Central Line Insertion and Management

Follow proper insertion practices (Nickel et al., 2024; Gupta et al., 2021)

• Select central venous catheter (CVC) based on the intended purpose and duration of use.
  • Use a midline catheter or peripherally inserted central catheter (PICC) if therapy is anticipated to be longer than six days.
  • Use CVCs with a minimal number of ports or lumens needed to care for the patient.
• Select the best insertion site to minimize infections and based on patient characteristics.
  • Avoid femoral vein for CVC access in adult patients.
  • Use subclavian vein instead of internal jugular, if possible, for non-tunneled CVCs and short-term therapy.
  • Avoid subclavian vein in hemodialysis patients and those with advanced kidney disease which may cause subclavian vein stenosis. Use a fistula or graft for permanent dialysis access.
• Perform hand hygiene by washing hands with soap and water or with alcohol-based hand rubs (ABHR) before and after inserting, replacing, accessing, repairing or dressing a CVC.
• Maintain aseptic technique.
  • If aseptic technique cannot be ensured (e.g., catheter inserted during an emergency), replace the catheter as soon as possible, preferably within 48 hours.
• Use maximal sterile barrier precautions including cap, mask, sterile gown, sterile gloves, and sterile full body drape.
• Prepare the insertion site with 2% chlorhexidine with alcohol.
  • If there is a contraindication to chlorhexidine, tincture of iodine, an iodophor, or 70% alcohol may be used. Safety of chlorhexidine in infants younger than two months of age is unknown.
  • Allow antiseptics to dry according to manufacturer’s recommendation before skin puncture.
• Ultrasound guidance may be used by trained staff to avoid multiple attempts. Use sterile single-use ultrasound gel.
• To stabilize the external portion of the catheter to the skin, use a securement device, which prevents motion of the CVC within the vessel lumen.
• Place a sterile gauze dressing or sterile, transparent, semipermeable dressing over the insertion site.
  • If there is bleeding at the site, use gauze until the site is dry.
  • Consider using gauze, sterile absorbent dressing, or gum mastic liquid adhesive for adult patients experiencing diaphoresis.
• Unless contraindicated, for patients 2 months of age and older, use a chlorhexidine-impregnated dressing with a Food and Drug Administration (FDA) approved indication to reduce CLABSI or catheter-related bloodstream infection (CRBSI) for short-term, non-tunneled central venous catheter insertion site protection.
• For premature neonates, chlorhexidine-impregnated dressings are NOT recommended to protect the site due to risk of serious adverse skin reactions.

• Bathe ICU patients over two months of age with a chlorhexidine preparation daily.
• Scrub access port or hub before each use with an appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70% alcohol).
• Use sterile devices to access catheters/ports and use a needleless system to access IV tubing.
• Perform routine dressing changes using aseptic technique with sterile gloves.
  • Change the dressing if it becomes loose, damp, or soiled.
  • Change gauze dressings on short-term CVCs at least every two days.
  • Change semipermeable dressings on short-term CVCs at least every seven days.
  • Regularly monitor catheter sites visually when changing the dressing or by palpation through an intact dressing. If patient has tenderness at the insertion site, fever without an obvious source, or other symptoms of infection, remove the dressing and assess the site.
• Change administration sets for continuous infusions no more frequently than every four days, but at least every seven days.
  • For blood and blood products, continuous or single unit, change after four hours.
  • For fat emulsions and parenteral nutrition change tubing within 24 hours of initiating the infusion.
  • If propofol is administered, change tubing every 6-12 hours or when the vial is changed.
• Advise patients to avoid submerging the catheter site in water for CVCs not tunneled or implanted (and for tunneled CVCs that are not healed).
  • Patients may shower if the catheter and dressing are protected with an impermeable dressing.
• Do not use topical antibiotic ointment or creams at insertion site, except for dialysis catheters, as these may promote fungal infections and antimicrobial resistance.
• Do not administer systemic antimicrobials or anticoagulants prophylactically.
• Promptly remove nonessential catheters.
  •  Assess the need for each CVC daily.
    • Do not remove CVCs based on fever alone; use clinical judgment before removal.
    • Do not routinely replace CVCs, PICCs, hemodialysis catheters, or pulmonary artery catheters to prevent catheter-related infections.

• Consider using antimicrobial/antiseptic-impregnated catheters and cuffs (chlorhexidine/silver sulfadiazine or minocycline/rifampin) when the CVC duration of use exceeds five days.
• Consider using antiseptic-impregnated caps for access ports.