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Central line best practice
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
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.