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Central venous catheters (CVC) are frequently used in critical care units, hemodialysis units, and oncology units for the administration of intravenous fluids, medications, blood products, parenteral nutrition, vasoactive medications, hemodialysis, and hemodynamic monitoring. Unfortunately, the presence of indwelling CVCs increases the risk of the formation of thrombi, emboli, and infection than patients with peripheral catheters by 200%. This activity outlines and reviews the care of patients who have an indwelling central venous catheter and the role of the interprofessional team in taking care of it. Objectives: Identify the risk factors associated with central venous catheter insertion. Describe evidence-based patient cleansing and skin preparation techniques. Explain evidence-based central venous catheter dressing change recommendations. Summarize interprofessional team strategies for improving care coordination and communication in patients with central venous catheters. Access free multiple choice questions on this topic.

Central venous catheters (CVC) are frequently used in critical care units, hemodialysis units, and oncology units for the administration of intravenous fluids, medications, blood products, parenteral nutrition, vasoactive medications, hemodialysis, and hemodynamic monitoring. Unfortunately, the presence of indwelling CVCs increases the risk of the formation of thrombi, emboli, and infection than patients with peripheral catheters by 200%.[1][2] Central line infections are more common than any other healthcare-related infection and account for 33,000 deaths per year. Additionally, CVC infections are associated with increased morbidity, mortality, length of stay, healthcare costs, diagnostic tests, and antimicrobial use. The development of central line-associated bloodstream infection (CLABSI) may increase the patients’ length of stay by up to three weeks for an average additional healthcare cost of $33,000.[3][4][1] Recommendations have been established and published by the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Centers for Disease Control and Prevention (CDC) to guide health care providers in the use of evidence-based practices for central line care.[2]

The majority of complications of central lines are immediate complications that result from the insertion procedure like pneumothorax, vascular perforation, and venous air embolism.[12] Other complications are delayed and manifest after some time and these include: The main delayed complications are those of CVC-associated infection, and it is these which are focused upon in this article. This complication is a relatively frequent event, affecting around 5% of patients with an inpatient stay in the United States. Although this rate is falling, it is a severe event with mortality of between 12 and 25%.[13] CVCs can also be complicated by line dysfunction, where the CVC fails to function either due to increased resistance or blockage. This can be due to site, patient positioning, and formation of fibrin sheaths within the lumen and blocking the distal ports.[12] It is possible to attempt to resolve a blockage through the use of alteplase or another fibrinolytic agent being inserted via the line in an attempt to dissolve the material.[14] Rarer complications include; fracture, where high pressures cause the CVC lumen to fracture, causing trauma to the vessel, central venous thrombosis, and stenosis associated with the CVC Site or portions of the catheter promoting coagulation and endovascular fibrous growth.[14][12]

There are a number of actions that can be implemented to improve the performance of central line care on a broader scale. Following and promoting hospital-specific or collaborative performance initiatives have been shown to improve compliance with evidence-based practice. The patient care team should perform CVC necessity reviews daily to ensure that central venous catheters are removed as soon as they are no longer necessary. Additionally, initiating and supporting a dedicated vascular team to address CVC insertion, maintenance, evaluation, and removal will decrease the incidence of central line complications.[1][2][18]

The following is a list of commonly recommended and implemented nursing care interventions for central lines.Education, Training, and Staffing All healthcare professionals working in a setting with indwelling CVCs should receive annual training on central line care. Updates regarding indications for the placement of CVCs, maintenance of CVCs, and infection control measures should be included.[3] Facilities may institute a CVC care team. Having a dedicated team of personnel who demonstrate competence in maintaining central lines has been shown to decrease central line-associated bloodstream infection (CLABSI). Additionally, ensuring adequate staffing in intensive care units (ICUs), decreasing the number of float nurses in the ICUs, and maintaining a low patient-to-nurse ratio reduces the incidence of catheter-related bloodstream infections. Skin Preparation Before the insertion of the central line, some traditional texts advocate bathing the patient from chin to ankle using chlorhexidine wash. This should be followed by preparing the skin for catheter placement by cleansing the insertion site thoroughly with chlorhexidine gluconate. Allow the area to dry fully before the provider proceeds with catheter insertion.[4][1][2] Catheter Securement Sutureless securement devices should be used to reduce the risk of infection at the central line site.[4][2] Catheter Site Dressing Regimen Central line dressings should not be changed every day unless they are loose or soiled. Current recommendations are to change gauze dressing every two days and transparent, semi-permeable dressing every seven days unless soiled or loose. If the patient is diaphoretic, has bleeding at the insertion site, or oozing from the insertion site, use a gauze dressing until the issue has resolved. Do not use topical antibiotic ointment or cream at the insertion site as this is ineffective. The exception would be with dressing changes to hemodialysis catheters, povidone-iodine, antiseptic ointment, or bacitracin/gramicidin/polymyxin B ointment may be applied to a hemodialysis catheter insertion site at the end of the dialysis session.[3][2] Patient Cleansing The patient with a central venous catheter should wash daily using chlorhexidine for skin cleansing.[3][2][19] Systemic Antibiotic Prophylaxis

Central line dressings should not be changed every day unless they are loose or soiled. Current recommendations are to change gauze dressing every two days and transparent, semi-permeable dressing every seven days unless soiled or loose. If the patient is diaphoretic, has bleeding at the insertion site, or oozing from the insertion site, use a gauze dressing until the issue has resolved. Do not use topical antibiotic ointment or cream at the insertion site as this is ineffective. The exception would be with dressing changes to hemodialysis catheters, povidone-iodine, antiseptic ointment, or bacitracin/gramicidin/polymyxin B ointment may be applied to a hemodialysis catheter insertion site at the end of the dialysis session.[3][2] Patient Cleansing The patient with a central venous catheter should wash daily using chlorhexidine for skin cleansing.[3][2][19] Systemic Antibiotic Prophylaxis Systemic antimicrobials should not be administered prophylactically in otherwise healthy patients. There are no indications that the prophylactic administration of systemic antimicrobials is beneficial, and the overuse of antimicrobials may lead to systemic resistance to these medications.[2] Replacement of Central Venous Catheters Central lines should be removed as soon as they are no longer necessary. However, central venous catheters should not be routinely replaced. Routinely replacing central venous catheters has been shown to increase the incidence of infection at central line insertion sites. Additionally, central lines should not be removed based solely on the presence of hyperthermia. Other noninfectious causes of fever should be considered, and other evidence of infection should be sought before replacing an existing central venous catheter.[3][2] Replacement of Administration Sets To decrease the incidence of CLABSI, intravenous (IV) administration sets should be changed no more frequently than every 96 hours but should be changed at least every seven days. IV tubing for blood, blood products, or fat emulsion product administration should be replaced within 24 hours of the initiation of the products. Additionally, IV tubing used for propofol administration should be changed at least every 6  to 12 hours or each time the vial is changed. Needleless Intravenous Catheter Systems

To decrease the incidence of CLABSI, intravenous (IV) administration sets should be changed no more frequently than every 96 hours but should be changed at least every seven days. IV tubing for blood, blood products, or fat emulsion product administration should be replaced within 24 hours of the initiation of the products. Additionally, IV tubing used for propofol administration should be changed at least every 6  to 12 hours or each time the vial is changed. Needleless Intravenous Catheter Systems The use of needleless IV catheter systems is highly recommended for reducing CVC complications. Needleless connectors and components should be changed with each IV administration set to change, no more frequently than every 72 hours. Access ports should be scrubbed with chlorhexidine, povidone-iodine, iodophor, or 70% alcohol and accessed only with sterile devices. All lumens are to be covered, preferably with disinfecting hub caps.[11][4][2]

Nursing staff must be appropriately trained in the care of CVCs. Although the evidence for familiarity and training leading to reduced complications is not easy to develop or prove, there is limited evidence from a single study showing that impermanent staff caring for patients led to an increase in the rate of CVC-associated infectious complications.[20]