The Sticky World of the Huber Needle and Accessing Your Port

11 Jan

When accessing a portacath/med port, sterile procedures must be followed. The following steps reflect my personal training and the Phoenix Children’s Hospital Procedure Brochure #810 for steps I do not use. How you were or will be trained may differ.

1. If desired, 30 to 60 minutes prior to the procedures, put EMLA or L-M-X 4 cream on the skin over the port.

1.a. Some people use a numbing cream before inserting their Huber needle; I have never used a numbing cream. I normally use a 22 gauge needle, which I find to be practically painless. However, I have been needled and pricked so often, my tolerance could be higher than average.

1.b. A common cream used to numb the portacath area is AstraZeneca’s EMLA (Eutectic Mixture of Local Anesthetic) cream (non-brand generics are available). This cream contains 2.5% each of lidocaine and prilocaine. MLA is a local anaesthetic for topical application, developed to anaesthetise intact skin and often used to prevent pain associated with needle insertion. Local dermal anaesthesia is achieved after approximately 60 minutes and the duration of anaesthesia is approximately two hours. Source: Wikipedia

2. If the heparin is refrigerated, take it out of the refrigerator about ten (10) minutes before you use it. Let it warm to room temperature. Cold heparin will not harm you, but you may feel the heparin’s coldness when injected. (I do not refrigerate my heparin; pre-filled heparin syringes do not require refrigeration.)

3. If the Cinryze is refrigerated, take it out of the refrigerator about ten (10) minutes before you use it. Let it warm to room temperature. Cold Cinryze will not harm you, but you may feel the coldness when injected. Prescription literature states Cinryze should be stored at 36F-77F. (I do not refrigerate my Cinryze; my prescription label reads, “Store at room temperature.”)

4. Clean the work area with soap and water, and let it dry.

5. Wash your hands with antimicrobial scrub for 30 to 45 seconds. Wash the entire surface of your hands. Wash under your fingernails, the backs of your hands, your wrists and between your fingers. Rinse completely and dry your hands with a clean towel or paper towel.

6. Remember, as you open the supplies, touch only the outside packaging until your hands are gloved. Keep everything sterile. Sterile means there are no germs at all. Once you open a package, it is not sterile. Even though you washed your hands, they are not sterile until they are in sterile gloves.

7. Prepare your Cinryze. Make sure you have the right amount of the right medicine, and it is the right time to give it.

7.a. Wipe the top of each Cinryze bottle with an alcohol pad.

7.b. Wipe the top of each sterile water bottle with an alcohol pad.

7.c. If Using Transfer Needles:

7.c.(1) Uncap the shorter needle of the double-ended transfer needle (included with Cinryze prescription) and insert into a sterile water bottle (included with Cinryze prescription). Up-end the sterile water bottle, uncap the other end, and insert the longer needle into a Cinryze bottle. Vacuum pressure will draw the sterile water into the Cinryze bottle. Carefully withdraw the longer needle from the Cinryze bottle and recap it. Carefully withdraw the shorter needle from the sterile water bottle and recap it. Gently roll (DO NOT shake–you’ll create bubbles and foam) reconstituted Cinryze bottle between your palms to mix and set aside.

7.c.(2) Repeat with second set of sterile water and Cinryze.

7.c.(3) Wipe the top of the Cinryze bottle again with an alcohol pad. Put a clean unused needle on a clean unused 10cc syringe. Uncap the needle. Pull back on the plunger to fill the syringe with 2cc of air. Put the needle into the Cinryze bottle top, and push all the air into the bottle. Pull back on the plunger to fill the syringe with 5cc of Cinryze. To remove air bubbles from the syringe, (a) point the syringe up, (b) gently tap the side of the syringe with your finger, (c) large air bubbles will rise toward the needle, and (d) press the plunger until a tiny amount of Cinryze squirts out with the air bubbles. Any small air bubbles that stay attached to the inside of the syringe after you tap are safe.

7.c.(4) Repeat with second bottle of reconstituted Cinryze until you have 10cc of solution in the syringe. Recap the needle and set aside.

7.d. If Using Mix2Vials:

7.d.(1) Remove the cover from a Mix2Vial (included with Cinryze prescription) and place the unit over the top of one of the sterile water bottles, pressing down firmly. Holding the sterile water bottle, lift the Mix2Vial plastic packaging up and off of the bottle. Turn the unit over and fit the other end of the Mix2Vial over the top of one of the bottles of Cinryze, pressing firmly straight down. Vacuum pressure will draw the sterile water into the Cinryze bottle. The contents should be thoroughly mixed with little foaming; if not, gently roll (DO NOT shake–you’ll create bubbles and foam) the conjoined bottles between your palms to mix; set aside. Do not remove Mix2Vial apparatus.

7.d.(2) Repeat with second set of sterile water and Cinryze.

7.d.(3) Open a 10cc syringe. Pull back on the plunger to fill the syringe with 2cc of air. Using a twisting motion, separate the reconstituted bottle Cinryze and its half of the Mix2Vial from the empty sterile water bottle and its half of the Mix2Vial. Set the sterile water half aside for later disposal. Screw the syringe onto the nipple on the Mix2Vial apparatus attached to the bottle containing the reconstituted Cinryze. Push all the air into the bottle. Pull back on the plunger to fill the syringe with 5cc of Cinryze. Unscrew the Mix2Vial apparatus and set aside for later disposal. To remove air bubbles from the syringe, (1) point the syringe up, (2) gently tap the side of the syringe with your finger, (3) large air bubbles will rise toward the needle, and (4) press the plunger until a tiny amount of Cinryze squirts out with the air bubbles. Any small air bubbles that stay attached to the inside of the syringe after you tap are safe.

7.d.(4) Repeat with second bottle of reconstituted Cinryze until you have 10cc of solution in the syringe. Leave the empty bottle and Mix2Vial in place and set aside.

8. If you use pre-filled saline and heparin, remove them from their plastic wrapping and set aside with the filled Cinryze syringe. (I use pre-fills.)

9. If you do not use pre-filled saline and heparin:

9.a. Wipe the top of the saline bottle with an alcohol pad. Put a clean unused needle on a clean unused 10cc syringe. Uncap the needle. Pull back on the plunger to fill the syringe with 2cc of air. Put the needle into the bottle top, and push all the air into the bottle. Pull back on the plunger to fill the syringe with 10cc of saline. To remove air bubbles from the syringe, (1) point the syringe up, (2) gently tap the side of the syringe with your finger, (3) large air bubbles will rise toward the needle, and (4) press the plunger until a small amount of saline squirts out with the air bubbles. Any small air bubbles that stay attached to the inside of the syringe after you tap are safe. Recap the needle and set aside.

9.b. Repeat.

9.c. Wipe the top of the heparin bottle with an alcohol pad. Put a clean unused needle on a clean unused 10cc syringe. Uncap the needle. Pull back on the plunger to fill the syringe with 2cc of air. Put the needle into the bottle top, and push all the air into the bottle. Pull back on the plunger to fill the syringe with 5cc of heparin. To remove air bubbles from the syringe, (1) point the syringe up, (2) gently tap the side of the syringe with your finger, (3) large air bubbles will rise toward the needle, and (4) press the plunger until a small amount of heparin squirts out with the air bubbles. Any small air bubbles that stay attached to the inside of the syringe after you tap are safe. Recap the needle and set aside.

10. Open the package of the non-coring Huber needle, but do not take the Huber needle out of the package. (I use LifeGuard.)

11. Take the clave or micro-clave cap out of the package and remove the cover from the connector end. (I’ve used both; the micro-clave was developed for pediatrics.)

12. Without putting the micro-clave down, pick up the capped end of the Huber needle’s IV tubing, uncap it, and twist the micro-clave onto the IV tubing end. The micro-clave/IV tubing end is no longer sterile and CANNOT be placed back into the Huber needle package. Let the micro-clave/IV tubing end rest on or just over the edge of the packaging and be sure that it does not touch any of the other sterile needle components.

13. Wipe the tip of the micro-clave with an alcohol pad.

14. Uncap/remove the needle from one of the saline syringes and connect it to the micro-clave.

15. Push the plunger of the saline into the IV tubing until drops of saline come out of the end of the needle that is still INSIDE the Huber needle package. Leave the syringe connected to the micro-clave OUTSIDE the Huber needle package.

16. Open the Central Line Dressing Change Kit. DO NOT touch anything inside yet.

17. Open any remaining supplies and let the contents drop into the kit WITHOUT TOUCHING the contents. Examples include, but are not limited to: Biopatch, Chloraprep Sepp Applicators.

18. Use a gauze square to wipe the EMLA or L-M-X 4 cream off the port site.

19. Usually, the mask is on top in your dressing change kit; put it on if you are working on someone else or if you have a cold, cough, or snotty nose (I hardly ever use mine when working on myself).

20. Remove the waterproof drape next and, using your fingertips and touching the drape as little as possible, position it over your workspace, plastic/waterproof side up.

21. You are now ready to ENTER THE STERILE ZONE. If you accidentally touch any non-sterile surface, you must START OVER from this point forward. This includes touching yourself (don’t touch your face or absent-mindedly scratch that itch!), don’t touch the unprotected work surface or the arm of a chair to help yourself up, don’t touch the outside of any packaging, just DON’T TOUCH ANYTHING THAT ISN’T STERILE.

22. Take out the packet of sterile gloves and place them on the drape. They should be marked right side up, or left and right. Unfold the outer packaging in the proper orientation.

22.a. Starting with your preferred hand and touching ONLY the INSIDE of the folded cuff with your other hand, slide your first hand with your thumb in the indicated direction (usually means palm up and thumb facing outward) into the first glove. DO NOT TOUCH the OUTSIDE of the glove with your UNGLOVED hand. Your UNGLOVED hand is NOT STERILE. Touching only the INSIDE of the cuff, pull the glove on and up over your hand and pluck the cuff into an unfolded position. Your first hand is now STERILE.

22.b. Using your gloved and sterile hand, you are now ready to glove your other hand. Since you are going to place your non-sterile hand into the inside of the second glove, you DO NOT want your STERILE hand touching the INSIDE of the second glove. The trick is to slide your gloved hand UNDER the cuff of the second glove while your second hand is holding down the inside of the cuff to open up the second glove enough for your second hand to begin the slip inside (palm up, thumb out). Sometimes it helps to grab the sterile paper wrapper with your GLOVED hand and fold it over the second glove to give you some extra maneuverability with your GLOVED hand if you are having trouble getting the cuff to pull apart. Pull the glove on and up over your hand and pluck the cuff into an unfolded position. Both of your hands are now STERILE. Applaud yourself, but DON’T give yourself a clap on the back! (This was the second hardest part for me to get a grip on (yeah, I love bad puns and didn’t even TRY to resist).)

22.c. Place the paper wrapping to one side to keep your work area uncluttered.

23. Sterilize the port area using the method that you and your doctor determines is best for you (for instance, I am allergic to Betadine and that’s what comes in my kit). Here are some possible techniques:

23.a. Take three Chloraprep Sepp (2 percent chlorhexidine gluconate and 70 percent isopropyl alcohol) applicators out of their package. Hold each applicator upside-down and squeeze the applicator until the plastic cracks. This releases the contents into the pad. Scrub back and forth over the port site with the pad on the applicator for 30 seconds. Repeat twice. Place used applicators on the drape. Let the port site dry for 30 seconds.

23.b. Open the Chloraprep (2 percent chlorhexidine gluconate and 70 percent isopropyl alcohol) or PVP (10% PVP povidone iodine solution equivalent to 1% available iodine; i.e., brand name Betadine) swabstick packet using the tear-notch. Gently squeeze the some of the excess liquid from the cotton heads of the three swabsticks to prevent excessive dripping. Remove the first swabstick and, using a circular motion and starting at the center of the port, swab outward about 3 inches on either side while rotating the swab such that all sides of the swab are used ONCE. You DO NOT want to transfer any germs or skin cells from one area of the port to another area. Repeat twice. If excessive dripping occurs, use the gauze pad supplied in the kit to light pat away the “juiciness.” Placed used swabsticks and gauze on the drape. Let the port site dry for 30 seconds.

24. Pick up the Huber needle using only the wings. Remove the needle cover.

25. With your other hand, find the edges of the port. Use two fingers to frame the port and hold the port in place.

26. Push the needle into the center of the port. Press it through the skin until the needle touches the bottom of the port. Tip: If you are doing this yourself, it really helps to stand in front of a full-length mirror (no kidding! this was nearly my undoing and the tip came from, of all people, my psychiatrist–you just never know who is going to save your lily white butt or how).

27. If you are using a Biopatch, slide it over the needle between your skin and the needle housing, bluish side out.

28. The attached saline syringe (even when it was in its plastic packaging) is NOT STERILE and this next step will take you OUT OF THE STERILE ZONE.

29. Pull back on the plunger of the saline syringe until blood flashes into the IV tubing attached. This lets you know the needle is in the right place.

29.a. If you do not get a flashback, check to see if the IV line clamp is OPEN. Without touching your skin because you are no longer sterile, carefully check the needle placement. Is the needle in far enough? Is the needle in the center (sometimes the needle slips between the port’s portal and septum–I bent many Hubers this way when I was learning). Try carefully wiggling the needle back and forth, forward and back.

29.b. If you still cannot get a backflash, remove the needle using the procedures for your needle type (see here) and start over from Step 10 with a new needle and dressing change kit.

29.c. If you still cannot get a backflash after Step 29.b., call your Home Health Care Nurse or physician’s office. Your port may be clogged, broken or infected.

30. Push the full contents of the saline flush into the port and unscrew the syringe. Set it aside.

31. Unscrew the needle or Mix2Vial from the Cinryze syringe, set it aside the needle for disposal in a sharps box later, and screw the syringe onto the micro-clave. Using a timer, gently depress the plunger so the 10cc of Cinryze is administered over ten minutes.

32. Uncap/remove the needle from the second saline, screw it onto the micro-clave, push the full contents of the saline flush into the port, and unscrew the syringe. Set it aside.

33. Uncap/remove the needle from the heparin, screw it onto the micro-clave, push the full contents of the heparin flush into the port, keep pressure on the syringe, and CLOSE the CLAMP on the IV tubing.

34. IF LEAVING THE NEEDLE IN THE PORT: If using a product line Skin Prep, apply the pad around the outside perimeter of the dressing site.

35. IF LEAVING THE NEEDLE IN THE PORT: Put a transparent dressing on the port (usually included in the change kit). Tip: If not already folded, fold the dressing in half. Then peel the backing off one-half of the dressing to the fold. Place the fold line in the dressing over the centerline of the port and needle, and press the dressing in place. Peel the remaining backing from the other half and press that half into place. This method keeps the dressing from curling and sticking to itself.

36. Put all the needles, including the double-ended transfer needle, in the sharps box.

37. Other materials can be placed in the trash.

I can do Steps 1 through 30 in about 5 minutes, and if I can do it, you can, too. I’d say it took me about 2 months to become really comfortable and get up to that speed, and I’m a freakin’ big chicken, so I expect you all to surpass me!

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