Care of Central Lines: A Practical Guidance

Central line-associated bloodstream infection is one of most serious and common complications of central venous catheters. It is defined as a laboratory-confirmed bloodstream infection in a patient with a central line at the time of, or within 24-h prior to, the onset of symptoms, in cases where the cultured organism is not related to an infection from another site. However, prevention of that serious complication by adhering to central line care bundle is of utmost importance.

Hand hygiene before and after central line insertions or manipulation.

Use liquid soap
6 stage hand washing technique
Dry hands with a sterile cloth

Site selection for the insertion of central lines

RIJ is first choice
Avoid femoral site as much as possible

US guided central line insertion

US guided vascular localization is compulsory
Clean the probe before procedure
Always scan & confirm the suitability of the site prior to procedure
Improvised glove barrier with gel inside
Sterile probe cover
Do not apply unsterile gel on site
Clean the probe again after the procedure

Skin preparation

1^st line; 2% chlorhexidine
(2^nd line; Povidone iodine)

30 second scrub
(2 minutes if groin)
1 minute to dry

Full barrier precautions during insertion of central lines

Non-sterile cap and mask
All hair should be under cap
Mask should cover nose & mouth tightly
Sterile gown and gloves
Fully cover the patient with sterile drape

Selection of appropriate catheter and technique

Catheter with minimum number of lumens needed
16 cm catheter for RIJ and 20 cm catheter for LIJ
Avoid subclavian route for dialysis catheter insertion when possible.
Use Seldinger technique and make sure guidewire is removed.

Documentation of the procedure

CVC insertion record should be filled by the operator
Insertion date should be clearly documented
Imaging should be ordered to confirm location and exclude complications

Post-insertion care: Hub care

Clean needleless connector/hub before every access with 70% alcohol
Perform at least 10 “scrubs” in a motion similar to juicing an orange
changing needless connectors
- With tubing change
- As needed if occluded or if visible blood or debris is seen in or on connector
- Every 96 hrs if not being accessed
- Prior to drawing blood cultures

Post-insertion care: Site care

Line should be well secured (silk/vicryl/nylon)
Transparent dressing should be applied
Timing of dressing change
- Any dressing that is damp, loose, or soiled Immediately
- Transparent dressing Every 7 days
- Gauze dressing Every 48 hours

Post-insertion care: Tubing care

Replace tubing used to administer propofol infusions every 6 or 12 hours, when the vial is changed
Replace tubing used to administer blood, blood products, or fat emulsions within 24 hours
not receiving blood, blood products or fat emulsions, replace administration sets that are continuously used, including secondary sets and add-on devices, no more frequently than at 96-hour intervals
Dedicated line for TPN when indicated

Screening for infections

Catheter tip for sampling should be sent only when indicated (routine practice is discouraged)
Blood for cultures from central lines should always accompanied by sample from a peripheral stab
Blood taken for cultures during the insertion of central line is considered as a peripheral sample

What is central line associated blood stream infections (CLABSI)

Central line-associated bloodstream infection is defined as a laboratory-confirmed bloodstream infection which develops within 48 hours of central line placement and is not considered to be related to an infection at another site of the patient.

Approximately 40%–80% of CLABSIs are caused by gram-positive organisms. Coagulase-negative Staphylococci, Staphylococcus aureus, and Enterococcus are the most common organisms. Methicillin-resistant staphylococcus is frequently seen. 20%–30% of infections CLABSIs are caused by gram-negativ

Reference:

Ceylon College of Critical Care Specialists