Clinical practice guidelines for breast cancer implantable intravenous infusion ports: Chinese Society of Breast Surgery practice guidelines 2021



## Level of evidence and recommendation strength
Level of evidence standard [bib_ref] Clinical practice guidelines for sentinel lymph node biopsy in patients with early-stage..., Ye [/bib_ref] Recommendation strength standard [bib_ref] Clinical practice guidelines for sentinel lymph node biopsy in patients with early-stage..., Ye [/bib_ref] Recommendation strength review committee A total of 84 members of the voting committee of this guideline, including 71 breast surgeons (84.52%), four oncologists (4.76%), four radiologists (4.76%), two pathologist (2.38%), two radiation therapist (2.38%), and one epidemiologist (1.19%).

## Target audience
Chinese breast disease specialists. Ultrasound localization or intra-operative use of ultrasound-guided venipuncture [bib_ref] Real-time twodimensional ultrasound guidance for central venous cannulation: a meta-analysis, Wu [/bib_ref] [bib_ref] Expert consensus and technical operation guidelines for implantable IV ports in Chinese..., Liu [/bib_ref] I Class A

## Recommendations

## Catheterassociated bloodstream infections
Strict asepsis; empirical use of antibiotics until drug sensitivity test results are available, and selection of drugs based on drug sensitivity after clarification of the infecting agent; removal of intravenous ports when treatment is ineffective [bib_ref] Central venous access in oncology: ESMO clinical practice guidelines, Sousa [/bib_ref] [bib_ref] Expert consensus and technical operation guidelines for implantable IV ports in Chinese..., Liu [/bib_ref] II Class A

## Catheterassociated thrombosis
Avoid repeated punctures; position the catheter tip correctly. Once catheterassociated thrombosis occurs, anticoagulation is preferred [bib_ref] Expert consensus and technical operation guidelines for implantable IV ports in Chinese..., Liu [/bib_ref] II Class A Recommendation 6: Infusion port maintenance.

## Featured content
Level of evidence Recommendation strength 6.1 Maintenance of IV ports by professionally trained health care professionals [bib_ref] Infusion therapy standards of practice, Gorski [/bib_ref] I Class A 6.2 Non-invasive needles should be used for puncture, with replacement of non-invasive needles every 7 daysI Class A 6.3 Catheter return and flow smoothness should be assessed after puncture [bib_ref] Infusion therapy standards of practice, Gorski [/bib_ref] I Class A 6.4 Sterile dressings are required to cover the puncture point and sterile clear dressings should be changed at least every 7 days, with sterile gauze dressings changed at least every 2 daysI 6.5 With syringes of 10 mL and above, the tube was flushed using a pulsatile maneuver and sealed by a positive-pressure maneuver [bib_ref] Infusion therapy standards of practice, Gorski [/bib_ref] II Class A 6.6 Tubes were flushed and sealed with saline or 100 U/mL heparin saline [bib_ref] Infusion therapy standards of practice, Gorski [/bib_ref] I Class A 6.7 Maintenance at least every 4 weeks between treatmentsI Class A

# Discussion
Implantable IV port indications and choice of access IV ports have changed the paradigm of care for patients receiving long-term infusions of cytotoxic or hyperosmolar, viscous drugs. In the literature, the long-term use of internal jugular vein implantation for the infusion port is more effective and safer than that for the subclavian vein. [bib_ref] Implanting totally implantable venous access ports in the upper arm is feasible..., Xu [/bib_ref] Femoral vein placement may be appropriate in cases of obstructed compression of the superior vena cava or other special circumstances. [bib_ref] Totally implantable venous access port via the femoral vein in a femoral..., Kato [/bib_ref] The arm port provides a better patient experience than the chest wall port because the placement site is hidden and there are no problems with changing the patient's dressing habits and exposing the implanted port site.

## Rational positioning of implantable iv port catheter tips
The American Society for Intravenous Infusion Nursing recommended that the tip of the central venous catheter be placed in the lower third of the superior vena cava, adjacent to the junction of the superior vena cava and the right atrium.The European Society for Medical Oncology guidelines recommended the ideal location of the tip at the junction of the superior vena cava and the right atrium. [bib_ref] Central venous access in oncology: ESMO clinical practice guidelines, Sousa [/bib_ref] Guidelines for the implantation and management of central venous access require imaging equipment. [bib_ref] Guidelines on the insertion and management of central venous access devices in..., Bishop [/bib_ref] Randomized controlled trial studies have shown that intra-operative X-ray fluoroscopy significantly reduces the rate of central venous catheter tip ectasia and the need to adjust catheter tip position compared to blind penetration. [bib_ref] Tip malposition of peripherally inserted central catheters: a prospective randomized controlled trial..., Glauser [/bib_ref] Prospective controlled studies have shown that the application of ECG positioning significantly reduces the risk of tip ectasia and is efficient and economical. [bib_ref] The accuracy of electrocardiogram-controlled central line placement, Gebhardre [/bib_ref] [bib_ref] Accurate placement of central venous catheters: a prospective, randomized, multicenter trial, Mcgee [/bib_ref] Prevention and management of common complications of implantable IV ports
Ultrasound-guided internal jugular vein puncture is relatively easy to perform, has fewer complications, and is a safer procedure compared to that in other veins. [bib_ref] Central venous access in oncology: ESMO clinical practice guidelines, Sousa [/bib_ref] The main cause of catheter-associated bloodstream infection pathogenesis is bacterial colonization of intravascular catheters. The typical presentation is chills and hyperthermia with elevated leukocyte counts. When infection is suspected, the use of the IV port should be suspended and intra-port and peripheral blood samples should be drawn for blood culture and drug sensitivity testing. Sensitive antibiotics should be selected for systemic treatment based on these test results. The IV port should be removed immediately upon anti-infective therapy failure. [bib_ref] Central venous access in oncology: ESMO clinical practice guidelines, Sousa [/bib_ref] [bib_ref] Expert consensus and technical operation guidelines for implantable IV ports in Chinese..., Liu [/bib_ref] IV port catheter-associated thrombosis is primarily guided by the formation of blood clots in the external wall of the tube or intra-catheter access. Once thrombosis is established, anticoagulation is preferred [bib_ref] Central venous access in oncology: ESMO clinical practice guidelines, Sousa [/bib_ref] [bib_ref] Expert consensus and technical operation guidelines for implantable IV ports in Chinese..., Liu [/bib_ref] ; furthermore, thrombolytic therapy is generally not recommended.

## Maintenance of implantable iv ports
The implantation and maintenance of IV ports should be performed by individuals and/or teams with educational Chinese Medical Journal 2021;134(16) www.cmj.org backgrounds in infusion therapy. The use of non-invasive needles can protect against the puncturing of the silicone septum of the injection seat. Health industry standards state that non-invasive needles should be changed every 7 days.
The non-invasive needle wing must be fixed and protected using sterile dressings. Sterile transparent dressings should be changed at least every 7 days and sterile gauze excipients should be changed at least every 2 days. The 10-mL syringe is recommended to assess the function of the device, as larger-diameter syringes produce lower injection pressure and help to protect the catheter. Pulsatile maneuvers can create a vortex in the lumen and increase the flushing effect and positive-pressure sealing can prevent blood reflux from the catheter tip. Our health industry standards state that IV ports should be maintained at least every 4 weeks between treatments.

## Removal of implantable iv port
Infusion ports that do not need to be retained or are not suitable for continued retention may be removed. After the removal, the device should be checked for integrity.