When should a central line (central venous catheter) be changed in critically ill patients?

Central Line Replacement in Critically Ill Patients

Central venous catheters in critically ill patients should NOT be routinely changed at scheduled intervals; instead, they should be removed promptly when no longer clinically necessary or when signs of infection or malfunction develop. 1

Evidence Against Routine Scheduled Replacement

The highest quality evidence demonstrates that routine replacement strategies are ineffective and potentially harmful:

• Scheduled replacement every 3 days does not prevent infection compared to replacement only when clinically indicated 2, 3
• Routine guidewire exchanges increase the risk of catheter-related bloodstream infections (relative risk 1.72) without reducing colonization rates 3
• New-site insertions for routine replacement increase mechanical complications (14 per 1000 catheter-days vs 3-4 per 1000 with guidewire exchange) 2
• The cumulative infection risk does not increase with duration of catheterization when proper care is maintained 4

When to Remove Central Lines

Immediate Removal Indications

Remove the catheter immediately when: 1

• The line is no longer clinically necessary (assess daily) 1, 5
• Signs of catheter-related bloodstream infection develop (fever without other source, positive blood cultures, purulent drainage) 1
• Local signs of infection appear at the exit site 1
• The catheter malfunctions and cannot be salvaged 1

Emergency Insertion Exception

• Catheters inserted during medical emergencies without proper aseptic technique must be replaced within 48 hours at a new site 1

Special Considerations for Critically Ill Patients

Duration-Based Catheter Selection (Not Replacement)

For hemodynamically stable critically ill patients: 1

• 6-14 days expected use: Central venous catheters are appropriate 1
• ≥15 days expected use: Consider PICCs over CVCs due to lower insertion complication risk, though infection and thrombosis concerns remain 1
• Beyond 15 days: Appropriateness is uncertain; weigh infection/thrombosis risks carefully 1

Patients with Coagulopathy

• Prefer PICCs over CVCs if use will exceed 15 days in critically ill patients with coagulopathies (DIC, sepsis) to minimize insertion bleeding risk 6

Context-Specific Replacement Intervals

The only guideline supporting scheduled replacement applies to a highly specific population (Stevens-Johnson syndrome/TEN patients with extensive skin loss):

• Central lines: Change every 5-7 days if signs of sepsis or local infection are present, ideally through non-lesional skin 1
• Peripheral lines: Change every 2-3 days under the same conditions 1

This recommendation reflects the unique infection risk in patients with massive epidermal loss and should not be extrapolated to general critical care populations.

Daily Assessment Protocol

Evaluate every patient with a central line daily for: 1, 5

• Ongoing clinical indication for central access 1
• Signs of infection (fever, leukocytosis, exit site erythema/purulence) 7
• Catheter function 1

Studies show that 27.7% of central line days lack appropriate indication, with 50.6% of patients having at least one day without justification 5. This represents substantial unnecessary risk exposure.

Common Pitfalls to Avoid

• Do not routinely change catheters every 3-7 days in general ICU populations—this practice is not evidence-based and increases complications 2, 3
• Avoid guidewire exchanges for suspected infection—this increases bacteremia risk; use new-site insertion instead 3
• Do not leave unnecessary catheters in place—nearly half of ICU patients have unjustified central lines on any given day 5
• Recognize that infection risk plateaus rather than continuously increases with catheter duration when proper care is maintained 4