Implant Insertion and Removal Materials for Insertion The

Implant Insertion and Removal

Materials for Insertion The following equipment is needed for insertion: • • • Sterile surgical drapes Sterile gloves Antiseptic solution Surgical marker Local anesthetic Needles and syringe Sterile gauze Adhesive bandage Pressure bandage

Patient Insertion Position View applicator from the side and not from above the arm. Non-dominant arm flexed, hand underneath head. This position deflects ulnar nerve away from insertion site.

Insertion Step 1. Position and mark

Insertion Step 2. Clean and anesthetize (with epi recommended) Step 3. Open blister pack and remove cap - should see implant by looking into tip of needle (DO NOT touch slider) Step 4. Stretch skin toward elbow If the purple slider is released prematurely, restart the procedure with a new applicator

Insertion Step 5. Viewing from the side puncture the skin – bevel in only Step 6. Lower the applicator, lift the skin, slide needle in fully Readjust as needed Insert bevel on an angle Lower angle & lift skin Slide in – all the way

Insertion Step 7. Without moving applicator, move the slider fully back until it stops. Step 8. Bandage, verify position and have pt. palpate Step 9. Apply small bandage then pressure bandage over it

Insertion If applicator is moved during insertion or if purple slider is not moved fully back, implant may protrude from insertion site If implant is protruding, remove and perform new procedure at same insertion site using a new applicator Do not push protruding implant back into incision

Post-insertion Steps May remove: Pressure bandage in 24 hours Small adhesive bandage over insertion site after 3 to 5 days Complete Patient Alert Card and give to woman to keep Complete adhesive label and affix to woman’s medical record (and/or record batch number if electronic medical record)

If Implant is Not Palpable After Insertion May not have been inserted or inserted too deeply: Check applicator: Needle should be fully retracted and only purple tip of the obturator should be visible Use other methods to confirm the presence of implant. X-ray, CT scan, Ultrasound, MRI

Radiopaque Implant X-ray Localization Mansour D et al. Contraception 2010; 82: 243– 9. Adapted with permission.

If Imaging Methods Fail to Locate the Implant Until presence of implant verified non-hormonal contraceptive method must be used Deeply-placed implants removed ASAP to avoid distant migration Serum etonogestrel assay can be requested to confirm presence of etonogestrel subdermal implant Contact Merck Canada for further guidance

Most Frequent Clinician-reported Events at Insertion (N=7364) Real-world Evidence: Nexplanon Observational Risk Assessment (NORA) Study Insertion event Number* % incidence 95% CI 93 1. 0– 1. 6 Deep insertion 65† 0. 9 0. 7– 1. 1 Partial insertion 27 0. 4 0. 2– 0. 5 Non-insertion 1 0. 0– 0. 08 Difficulty removing protection cap 93 1. 0– 1. 5 Difficulty sliding needle to full length in skin 30 0. 4 0. 3– 0. 6 Difficulty handling the device/visualization 17 0. 2 0. 1– 0. 4 Incorrect insertion Insertion-related challenge 13 * *Number of insertions; † 26 (60%) were reported by a single clinician CI, confidence interval Reed S et al. Contraception 2019; 100: 31 -6.

Removal The following equipment is needed for the implant removal: • • • Sterile surgical drapes Sterile gloves Antiseptic solution Surgical marker Local anesthetic Needles and syringe Sterile scalpel Forceps (straight and curved mosquito) Sterile adhesive wound closure Sterile gauze Pressure bandage

Removal Step 1. Locate the implant and push down, mark the distal end Step 2. Clean, anesthetize (inject under implant!) Step 3. Push down, make parallel incision

Removal Step 4. Implant should pop through incision, grasp the implant with forceps, remove and confirm length Step 5. Dissect if needed Step 6. Insert new Nexplanon in same incision prn Step 7. Sterile adhesive wound closure and pressure bandage

After Removing the Implant Remove: Pressure bandage after 24 hours Sterile adhesive wound closure after 3 to 5 days Restart contraception immediately

Possible Factors Complicating Removal Implant not inserted correctly Implant inserted too deeply Implant not palpable Implant encased in fibrous tissue Implant has migrated

Removal of a Non-Palpable Implant Localization and removal of non-palpable implants is recommended ASAP Exploratory surgery is strongly discouraged Once localized, implant should be removed by HCP experienced in removing deeply placed implants, consider ultrasound guidance If not found consider radiographic examination of chest

Insertion Video Link to: http: //www. nexplanonvideos. com/home_lander_subs. html? country=EN|Nexplan on