Perioperative management - TIVAD implantation - general and visceral surgery
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Indications
- Long-term parenteral nutrition
- Intravenous chemotherapy (when peripheral venous access is not possible)
- Long-term infusion regimen
Contraindications
- Systemic infection possibly involving the implant
- Subclavian vein thrombosis
- Contralateral pneumothorax
- Local eczema/fungal infection
- Previous radiotherapy with radiation-induced keloid formation
- Major coagulation disorder (markedly pathologic plasma coagulation panel; platelets < 30 Gpts/L)
Preoperative diagnostic work-up
- Clinical examination (swollen arm, visible collateral circulation near the shoulder signifying subclavian vein thrombosis, previous dissection and radiotherapy of ipsilateral axilla, lymphedema of ipsilateral arm with positive Kaposi-Stemmer’s sign)
- In previous punctures/catheter insertion in vessels of the neck: Preoperative duplex ultrasound
- Lab studies in case of previous pathologic standardized coagulation panels: RBC, PT, PTT, platelet count
Special preparation
- Peripheral venous access (contralateral arm) and initiation of a venous drip
- Shaving of chin, lateral neck triangle and chest down to the level of the nipples
- Surgical skin prepping of lateral neck triangle from the median line to the nipple
Informed consent
- Risk of pneumothorax in about 2% of subclavian vein punctures with lung injury → chest tube insertion
- Venous and arterial vascular injury requiring surgical revision
- Secondary bleeding, locally and in vascular injury
- Brachial plexus injury with persistent paresthesia and pareses
- Wound infection with possible TIVAD infection → surgical explantation
- TIVAD dislocation and dysfunction (kinking, puncture not possible etc.)
- Venous air embolism during insertion, possibly with cerebral hypoperfusion and subsequent neurologic deficits
- Arterial malinsertion with stroke
Anesthesia
The procedure is performed under local anesthetic, e.g., 1% mepivacaine 10 mL. When available, an anesthesiologist should be on standby to sedate the patient, if needed, with, e.g., intravenous benzodiazepine (iv. midazolam 2 mg, depending on BP and oxygen saturation).
Positioning
Position the patient supine on the OR table. It is helpful to insert a small folded-up pillow between the shoulder blades, so that both clavicles course in a slightly posterior direction. Adduct the arm of the side to be punctured, leaving enough mobility to pull it caudad should it become necessary to enlarge the subclavian space and/or the space between the clavicle and first rib.
Operating room setup
Special instruments and fixation systems
- TIVAD system
- Mosquito clamp with branches sheathed in plastic tubing, to be used in atraumatic clamping of the port tubing
- Small dilating forceps for tunneling
- Small Langenbeck retractors for lifting the subcutis and inspecting the pouch.
Postoperative management
Postoperative analgesia: Nonsteroidal anti-inflammatory drugs usually suffice
Follow this link to PROSPECT (Procedures Specific Postoperative Pain Management).
This link will take you to the International Guideline Library.
Postoperative care: Postoperative radiographic imaging of the TIVAD Only access the TIVAD port with a special needle (Huber) which does not core the silicon membrane as with regular injection needles. The TIVAD may be used as soon as the procedure has been completed. Sterile no-touch technique is highly recommended, and flush the system with saline before each infusion.
Deep venous thrombosis prophylaxis: Unless contraindicated, the low risk of thromboembolism calls for prophylactic physical measures and conceivably low-molecular-weight heparin, possibly adapted to weight or dispositional risk, until full ambulation is reached.
Note: Renal function, HIT II (history, platelet check).
This link will take you to the International Guideline Library.
Ambulation: Immediate mobilization
Physiotherapy: Not required
Diet: Unrestricted
Bowel movement: No intervention
Work disability: Depends on the underlying disorder necessitating the TIVAD implantation