CHEST PORT

*This is a basic guide to how to place a port, but it varies so much from doctor to doctor that I may not cover one variant of the placement. 

Reason for exam

•  Central venous access in the setting of long term cancer treatment. 
•  Reliable vascular access needed for other treatment

Supplies

• Ultrasound Probe cover (Ultrasound Machine)
• Micropuncture Kit
• Chest Port Kit
• Dissolvable sutures
• Skin Glue
• Dressing
• Access needle for port if desired for immediate access.

Additional information

• Lidocaine with epinephrine is usually used. 
• Heparin saline will be used to lock the catheter. 
• An antibiotic is usually given at the time of placement
• Traditionally placed on the right. Location can be changed to the left side when other cancer treatment may be affected by port location.
• An antibiotic like 2G of Ancef is typically given or a substitute for allergy
• The case is typically done under conscious sedation

Technique

Verify placement based on history, patient preference, and vein patency. Once placement is verified, you can begin the prep and create a sterile environment. Prep from the side of the neck, up to the ear, and from midline on the chest to shoulder, down to slightly above the nipple line. Line the area with towels or a window drape to create a sterile field. Once your port and table are ready, you can get the doctor. 

*There are many different ways to get the port ready for the doctor. I feel like every doctor does it slightly different. But, the tunneler usually goes on the end of the catheter, the catheter gets flushed, the port gets flushed, and the port may or may not be put together. Ask your doctor how they like their port prepared and make a case card if it is too hard to keep up with. They will also use various sizes of vicryl (absorbable sutures).*

After prepping the ultrasound machine, the doctor will locate the vein and begin by numbing the tissue at the vein. They may or may not numb down their expected track at this time, and they may or may not numb where they will place the port pocket at this time as well.

Once the numbing is complete at the vein, the doctor will use an 11 blade to make a small puncture hole. Next, the micropuncture kit will be used to gain access to the jugular vein. Using the Seldinger technique, the vein is accessed with the needle, a wire is placed through the needle and passed further down the vein. The needle is removed and the micropuncture sheath is placed into the vein over the wire. 

As the assistant, you would pass the wire to the doctor, or if the access is tenuous, you may thread the wire into the needle. You or the doctor will manage the sharps as you go, like placing the needle in the sharps area. Once the needle is out, you may load the micropuncture sheath over the wire. Once you have the micropuncture sheath in, the doctor will remove the inner wire and stiffener, and load the 035 J wire that comes in the kit. 

Now that the wire is in the patient and below the diaphragm, the focus moves to the pocket for the port. After numbing the track and the pocket area, a 15 blade is used to dissect the skin enough to create a pocket big enough for the port reservoir. Many different instruments can be used to create this pocket, like curved hemostats, scissors, finger, etc, and an Army/Navy tool can be used to get the port into the new cavity. 

At some point, either before the pocket is created or after, a tunnel under the skin must be created for the catheter to sit underneath the skin. The tunnel is created from the chest port pocket, to the venotomy with a stiff, blunt rod attached at the end of the catheter. Now that the catheter is cut to desired length, it is ready to go into the body.

The 035 wire that is in the selected vein will now have the micropuncture sheath removed, and exchanged for a peel away sheath. Once the peel away is in place, the inner dilator and the wire will be removed. Now the catheter of the port will be fed into the body as the peel away is removed. 

After verifying that the chest port reservoir and catheter tip is in place with flouro, you can begin to close. A dissolvable suture will be used to bring the skin back together where the pocket was created. Surgical glue or steri strips can be used to keep this wound closed. At the vein in the neck a dissolvable suture or surgical glue or both can be used.

These access points can be dressed by your facility standards, and the port can be left accessed if desired. The catheter is typically locked with low dose heparin saline.

Patient can be discharged in a normal manner.

Lesson Summary

Placing a chest port is essential for central venous access in long-term cancer treatment. The following supplies are necessary:

• Ultrasound Probe cover (Ultrasound Machine)
• Micropuncture Kit
• Chest Port Kit
• Dissolvable sutures
• Skin Glue
• Dressing
• Access needle for port

Key points to note during the procedure:

• Lidocaine with epinephrine is typically used for numbing.
• Heparin saline is used to lock the catheter.
• An antibiotic is given at the time of placement.
• The port is traditionally placed on the right but can be placed on the left if necessary.

The procedure is done under conscious sedation. The process involves verifying placement, preparing the sterile environment, and working closely with the doctor.

The steps to follow during the procedure:

• Prep the area from the side of the neck, up to the ear, and from midline on the chest to shoulder.
• Create a sterile field using towels or a window drape.
• Prepare the port as per the doctor's preferences - flushing the catheter and port, assembling the port, etc.
• Locate the vein using ultrasound, numb the tissue, and create a small puncture hole.
• Utilize the Seldinger technique to gain access to the jugular vein.
• Dissect the skin to create a pocket for the port reservoir.
• Create a tunnel under the skin for the catheter to sit.
• Feed the catheter into the body through the peel-away sheath.
• Verify the position of the port reservoir and catheter tip with fluoroscopy.
• Closing the incisions using dissolvable sutures, surgical glue, or steri strips.

After the procedure is completed, the patient can be discharged in a normal manner, with the catheter typically locked using low-dose heparin saline. Access points can be dressed as per facility standards.