Central Line Insertion and Management

Follow proper insertion practices (CDC, 2011; Marschall et al., 2014)

• 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 greater 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 (i.e., 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 > 0.5% 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 prior to skin puncture.
• Ultrasound guidance may be used by trained staff to avoid multiple attempts.
• Place a sterile gauze dressing or sterile, transparent, semipermeable dressing over the insertion site.
  • If patient is diaphoretic or there is bleeding at the site, use gauze until the site is dry.
• For patients 18 years or 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 patients younger than 18 years with short-term, non-tunneled central venous catheters:
  • For premature neonates, chlorhexidine-impregnated dressings are NOT recommended to protect the site due to risk of serious adverse skin reactions.
  • There is insufficient evidence to make any recommendation about the use of chlorhexidine-impregnated dressings for pediatric patients less than 18 years old and non-premature neonates.

• Bathe ICU patients over two months of age with a chlorhexidine preparation daily.
• Scrub access port or hub prior to 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.
  • Monitor catheter sites visually when changing the dressing or by palpation through an intact dressing on a regular basis. 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 prior to 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.