Denver Ascites Shunt PAK 42-2050/42-2055 - CareFusion

3. After entering the peritoneal cavity, advance the
needle a short distance into the cavity, taking
care to avoid injury to the visceral structures.
4. Insert the J-Tip guidewire into the peritoneal
cavity through the 18 gauge needle. Advance the
guidewire several centimeters into the peritoneal
cavity and then remove the introducer needle
leaving an appropriate amount of guidewire
exposed.
Caution: Do not allow the guidewire to inadvertently
advance totally within the patient.
Caution: Damage to or embolization of the guidewire
may result if it is withdrawn through the needle.
5. Pass the 16 Fr. peel-away introducer (dilator and
peel-away sheath) over the guidewire through the
external oblique fascia. Use a rotational
movement while advancing the dilator and
sheath, to help prevent any sheath damage. The
posterior fascia may offer some resistance
during this maneuver.
Caution: Do not allow the guidewire to inadvertently
advance totally within the patient.
6. Remove the guidewire and dilator. This should
result in a free flow of ascitic fluid.
7. If the ascitic fluid has not yet been drained and
partially replaced with sterile saline or lactated
Ringer’s solution, it can be done at this time.
(See Patient Preparation on Page 3).
Caution: Care should be taken when draining
ascites, as rapid evacuation of ascitic fluid may
result in circulatory or vascular collapse.
8. Insert the peritoneal catheter of the shunt into
the peel-away sheath and remove the sheath in a
symmetrical manner, exercising care not to
withdraw the catheter.
Caution: Do not use forceps on the introducer to
break its handle and /or peel the sheath.
Caution: It is very important to peel the sheath away
from the catheter in a symmetrical manner. If the
catheter begins to withdraw while the sheath is
being peeled, hold the catheter in place and carefully
peel the sheath away symmetrically.
Caution: The peel-away sheath should withdraw
freely from the body. If resistance is encountered, do
not force the peeling action of the sheath or its
withdrawal. Make procedural corrections, then
continue.
9. Check shunt function by compressing the pump
chamber several times. There should be a free
flow of fluid, which is enhanced by pumping.
Once flow has been established, place a rubber
shod clamp across the tip of the venous catheter.
Caution: The clamp should be covered with rubber
to avoid damage to the venous catheter.
Tunneling Procedure
1. Make a small (approximately 2 cm) subclavicular
incision through the guidewire insertion site.
2. Place the venous catheter tip over the end of the
tunneler. Remove the clamp from the catheter.
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3. Insert the tunneling device into the subcostal
incision and advance it up toward the
subclavicular incision, along a path lateral to the
breast.
4. Continue to advance the venous catheter until the
pump chamber is in proper position in the
previously dissected pump chamber pocket.
Note: Ensure that there are no kinks in the tunneled
portion of the catheter.
5. Remove the tunneling probe from the catheter.
There should be free flow of ascitic fluid from the
tip of the venous catheter. If there is no free flow
of fluid, press the pump chamber several times
to verify shunt function. After flow has been
confirmed, reclamp the venous catheter.
6. Place several 3-0 monofilament sutures through
the suture pad on either side of the pump
chamber to prevent rotation.
7. In patients with excessive subcutaneous tissue, it
is advisable to thin the tissue down to
approximately ¼” over the pump chamber to
facilitate locating the chamber later.
8. It is advisable to mark the skin over the lower
two-thirds of the pump chamber so that the
patient or attendant will have no difficulty locating
the proper position for pumping.
Venous Catheter Insertion
Caution: Individual patient anatomy, such as obesity
or loose subcutaneous tissue, may require
procedural variations to reduce the risk of
inadvertent catheter withdrawal from the vein.
1. Measure the venous catheter of the shunt to
allow the tip to lie at the junction of the superior
vena cava and the right atrium. This can be
judged by making a gentle curve along the
clavicle and extending the catheter down to the
second intercostal space on the chest wall. Cut
off the rest of the catheter, making the cut
transverse to the long axis of the catheter.
Note: Placement of the venous catheter tip above the
level of the cavo-atrial junction may lead to occlusion
or encapsulation of the catheter.
2. Introduce the 12 Fr. vein dilator with peel-away
sheath over the guidewire and advance it through
the subclavian fascia. The fascia often presents
some resistance, but applying steady pressure
will allow the dilator to slip into the subclavian
vein.
Caution: Advancing the introducer into the
subclavian vein may potentially injure mediastinal
structures.
3. Remove the guidewire and dilator from the
sheath. Place your thumb over the exposed
sheath orifice to inhibit the entry of air into the
vein and excessive blood loss.
4. Remove the clamp from the venous catheter and
once again ensure that there is free flow of ascitic
fluid.