Vascular Access Devices: PICCs and Ports

Vascular access devices, or PICCs and ports, allow repeated and long-term access to the bloodstream for frequent or regular administration of drugs, like intravenous (IV) antibiotics.

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Who Needs Vascular Access Devices?

Vascular access devices may help people with cystic fibrosis who need intravenous (IV) antibiotic treatments for more than just a few days, such as during an exacerbation. After a few days, regular IVs can become infected, irritate the small veins, or fall out of the vein. Venous access devices, such as peripherally inserted central catheters (PICCs) are designed to be used for days, weeks, or months. Implantable devices, such as ports, are designed to be used for years. They are made of material that doesn't become infected easily and will remain in place if treated with proper care. Plus, the complication rate is low.

Ports are made of flexible, strong plastic and come in many sizes. They can be split into channels (called lumens) to deliver multiple drugs, but for routine CF care, a single lumen is usually enough. For people who need them, however, double ports are available.

What Kind of Access Devices Are There?

Although there are many different types and brands of access devices, the two main categories are PICC lines and ports. The choice of which one to use is based on how long the catheter will be left in place.

PICCs are used for short-term delivery of IV medications, usually over weeks. Ports are used for longer-term delivery of IV medications, usually over months or often years.

Although PICCs and ports have many similarities, if you need IV antibiotics to treat an exacerbation, you will likely get a PICC line placed. They are much more practical than regular IV catheters, which are often inserted in the crook of the arm or the back of the hand. A PICC can be left in place for several weeks or even months, which may be necessary for people who are on long-term antibiotics.

What Is a PICC?

A PICC line is a long, very thin, flexible tube (a catheter) that is usually placed into one of the large veins in the arm (with a short portion of tube and an injection cap showing). It is secured to your skin with an adhesive device, an internal securing device or stitches. This tube is threaded into a large vein above the right side of the heart.

PICCs are often placed just above or just below the elbow. They are occasionally placed through a vein on the side of the neck or near the collar bone. You may hear the term "midline" catheter. This is a type of PICC, but it is a bit shorter and usually goes through a vein in the upper arms. 

Your care team will use the PICC line to give IV medications or fluids. PICCs are intended for temporary use for people who need therapy only once or twice a year. They typically receive one round of antibiotic treatments before the PICC is removed.

Because the tube is so small and flexible, the line can last several weeks, which means fewer needle pokes and less pain. The PICC line can be flushed and capped when not in use. When it is time to give medicine, the medicine is connected to the PICC line and disconnected again when the medicine is finished. 

What Is a Port? 

An implanted port is a device that allows repeated and long-term access to your bloodstream. It can be used for antibiotics, IV nutrition, and other IV fluids. When someone gets a port placed, they will not need IV catheters like peripheral IVs or PICC lines (unless more than one access is required).

The port is made of two parts: a medical-grade rubber catheter, which is placed in a large vein in the chest (similar to the location of the PICC catheter), and the "port" which is attached to this catheter.

Both of these parts are "implanted," that is, placed completely beneath the skin. No part of the device lies outside the skin. There is usually a small bump, about the size of a nickel. You will not need to wear a bandage after the incision is healed unless the port is being used.

Because the device is completely under the skin, it must be accessed to be used. When medications or other fluids are needed intravenously, the device is reached using a small, right-angled needle (only this type of needle should be used with the port). This fine-gauge needle is inserted through the skin into the rubber round part of the port. You might feel a small prick. If you prefer, a numbing cream can be used. The needle is connected to the IV tubing and capped. 

A dressing (type of bandage) is then applied to protect the area to keep out air, dirt, and germs where the IV is inserted. The IV tubing protrudes from the dressing, allowing you to connect it to your medication. When you no longer need to use the port, the dressing and needle are removed, leaving the intact skin. A nurse, either in the hospital or in the clinic, usually accesses the port. If you like, you or a family member can learn how to do this.

When access to the port is not needed, the port needs to be flushed once a month. This can be done by a nurse, or by you or a family member if you feel comfortable doing it.

Your care team may suggest a port if you need IV antibiotics frequently or if placing a PICC has been difficult because it is hard to locate a vein or the PICC has been painful. One advantage of having a port is that it only has to be placed once to be available for a long time when you need it (and little maintenance is required between infusions).

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What Access Device Is Right for Me?

The advantage of having a port over having a PICC or peripheral IV is that it is a long-term device. A port lasts for many years and may be used repeatedly. When IV access is not needed it stays in place and there is less maintenance. The port does not interfere with your daily activities. It is hidden beneath the skin, with only a small bump to indicate where it is. 

Choose the device that is best for you. If you need help deciding, ask the team of specialists who place implantable devices to give you information about the procedures and to share their experiences. There is minor surgery involved in having a port placed, and there is a device hidden beneath your skin that stays in place, even when you do not receive any medication through it. You may feel self-conscious about how visible the small bump will be. Ask questions of your care team, and speak to a member of the team that will actually be placing the port.

How Do I Prepare for Vascular Access Device Placement?

The care team responsible for your device placement will provide specific pre-procedure instructions. You will receive information about the time you should arrive for placement (if you are at home before placement).

Typical instructions include stopping certain medications or not eating or drinking after midnight the night before the procedure.

What Can I Expect During Placement?
These lines can be placed by many medical professionals who have received special training to perform the procedure. This includes physicians, physician assistants, nurse practitioners, registered nurses, or radiology technicians.  

Different hospitals have different approaches and protocols for the placement of vascular access devices. They are always placed under germ-free conditions. The skin in the area where the device will be placed will be cleaned and disinfected.

What Happens During PICC Placement? 

In some institutions, PICCs can be placed at the bedside with local anesthesia to numb the skin. In others, providers may perform the procedure in the radiology suite. Usually your veins are located using an ultrasonography machine or a fluoroscopy machine (X-ray projected onto a TV screen). After it is placed, you'll probably have an X-ray taken to make sure the catheter is in the right place. Then the PICC is covered with a small dressing to prevent infection.

What Happens During Port Placement?

The procedure to put in a port is more invasive than for a PICC, but usually it's done as an outpatient procedure. Ports are usually placed in the radiology department or in an operating room.

Typical locations for port placement include your upper chest area just below your collarbone or inside the upper part of your arm. The team placing the port will mildly sedate you, numb the area, make an incision about 1 inch long, and then place the port in a skin pocket. Once healed, there will be a bump and a small scar. Once a port is placed, you will need to care for the implantation site while the incision heals. Your care team will give you instructions about how to care for the incision and pain medication if it is necessary.

To start infusions, your team will swab an antiseptic over the port, then pierce the middle part just underneath the skin (called the "septum") with a special type of needle called a Huber needle. Once the needle is in place, you can receive medications or have blood drawn for up to a week before the needle needs to be replaced.

Peter Frey discusses the role he plays in helping use and care for his wife, Mary's, port in the following video.

 

How Do I Care for My PICC?

You can perform most normal activities with a PICC (except swimming) as long as you keep a dry dressing on the site. You can shower by covering the site with a plastic covering. You will also be advised to avoid any type of activity that might irritate or dislodge the catheter. This includes activities that require strenuous use of your arm, such as weightlifting or tennis. Your care team will show you how to keep the site dry and what activities to avoid.

How Do I Prevent Infection in My Vascular Access Device?

Keeping the PICC line clean is a must. It is very important to prevent infection. An infection might require removal of the line. A nurse will show you how to keep your supplies sterile, so that no bacteria can enter the line and cause an infection. The dressing and cap must be changed weekly. You should wash your hands well before handling the line. 

Flushing the PICC Line and General Care

The PICC line must be flushed regularly so fluids will flow easily. If the line becomes clogged, it may have to be removed. A nurse will teach you how to flush the line and give medicines.

To properly care for your PICC line, remember:

  • Don't do any strenuous activity or heavy lifting for the first 48 hours after the line is placed.
  • Never use scissors to remove the tape or dressing from around the line.
  • Always tape the line to your arm to prevent it from snagging on objects.
  • Cover the line with plastic when showering so the dressing does not get wet. (Waterproof cast covers work well.) Do not let the ends of the line hang in the bathwater. 
  • Do not swim or submerse yourself in water.
  • Change the dressing and cap every seven days or sooner if the dressing starts to lift up.
  • Do not participate in rough or contact sports, as the line may move or be damaged. To prevent damage to the line, do not use pins, sharp clamps, or scissors near it. 
  • Avoid having dental work done while the line is in place, as bacteria can be released into the bloodstream and attach to the end of the line. If dental work is necessary, tell the dentist about the line at least five days before the dental work.

Make sure you have information on hand about your PICC line, including: 

  • Home care support
  • Supply company
  • Doctor
  • Line type
  • Size
Problem  Possible Cause  What to Do 
  • Fever, chills
  • Soreness, redness, or pus at the line insertion site
  • Swollen arm 
  • Infection 
  • Take temperature.
  • Call doctor.
  • Flushing problems
  • Unable to push medicine or fluids into PICC line
  • Line may be clamped.
  • Line may be kinked.
  • Line may be clotted. 
  • Unclamp it.
  • Remove the kink.
  • If not kinked or clamped, do not force the solution into the tube. Call the home care nurse. 
  • Leaking from the line
  • Cap on PICC line not screwed on tightly
  • A hole in the line
  • Tighten the injection cap.
  • Check the line for a tear.
  • If you see a leak in the line, clamp it or fold it over and pinch it between the leak and the skin and call your home care nurse right away.
  • If you have trouble breathing or chest pain, lie on left side and call 911. 
  • PICC line accidentally comes out
 
  • Press down on the site for at least 5 minutes.
  • Apply antibacterial ointment and cover it with a bandage.
  • Call your doctor or home care nurse.
  • Redness of skin where the tape was
  • Sensitivity to tape 
  • May need to change and type of tape used
  • Redness and/or tenderness of upper arm
  • Mechanical phlebitis (vein irritation from line) which may occur within first few days after line placement
  • This is not an infection.
  • Apply warm packs.
  • Notify doctor or nurse.
  • Length of exposed line is increased
  • Line has been pulled out partially or completely.
  • Do not push line back in.
  • Cover line with gauze.
  • Call home care doctor or nurse.
  • Whooshing sound in ear
  • Numbness/tingling in arm
  • Discomfort in the jaw, ear, teeth, or face on PICC side of body
  • Line may have moved.
  • Line causing nerve irritation.
  • Stop medication.
  • Notify doctor or nurse.

 

The PICC must be flushed by injecting a small amount of germ-free saline into it. Your care team can show you how to flush the PICC.

Some people find flushing a port difficult. If so, a nurse in the hospital or even a nurse who comes to your home can help you with flushing your port. Many people want to learn to do this themselves to be as independent as possible, but they must be trained to perform flushing properly to reduce the chance of infection at the site of the catheter.

Managing the upkeep of PICCs and ports and monitoring for complications is generally simple, but should be done regularly and with the help of your care team.

How Do I Care for My Port?

When the port is new, you may experience some discomfort. This usually lasts about a week. During those first few days, look for any increase in redness, swelling, drainage, or warmth around the incision on the skin. If you see unusual changes on the skin, notify your CF doctor or nurse. This small incision is normally tender, as any small cut would be, and as it heals this feeling disappears. If you have stitches, they will be removed in the first week or so.

Your doctor may give you some special instructions for caring for your port when it is new. These usually include avoiding lifting your arm on the side where the port is placed and resting for the first 24 hours after the procedure. You may eat your regular diet.

There are usually no restrictions on getting the port wet, as long as the incision is healed and the port is not in use. Check with your CF care team for specific instructions.

Many patients continue to use a vest with a port in place. You can avoid irritation, which can be caused by movement of the vest, by rolling a small washcloth into a log and wrapping it in a circle around the port while you use the vest. 

The manufacturer of your vest may also provide a durable foam piece to prevent irritation while you use your vest. Ask your CF care team about how you can get a durable foam piece or contact the manufacturer of your vest directly. 

Both PICCs and ports need to be flushed with germ-free saline after an infusion of medication to prevent the catheter from getting plugged by a blood clot. Your care team will tell you how often to do this, but it is at least daily for PICCs to about monthly for ports that have not been used. If you are currently receiving IV therapy, you or your nurses will flush the line after each dose of medicine. 

Your device should never be painful or uncomfortable to use. If it is, notify your care team immediately. This could be the beginning of an infection or clot. Your port will be sore for a few days after it has been inserted, but it should be free of discomfort after that.  

Contact your care team if you experience any swelling, redness, or puffiness around your device. This could be an early sign of an infection or a clot.

Although rare, implantable devices can become infected. Contact your care team if you have fever, chills, or other signs or symptoms of infection. Contact your CF health care team if you see these other problem signs: 

  • Leaking from the catheter or site. Leaking may mean a hole or break in your tubing, or blockage in the catheter. Ask your care team to examine your device, and know that it can always be exchanged for a new one (usually at the same site).
  • Blood backing up in your infusion tubing. Blood should not back up in your tubing. If it does, there may be pressure at the catheter tip that can lead to clots. 
  • Resistance to flushing. Feeling resistance may mean you have a clot, which often can be treated at home or in the clinic using clot-busting drugs called thrombolytics.

Will My Insurance Cover Placement?

Insurance plans typically cover placement of a PICC or port, as well as the equipment you will need at home. However, you should check with your insurance provider to ensure that placement and equipment are covered and identify what your out-of-pocket expenses may be.

You can also contact Cystic Fibrosis Foundation Compass, a free, personalized service that can help you with insurance, financial, legal, and other issues. Dedicated Compass case managers can assist in coordinating benefits or providing information about benefits offered under your plans. Contact Compass at:

844-COMPASS (844-266-7277)
Monday - Friday, 9 a.m. - 7 p.m. ET
compass@cff.org

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