What are the best practices for managing central lines (central venous catheters) to prevent complications?

Best Practices for Managing Central Lines to Prevent Complications

Implementing a comprehensive bundle of evidence-based practices is essential for preventing central line-associated bloodstream infections (CLABSIs) and other complications, including the use of aseptic techniques, maximal barrier precautions, chlorhexidine skin preparation, appropriate site selection, and daily assessment of line necessity. 1

Insertion Practices

• Perform central venous catheterization in an environment that permits aseptic techniques, using a standardized equipment set and following a checklist or protocol 1
• Use an assistant during central line placement to help maintain sterile technique 1
• Implement maximal barrier precautions including sterile gowns, sterile gloves, caps, masks covering both mouth and nose, and full-body patient drapes 1
• Apply chlorhexidine-containing solution for skin preparation in adults, infants, and children 2
• For neonates, determine the use of chlorhexidine solutions based on clinical judgment and institutional protocol due to potential skin reactions 2
• Use ultrasound guidance for vessel identification and venipuncture, particularly when selecting the internal jugular vein for cannulation 2, 3
• Select insertion sites based on clinical need, with upper body sites preferred to minimize thrombotic complications 2, 3
• Avoid femoral site in adult patients due to higher risk of infection and thrombotic complications 2, 3

Maintenance Practices

• Inspect the catheter insertion site daily for signs of infection 2, 4
• Use transparent bioocclusive dressings to protect the central line insertion site 2
• Consider using chlorhexidine-impregnated dressings for adults, infants, and children when not contraindicated 2
• Cap all stopcocks or access ports when not in use to maintain a closed system 2, 5
• Perform routine flushing with saline solution after completing any infusion or blood sampling 2, 5
• Consider daily chlorhexidine bathing for ICU patients over two months of age to reduce infection risk 1
• Evaluate the continued need for the central line daily and promptly remove when no longer clinically necessary 1, 2

Prevention of Complications

Infectious Complications

• Do not routinely administer intravenous antibiotic prophylaxis 1
• Consider antibiotic or antiseptic-impregnated catheters for selected high-risk patients based on infection risk, cost, and anticipated duration of catheter use 2, 6
• Implement a multidimensional approach including bundles, education, surveillance, compliance monitoring, and performance feedback 1, 7

Mechanical Complications

• Use proper flushing protocols, including turbulent flushing technique with 10 mL or larger syringes 5
• Consider continuous infusion using nutritional pumps to prevent intraluminal obstruction 5
• Check for occlusion and rule out external causes of resistance if backflow occurs 5

Thrombotic Complications

• Select upper body insertion sites to minimize thrombotic risk 2, 3
• Position the catheter tip at or near the atrio-caval junction 1
• Choose a catheter with the smallest caliber compatible with the required infusion therapy 1

Management of Complications

Catheter-Related Infections

• If infection is suspected, collect paired blood cultures from the catheter and a peripheral vein before starting antibiotics 2
• Remove short-term central lines in cases of evident local infection at the exit site, clinical signs of sepsis, or positive cultures 1
• For long-term venous access, removal is required for tunnel infection, port abscess, septic shock, fungal or highly virulent bacterial infections, or complicated infections 1

Catheter Occlusion

• Irrigate gently and flush with 10 mL of normal saline to clear blood from the catheter lumen 5
• Consider pharmacological clearance for persistent obstruction, using solutions appropriate for the type of obstruction 5

Common Pitfalls to Avoid

• Failing to use ultrasound guidance when available, which significantly reduces mechanical complications 3, 8
• Ignoring site-specific risks, as each approach has unique complications 3
• Overlooking daily assessment of continued central line necessity 1, 4
• Neglecting proper hand hygiene, which is the single most crucial step in preventing CLABSIs 4
• Underestimating the importance of maintenance practices, which are as critical as insertion practices in preventing infections 9, 4