LONG-TERM IV ACCESS

 

Jerry K. Myers, M.D.

 

     Long-term IV access is necessary in many areas of medicine. Chemotherapy, IV nutrition, IV medications, obtaining blood for testing, and receiving blood products are just a few of the areas where the need for intermittent or continuous long-term IV access is utilized.

     There are several different methods for obtaining access for IV therapies. One method is simply placing an intravenous line either centrally (in the large vein entering the heart called the cava) or peripherally (in the smaller veins in the arms or legs) each time access is needed, for instance for monthly chemotherapy. This not only is uncomfortable for the patient, but also creates a lot of “wear and tear” on the venous system as a whole. This has brought up the development of specialized catheters that can be inserted and left in place for continuous or intermittent long-term usage.

     There are basically two types of these catheters that we currently utilize. The less frequent of the two used is a catheter (Broviak, Hickman, etc.) that enters the central system via the subclavian vein (the vein that runs underneath the clavicle) and is then tunneled for several inches under the skin (to help prevent infections) before it exits externally to be hooked up to IV fluids or have injections placed into it. The obvious disadvantage of this type catheter is that one has an external catheter hanging out of the skin to deal with. One advantage of it is that injections go directly into the catheter tip as opposed to into the skin as with the other type of catheter system.


     The second type of system is the most common and the one we use most of the time. It goes by various names, but is most commonly called an Infusaport. This catheter again enters the subclavian vein to gain access to the central system, but instead of exiting the skin, the catheter is attached to a small reservoir (commonly called a port) that is embedded just under the skin, so that nothing is left externally. Thus, the obvious advantage is there is nothing external to have to deal or hassle with as in the Broviak type device. Access to the reservoir is obtained with a specialized angle-tipped needle (through the skin), and infusions or blood withdrawal are thus obtained through the “Infusaport.” Placement and complications of each catheter are similar, but we will keep our attention mainly on the Infusaport.


     The port is placed under anesthesia in the operating room. Once secured in place, the Infusaport can be used as one would use any other IV – with the added convenience of never have to “hunt” for a vein to place the IV in.


     The Infusaport requires minimal care. The surgical wound must be cared for as in any other surgery. Usually absorbing sutures are utilized, so there are no stitches to remove. If no complications occur, one is usually home as an outpatient. The port will need to be injected periodically with a small amount of heparin (a blood thinner) to keep the lumen of the catheter free of clots. Otherwise, one can resume full activities, basically ignoring the fact that the port exists.


     Although the benefits of having the very convenient IV access, for most people, far outweigh the potential complications, one must be aware of the low but possible problems with the device.

     There are several problems that can occur during the insertion of the device. Although uncommon, one is that some people cannot technically have the device inserted because of some anatomical or physiological problem in doing so. The other is a more potential problem of lung collapse at the time of catheter insertion. When a direct needle stick is done under the clavicle to get into the subclavian vein, the pleura (lining of the lung) may lie so close to the vein that it is punctured while trying to enter the vein. The pleura actually lies only 1-mm from the vein in some people. If this happens, it may present no problem other than observing the condition a day or two in the hospital or may require a chest tube (small tube placed under local anesthesia into the chest to expand the lung) placement for several days. Regardless, the potential of this occurrence must be understood prior to undergoing the port placement.

     The most common problem with the device itself (that can possibly be life threatening) is infection. The device is continuously invaded with needles and various medicines and fluids which present the potential of bacterial infection with each usage. Even though the device is relatively inert, any foreign body presents the possibility of infection. Many of the reasons that the device is being utilized for create an immune deficiency problem that further increases infection risks. If infection occurs – the device is usually removed.


     The next most serious – although uncommon – problem that must be understood is clotting of the subclavian vein in which the catheter lies. This vein drains the blood from the arm, so clotting of it can present a potential long-term problem with swelling of the arm. This is usually a self-limiting problem treated adequately with anticoagulants.


     Other more common problems are functional. The port or catheter might kink or twist. When this happens, it is a nuisance rather than a significant problem, but usually requires surgery to take care of teh pproblem. Occasionally a new device will have to be inserted in the place of the poorly functioning one.


     As stated, most people feel the benefits far outweigh the potential problems that may occur with Infusaports and are very satisfied with their usage. For most conditions, as chemotherapy, the devices are removed at the end of the treatment period with few complications occurring in the interval. They have been a very rewarding addition to many patients needing long-term IV access.

    



 
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