of naloxone, as needed.

        11. Keep head of bed elevated 30 degrees.

        12. Assess for signs and symptoms of urinary retention,
            pruritus, nausea, vomiting, and loss of sensation in lower
            extremities as indications of opioid toxicity or catheter
            migration.

        13. Intensive homecare teaching is imperative to the patient and
            caregiver (Mercadante, 1999).

            a.  Explain injection of medication technique, catheter
                care, dressing changes, infection precautions, and signs
                to report to the physician.

            b.  Maintain frequent telephone contact or home visits.

            c.  Intrathecal treatment is more suitable than epidural for
                home treatment because of lower doses and volume of
                drugs.

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    c.  Routine maintenance and care (Dawson, 2001; Kasuda et al., 2002;
        McIntosh, Spaven, & Hagen, 1999; Paice, DuPen, & Schwertz, 1999)
        (see Appendix 9, page 129 in the original guideline document)

        1.  Site cleansing with an antiseptic solution

            a.  See previous information under Placement.

            b.  Studies with epidural and intrathecal catheters have
                focused on insertion and not on cleansing the port or
                pump site for access. Results are mixed between
                povidone-iodine and chlorhexidine (Kasuda et al., 2002;
                Kinirons et al., 2001).

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        2.  Dressing changes

            a.  See previous description of gauze and transparent
                dressings in Section II-A, page 3 in the original
                guideline document.

            b.  Authors of one study (Mann et al., 2001) found
                chlorhexidine impregnated dressing to reduce bacterial
                colonization of epidural short-term catheter exit sites.

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        3.  Flushing

            a.  Catheter (temporary and permanent): 1-2 ml of
                preservative-free normal saline after use

            b.  Port: 3 ml of preservative-free normal saline after use

            c.  Pump: No flushing required

            d.  Routine flushing not necessary because tip in CSF

            e.  Daily site inspection for drainage, erythema, and edema

            f.  Solutions: Researchers of one study used
                preservative-free epidural solution up to 14 days
                without an occurrence of an infection (McIntosh, Spaven,
                & Haven, 1999).

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    d.  Administering analgesics through catheter or port (see Section
        VII, page 73 in the original guideline document)

        1.  Access using procedure described previously for venous ports
            and tunneled catheters, with the exception of using sterile
            gloves (Goodman, 2000).

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        1.  Gently aspirate 1 ml. If blood or greater than 0.5 ml of CSF
            is aspirated, notify the physician and do not administer
            drug.

        2.  Slowly and steadily inject the medication.

        3.  Flush the catheter with 1-2 ml of preservative- free normal
            saline, and the port may be flushed with up to 3 ml of
            preservative-free normal saline to ensure medication has
            reached epidural or intrathecal space.

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    e.  Filter and injection cap change: A filter may not be required if
        the drug is filtered prior to drug administration or if the
        portal body contains a filter.

        1.  Change filter (60 micron) and injection cap every week or
            more frequently if damage or leaks occur.

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        1.  Wash hands.

        2.  Prepare appropriate equipment for the procedure.

        3.  Apply sterile gloves.

        4.  Attach the new injection cap to the new filter, and flush
            the system with preservative-free normal saline.

        5.  Clean the connection between the catheter and the filter
            with a povidone-iodine swab, allowing it to dry completely.

        6.  If any excess exists, remove with sterile gauze.

        7.  Remove old filter and injection cap.

        8.  Screw on the new filter and injection cap securely.

        9.  Place a label saying \"epidural\" or \"intrathecal\" around
            the tubing near the hub.

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    f.  Contact homecare agency for follow-up and patient support, if
        appropriate.

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7.  Complications (see the \"Potential Harms\" field for a summary of
    complications or see the original guideline document for full
    details)

8.  Education and documentation (see Section VIII, page 80 in the
    original guideline document)

**Intraperitoneal Catheters**

1.  Description of device (See the original guideline document for full
    details.)

2.  Advantages and disadvantages of catheter selection (see Table 13 in
    the original guideline document for full details)

3.  Patient selection criteria

    a.  Patients receive intraperitoneal (IP) therapy for the following
        malignancies.

        1.  Ovarian cancer (Makhija et al., 2001)

            a.  Microscopic residual disease (less than or equal to
                0.5 cm) after initial surgical debulking

            b.  Consolidation therapy after conventional IV therapy or
                after negative second-look surgery

            c.  Extended therapy after second-look exploration for
                patients with small volume residual disease (less than
                or equal to 0.5 cm)

            d.  Tumor confined to the peritoneum

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        2.  Gastrointestinal malignancies (Horsell et al., 1999)

            a.  Initial treatment in patients with small-volume IP
                disease

            b.  Adjuvant therapy for patients with a high risk of
                relapse

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        3.  Mesothelioma that is limited to the peritoneum (Mongero et
            al., 1999)

        4.  Palliative treatment for ascites in gynecologic,
            gastrointestinal, lymphoma, lung, and breast cancers

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    b.  Patient characteristics

        1.  Patients should be free of abdominal adhesions, which would
            limit even distribution of IP therapy (Berek, 2000).

            a.  If inserted during initial surgical exploration, therapy
                should begin within seven days (Berek, 2000).

            b.  Peritoneal distribution can be checked in radiology
                department by inserting radiopaque dye diluted in 2
                liters of fluid, followed by computed tomography scan of
                the abdomen (Berek, 2000).

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        2.  Patients must have the physical and cognitive ability to
            care for a catheter or have a significant other provide
            care.

        3.  Patient should be able to tolerate large volumes of IP
            fluid.

        4.  Types of IP therapy: IP chemotherapy is still controversial
            and is not the standard of care because of toxicities,
            technical difficulties of delivery, and absence of
            taxane-era randomized data (Makhija et al., 2001). IP
            chemotherapy has not shown an increase in overall survival
            versus conventional therapy, except in patients with stage
            III ovarian cancer.

            a.  IP chemotherapy delivers a high concentration of drug
                directly to the peritoneal space. Drugs that achieve the
                best peritoneal/plasma concentration ratio are those
                that have a high molecular weight, extensive first pass
                hepatic inactivation, and rapid plasma clearance
                (Makhija et al., 2001).

            b.  Chemotherapy can directly penetrate into the tumor by
                means of free surface diffusion and through the blood
                vessels that nourish the tumor.

            c.  Drugs can be given in higher doses than intravenous
                route, providing prolonged tumor exposure with decreased
                systemic effect (as the majority of drug is detoxified
                by the liver) to minimize the appearance of
                drug-resistant cells and to obtain higher clinical
                response.

            d.  Drug remains in the peritoneal cavity according to the
                drug clearance properties (Sakuragi et al., 2000).

                i.  Drugs used are specific to the disease being
                    treated.

                ii. Drugs considered venous irritants and vesicants have
                    a similar effect on the peritoneum, causing pain,
                    burning, and sclerosing. They may be chosen for
                    their sclerosing effect rather than their
                    antineoplastic effect (Walczak & Heckman, 1999).

                iii. Drugs that have a high local toxicity that causes
                     pain and the tendency to create adhesions are not
                     used for planned multiple-course therapies (Walczak
                     & Heckman, 1999).

                iv. IP administration of biologic response modifiers,
                    such as interferon, interleukin-2, and tumor
                    necrosis factor, has been researched extensively.
                    Rationale for use is the enhancement of the immune
                    system and for cytotoxic effect. They may be given
                    in combination with chemotherapy (Hirte et al.,
                    1997; Sartori et al., 2001).

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            e.  Drainage of chronic ascites accumulation in the
                palliative setting for gynecologic, gastrointestinal,
                lymphoma, and other cancers. Patients experience severe
                discomfort from fluid accumulation, as evidenced by
                shortness of breath, inability to eat, decreased
                mobility, abdominal pain, and fatigue (Eriksson &
                Frazier, 2000).

                v.  Patient has intractable ascites that requires
                    multiple paracentesis.

                vi. Ascites fluid must be clear, nonmucinous.

                vii. Prognosis must be greater than one month.

                viii. Benefits of IP catheter must outweigh risks.

                ix. Patient and family must be able to care for the
                    external catheter.

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4.  Insertion procedures

    a.  External tunneled catheters (Coles & Williams, 2000)

        1.  Consent form is obtained.

        2.  Catheter can be placed at the time of the initial surgical
            exploration for the disease, laparoscopically under general
            anesthesia, or as a separate surgical procedure under local
            anesthesia, with or without IV sedation. Omentectomy is
            highly recommended (Reissman et al., 1998), if not already
            performed during the initial cancer surgery.

        3.  The catheter is placed through the anterior abdominal wall
            at the level of the umbilicus.

        4.  The entire IP segment of the catheter, with its multiple
            exit holes, must be placed in the peritoneum to avoid drug
            extravasation. The tip of the catheter is directed toward
            the cul de sac of the pelvis (Berek, 2000).

        5.  After closure of the peritoneum, an SC tunnel is made to
            minimize infection and prevent dislodgment.

        6.  The external portion of the catheter is placed away from the
            initial puncture site and sutured in place until adequate
            healing around the cuff occurs.

        7.  The external catheter is placed off the side of the midline
            and away from the belt line to provide easy access for the
            patient.

        8.  Dacron cuffs are placed as previously described. Single
            Dacron cuff catheters are used primarily in oncologic
            situations because of the decreased length of time they will
            be used (usually less than a year) and because the surgical
            placement is more simple. Both single- and double-cuff
            catheters have been shown to be equally effective in
            preventing infection (Eklund et al., 1997).

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    b.  Implanted SC port (Makhija et al., 2001)

        1.  The catheter can be placed during the initial surgical
            exploration for the disease, laparoscopically under general
            anesthesia, or as a separate surgical procedure under local
            anesthesia with or without sedation. Omentectomy is
            recommended.

        2.  The IP catheter portion of the device is placed as it is in
            the external catheter procedure (see Section II-H, page 46
            in the original guideline document).

        3.  After closure of the peritoneum, an SC tunnel is made to the
            selected port site, preferably over a bony prominence
            (usually a lower rib) to stabilize access.

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5.  Postoperative care (Elkabir et al., 1999; Moore et al., 1998)

    a.  Assessment of the patient for surgical complications

        1.  Pain at the exit site: Administer analgesics. Pain resolves
            in five to seven days.

        2.  Bleeding into the peritoneum: Patients may have continuous
            exchanges of 1 liter dialysate with no dwell time until the
            returned fluid is clear. Bleeding may be significant enough
            to require blood transfusions.

        3.  Potential for bowel perforation: Assess patient for severe
            abdominal pain, fever, and tense abdomen. Monitor bowel
            sounds.

        4.  Peritonitis: Assess patient for fever, nausea, vomiting,
            severe abdominal pain, and cloudy peritoneal fluid. If
            peritonitis is suspected, send cultures and administer
            antibiotics and analgesics as ordered.

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    b.  Assessment of catheter complications (Coles & Williams, 2000)

        1.  Leakage around the exit site of the external catheter:
            Chemotherapy is avoided for five to seven days to minimize
            leakage. The first course of chemotherapy may be placed in
            1,000-1,200 ml of fluid, with subsequent treatments in 2,000
            ml when the area has completely healed (Gynecologic Oncology
            Group, 2001).

        2.  Tunnel or exit site infection: Assess wound for drainage,
            erythema, and tenderness. Administer antibiotics as ordered.
            Maintain aseptic technique when caring for the catheter.

        3.  Catheter dislodgment: Assess patient for abdominal pain.
            Assess exit site for absence of sutures on the external
            catheter or for the presence of a visible Dacron cuff
            exuding from the skin. Notify physician of dislodgment of
            catheter. Implanted port catheter dislodgment may be
            evidenced by an inability to flush or drain off fluid.

        4.  Nonfunctioning catheter: Assess ability to flush or withdraw
            peritoneal fluid. Reposition patient, and attempt to flush
            with sterile normal saline (NS). Administer heparin flush
            (10-100 units/ml). Notify physician of problem. Dye studies
            may be required to determine cause of problem.

        5.  Bleeding: Assess exit site dressing for bleeding. Apply
            pressure if necessary. Notify physician of excessive amount.
            Assess peritoneal fluid for blood. Patient may require
            flushing of the peritoneal cavity with a few cycles of
            dialysate or NS solution containing heparin (500 units/l) to
            minimize the chance of clotting in the catheter (Coles &
            Williams, 2000).

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    c.  Education of the patient and family (Moore et al., 1998)

        1.  Treatment regimen, rationale, side effects, and signs of
            infection (for both catheters)

        2.  For external catheters: Exit site care, catheter care, and
            frequency of dressing and cap changes

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6.  Removal of devices

    a.  External catheters can be removed at the bedside or in the
        operating room under local anesthesia. Late complications of
        abscesses at the exit site from the retained Dacron cuff if
        removed at the bedside have been documented. Therefore, when
        therapy is completed, it is recommended that the catheter be
        completely removed surgically to prevent long-term complications
        of catheter migration, abscess, or persistent tunnel infections
        (Elkabir et al., 1999; Ghosh, Geller, & Twiggs, 2000).

    b.  Implanted SC ports require removal in the operating room under
        local anesthesia or may remain in place indefinitely.

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7.  Maintenance care (Gynecologic Oncology Group, 2001) (see Appendix
    10, page 130 in the original guideline document)

    a.  Aseptic technique is required to prevent catheter tunnel
        infection and peritonitis. All equipment must be sterile. Use of
        sterile mask and gloves is highly recommended because of the
        vulnerability of the patient population to infection (Lee, Lau,
        & Yeong, 2000; Murphy & Rossi, 1995).

    b.  External catheters are accessed with needleless (or needle-free)
        system.

        1.  Open supplies, including syringe, needleless connections,
            catheter cap and catheter clamp, gauze, gloves, and mask,
            onto a sterile field.

        2.  Cleanse exit site, catheter, and catheter cap using
            povidone-iodine swabs in an outward spiral fashion, being
            careful not to go over the same area twice. Allow to air
            dry. Alcohol or acetone-based cleaning solutions are not
            recommended, as they are incompatible with the polymer
            material used to develop these catheters (Corpack
            Medsystems, 2001; Vas-Cath, 1988).

        3.  Change the sterile needleless cap before connecting infusion
            tubing.

        4.  Flush catheter with 20 ml sterile NS to ensure patency.

        5.  Withdraw peritoneal specimen for testing as ordered. Assess
            characteristics of fluid.

        6.  Connect patient to infusion tubing; start infusion and
            assess for leakage, ease of flow, SC infiltration, and pain.

        7.  Apply occlusive dressing, and anchor tubing with a stress
            loop to prevent excess pulling.

        8.  Administer treatment as ordered.

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    c.  Implanted port requires noncoring needle to access (Gynecologic
        Oncology Group, 2001).

        1.  Open supplies, including syringe, noncoring needle, catheter
            cap, gauze, mask, and gloves into a sterile field.

        2.  Draw up 20 ml sterile NS aseptically, attach needleless cap
            to noncoring needle tubing, and prime with NS.

        3.  Cleanse access site with cleansing agent.

        4.  After inserting needle into port (see page 47 of the
            original guideline document), flush with 20 ml sterile NS to
            ensure patency. Assess for leakage, ease of flow, SC
            infiltration, and pain. Withdraw peritoneal specimen as
            ordered.

        5.  Connect patient to infusion tubing: Start infusion and
            assess for SC infiltration, leakage, ease of flow, and pain.

        6.  Apply occlusive dressing, and anchor tubing with a stress
            loop to prevent excess pulling.

        7.  Administer treatment as ordered.

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    d.  After treatment is complete, the catheter is clamped. Fluid
        dwells in abdomen for length of time ordered by physician,
        usually four to six hours.

    e.  Fluid may be drained off or allowed to absorb per physician
        order.

    f.  The external catheter is flushed aseptically with 20 ml sterile
        NS. The implanted port is flushed with 20 ml sterile heparinized
        saline (10--100 units/ml) to maintain a heparin lock in the
        portal chamber, and tubing is disconnected. It is also
        recommended that implanted peritoneal ports be flushed with
        heparin once a month per the manufacturer.

        1.  The external catheter dressing remains in place for one week
            in the immediate postoperative period, unless excess soiling
            occurs. After the first week, dressings are changed three
            times a week; catheter caps and clamps are changed once a
            week.

        2.  A new sterile dressing is placed over the access site of the
            implanted port after the needle is removed and remains in
            place for 48 hours.

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8.  General practice issues (Moore et al., 1998) (see the original
    guideline document for full details)

    a.  Administration of IP fluids and medications

        1.  Verify order and review patient labwork.

        2.  Explain procedure to patient.

        3.  If ordered, insert indwelling urinary catheter to facilitate
            monitoring of intake and output. Place patient in
            semi-Fowler\'s position to promote comfort.

        4.  Establish IV line, and administer ancillary medication,
            including antiemetics. Although peritoneal drugs have fewer
            systemic effects than IV drugs, some of the drug crosses
            into the venous system, especially if IP drug is allowed to
            be absorbed instead of drained. Controlling systemic effects
            with IV drugs allows for significant dose escalation.

        5.  Drain fluid prior to infusion of chemotherapy so patients
            with large volumes of ascitic fluid may tolerate the therapy
            better.

        6.  Warm IP fluid to body temperature to minimize cramping and
            shivering by soaking IP fluid in warm bowl of water or using
            heating pad.

        7.  Infuse fluid as ordered, usually over 30 minutes to two
            hours. In adult patients, a minimum of 2 liters of fluid is
            required to ensure distribution of drug throughout the
            peritoneal cavity. Chemotherapy, placed in 1 liter of fluid,
            and 1 liter of NS is connected to dialysis tubing. The
            infusion is begun with 300 ml of NS, which allows the nurse
            to evaluate the ease of flow, presence of leakage,
            loculation, or extravasation. If no complications, the NS
            can be stopped, and the chemotherapy can be infused. The
            complete 1 liter of chemotherapy is given and followed by
            the remainder of the 1 liter of NS to flush the line. For
            infusions on sequential days, 1 liter of fluid is
            sufficient, because the peritoneal space can absorb
            approximately 1 liter of fluid in 24 hours.

        8.  When fluid has infused, close clamp for duration of dwell
            time, usually 4-6 hours. During that time, assist the
            patient to turn from side to side every 15-30 minutes to
            improve distribution throughout the abdomen.

        9.  After dwell time, if ordered, open drainage clamp and allow
            fluid to drain for 30 minutes to 2 hours. If fluid will not
            drain, attempt to reposition the patient, instruct patient
            in Valsalva maneuver, apply manual pressure to abdomen, or
            irrigate catheter with sterile NS. Drainage is more rapid
            with an external catheter, but the implanted port will allow
            drainage of 2 liters in about 1-2 hours.

        10. Instruct patient, if an outpatient, to wear loose clothing
            with expandable waistline and to arrange for transportation
            home.

        11. Disconnect all tubing as previously described. Apply new
            dressing.

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    b.  Palliative use of the IP catheter for drainage of ascites in
        selected patients: Patients and families may be taught how to
        perform this procedure in the home with the support of homecare
        or hospice services (Lee, Lau, & Yeong, 2000; Murphy & Rossi,
        1995).

        1.  The catheter is accessed as previously described.

        2.  Fluid is drained, using a needleless system, into a drainage
            bag, via gravity or with the use of vacuum bottles.

        3.  Assess the patient\'s reaction to fluid drainage. A roller
            clamp may be used to adjust rate of drainage if patient
            becomes orthostatic, as evidenced by complaints of
            light-headedness or dizziness, or experiences pain.

        4.  After drainage is complete, tubing is disconnected, with an
            occlusive dressing placed over the site, as previously
            described.

        5.  Education of the patient and family about the external
            catheter should include the following.

            a.  Exit site, catheter, and cap care

            b.  Dressing change three times a week, which can be done by
                the family

            c.  Weekly cap and clamp change

            d.  Implanted port does not require dressing change and
                access site cleaning when not in use. Family can be
                taught to access device.

            e.  Signs and symptoms of infection

            f.  Signs and symptoms to call physician

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9.  Complications (see the \"Potential Harms\" field for a summary of
    complications or see Table 14 in the original guideline document for
    full details)

10. Education and documentation (see Section VIII, page 80 in the
    original guideline document)

**Implanted Pumps**

1.  Device description (See the original guideline document for full
    details.)

2.  Advantages of continuous infusion therapy

    a.  For all drugs, the peak and valley effect is eliminated.

    b.  Infusion therapy achieves constant drug administration.

    c.  Advantages for antineoplastic drugs include the following.

        1.  Continuous drug administration over many cell cycles yields
            increased cell kill (Martin, 2002).

        2.  A higher concentration of chemotherapy is delivered to the
            tumor than would be possible with systemic therapy (Kemeny &
            Fata, 2001; Medtronic Neurological, 2001).

        3.  Less acute systemic toxicity occurs because smaller doses
            are infused regionally (Ensminger, 2002).

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3.  Patient selection and treatment criteria

    a.  Patient can be a young adult or adult.

    b.  Patient has sufficient body mass to hold implanted pump.

    c.  Patient has adequate performance status and ability to tolerate
        surgical procedure.

    d.  Patient has a disease and conditions that respond to continuous
        infusion therapy through an implanted pump (Civalleri et al.,
        1998; Damascelli et al., 1999; Ensminger, 2002; Heslin et al.,
        2001; Kemeny, 2001; West, 1998). Hepatic arterial infusion is
        the most common use for an implanted pump. Other indications:

        1.  Colorectal cancer with liver metastasis

        2.  Renal cell carcinoma

        3.  Head and neck tumors

        4.  Brain tumors

        5.  Chronic pain conditions

        6.  Neuromuscular spasticity and dystonia

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    e.  Drugs used in an implanted pump must be Food and Drug
        Administration (FDA) approved for treatment of specific
        diseases.

        1.  Examples of drugs approved for intra-arterial infusion
            include floxuridine, doxorubicin, methotrexate, bleomycin,
            cisplatin, 5-fluorouracil, amikacin, heparin, and glycerin.

        2.  Examples of drugs approved for intrathecal infusion are
            morphine, clonidine, baclofen (Hildebrand, Elsberry, &
            Hassenbusch, 2003), and hydromorphone (Hildebrand, Elsberry,
            & Anderson, 2001). These solutions must be
            preservative-free.

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    f.  Contraindications for pump implantation

        1.  Large-volume infusions required.

        2.  Disseminated disease contraindicated for regional therapy

        3.  Brief life expectancy

        4.  Evidence of infection (Medtronic Neurological, 2001)

        5.  Programmable pump contraindicated

            a.  When pump cannot be implanted less than 2.5 cm from
                surface

            b.  When patient has another implanted, programmable device,
                such as a pacemaker

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4.  Patient setting

    a.  Can be used in all settings by trained personnel (Manufacturer
        representatives are available resources.)

    b.  Reimbursement

        1.  Pump placement is usually reimbursable.

        2.  Reimbursement for non-FDA approved uses must be considered
            on a case-by-case basis with each patient\'s insurance
            company. The insurer considers the research base for the
            route and drug regimen, as well as the patient\'s life
            expectancy.

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5.  Insertion procedures and perfusion checks (Curley et al., 1993)

    a.  See appropriate sections for the insertion procedures of
        arterial (III) or intrathecal (V) catheters.

    b.  Catheter insertion and pump implantation may be performed as
        separate procedures or during the initial tumor resection
        procedure.

    c.  Pump implantation is performed in the operating room under
        anesthesia after obtaining informed consent.

    d.  Pumps are most commonly inserted through an open surgical
        procedure. A laparoscopic technique can be used to insert pumps
        in the abdomen (Urbach et al., 2001).

    e.  Pump reservoir is filled and catheter access port is flushed
        after connecting the catheter to the pump.

    f.  Incision for pump pocket is approximately 8 cm long and is
        located in the lower left or right quadrant of abdomen, below
        umbilicus or in the infraclavicular fossa for head, neck, and
        brain tumors.

        1.  The pump is placed in the subcutaneous pocket and sutured to
            the fascia with nonabsorbable sutures. To avoid stress on
            the suture line when the pump is accessed, the suture line
            should not transverse the center or secondary port septums.

        2.  The incision is closed and covered with a sterile dressing
            or pressure dressing.

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    g.  The pump is initially accessed four to six days postoperatively.

    h.  A perfusion check is performed.

        1.  Catheter tip placement and desired site of infusion are
            verified intraoperatively.

        2.  Postoperative days four through six and before drug therapy
            is initiated, a perfusion study or x-ray is done to verify
            region of perfusion and catheter tip placement.

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6.  Postoperative care

    a.  Assess implantation site for bleeding, drainage, swelling, or
        seroma.

    b.  Maintain pressure dressing for 24 hours or until no bleeding is
        present.

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7.  Removal: The pump is removed in the operating room under local
    anesthesia, and the catheter is removed subcutaneously.

8.  Patient education

    a.  Patient should report any edema, fever, erythema, or pain at
        site (Medtronic Neurological, 2001).

    b.  Provide patient with MedicAlert® (Turlock, CA) emblem, which
        alerts healthcare professionals in emergency situations, and a
        pump identification card for when the device triggers metal
        detectors.

    c.  General activity restriction: Avoid sports or activities that
        might cause injury or dislodgment of pump.

    d.  IsoMed pump: Avoid extended exposure to activities that may
        alter pump temperature and therefore pump flow rate (Medtronic
        Neurological, 2001).

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9.  General practice issues (Goodman, 2000; Martin, 2002; Medtronic
    Neurological, 2001; West, 1998)

    a.  The nurse should be familiar with the device, drug-related
        complications, and demonstrate implanted pump access competency.
        Education materials and clinical representatives are available
        from the manufacturer.

    b.  Identify the pump model number, reservoir size, and flow rate
        (Medtronic Neurological, 2001).

    c.  Use aseptic technique when accessing the pump septum.

    d.  Position the needle properly in the reservoir of the pump prior
        to drug instillation.

        1.  Access the pump reservoir and not the secondary port.

        2.  Improper injection through the secondary port (resulting in
            bolus administration) or into the subcutaneous tissue may
            result in precipitation, overdose, or extravasation
            (Medtronic Neurological, 2001).

        3.  Incorrect needle placement may damage the segment of the
            catheter in the pump pocket.

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    ```
    e.  The pump must be refilled on a schedule. The interval depends on
        drug concentration, drug stability, pump reservoir volume, daily
        dose, and various treatment considerations. The pump should
        never become completely empty.

        1.  Drugs must be stable for the length of infusion time in the
            pump and compatible with the pump\'s composition material.

        2.  Bolus injections through the secondary port do not have the
            constraints of compatibility or stability because of the
            minimal contact time with the material and speed of infusion
            (Graham & Holohan, 1994).

        3.  Plan refill schedule, taking into account any office
            closures and patient vacations and holidays. The pump
            usually requires a refill every two weeks.

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    ```
    f.  Overfilling the pump reservoir will result in over
        pressurization and over infusion of medication.

    g.  Drug dose calculations are as follows.

        1.  Use manufacturer guidelines for calculating amount of drug
            needed to refill the pump (see Figure 9 in the original
            guideline document for an example of calculating an FUDR
            infusion refill).

        2.  Intra-arterial infusion will require liver function tests
            prior to calculating dose.

        3.  Calculate daily dosage needed.

        4.  Calculate next refill date.

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    ```
    h.  Fluid should return immediately after accessing. If fluid is not
        obtained after accessing reservoir, do the following.

        1.  Verify the needle is through the septum and in the pump
            reservoir.

            a.  Manually palpate pump features.

            b.  Ensure the needle is against the stop.

            c.  Check last refill date to ensure pump is not empty.

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        ```
        2.  If the septum cannot be located, notify a physician. An
            x-ray of the pump can verify its location.

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    ```
    i.  Inform physician of the following situations.

        1.  Inability to obtain fluid from the pump after access

        2.  Signs and symptoms of infection

        3.  Development of pump erosion or seroma

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    ```
    j.  Document refill information.

        1.  Date and time of refill

        2.  Number of days since last refill

        3.  Return volume from pump after access

        4.  Infused volume (previous refill volume minus return volume)

        5.  Pump flow rate (infused volume divided by number of days
            since last refill)

        6.  Pump drug concentration

        7.  Drug refill volume

        8.  Injection via secondary port

        9.  Patient\'s response to procedure

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10. Access procedures (Medtronic Neurological, 2001) (see Figure 10 in
    the original guideline document)

    a.  Supply kit contents and access/refill procedures for the
        Medtronic pumps are outlined in Table 17 in the original
        guideline document. A programmer is necessary to change the flow
        rate of the SynchroMed pump. Adjusting the rate and obtaining
        printouts on the SynchroMed pump are beyond the scope of this
        module. Contact the manufacturer for this information.

    b.  Accessing the secondary port of either pump is similar to
        accessing an implanted port (see Section II-H, page 47 in the
        original guideline document). However, the precise procedure can
        be obtained through the manufacturer guidelines before accessing
        the port.

    c.  Solutions used for maintenance infusion or between drug
        intervals include the following.

        1.  Intra-arterial: Heparinized NS (1,000 u/ml).

        2.  Intrathecal: Preservative-free NS

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    ```
    d.  The pumps require the use of a 22-gauge noncoring needle to
        preserve the integrity of the septum.

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11. Complications (see the \"Potential Harms\" field for a summary of
    complications or see Table 18 in the original guideline document for
    full details)

12. Education and documentation (see Section VIII, page 80 in the
    original guideline document)

**Education and Documentation Issues for Access Devices**

1.  Ensure that patient\'s or significant other\'s teaching about access
    device is documented in the healthcare record.

2.  Nurse education and competency in caring for patients with access
    devices are documented in personnel records.

**Controversial Issues**

See the original guideline document and Table 19 for a summary of
controversial issues.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=8338)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence is not specifically stated for each recommendation.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Nurses properly educated and trained in the use of access devices
    should provide care, and instruction to the patient, that will
    result in a reduction in the number and type of complications
    associated with the use of access devices.

-   The quality of life of patients with cancer has improved
    dramatically in the past decade with the development of access
    device technology.

#### POTENTIAL HARMS

Refer to Table 4 in the original guideline document for a list of
general insertion complications of vascular access devices (VADs). The
following is a summary of complications associated with specific
devices. Refer to the original guideline document for full details.

**Peripheral Intravenous Catheters**

-   Bleeding

-   Vein injury

-   Nerve injury

-   Infiltration

-   Phlebitis

-   Thrombosis

-   Infection

**Subcutaneous (SC) Infusion Devices**

-   Local reaction including insertion site erythema, edema, induration,
    and pain/discomfort

-   Leakage or pooling of fluid at the insertion site

-   Obstruction

-   Sloughing of tissue

-   Infection

-   Puncture of vessels

-   Fluid overload

**Midline Catheters**

-   Same as peripheral IV catheters above

**Peripherally Inserted Central Catheters (PICCs)**

-   Refer to vascular access device section and Tables 4 and 5 in the
    original guideline document for details.

**Central Venous Lines**

-   Refer to vascular access device section and Table 4 in the original
    guideline document for details.

**Tunneled Central Venous Catheters (CVCs)**

-   Refer to vascular access device section and Tables 4 and 5 in the
    original guideline document for details.

**Implanted Venous Port & Apheresis/Hemodialysis Catheters**

-   Refer to vascular access device section in the original guideline
    document for details.

**Arterial Access Devices**

-   The most common complications are infection, catheter
    migration/dislodgment, occlusion/thrombosis, and bleeding at the
    exit site. Refer to Table 10 in the original guideline document for
    full details. In addition, less common complications include
    percutaneous arterial catheter leak, hepatic artery injury, arterial
    spasm during insertion or infusion, cerebral vascular accident,
    migrating embolization coils or microcoils, and skin reaction.

**Intraventricular Access Devices**

-   Infection

-   Malposition or migration of catheter

-   Bleeding

**Epidural and Intrathecal Access Devices**

-   Infection

-   Malposition or migration of catheter

-   Bleeding

-   Disconnection of catheter from portal body

-   Fibrosis formation

-   Dislodgment of needle from port

-   Erosion of port or pump through skin

**Intraperitoneal Catheters**

-   Patient discomfort

-   Inflow failure

-   Outflow failure

-   Drug extravasation

-   Exit site infection

-   Tunnel infection

-   Peritonitis

-   Slow infusion rate of solution

-   Systemic toxicity of the chemotherapy administered

-   Leakage at exit site

-   Chemical peritonitis

-   Sclerosing encapsulating peritonitis

Refer to Table 14 in the original guideline document for additional
details.

**Implanted Pumps**

-   Local reactions

-   Catheter occlusion

-   Equipment problems

-   Infection

-   Extravasation of vesicant

-   Pump inversion in subcutaneous pocket

-   Drug crystallization

-   Skin necrosis over pump

Refer to Table 18 in the original guideline document for additional
details.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

-   Alcohol- and iodine-containing products may be contraindicated for
    use to clean or come in contact with certain catheter materials and
    some types of protective caps. Contact may weaken or compromise the
    material over time.

-   Use of heparin may be contraindicated in patients at risk for
    heparin-induced thrombocytopenia.

-   If a nontunneled catheter is involved, a guidewire exchange of
    catheter may be contraindicated because the infection could be
    reintroduced into the bloodstream.

-   Midline catheters are contraindicated for solutions with final
    concentrations \>10% glucose or \>5% protein.

*Contraindications for Subcutaneous Infusion Devices*

-   If patient has generalized edema, poor peripheral circulation, or
    minimal subcutaneous (SC) tissue, although cachexia is not an
    absolute contraindication for subcutaneous infusion

-   When rapid control of severe pain or frequent boluses or changes are
    needed

-   If patient has a bleeding or coagulation disorder

-   When rapid infusion or more than 3,000 ml/24 hours are required

*Intravenous Therapy Planned Appropriate for Midline Catheter*

-   *Contraindicated intravenous fluids include*:

    -   Continuous infusion of vesicants

    -   Solutions with glucose concentration \>10%

    -   Solutions with protein concentration \>5%

-   Performing the Valsalva maneuver decreases the risk of air embolism
    during catheter removal. The maneuver is contraindicated in patients
    with increased intracranial pressure or if intubated.

    -   *Contraindications for arterial access*:

        -   Acute infection, prolonged fever, and absolute neutrophil
            count \<1,500 mm^3^

        -   Severe coagulopathy

    -   *Contraindications for pump implantation*

        -   Large-volume infusions required

        -   Disseminated disease contraindicated for regional therapy

        -   Brief life expectancy

        -   Evidence of infection

        -   Programmable pump contraindicated

            -   When pump cannot be implanted less than 2.5 cm from
                surface

            -   When patient has another implanted, programmable device,
                such as a pacemaker

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

The guideline document was published by the Oncology Nursing Society
(ONS). ONS neither represents nor guarantees that the practices
described therein will, if followed, ensure safe and effective patient
care. The recommendations contained in the guideline document reflect
ONS\'s judgment regarding the state of general knowledge and practice in
the field as of the date of publication. The recommendations may not be
appropriate for use in all circumstances. Those who use the guideline
document should make their own determinations regarding specific safe
and appropriate patient-care practices, taking into account the
personnel, equipment, and practices available at the hospital or other
facility at which they are located. The editors and publisher cannot be
held responsible for any liability incurred as a consequence from the
use or application of any of the contents of these guidelines. Figures
and tables are used as examples only. They are not meant to be
all-inclusive, nor do they represent endorsement of any particular
institution by the ONS. Mention of specific products and opinions
related to those products do not indicate or imply endorsement by ONS.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Staff Training/Competency Material

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness\
Safety

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Oncology Nursing Society (ONS). Access device guidelines:
recommendations for nursing practice and education. 2nd ed. Pittsburgh
(PA): Oncology Nursing Society (ONS); 2004. 141 p. \[433 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1996 (revised 2004)

#### GUIDELINE DEVELOPER(S)

Oncology Nursing Society - Professional Association

#### SOURCE(S) OF FUNDING

Oncology Nursing Society

#### GUIDELINE COMMITTEE

Not stated

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Authors*: Diane G. Cope, PhD, ARNP-BC, AOCN; Susan A. Ezzone, MS, RN,
CNP; Mary E. Hagle, PhD, RN, AOCN; Debra J. McCorkindale, RN, BSN;
Andrea B. Moran, RN, BSN, OCN; Judith K. Sanoshy, RN, BSN, OCN; Lois A.
Winkelman, RN, MS, AOCN

*Reviewers*: Deborah L. Bolton, RN, MN, CNS, NPIII, OCN; Eileen Danaher
Hacker, PhD, RN, AOCN; Suzanne LaVere Herbst, RN, MA; Patricia A.
Spencer-Cisek, MS, APRN-BC, AOCN; Lisa Schulmeister, RN, MN, CS, OCN;
Jennifer S. Webster, MN, MPH, RN, CS, AOCN; Laura J. Zitella, RN, MS,
ACNP, AOCN

*Editor*: Dawn Camp-Sorrell, MSN, FNP, AOCN

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of this guideline.

This guideline updates a previous version: Oncology Nursing Society
(ONS). Access device guidelines: recommendations for nursing practice
and education. Pittsburgh (PA): Oncology Nursing Society; 1996. 83 p.

#### GUIDELINE AVAILABILITY

Electronic copies: Not available at this time.

Print copies: Available for purchase from the Oncology Nursing Society,
125 Enterprise Drive, Pittsburgh, PA 15275-1214; telephone,
412-859-6100; fax, 412-921-6565. The ONS Publications Catalog is
available online at the [Oncology Nursing Society (ONS) Web
site](http://www.ons.org/).

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on June 5, 1999. The information was
verified by the guideline developer as of June 30, 1999. This summary
was updated by ECRI on May 4, 2006. The updated information was verified
by the guideline developer on May 24, 2006. This summary was updated by
ECRI Institute on June 22, 2007 following the U.S. Food and Drug
Administration (FDA) advisory on heparin sodium injection. This summary
was updated by ECRI Institute on March 14, 2008 following the updated
FDA advisory on heparin sodium injection.

#### COPYRIGHT STATEMENT

This summary is based on the original guideline, which is copyrighted by
the Oncology Nursing Society (ONS).

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
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Guidelines represented on the NGC Web site are submitted by guideline
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Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

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Date Modified: 11/3/2008