What are the management protocols for a portal catheter?

Management Protocols for Portal Catheters

The management of portal catheters requires strict adherence to evidence-based protocols to prevent complications, particularly catheter-related bloodstream infections (CRBSI), which can significantly impact patient morbidity and mortality. 1

Insertion and Site Care

• Use maximum sterile barrier precautions including cap, mask, sterile gown, sterile gloves, and a sterile full-body drape for insertion of portal catheters 1
• Perform antiseptic skin preparation with >0.5% chlorhexidine preparation before catheter insertion and during dressing changes 1
• Cover the catheter site with either sterile gauze or sterile transparent semipermeable dressing 1
• Change transparent dressings on tunneled or implanted catheter sites weekly until the insertion site has healed 1
• No dressing is required on well-healed exit sites of long-term cuffed and tunneled catheters 1
• Examine the catheter exit site or port cannulation site for proper position and absence of infection by experienced personnel before accessing the system 1

Routine Maintenance

• Do not routinely replace central venous catheters, PICCs, or hemodialysis catheters to prevent catheter-related infections 1
• For port systems, maintain patency using a regular flushing schedule once every 30 days, which is a significant advantage compared to daily maintenance required with externally placed venous catheters 2
• Replace administration sets, including secondary sets and add-on devices, no more frequently than at 72-hour intervals, unless catheter-related infection is suspected 1
• Clean injection ports with 70% alcohol or an iodophor before accessing the system 1
• Cap all stopcocks when not in use 1

Infection Prevention

• Use aseptic technique to prevent contamination of the catheter or port system, including the use of a surgical mask for staff and patient and clean gloves for all catheter connect, disconnect, and dressing procedures 1
• Do not administer systemic antimicrobial prophylaxis routinely before insertion or during use of an intravascular catheter to prevent catheter colonization or CRBSI 1
• Use prophylactic antimicrobial lock solution only in patients with long-term catheters who have a history of multiple CRBSI despite optimal adherence to aseptic technique 1
• Daily skin cleansing with a 2% chlorhexidine-impregnated wash cloth can reduce the incidence of multidrug-resistant CRBSI in patients with short-term catheters 1

Management of Suspected Infection

• Do not remove central venous catheters or PICCs on the basis of fever alone; use clinical judgment regarding the appropriateness of removing the catheter if infection is evidenced elsewhere or if a noninfectious cause of fever is suspected 1
• For suspected exit site infections, obtain cultures of any drainage from the exit site and blood cultures 1
• Uncomplicated exit site infections (without systemic signs of infection, positive blood cultures, or purulence) should be managed with topical antimicrobial agents based on exit site culture results 1
• If an uncomplicated exit site infection fails to resolve with topical therapy or is accompanied by purulent drainage, administer systemic antibiotics based on antimicrobial susceptibility of the causative pathogen; remove the catheter if treatment with systemic antibiotics fails 1

Catheter Replacement Guidelines

• Do not use guidewire exchanges routinely for non-tunneled catheters to prevent infection 1
• Do not use guidewire exchanges to replace a non-tunneled catheter suspected of infection 1
• Use a guidewire exchange to replace a malfunctioning non-tunneled catheter if no evidence of infection is present 1
• Use new sterile gloves before handling the new catheter when guidewire exchanges are performed 1

Special Considerations for Different Types of Infections

• For tunnel infections or port abscesses, remove the catheter, perform incision and drainage if indicated, and administer 7-10 days of antibiotic therapy in the absence of concomitant bacteremia or candidemia 1
• The decision to remove or retain a catheter depends significantly on the type of organism involved in the infection - S. aureus and Candida catheter colonization are more likely to be associated with CRBSI and complications than enterococci or gram-negative bacilli 1
• If other vascular sites are unavailable and the patient is at increased risk for bleeding in the setting of CRBSI not complicated by an exit site or tunnel infection, consider exchanging the infected catheter over a guidewire 1

Common Pitfalls and Caveats

• Avoid routine replacement of catheters as this does not reduce infection rates and increases the risk of mechanical complications 1
• Recognize that one in four patients with S. aureus colonization of an intravascular catheter may develop S. aureus bacteremia if they do not receive immediate anti-staphylococcal antibiotics 1
• Do not use topical antibiotic ointment or creams on umbilical catheter insertion sites due to the potential to promote fungal infections and antimicrobial resistance 1
• When evaluating fever in dialysis patients with portal catheters, consider non-infectious causes such as reactions to dialyzer membrane, dialysate, or medications 3