What are the key steps and considerations for performing a central line procedure?

Central Line Placement and Management: Key Talking Points

For safe and effective central line placement, follow a standardized protocol that includes proper education, sterile technique, and evidence-based maintenance practices to minimize complications such as infections and thrombosis.

Pre-Procedure Preparation

• Ensure all healthcare personnel involved in central line procedures undergo comprehensive education and competency assessment before performing these procedures 1
• Prepare all necessary equipment in advance and create a sterile field 1
• Perform hand hygiene using either alcohol-based waterless product or soap and water before catheter insertion or manipulation 1
• Implement maximum sterile barrier precautions including mask, cap, sterile gown, sterile gloves, and large sterile drape covering the patient 1

Site Selection

• Avoid using the femoral site due to increased risk of infection and thrombosis, especially in ICU settings 1
• Consider subclavian or internal jugular veins as preferred insertion sites 1
• For patients requiring hemodialysis, avoid subclavian sites due to risk of stenosis 1
• Right-sided insertion is generally preferred over left-sided placement to reduce thrombosis risk 2

Insertion Procedure

• Use ultrasound guidance for catheter insertion to reduce complications and improve success rates 1
• Apply alcoholic chlorhexidine solution (minimum 2% CHG) to the insertion site and allow it to dry completely before puncturing the skin 1
• Use either open technique (cephalic vein cut-down) or percutaneous approach, with the open technique offering lower risk of immediate complications 1
• Verify catheter tip position using intraoperative fluoroscopy, post-operative chest X-ray, or intracavitary ECG method 1
• Select a catheter with the minimum number of lumens necessary for patient management 1

Post-Procedure Care

• Monitor vital signs (temperature, pulse, blood pressure, respiratory rate) every 4 hours after the procedure 1
• Obtain a chest X-ray if the patient experiences dyspnea or chest wall pain 1
• Place a sterile, transparent dressing over the insertion site and replace it no more than once weekly unless soiled or loose 1
• Consider daily chlorhexidine bathing for ICU patients over two months of age to reduce infection risk 1

Maintenance and Prevention of Complications

• Perform routine flushing with saline after completion of any infusion or blood sampling 1
• For subcutaneous ports not in active use, perform a four-weekly flush; for tunneled cuffed catheters and PICC lines, perform weekly flushes 1, 3
• Use proper flushing technique with 10mL or larger syringes to prevent catheter damage 3, 2
• Replace administration sets and needle-less connectors at least every 7 days (or within 24 hours after blood, blood products, or fat emulsion infusions) 1

Infection Prevention and Management

• Implement a bundle approach to reduce central line-associated bloodstream infections (CLABSI) 1, 4
• If CLABSI is suspected, collect paired blood cultures from the catheter and a peripheral vein before starting antibiotics 1
• Use alcohol, iodine tincture, or alcoholic chlorhexidine for skin preparation before blood collection 1
• Consider empirical antibiotic treatment with vancomycin if CLABSI is suspected before blood culture results are available 1

Troubleshooting Catheter Problems

• For blocked catheters, check for external causes of resistance such as kinks in the catheter limb or patient position 3
• Use gentle back-and-forth motion to promote catheter patency, followed by flushing with 10 mL of normal saline using a turbulent flushing technique 3
• Avoid using syringes smaller than 5 mL as they generate higher pressure that could damage the catheter 3
• If catheter function cannot be restored, consider radiological assessment to evaluate for mechanical occlusion, catheter malposition, or thrombosis 3

Common Complications and Prevention

• Infection: Maintain strict aseptic technique and adherence to bundle protocols 5, 6
• Thrombosis: Consider proper catheter tip positioning at the junction between the superior vena cava and right atrium 1
• Mechanical complications: Use ultrasound guidance during insertion to minimize risk of pneumothorax, arterial puncture, and malposition 1, 7
• Air embolism: Ensure all connections are secure and clamp catheters during tubing changes 7

Quality Improvement Measures

• Implement collaborative performance-improvement initiatives with designated physician and nursing team leaders 1
• Use checklists to assess compliance with bundle elements 1, 4
• Empower staff to stop procedures if protocols are not followed 1
• Monitor CLABSI rates and provide feedback to staff to improve outcomes 4, 6