What is the best way to manage a central line in an adult or pediatric patient with a confirmed medical need for central venous access?

Central Line Management

Manage central lines using maximal sterile barrier precautions during insertion, chlorhexidine-based skin antisepsis, ultrasound guidance for placement, daily assessment of continued need with prompt removal when no longer essential, and meticulous maintenance protocols including proper hand hygiene and dressing care. 1

Site Selection and Insertion Technique

Preferred Insertion Sites

• Use the subclavian site over jugular or femoral sites in adults for non-tunneled CVCs to minimize infection risk 1
• Avoid femoral vein access in adult patients due to significantly higher infection and thrombotic complication rates 1, 2
• Exception: Avoid subclavian sites in hemodialysis patients and those with advanced kidney disease to prevent subclavian vein stenosis 1
• In pediatric patients, upper or lower extremities or scalp (in neonates/young infants) are acceptable insertion sites 1

Ultrasound Guidance

• Use ultrasound guidance for CVC placement to reduce cannulation attempts and mechanical complications (pneumothorax, arterial puncture, hemothorax) 1
• Real-time ultrasound guidance is particularly recommended for internal jugular vein cannulation 1
• Operators must be fully trained in ultrasound technique before use 1

Insertion Bundle: Maximal Sterile Barrier Precautions

Required Components

• Apply maximal sterile barrier precautions for all CVC and PICC insertions, including: 1, 2
  • Cap covering all hair
  • Mask covering both mouth and nose
  • Sterile gown
  • Sterile gloves
  • Sterile full-body drape covering the entire patient

Skin Antisepsis

• Prepare skin with >0.5% chlorhexidine in alcohol solution before CVC insertion and during dressing changes 1, 2
• For adults, infants, and children: chlorhexidine-containing solution is the standard 1, 2
• For neonates: Use chlorhexidine cautiously based on clinical judgment and institutional protocol; 2% chlorhexidine has been associated with skin burns in premature infants—avoid pooling and consider 0.5% solution as alternative 1
• If chlorhexidine is contraindicated: use tincture of iodine, iodophor, or 70% alcohol 1

Catheter Selection

Number of Lumens

• Use a CVC with the minimum number of ports/lumens essential for patient management 1
• Single-lumen catheters are preferred when clinically feasible to reduce infection risk 1
• If multi-lumen catheter is required, designate one lumen exclusively for parenteral nutrition 1

Duration-Based Selection

• For IV therapy likely exceeding 6 days: use midline catheter or PICC instead of short peripheral catheter 1
• For long-term access (>3 months): consider tunneled catheters or totally implantable devices 1, 3
• Antimicrobial-coated CVCs (chlorhexidine/sulfadiazine or rifampicin/minocycline) should be used in high-risk patients when CLABSI rates remain elevated despite comprehensive prevention strategies 1, 2

Daily Maintenance and Monitoring

Site Assessment

• Evaluate the catheter insertion site daily by palpation through dressing to detect tenderness 1, 2
• With transparent dressings: perform visual inspection daily 1
• Do not remove gauze/opaque dressings unless patient has clinical signs of infection (local tenderness, erythema, warmth) 1

Dressing Management

• Use transparent bioocclusive dressings to protect the insertion site 2
• Chlorhexidine-impregnated dressings may be used in adults, infants, and children unless contraindicated 2
• Change dressings when they become damp, loosened, or visibly soiled 1

Hand Hygiene

• Perform proper hand hygiene before and after any contact with the catheter or insertion site—this is the single most crucial intervention to prevent CLABSI 2, 4

Hub and Access Management

• Disinfect catheter hubs, stopcocks, and needle-free connectors before each access 1, 2
• Cap stopcocks or access ports when not in use 2
• Perform routine saline flush after completing any infusion or blood sampling 2

Removal Criteria

When to Remove

• Promptly remove any CVC that is no longer clinically essential 1, 2
• Remove if patient develops signs of infection (fever, local inflammation, positive blood cultures suggesting CRBSI) 1
• Remove if catheter malfunctions 1
• Replace catheters inserted during medical emergencies (when aseptic technique could not be ensured) within 48 hours 1

Femoral Catheter Duration

• Femoral catheters should not remain in place >5 days due to high infection and dislodgement rates 5
• Femoral catheters are only appropriate for bedbound patients 5

Special Considerations

Coagulopathy

• Routine correction of coagulopathy is only necessary if: 1
  • Platelet count <50 × 10⁹/L
  • aPTT >1.3 times normal
  • INR >1.8
• The risks of correction (infection, lung injury, thrombosis) may exceed local bleeding risk—consider giving blood products reactively rather than prophylactically 1

Arterial Injury During Insertion

• If unintended arterial cannulation occurs with a large-bore catheter/dilator: leave the catheter in place and immediately consult vascular surgery or interventional radiology before removal 1
• Immediate removal has been associated with severe complications (cerebral infarction, arteriovenous fistula, hemothorax) 1

Pediatric-Specific Considerations

• Most pediatric CVC procedures require general anesthesia (except PICCs) 1
• Use narrower guidewires (0.021" vs 0.032" in adults) which are prone to kinking 1
• Neonatal catheters range from 28G to 4.5-Fr triple-lumen; tunneled Broviac catheters available down to 2.7-Fr 1
• X-ray confirmation of tip position remains standard in pediatrics 1

Confirmation of Placement

During Insertion

• Confirm venous residence of guidewire after threading using ultrasound, TEE, continuous ECG (narrow-complex ectopy), or fluoroscopy 1
• After catheterization and before use: confirm venous location via manometry or pressure waveform measurement 1

Final Tip Position

• Confirm final catheter tip position as soon as clinically appropriate 1
• For CVCs placed in operating room: obtain chest radiograph no later than early postoperative period 1
• Methods include chest radiography, fluoroscopy, or continuous ECG 1

Implementation Strategies

System-Level Interventions

• Use standardized equipment sets for central venous access 1, 2
• Implement checklists or protocols for CVC placement and maintenance 1, 2
• Utilize an assistant during CVC placement 1, 2
• Bundle implementation (insertion + maintenance bundles) reduces CLABSI incidence by approximately 56% (IRR 0.44,95% CI 0.39-0.50) 6

Antibiotic Prophylaxis

• Do not administer routine IV antibiotic prophylaxis for CVC insertion 1, 2
• For immunocompromised patients and high-risk neonates: consider prophylaxis on case-by-case basis 1, 2