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Use of the Implanted Intraperitoneal (IP) System (1.30)

Use of the Implanted Intraperitoneal (IP) System (1.30) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Cardiovascular and Infusion

1.30

NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
November 30, 2015

Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 1.30

Original
Revision

Page
1
of 5

Title: Use of the Implanted Intraperitoneal (IP)
System for Chemotherapy Administration

I. PURPOSE

To ensure safe use and maintenance of the implanted intraperitoneal (IP) system.

II. POLICY

A. Nurses who have been trained to access venous ports may access IP ports AFTER
they have successfully completed the competency assessment which includes
demonstration of IP port access under the direct supervision of another RN who
has been deemed competent. They may then administer IP chemotherapy/fluids.
B. Only nurses who are credentialed in chemotherapy may administer chemotherapy
via an IP port.
C. Orders for chemotherapy via the IP port are verified according to UWHC Hospital
Administrative Policy 8.59, Chemotherapy Processes: Informed Consent,
Ordering, Verification, Administration, Documentation and Patient/Family
Education.

III. GENERAL INFORMATION

The IP system consists of a catheter attached to a port, and is used to access the
peritoneal cavity for administering chemotherapy. The IP port requires no
maintenance by the patient and is flushed only after use to maintain patency. The
device is placed surgically, and is usually located in the upper left or right quadrant to
facilitate ease in access. Ports may be placed over the lower abdomen on the right or
left side.

The intraperitoneal system is accessed via sterile technique by inserting a 90 degree
angle non-coring needle through the skin and port septum. Review the patient's
clinical record prior to accessing the port to verify that the patient has an abdominal
port that is in the peritoneum.

IV. SUPPLIES

A. Health Facts For You 4208, Your Guide to Intraperitoneal Chemotherapy
B. 1 underpad
C. 2% ChloraPrep® 3 mL applicator
D. Sterile gloves
E. 19-20 gauge ¾ in. to 1 ½ in. 90 degree angle non-coring needle with attached
tubing

Page 2 of 5

F. Optional (1% lidocaine and safety needle or topical anesthetic) (according to
Delegation Protocol 29, Analgesic Techniques Prior to IV Catheter Insertion and
other needle related procedures). Lidocaine LMX (4%) cream may also be
ordered to apply to port site 60 minutes prior to accessing with needle.
G. 1-2 sterile barriers
H. Sterile 2x2 or 4x4, as needed
I. Hubguard foam tape strips
J. Transparent adhesive dressing
K. Tape
L. 2 - 0.9% sodium chloride flush syringes or:
ξ 30 mL sterile syringe with luer lock
ξ 30 mL vial sterile normal saline (not previously opened)
ξ Needleless vial adapter or 18 gauge 1 ½ σ safety needle
M. IV tubing and 50 mL normal saline bag.
N. Infusion solution warmed to 37-40 degrees Celsius (usually normal saline or
D5W), as ordered (NOTE: Fluids for IP infusion should be warmed in the
warming cabinet set to 37 degrees Celsius). Warmed solution used for
chemotherapy will be given to pharmacy prior to drug administration time.

V. PROCEDURE

A. Preparation
1. Have the patient void prior to beginning infusion.
2. Perform hand hygiene according to UWHC Hospital Administrative
Policy 13.08, Hand Hygiene.
3. Prime IV tubing with 50 mL normal saline bag.
a. If Taxol is being given IV, this tubing should have a y-site to hook
up non-PVC tubing that is primed by pharmacy with dextrose 5 %.
4. Place underpad to protect bed/clothing.
5. If patient has lidocaine LMX (4%) cream applied to port site, remove
dressing and wipe cream off of site.
6. Position patient to expose port site. Palpate site to locate septum and
assess site for swelling, drainage, erythema, tenderness. Notify provider if
swelling, drainage, erythema, or tenderness is present.
B. Accessing System
1. Set up on sterile field on side table or stand:
a. 1-2 sterile barriers or fenestrated drapes
b. Non-coring type needle – 19-20 gauge, ¾-1 ½ in, 90 degree non-
coring Huber needle with attached tubing. Choose a needle length
based on the proximity of the port to the patient’s skin.
c. Sterile gauze 2x2/4x4 pads, as needed
d. Hubguard foam tape strips
e. Transparent adhesive dressing (4 in. x 4 3/4 in.)
f. 30 mL syringe with luer lock
g. 30 mL vial sterile normal saline
h. Needleless vial adapter or 18 gauge safety needle
2. Perform hand hygiene according to UWHC Administrative Policy 13.08,
Hand Hygiene.

Page 3 of 5

3. Put on sterile gloves. Prep with ChloraPrep® applicator using a back and
forth friction scrub for a minimum of 60 seconds, and allow to air dry
completely. Place sterile barrier/drape over patient and below port.
4. Maintain aseptic technique by handling non-sterile saline vial or pre-filled
saline flush syringes with sterile gauze and gloves. Draw up 30 mL saline
or use pre-filled saline flush to prime extension tubing connected to non-
coring type needle.
5. Close clamp. Leave syringe attached to tubing.
6. Stabilize port against abdominal wall/underlying structures with non-
dominant hand.
7. Rest syringe on sterile barrier. Insert non-coring type needle into septum at
a 90 degree angle. Push the needle down until it reaches the bottom of the
port chamber. Do not tilt or rock the needle once the port has been entered.
Either movement may damage the septum.
8. Open clamp. Aspirate to check for peritoneal fluid. It is not always
possible to withdraw peritoneal fluid, however if obtained, discard fluid
prior to flushing. Flush with at least 20 mL of normal saline to confirm
that fluid flows through the system. Assess for leakage, ease of flow,
subcutaneous infiltration, and pain. Notify provider if leakage, latency,
leakage, infiltration, or pain is present. Close clamp.
a. Restriction of inflow or abdominal or rectal pain associated with
inflow could be related to misplacement of the catheter against an
internal organ or segment. Have patient raise arms or move torso
and reattempt flushing.
b. To avoid excessive pressure while flushing or infusing fluid, use a
10 mL or larger size syringe and only infuse fluid via gravity.
9. Remove syringe from non-coring needle tubing and connect IV tubing,
primed with non-chemotherapy drug containing fluid (normal saline in a
50 mL bag). Infuse via gravity approximately 30-50 mL of non-drug
containing fluid.
a. A catheter is considered patent if it flushes easily, free flows well
to gravity, and the site remains without redness, edema, tenderness,
or any other signs of subcutaneous fluid accumulation. If any one
of these conditions is not met, do not begin infusion. Notify
physician and a dye study will be ordered.
b. If you get a blood return, do not start infusion; notify physician.
10. Support needle as needed with sterile 2x2 or 4x4 pads. Secure with sterile
hub guards over wings of non-coring needle, secure extension tubing, and
cover with a transparent adhesive dressing. (See Figure 1.)

Page 4 of 5


Figure 1 (UWHC)

C. Infusion Procedure
1. Place patient in semi-Fowler’s position to promote comfort, but keep head of
bed less than 30 degrees to minimize risk of needle becoming dislodged.
2. Following safe handling guidelines for chemotherapy administration (UWHC
Hospital Administrative Policy 8.89, Preventing Non-therapeutic Exposure to
Hazardous Drugs), hang chemotherapy solution warmed to 37-40 degrees
Celsius and infuse via gravity over the time indicated. (Each bag is infused as
fast as possible, or as tolerated at a slower rate, typically over 30-60 minutes.
Do not administer via an infusion pump.)
a. Increased abdominal swelling and pressure may cause the patient some
discomfort, dyspnea, and/or GI symptoms. Monitor the patient for these
side effects and slow the infusion rate to help alleviate some of these
symptoms.
b. Assess the port during the infusion for asymmetry or leaking, which may
indicate needle dislodgement.
c. If more than one agent is to be administered, follow each drug with 20
mL normal saline flush. Compatible drugs may be mixed in infusion
solution.
3. Encourage the patient to remain in bed during IP infusion to protect needle
placement. If necessary, patient may get up to use commode (preferred) or the
bathroom. Check needle placement every 1-2 hours, and after patient returns
from bathroom, to make sure it has not dislodged from the port.
4. At the completion of the infusion, disconnect IV tubing. Attach syringe and
flush according to MD order. IP ports are usually flushed with 20 mL normal
saline, followed by 10 mL of heparin (10 units/mL), using positive pressure
technique.
5. Withdraw the needle while pressing down on the port with two fingers.
6. Apply pressure to needle site with sterile 2x2 pad until drainage ceases. Cover
with band-aid.
7. ONLY after all the IP solution is infused and the port is de-accessed, have
patient turn side to side every 15 minutes for 2 hours, to evenly distribute drug
and fluid. (Turning during IP infusion increases the risk the needle may
become dislodged.)
D. Documentation
A. Document port access, site assessment, and patency assessment in the clinical
record.

Page 5 of 5

B. If port accessed for paracentesis, document amount of fluid drained and
characteristics in the clinical record.

VI. UWHC CROSS REFERENCES

A. Delegation Protocol 29, Analgesic Techniques Prior to IV Catheter Insertion and
Other Needle Related Procedures
B. Health Facts For You (HFFY) 4208, Your Guide to Intraperitoneal Chemotherapy
C. Hospital Administrative Policy 5.27, Waste Management
D. Hospital Administrative Policy 8.59, Chemotherapy Processes: Informed Consent,
Ordering, Verification, Administration, Documentation and Patient/Family
Education
E. Hospital Administrative Policy 8.89, Preventing Non-therapeutic Exposure to
Hazardous Drugs
F. Hospital Administrative Policy 13.08, Hand Hygiene
G. Nursing Patient Care Policy 11.10, Percutaneous Paracentesis

VII. REFERENCES

A. Hydzik, C. (2007) Implementation of intraperitoneal chemotherapy for the
treatment of ovarian cancer. Clinical Journal of Oncology Nursing, 11(2), 221-225.
B. Oncology Nursing Society Access Device Guidelines, 2011
C. Oncology Nursing Society ONS Chemotherapy Administration Safety Standards,
2011
D. Potter, K. L., & Held-Warmkessel, J. (2008). Intraperitoneal chemotherapy for
women with ovarian cancer: nursing care and considerations. Clinical Journal of
Oncology Nursing, 12(2), 265-271.

VIII. REVIEWED BY

Clinical Nurse Specialist, Oncology Nursing Services
Oncology Care Practice Committee
Nursing Patient Care Policy and Procedure Committee, October 2015

SIGNED BY

Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer