Central Line Management

Central line management is typically performed by skilled nursing or medical staff. Patients generally should not be manipulating or using the access site unless adequately trained in the use and care for the line, as in the case of a patient receiving home-based antibiotic infusions.

Health care workers hands may be contaminated with organisms found in the hospital environment; therefore, hand hygiene remains an important measure in reducing not only nosocomial infections but catheter-based infections. When placing a central line, hand hygiene and routine sterile practice should be the practice every time.[9] 

During initial central line placement, the use of soap and water or alcohol-based scrubs should standard before donning sterile gloves. Using sterile precautions, sterile drapes, sterile gowns, and gloves will help minimize contamination of the catheter during the insertion phase. Furthermore, appropriate skin preparation with 0.5% chlorhexidine is preferable to povidone iodine, or 70% alcohol as a means to decrease the skin flora and reduce catheter-based infections, unless the patient has an allergy to chlorhexidine. After competition of the procedure, a sterile dressing should be applied over the insertion site before using the line.[3][6][7][9]

After insertion, any manipulation or use of the catheter should take place only after standard hand hygiene and clean glove practices. Routine inspection of the central line, regardless of location, should be performed daily. A daily inspection should ensure that the line is properly in place, free from infection, and in working order. Dressing changes for central lines should occur every 5 to 7 days with a transparent dressing or every two days with a gauze dressing. [9] However, if the dressing has a break in the seal or becomes visibly soiled, it should be changed.

It is also advisable to disinfect injection ports, needless connectors, and catheter hubs with either 70% alcohol or chlorhexidine swabs before use. Recommendations also include changing the intravenous administration set every 96 hours. If intravenous administration sets are used to infuse lipid-containing solutions, medications like TPN or propofol, the sets should be exchanged every 24 hours. With the infusion of blood products, the intravenous set should be changed every 24 hours. When a catheter hub is not in use, then catheter locks should be applied.[10][11][12]

If the dressing becomes visibly soiled or removed for any reason, then proper cleaning and replacement of a new sterile dressing should be placed. Using gloves, remove the old dressing with careful attention to minimizing catheter insertion site manipulation. While using appropriate sterile technique, it is advisable that a chlorohexidine solution should be used to sterilize the area surrounding the catheter site. Once dry, a sterile dressing should be reapplied and remain in place for another 5 to 7 days or until the catheter is removed.[9] 

Most importantly, every day the need for central venous access should be reevaluated. Whenever central access is no longer necessary, the central line should be removed promptly.

As with any procedure, there is the risk of complications associated with central line use. If the catheter, for any reason, should fail to work (infuse, flush, or aspirate) it should be promptly removed from the patient and inspected before discarding. If the insertion site shows signs of active infection; new onset erythema, swelling, or purulent drainage; the catheter should be removed. In the event of catheter thrombosis, the use of thrombolytics can be attempted; however, failure to safely dissolve the thrombus should prompt removal of the catheter. After removal of the central line, it is advisable to choose a new site if there is a continued need for central venous access.[3]

The goal of routine central line management is to reduce catheter-based infections. Complications such as abscess, cellulitis, and bacteremia are common and lead to poor patient outcomes, increased use of antibiotics, and increased hospital length of stay.

Central line management is a crucial skill that is necessary on a routine basis to help lessen or prevent catheter-based infections and complications. Initial placement of central lines is typically by trained physicians, physician assistants, and nurse practitioners in a sterile fashion. However, routine care and management are primarily going to be performed by trained nurses in the ICU or general wards. Every healthcare team member has a responsibility to evaluate the ongoing need for central venous access and ensure prompt removal when no longer necessary. Routine evaluation by every team member will ensure that appropriate handling and care of the central line is being performed to help reduce the risk of catheter-associated complications.