Continuing Education Activity

Central venous access is required for many hospitalized patient. Placement of central line catheters is done for many reasons, including inadequate peripheral venous access, the need for hemodynamic monitoring, the need for peripherally incompatible infusions, and for provision of extracorporeal therapies. After obtaining access, the management of central catheters revolves around preventing catheter-based skin site or bloodstream infections, central line thrombosis, and mechanical complications. This activity illustrates how to safely manage central lines and highlights the role of the interprofessional team in preventing complications.

Objectives:

• Identify the equipment needed for dressing changes at the site of central line insertion.
• Outline the potential complications of central lines.
• Describe the antiseptic techniques used to prevent infections of central lines.
• Explain some interprofessional team strategies to improve care coordination and communication to ensure that patients with central lines do not develop complications.

Introduction

Central venous access is a standard procedure performed on the hospitalized patient. Placement of central line catheters is for various reasons such as inadequate peripheral venous access, hemodynamic monitoring, infusion of peripherally incompatible infusions, and extracorporeal therapies. After obtaining access, the management of central catheters revolves around preventing catheter-based skin site or bloodstream infections, central line thrombosis, and mechanical complications. Catheter maintenance should involve using aseptic techniques when handling or manipulating catheters. Most hospitals have protocols for routine catheter site inspection, dressing changes, and prompt removal of the catheter when no longer needed.[1][2]

Anatomy and Physiology

The basis of site selection for central venous access centers on the patient’s anatomy and procedure indication. The most common locations for central lines access include the jugular vein, subclavian vein or the femoral vein. The site is typically chosen based on the type of access needs, operator ability, and duration of need. Though any site can be viable, if the option exists, a subclavian or jugular approach should be chosen over the femoral approach based on current evidence. Studies show that the risk of catheter infection is generally higher with catheters placed in the femoral vein compared to the internal jugular or subclavian veins.[3][4]

Indications

Routine care of the central line should take place every time the catheter is manipulated, accessed, or used.

Contraindications

There are few relative contraindications to standard central line insertion.  Although bleeding post insertion is uncommon, moderate-to-severe coagulopathy before initial placement is a relative contraindication. If possible, correction of the underlying coagulopathy or thrombocytopenia should occur first; however, this sometimes is not a viable option in an unstable patient. Other relative contraindications include site-specific considerations. It is worth noting that one should avoid insertion sites with known indwelling intravascular hardware; this would include permanent hemodialysis catheters or pacemaker leads. After insertion, there is no contraindication to routine catheter maintenance and care. In the event of insertion site infection, decreased functionality, or new bacteremia, the catheter should be removed. However, if there is a need to maintain critical venous access to maintain the stability of the patient, then the line should be utilized until another working site of access is available.[5]

Equipment

Routine manipulation of the central line:

• Alcohol or chlorohexidine swabs
• Non-sterile nitrile gloves
• Soap and water/alcohol hand scrub
• Catheter hub locks

Sterile Dressing Change[1][3][6][7][8]:

• Hairnet
• Face mask
• Size appropriate sterile gloves
• Chlorohexidine prep stick
• Sterile gauze
• Biopatch
• Transparent or gauze dressing

Personnel

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.

Preparation

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] 

Technique

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.

Complications

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]

Clinical Significance

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.

Enhancing Healthcare Team Outcomes

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.