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Clinical procedure - totally implantable venous access device (TIVAD) - accessing and deaccessing

This resource provides guidance on how to safely undertake the procedure. Institutional practice may vary in accordance with local policy.

Only health care professionals who have attained competency (as per institutional guidelines) should perform this procedure.

Aseptic Non Touch Technique (ANTT®) used for this procedure includes Standard-ANTT®and Surgical-ANTT® r

Standard-ANTT® is a framework and management approach for relatively simple and shorter invasive procedures.

The aim is to maintain asepsis of all Key-Parts using standard precautions (e.g. hand hygiene and non-sterile gloves), a General Aseptic Field (e.g. decontaminated and disinfected procedure tray) and Key-Part Protection by Micro-Critical Aseptic Fields (e.g. sterile caps on syringe tip, inside of recently opened sterile packaging) and non-touch technique.

Surgical-ANTT® is a framework and management approach for more technically challenging or longer procedures with numerous Key-Parts and Key-Sites.

The aim is to maintain asepsis of all Key-Parts and Key-Sites using standard precautions (e.g., hand hygiene and sterile gloves) and Critical Aseptic Field management (e.g., sterile drape, dressing pack).

If TIVAD is to remain accessed: use Surgical-ANTT®

If TIVAD is to be accessed, flushed, locked and deaccessed either: Standard-ANTT® or Surgical-ANTT® can be used. Refer to local policy.

  Related eLearning: Central venous access devices

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  1. Perform hand hygiene
  2. Identify patient as per local policy
  3. Assess the patient:
    1. palpate the TIVAD body to determine depth and orientation to identify the most appropriate length and gauge needle for the individual patient and prescribed treatment
    2. observe TIVAD body site, tunnel and site where the catheter enters the vein for abnormalities e.g. erythema, exudate, swelling and/or tenderness

If abnormalities detected, do not proceed with access and discuss with medical staff

  1. Discuss pain management e.g. use of topical anaesthetic cream/patch with patient, family/carer prior to access and allow appropriate time
    1. remove cream, patch if used prior to access

The following is a list of recommended equipment required to undertake this procedure:

  • trolley 
  • cleaning agent as per local policy
  • waste bag
  • personal protective equipment (PPE)
  • basic sterile dressing pack
  • sterile gloves
  • 2% chlorhexidine gluconate and 70% isopropyl alcohol swab stick
  • needleless connector (if TIVAD to remain accessed)
  • non-coring needle with bonded extension tubing
  • sterile transparent bordered semipermeable polyurethane dressing
  • 10 to 20 mL luer lock syringe/s
  • 10 sterile sodium chloride 0.9% ampoule/s
  • blunt drawing up needle
  • intravenous administration line/s and intravenous fluid/s (as required)

Preparation

  1. Perform hand hygiene
  2. Decontaminate and disinfect trolley as per local policy
  3. Gather equipment
  4. Proceed to patient area and perform hand hygiene
  5. Explain the procedure to the patient, family/carer and obtain verbal consent
  6. Check flushing/locking/intravenous fluids with another health professional as required
  7. Ensure patient is in a comfortable position and TIVAD body is accessible
  8. Perform hand hygiene
  9. Palpate the TIVAD body, identifying the septum
  10. Perform hand hygiene
  11. Set up equipment
  12. Perform hand hygiene
  13. Put on PPE including sterile gloves
  14. Prime non-coring needle
    1. if TIVAD is to remain accessed, attach needleless connector to non-coring needle and prime with sterile sodium chloride 0.9%
    2. if TIVAD is to be flushed, locked and deaccessed – prime non-coring needle with sterile sodium chloride 0.9%, needleless connector not required

Access

  1. Skin antisepsis: clean the skin over the TIVAD body and all skin under the dressing with 2% chlorhexidine and 70% isopropyl alcohol swabstick using gentle friction for at least 30 seconds and allow to fully air dry
  2. Place sterile drape from dressing pack near TIVAD body to create clean area and ask patient not to touch
  3. Locate and stabilise the TIVAD body between the index and middle finger and thumb of non-dominant hand
  4. Inform patient of needle insertion and ask to hold breath (if possible)
  5. TIVAD access (see diagram below): hold non coring needle in the dominant hand and  
    1. insert at a 90o angle with a firm and decisive action through the skin into TIVAD septum (Key-Site) until needle tip touches the bottom of TIVAD body
    2. outlet where the fluid exits the non coring needle faces away from where the catheter enters the TIVAD body
    3. non coring needle sits flush with skin

Diagram of accessing TIVAD

© K Curtis 2021

  1. Ensure extension tubing and needleless connector remains on sterile drape and Key-Parts are protected

TIVAD patency and flushing

  1. Assess patency:

Aspiration - blood return:

  1. attach empty 10 mL luer lock syringe to needleless connector (Key-Part) on extension tubing of non-coring needle 
  2. unclamp non-coring needle extension tubing and aspirate 5 mL blood and discard return, assessing ease of withdrawal. Discard syringe

Injection - flushing:

  1. attach syringe with sodium chloride 0.9% and inject while assessing ease of flushing - using a pulsatile technique and complete with the appropriate clamp-disconnection technique for the type of needleless connector:
Type of needleless connector Completion of flushing technique
Negative clamp PRIOR to finishing flush and disconnecting the syringe
Positive clamp AFTER finishing flush and disconnecting the syringe
Neutral no specific clamping sequence required
Anti-reflux no specific clamping sequence required

Adults: 20 mL using x2 10 mL syringes or x1 20 mL syringe

Paediatrics: as clinically appropriate - at least double the volume of the TIVAD and attachments or as per adults

If not using a manufactured prefilled syringe with antireflux features, leave small volume e.g. 0.5 mL in syringe to avoid ‘bottoming out’ the syringe.

Patency assessment requires checking both aspiration and injection ability

  1. Any alteration to either easy (1) blood return or (2) injection:
    1. primary strategies: reposition the patient, ask patient to take a deep breath, either hold the breath or cough
    2. check needle is appropriately inserted – refer to step 19 a - c
    3. secondary strategy: for TIVADs flushed and locked with sodium chloride 0.9% , flush with 10 to 20 mL of sodium chloride 0.9% using pulsatile action
    4. attempt to aspirate blood again
    5. if still no blood return, discuss with vascular access specialist nurse and refer to CVAD Patency Algorithm
  2. Proceed to step 24 if TIVAD is being deaccessed or step 25 if TIVAD is being used for prescribed therapy 

Locking

  1. Repeat step 20. c with second 10 mL syringe of sodium chloride 0.9%or locking solution as per local policy. Alternatively use x1 20 mL syringe with 20 mL sodium chloride 0.9% for flushing and locking

Apply dressing

  1. If TIVAD is remaining accessed, apply dressing ensuring needle and first part of non-coring needle extension tubing is covered and closed

© K Curtis 2021

  1. Add date and time strip to the side of the dressing

Connecting IV administration lines

  1. Disinfect needleless connector (Key-Part): using non-touch technique, scrub the needleless connector with large 2% chlorhexidine and 70% isopropyl alcohol swab for at least 15 seconds (refer to local policy) using vigorous friction and allow to fully air dry
  2. Using non-touch technique, connect primed IV administration line to the needleless connector (Key-Part) and commence infusion as ordered
  3. Anchor tubing 

Deaccessing TIVAD

  1. Perform hand hygiene
  2. Remove dressing using non-touch technique
  3. Using non dominant hand, stabilise TIVAD body and base of non coring needle between fingers and thumb
  4. With dominant hand, withdraw needle in firm decisive action and engage the safety mechanism on the non-coring needle. Discard immediately into sharps container
  5. Place small, sterile dressing e.g. intravenous pressure dot over site for approximately one hour or if CVAD access required – re-access TIVAD as per Step 14 – 26

Procedure completion and documentation

  1. Discard waste and clean trolley
  2. Remove PPE and discard
  3. Perform hand hygiene
  4. Document the procedure in the medical records 

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Bibliography

Gorski, L. A., L. Hadaway, M. E. Hagle, et al. 2021. "Infusion Therapy Standards of Practice, 8th Edition." J Infus Nurs 44(1S Suppl 1):S1-S224.

No abstract available

Version 6

Date Summary of changes
19/07/2021

Reviewed and updated in tandem with eviQ education CVAD module review. Terminology updated throughout to reflect current evidence base, national and international guidelines. Aseptic Non touch Technique (ANTT®) information and terminology incorporated. Links to CVAD modules added.  Images added relevant to content.

  • Information from ID 899 Clinical procedure - Implanted venous port - deaccessing and locking incorporated and ID 899 archived.
  • Title changed to Clinical procedure - totally implantable venous access device (TIVAD) - accessing and deaccessing.

Sections updated as follows:

  • Pre-procedure updated.
  • Equipment updated.
  • Procedure information updated and presented in following distinct sections: Preparation, Access, TIVAD patency and flushing, Locking, Apply dressing, Deaccessing and Procedure completion and documentation.
  • Links added to new resources - CVAD Patency Algorithm and CVAD assessment and documentation tool.
  • Content updated to reflect current evidence and guidelines.
  • References section added.

Version number increased to V.6. Next review in 2 years.

Version 5

Date Summary of changes
30/10/2019 Reviewed electronically by Nursing Reference Committee. Minor changes to procedure to align with other clinical resources. Links updated. Next review 2 years.

Version 4

Date Summary of changes
12/07/2011 Reformatted to comply with point of care template.
Rationale and references have been moved to the resource document that is linked from this procedure.
22/10/2012 Updated link to flushing and locking table.
01/08/2013 Reviewed and updated with minor changes.
04/03/2015 Reviewed and updated with minor changes.
31/05/2017 Transferred to new eviQ website.

This document reflects what is currently regarded as safe practice. While every effort has been made to ensure the accuracy of the content at the time of publication, the Cancer Institute NSW does not accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omission in the contents of this work. Any reference throughout the document to specific pharmaceuticals and/or medical products as examples does not imply endorsement of any of these products. While eviQ endeavours to link to reliable sources that provide accurate information, eviQ and the Cancer Institute NSW do not endorse or accept responsibility for the accuracy, currency, reliability or correctness of the content of linked external information source. Use is subject to eviQ’s disclaimer available at www.eviQ.org.au

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19 Oct 2021