What are the best practices for catheter insertion and management to prevent complications?

Best Practices for Catheter Insertion and Management to Prevent Complications

The most effective strategy to prevent catheter-related complications is to use maximal sterile barrier precautions during insertion, select the appropriate insertion site based on patient factors, and promptly remove catheters when no longer needed. 1, 2

Catheter Selection and Site Placement

Site Selection Algorithm:

1. For central venous catheters in adults:

   • First choice: Subclavian site (lowest infection risk for non-tunneled CVCs) 1, 2
   • Second choice: Internal jugular site 2
   • Avoid: Femoral site (highest infection risk) 1, 2

2. Special populations:

   • Hemodialysis patients: Avoid subclavian site (risk of stenosis) 1, 2
   • Pediatric patients: Prefer radial, dorsalis pedis, and posterior tibial sites; avoid brachial site 2

3. For peripheral catheters:

   • Use midline catheter or PICC when IV therapy will exceed 6 days 1
   • Avoid steel needles for administering fluids that might cause tissue necrosis 1

Insertion Technique

Maximal Sterile Barrier Precautions:

• Required for all central lines: Cap, mask, sterile gown, sterile gloves, and full-body sterile drape 1, 3
• This approach significantly reduces catheter-related infections compared to using only sterile gloves and small drapes 3

Hand Hygiene:

• Perform hand hygiene before and after palpating, inserting, replacing, accessing, or dressing any catheter 1
• Hand hygiene is required even when gloves are worn 1

Skin Preparation:

• Preferred: 0.5% chlorhexidine preparation with alcohol 1, 2
• Alternatives (if chlorhexidine contraindicated): Tincture of iodine, iodophor, or 70% alcohol 1, 2
• Allow antiseptic to completely dry before insertion (at least 2 minutes for povidone-iodine) 1
• Never use organic solvents (acetone, ether) on the skin 1

Catheter Maintenance

Dressing Management:

• Use either sterile gauze or sterile, transparent, semi-permeable dressing 1
• Use gauze dressing if the patient is diaphoretic or if the site is bleeding/oozing 1
• Replace dressings:
  • Gauze dressings: Every 2 days 1
  • Transparent dressings: At least every 7 days 1
  • Any dressing: Immediately if damp, loosened, or visibly soiled 1

Site Assessment:

• Evaluate the catheter insertion site daily 2
• For transparent dressings: Visual inspection 1
• For gauze/opaque dressings: Palpation for tenderness 1
• Remove dressing and inspect visually if signs of infection are present 1

Administration Sets:

• Replace standard administration sets no more frequently than every 72 hours 1
• Replace tubing used for blood products or lipid emulsions within 24 hours 1
• Replace propofol administration tubing every 6-12 hours per manufacturer's recommendation 1

Catheter Removal

Indications for Removal:

• When the catheter is no longer essential 1, 2
• Development of phlebitis (warmth, tenderness, erythema, palpable venous cord) 1, 2
• Signs of catheter-related infection 2
• Catheter malfunction 2

Timing of Replacement:

• Do not routinely replace central venous catheters solely to reduce infection risk 1, 2
• Replace peripheral venous catheters every 72-96 hours in adults 1
• Replace catheters inserted during emergency situations (when aseptic technique couldn't be ensured) within 48 hours 1

Common Pitfalls and How to Avoid Them

1. Unnecessary catheterization: Only insert catheters when absolutely necessary for patient care 4

2. Improper site selection: Consider both infection and mechanical complication risks when selecting a site; avoid femoral site in adults when possible 1, 2

3. Inadequate barrier precautions: Always use maximal sterile barrier precautions for central line insertion, which reduces infection risk 6.3 times compared to minimal precautions 3

4. Prolonged catheter duration: The longer a catheter remains in place, the higher the infection risk; remove promptly when no longer needed 1, 2

5. Suboptimal dressing care: Ensure dressings remain intact and replace when compromised; do not submerge catheters in water 1

6. Using antibiotic ointments: Do not use topical antibiotic ointment or creams on insertion sites (except for dialysis catheters) due to risk of fungal infections and antimicrobial resistance 1

7. Inadequate hub/connector care: Minimize contamination risk by wiping access ports with appropriate antiseptic before use 1