This document provides information and best practices for central and peripherally inserted central catheters (PICCs). It discusses indications for central lines, types of central lines including non-tunneled and PICCs, catheter placement and tips, dressing changes, flushing procedures, and documentation standards. The document emphasizes following Centers for Disease Control and Prevention guidelines to prevent infections, including using sterile technique and chlorhexidine for dressing changes and site access. It also stresses the importance of daily site assessments and prompt removal of unnecessary lines.

1. Central and PICC Lines
Care and Best Practices
Mary Larson, SN
St. Cloud State University

2. Mary Larson
 Hometown: Atwater, MN
 St. Cloud State University Nursing Program: December 21st
 Capstone Semester
 Preceptor: Jamie Daniel
 180 Direct Patient Care Hours, 90 Leadership Hours (40 at Meeker Memorial)
 Leadership Project- Teaching

3. Pre-Quiz

4. Central Venous Access
 Catheters inserted into large veins in central circulation
 Tip of catheter threaded to reside in lower third of the vena cava
 Chest X-ray to confirm correct placement

5. Central Venous Access
Indications:
 Patients requiring multiple sites for IV access
 Patients lacking useable peripheral IV sites
 Patients requiring central venous pressure monitoring
 Patients requiring total parenteral nutrition
 Patients receiving incompatible medications
 Patients requiring multiple infusions of fluids, medications, or chemotherapy
 Patients requiring long term antibiotic therapy
 Patients subject to frequent blood sampling or receiving blood transfusions
 Patients requiring a temporary access site for hemodialysis
 Patients receiving infusions that are hypertonic, hyperosmolar or infusions that
have divergent pH value

6. Non-Tunneled Percutaneous Central
Venous Catheter
 AKA Central Line
 Inserted by physician
 Subclavian vein of upper chest or internal jugular veins in the neck
 Occasionally femoral – higher rates of infection
 Measure 7-10 inches (18-25 cm)
 1 to 5 Lumens
 Used most common: Trauma, critical care, surgery
 No recommended dwell time: used for short term, not the catheter of choice
for home care or ambulatory clinic settings

7. Peripherally Inserted Central Venous
Catheters (PICC)
 Long catheter, inserted in vein of antecubital fossa or middle of upper arm
 Basilic vein preferred, cephalic used if necessary
 Inserted by physicians or specially trained nurses
 Length 18-29 inches (45-72 cm), 1-3 Lumens
 Optimal dwell time unknown: reported to dwell successfully for months or
even years
 Lower rate of Central Line Assoc. Bloodstream Infections (CLABSI) than
Central Lines
 Patients requiring lengthy antibiotics, chemotherapy, parenteral nutrition, or
vasopressor agents – benefit from PICC line.

8. Lumens
 Central Line: 1-5
 PICC Line: 1-3
 Port Designation: (with 3 Lumens)
 Proximal
 Blood Sampling
 Medications
 Blood Administration
 Medial
 TPN
 Medications (Only if TPN use in not anticipated)
 Distal
 CVP monitoring
 Blood Admin
 High Volume or Viscous Fluids
 Colloids
 Medications

9. Catheter Dressings
 Center for Disease Control and Prevention (CDC)
 Recommendations:
 Use either sterile gauze or sterile transparent semipermeable dressing
 If pt is diaphoretic or site is bleeding or oozing, use gauze until
resolved
 Replace dressing if damp, loosened, or visibly soiled
 Do not use antibiotic ointments or creams
 Dressing changes:
 Short-term CVC sites q 2 days for gauze and at least q 7 days for
transparent
 PICC-24 hours post insertion, then transparent dressings q 5-7 days unless
soiled or loose, gauze q 2 days unless wet, soiled, or non-occlusive
 >5% Chlorhexidine to cleanse skin during dressing changes

10. Dressing Changes
 Dressing Removal:
 Stabilize catheter and Luerlock hub to prevent dislodgement
 Separate dressing away from Luerlock hub and toward insertion site
 Chlorhexidine should be used to swab in a back and forth pattern for 30
seconds to ensure the skin is clean and disinfected
 If patient is diaphoretic with a great deal of fluid present on skin, area should
be scrubbed for 2 minutes to ensure bactericidal activity
 During dressing change- assess external catheter length to determine if
migration had displaced catheter tip
 Sterile occlusive dressing should cover entire insertion site, suture wing and
at least 2.5 cm of the extension tubing is recommended

11. Dressing Change Procedure
 Gather supplies
 Hand hygiene
 Don clean gloves and mask (patient)
 Remove old dressing (toward insertion site) and discard
 Remove gloves, perform hand hygiene, and don sterile gloves
 Inspect catheter, site, surrounding skin, and pt’s arm/chest/neck
 Cleanse site (chlorhexidine) back and forth motion
 Allow to air dry
 Secure catheter in place
 Apply sterile dressing to site
 Document date, time, and initials on new dressing
 Document the procedure, any complications, and external catheter length to
patient’s chart

12. Caps: Needleless Access Devices
 CDC recommends changing caps at least as frequently as administration sets
 No benefit to changing these more frequently than every 72 hours
 TPN/Lipids (enhance microbial growth)
 Accessing: “Scrub the Hub” for 15 seconds
 Types:
 Negative Displacement Device
 Neutral Displacement Device
 Positive Displacement Device
 At Meeker Memorial: Baxter Clearlink System (Negative Displacement)

13. Flushing Lines
 A single use syringe should never be used more than once
 10 mL syringes should not be divided into several doses and used for multiple
lumens
 Never use a syringe smaller than 10 mL
 The pressure created by smaller syringes could damage the catheter
 Volume: Minimum of twice the volume of the catheter should be used to flush
 In general for adults 10 ml is sufficient
 0.9% NaCl solution should be used
 Frequency: If being used a minimum of q 8 hours, flush with 10 mL NS before
and after every use and for lines in maintenance mode flush with 10 mL NS
every 24 hours.
 Flush using a pulsative or “stop-start” technique
 Creates turbulence within the catheter to adequately flush medications from the
line

14. Preventing:
Blood Reflux
 Major problem
 Catheters are deep in the body, reflux cannot be seen when it occurs
 Caused by inadequate flushing, also b/t flushes caused by increased
intravascular pressure (ex: coughing, vomiting) leading to biofilm formation and
buildup, occlusion, and even infection
 Prevention Strategy: Know which type of needleless connector is being used.
 Negative Displacement (Meeker Memorial – Baxter Clearlink System)
 Catheter must be clamped BEFORE syringe is removed
 Neutral Displacement
 Fluid should remain neutral, therefore clamping can be done before or after syringe removal
 Positive Displacement
 Important to clamp the catheter AFTER the syringe is removed in order to get displacement
https://www.youtube.com/watch?v=X5wIhmR0SIE

15. Assessment
 Visually examine insertion site daily for erythema, drainage, tenderness,
suture integrity, and catheter position
 Routine IV site assessments
 Routinely assess dressings (change if necessary)
 Daily assessment of need for Central Line and promptly discontinue lines
which are no longer indicated
 Nursing staff should be encouraged to notify physicians of Central Lines which
are unnecessary

16. Documentation
 The following should be included in the patient’s chart:
 Product Name
 Date of insertion, inserter
 Anatomical location
 Catheter depth according to catheter reference markings
 X-ray confirmation of catheter tip location
 Port designation for infusions/measurements, e.g. TPN, CVP, Medications
 Ensures uniform use of lumens
 Amount, type, and frequency of flush solution
 Dressing and tubing changes
 Document exposed catheter length with dressing changes
 Site assessments
 Every shift
 Complications
 Catheter removal and application of air-impermeable dressing

17. References
 Angiodynamics (2014). Bioflo picc with endexo technology: Directions for use.
Marlborough, MA: Navilyst Medical, Inc.
 Arrow (1996). Central venous catheter: Nursing care guidelines. Reading, PA: Arrow
International, Inc.
 Centers for Disease Control and Prevention (2011). Basic infection control and
prevention plan for outpatient oncology settings. Retrieved from
http://www.cdc.gov/HAI/settings/outpatient/basic-infection-control-prevention-plan-
2011/central-venous-catheters.html
 Centers for Disease Control and Prevention (2011). Guidelines for the prevention of
intravascular catheter-related infections. Retrieved from
http://www.cdc.gov/hicpac/bsi/bsi-guidelines-2011.html
 Ignatavicius, D.D., & Workman, M.L. (2013). Medical-surgical nursing: Patient-centered
collaborative care (7th ed.). St. Louis, MO: Elsevier Saunders.
 Kallen, A. (2009). Central line-associated bloodstream infections (clabsi) in non-intensive
care unit (non-icu) settings toolkit. Atlanta, GA: Centers for Disease Control
and Prevention.
 Schallom, L., & Shomo, J.E. (2011). Keeping the lines open with evidence-based
practice and technologies: A continuing educational activity for pharmacists and
nurses. Irving, TX: VHA, Inc.
 The Nebraska Medical Center (2012). Standardizing central venous catheter care:
Hospital to home (2nd ed.). Omaha, NE: The Nebraska Medical Center.

18. Questions?

19. Post-Quiz