What to do if a patient with no signs of infection reports being unable to feel their port-a-cath (implantable venous access device)?

Management of a Patient Unable to Feel Their Port-a-Cath

When a patient reports being unable to feel their port-a-cath but shows no signs of infection, the patient should undergo prompt radiographic evaluation to determine the position of the port device.

Initial Assessment

When a patient reports they can no longer feel where their port is located, several potential complications should be considered:

1. Port migration - The port reservoir may have shifted from its original implantation site
2. Catheter dislodgement - The catheter portion may have moved from its intended position
3. Fibrin sheath formation - Causing changes in how the port feels through the skin
4. Port rotation - The port may have flipped or rotated within the pocket

Key Physical Examination Findings to Note

• Absence of signs of infection (no erythema, tenderness, warmth, or drainage)
• Inability to palpate the port reservoir
• Any swelling around the previous port site
• Any discomfort when attempting to locate the port

Diagnostic Approach

1. Obtain chest radiograph - This is the first-line diagnostic test to verify port position 1

   • Anteroposterior and lateral views to confirm catheter tip location and port reservoir position
   • Evaluate for any catheter fracture, disconnection, or migration

2. Port function assessment (if port can be accessed)

   • Attempt to flush the port with saline
   • Check for blood return
   • Assess for resistance during injection

Management Algorithm

If Port Is Visualized in Abnormal Position:

1. Do not attempt to access the port until position is confirmed
2. Consult with interventional radiology or the surgical team that placed the port
3. Schedule port repositioning or replacement if migration is confirmed 2

If Port Is in Normal Position but Not Palpable:

1. Consider ultrasound-guided port access to confirm location and functionality
2. Evaluate for potential causes:
   • Weight gain causing deeper port placement
   • Fibrous tissue formation around the port
   • Subcutaneous edema

If Port Shows Signs of Malfunction:

1. Port angiography may be needed to identify specific issues such as:
   • Catheter thrombosis (53.4% of port complications)
   • Pinch-off syndrome (24.2%)
   • Catheter migration (7.2%)
   • Catheter retraction (6.3%)
   • Catheter rupture (4.0%) 3

Special Considerations

• Port migration has been associated with severe cough and vigorous changes in intrathoracic pressure 2
• Catheter fracture or disconnection requires immediate removal to prevent further migration into the heart or pulmonary vessels 4
• Regular monitoring of port position is recommended when the port is not in active use 2

Prevention of Complications

• Obtain chest radiograph before initiating a new course of therapy through the port 2
• Regular evaluation of port function and position, especially in patients with risk factors for complications
• Consider more frequent monitoring in patients with severe cough or conditions that increase intrathoracic pressure

Common Pitfalls

• Assuming infection when the patient cannot feel the port - While infection is a serious complication of ports, inability to feel the port without other symptoms is more likely due to mechanical issues
• Attempting to access a port that cannot be properly palpated - This increases risk of extravasation and tissue damage
• Delaying evaluation - Port migration or catheter dislodgement can lead to serious complications if not addressed promptly

Port-related complications occur in a significant percentage of patients. Early recognition and management of port position issues can prevent more serious complications such as extravasation of medications, catheter embolization, or venous thrombosis.