What are the best practices for managing central venous access (CVA) via central line?

From the Guidelines

Best practices for managing central venous access (CVA) via central line include strict adherence to aseptic technique during insertion and maintenance, with the subclavian vein being the preferred site due to lower infection risk, as supported by the most recent guidelines 1.

Key Recommendations

• Central lines should be inserted using maximal sterile barrier precautions including cap, mask, sterile gown, gloves, and full-body drape.
• The insertion site should be prepared with >0.5% chlorhexidine with alcohol solution and allowed to dry completely before insertion.
• Daily assessment of the need for the central line is essential, with prompt removal when no longer necessary.
• Dressing changes should occur every 7 days for transparent dressings or when the dressing becomes damp, soiled, or loose.
• Chlorhexidine-impregnated dressings can reduce infection rates.
• Access ports should be scrubbed with alcohol or chlorhexidine for at least 15 seconds before each access.
• Tubing changes should occur every 96 hours for continuous infusions (except lipids, blood products, or TPN, which require more frequent changes).
• Hand hygiene before any line manipulation is critical.
• Regular documentation of site appearance, dressing condition, and patient symptoms is necessary.

Site Selection

• The subclavian vein is generally preferred over the jugular or femoral sites when possible due to lower infection risk, as recommended by recent guidelines 1.
• The femoral vein should be avoided unless there is a contraindication to the other sites, due to the increased risk of infection and concerns about thrombosis 1.

Insertion Technique

• Insertion of an implantable venous access device should be carried out under strict sterile conditions, in the operating room 1.
• Chlorhexidine solutions with alcohol should be used for skin preparation 1.
• Antimicrobial prophylaxis is not recommended for catheter insertion or maintenance 1.

Maintenance and Removal

• Routine flushing with saline, after the completion of any infusion or blood sampling, is recommended 1.
• To maintain patency of subcutaneous ports not in active use, a four weekly flush is recommended 1.
• For tunnelled cuffed catheters and PICC lines, a weekly flush is recommended 1.
• Central lines should be removed promptly when no longer necessary to reduce the risk of infection and other complications 1.

From the Research

Best Practices for Managing Central Venous Access (CVA) via Central Line

• Implementing a comprehensive central line insertion and maintenance bundle can reduce central line-associated bloodstream infections (CLABSI) rates 2
• Using antimicrobial-coated catheters with chlorhexidine-impregnated dressings can prevent central line-related infections 3, 2
• Standardizing weekly central venous catheter (CVC) site dressing changes and using antithrombotic and antimicrobial-coated CVCs with fewer lumens can also reduce CLABSI rates 2
• Educational interventions, such as continuing education on infection prevention, can be effective in reducing CLABSI rates in adult intensive care units (ICUs) 4
• Monitoring and feedback are crucial components of a successful CLABSI prevention program, and a surveillance program can help monitor outcomes and adherence to evidence-based central line insertion and maintenance practices 5

Key Components of Central Line Insertion and Maintenance Bundles

• Use of antimicrobial-coated catheters and chlorhexidine-impregnated dressings
• Standardization of weekly CVC site dressing changes
• Use of antithrombotic and antimicrobial-coated CVCs with fewer lumens
• Root-cause analysis of all CLABSI cases
• Passive disinfection caps on vascular access ports
• Continuing education on infection prevention

Reduction of CLABSI Rates

• Implementation of a comprehensive central line insertion and maintenance bundle can reduce CLABSI rates by 42% 2
• Educational interventions can reduce CLABSI rates in adult ICUs, with statistical significance found in all studies except one 4
• Use of antimicrobial-coated catheters and chlorhexidine-impregnated dressings can reduce CLABSI rates, although the effectiveness of these interventions may vary depending on the specific context and population 3, 6