NURSES MAKES

DIFFERENCE
Care of Central line and
PICC line
 OBJECTIVE
 Able to explain regarding CV line and PICC line, Indication and Contraindications of CV​
lines
 Anatomical importance of CV line
 How to insert a CV line
 ​Complications
 Clinical significance of CV lines
 Role of Nurses in CV line care
 ​Summary​
 3

INTRODUCTION

A central venous catheter (CVC) is an indwelling device inserted into a large,

central vein (most commonly the internal jugular, subclavian, or femoral or
through veins in the arms known as a PICC, or peripherally inserted central
catheters) and advanced until the terminal lumen resides within the inferior vena
cava, superior vena cava, or right atrium.
 ANATOMY & PHYSIOLOGY
There are three main access sites for the
placement of central venous catheters,
namely internal jugular, common femoral,
and subclavian veins. These are the
preferred sites for temporary prominent
venous catheter placement. Additionally,
for mid-term and long-term central
venous access, the basilic and brachial
veins are utilized for peripherally inserted
central catheters (PICCs).
 IJV

• The internal jugular vein (IJ) is often chosen for its reliable anatomy,
accessibility, low complication rates, and ability to employ ultrasound
guidance during the procedure.
• Compared to the left, the right IJ forms a more direct path to
the superior vena cava (SVC) and right atrium.
• It is also wider and more superficial, thus presumably easier to
cannulate.
• ultrasound guidance provides the best chance of locating the vein and
avoiding other structures owing to anatomic variability.
 SC
• The SC site has the advantage of low rates of both infectious and thrombotic
complications.
• SC site is accessible in trauma when a cervical collar negates the choice of the
IJ
• The SC vein can be accessed above or below the clavicle, The supraclavicular
approach offers a well-defined landmark for insertion at the
clavisternomastoid angle, a shorter distance from a puncture to the vein, and
a straighter path to the SVC, with less proximity to the lung.
• Disadvantages include a higher risk of pneumothorax, less accessibility to use
ultrasound for CVC placement, and the non-compressible location posterior
to the clavicle.
• The subclavian vein is closely associated with several structures. The vein is
typically anterior and superior to the subclavian artery. The lung is just
inferomedial to the vein. The phrenic nerve just deep to the brachiocephalic
vein at the confluence of the subclavian vein and internal jugular vein. The
brachial plexus and right-sided thoracic duct are also nearby and vulnerable
to injury.
 FV
• The femoral site is sometimes preferable in critically ill patients because
the groin is free of other resuscitation equipment and devices which may
be required for monitoring and airway access. Central venous access in
the common femoral vein offers the advantage of being an easily
compressible site, which may be helpful in trauma and other
coagulopathic patients.
• Iatrogenic pneumothorax is not a concern. Patients may be more
comfortable with a femoral CVC because it allows relatively free
movement of the arms and legs compared to other sites.
• Femoral CVCs are typically associated with increased thrombotic
complications and likely an increased rate of catheter-associated
infections.
• Femoral central lines do not allow for accurate measurement of central
venous pressure (CVP)
 INDICATIONS
There are multiple indications for central line placement:
 Drug administration: - vasoactive medication
 Prolonged intravenous therapies or inability to obtain venous access.
 Parenteral nutrition administration
 Extracorporeal therapies like Dialysis and Plasmapheresis
 Difficult peripheral venous access –
 Monitoring – CVP
 Special treatment – transvenous pacemaker placement
CONTRAINDICATION
9

 Embolic Issues Existing central venous clots –

 Valve vegetations – (infective endocarditis)
 Tumors -
 Bleeding Risk
 Previous trauma or surgery to the site.
 Pharmacological treatment affecting the patient's clotting.
 Infection at the site of insertion is an absolute contraindication.
 ARTICLE REQUIRED FOR CENTRAL LINE: 10

Sterile products
1. Personal protective equipment: including gloves, gown
drape
2. Gauze (4x4)
3. Chlorohexidine swabs or similar antiseptic agent
4. Sterile ultrasound probe cover with sterile ultrasound gel
5. Biopatch
6. luer locks" or catheter caps for each lumen
CENTRAL VENOUS CATHETER KIT,
which generally includes
1. Central venous catheter (triple-lumen, dual-lumen, or
large bore single-lumen)
2. 18 gauge introducer needle, with a syringe
3. #11 blade Scalpel
4. Guidewire
5. Vasodilator
6. Suture material (generally 3-0 silk suture with a straight
needle or a needle driver)
7. Saline lock (number depends on the type of device)
8. 1% lidocaine, small gauge needle (25 or 27 gauge),
syringe
9. Ultrasound machine with a high-frequency linear
transducer
CVP INSERTION PROCEDURE
• Consent 12

• Equipment's
• Clear the room
• Use the ultrasound machine to assess the preferable access site
• Place the patient in an anatomically advantageous position for the procedure.
• Clear away clothing, jewelry, and any non-essential equipment which may impede the
preparation of a clear sterile field.
• The patient should be placed on a cardiac monitor that can cycle vital signs every 5 minutes
and maintain telemetry.
• Clean and prepare the patient for the procedure.
• Once a sterile field has been created, clean the site with your chosen antiseptic
• Don the PPE
• prepare the central venous catheter by attaching saline locks with saline flushes and flushing
all of the ports to ensure that there are no equipment issues.
• Place the sterile drape over the patient and Assure that all equipment is within reach before
initiating the procedure.
 13

CVP INSERTION PROCEDURE

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TECHNIQUE
14

Seldinger technique
This is a technique for central venous catheterization. The desired vessel is punctured
with a sharp hollow needle, syringe is detached and guidewire is advanced through the
lumen of the needle, and then the needle is withdrawn. Central catheter is then passed
over the guidewire into the vessel.

Modified Seldinger technique

This is a technique for central venous
catheterization. We will use needle that is
covered with guiding sheath. After desired
vessel puncture, guiding sheath is instantly slid
over the needle into the vessel. The needle is
withdrawn, guidewire is advanced through the
guiding sheath, central catheter is placed into
the vessel.
COMPLICATION: - DURING PROCEDURE
1. Arrhythmias – typically ventricular or 7. Pulmonary embolism
bundle branch blocks due to guidewire 8. Local cellulitis
irritation of the atria or ventricle 9. Catheter infection
2. Arterial puncture 10. Cardiac tamponade
3. Pulmonary puncture with or without 11. Intravascular loss of guide wire
resultant pneumothorax 12. Haemothorax
4. Bleeding – hematoma formation, which 13. Phrenic nerve injury
can obstruct the airway 14. Brachial plexus injury
15. Cerebral infarct from carotid artery
5. Tracheal injury
cannulation
6. Air emboli during venous puncture or 16. Bladder & Bowel perforation
removal of the catheter
CLINICAL SIGNIFICANCE 16

 Be fully prepared for the procedure, and assure that all necessary personnel and equipment
are readily available.

 Ensure that sterile products are not contaminated and that there is no evidence of damage to
the packaging. Follow sterile procedures at all times.

 When using the IJ or SC site for access, be sure to obtain a stat portable chest x-ray
immediately after procedure.
CLINICAL SIGNIFICANCE 17

 If one has a failed attempt at the IJ site and needs to seek access at another site, the ipsilateral
subclavian is preferred. One may anticipate this possibility by cleaning and prepping both the
IJ and SC site on the side of the procedure.

 If unsure of the placement of a guidewire , and limited views on ultrasound, use manometry to
confirm.

 Subclavian access does appear to have fewer infections but potentially higher procedural
complications, especially if performed by less experienced person.

 The internal jugular, subclavian, and femoral veins have higher success rates and fewer
complications when performed with ultrasound.
CLINICAL SIGNIFICANCE 18

 The clinician must maintain hold of the guidewire at all times while it is inside the patient.
The wire can be lost inside the patient and may migrate into the right ventricle or inferior
vena cava, leading to additional invasive procedures to recover the wire.

 Always ensure that the catheter is appropriately placed through one or several methods:
radiographic evidence, measurement of CVP, or by analyzing a venous blood gas.

 Never use excessive force during any part of this procedure. It will lead to damage to local
structures.
 19
CATHETER CARE

 An adherent transparent polyurethane film. advantage of allowing constant inspection of the

site

 The access hubs of the CVC are another important potential source of introducing infection,
and this possibility must be reduced by careful adherence to cleaning and aseptic non-touch
technique (ASNTT) when using the hubs and connecting infusions.

 Central venous catheters must be flushed every day to prevent clotting and keep it clear of
blood. Depending on the type of catheter flush it with either heparin or saline solution.
 20

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.

.
DRESSING

 The care of a central line includes routine inspection and dressing changes.

 The dressing changes allow a more detailed site inspection and cleansing of the skin/site.

 Frequent hand hygiene, sterile gloves, and masks for the provider and patient are essential for
dressing changes.
 The start procedure it should begin with skin cleansing. The majority of catheter-associated
infections have been shown to be related to skin colonization. This risk has been shown to be
reduced sixfold by skin cleansing with chlorhexidine solution. Therefore it is recommended to
use 2% chlorhexidine-containing solution.
DRESSING

 The use of antibacterial preparations shown to result in lower rates of sepsis related to CVCs
but has also been demonstrated to increase the risk of resistant bacterial infections and
Candida colonization and subsequent infection.
 After removing the soiled dressing, a new pair of sterile gloves should be donned before
proceeding with the dressing change.
 Nurse should perform a careful assessment of the catheter insertion site daily, noting the
dressing change date listed on the dressing, and encouraging the patient to report any swelling
or pain at the insertion site.
CVP DRESSING CHANGE 23

CVP DRESSING CHANGE

CENTRAL LINE BLOOD SAMPLE DRAW
24
 POST-PROCEDURAL
25

COMPLICATIONS:
• Catheter-related bloodstream infections – bacterial or fungal
• Central vein stenosis
• Thrombosis
• Delayed bleeding with multiple attempts in a coagulopathic
patient
NURSING RESPONSIBILITY AFTER PROCEDURE
26

• Nursing officer should wait for the confirmation regarding

placement of CVC before using the line to administer medications.
Both the nurse and the clinician should be aware of and keep track
of when the line was placed.

• Nursing Officer must inspect the CVC for infections, hematoma,

thrombosis of the catheter, and signs of pneumothorax and bleeding
at the time of dressing.

• There has been a benefit demonstrated by 48 hourly dressing

changes with the use of chlorhexidine washes at every change
compared to similar care at 7-day intervals.
 27

DAILY CARE OF PATIENT WITH CENTRAL LINE

 Daily inspection of the access site and device patency should be performed
during nursing rounds.
 In particular, nursing officers must disinfect injection ports, catheter hubs, and
needleless connectors with institutionally approved antiseptics like 2%
chlorhexidine.
 Intravenous administration sets should be changed regularly per hospital policy.
DAILY CARE OF PATIENT WITH CENTRAL LINE
28

 Dressings should be changed if visibly soiled. This must be performed with proper
sterile technique.

 Any manipulation of the catheter site should be done using a sterile procedure. A
surgical cap, mask, and sterile gloves must be worn to minimize infection.

 The site should be cleaned with approved antiseptics, allowed to dry, and a sterile
occlusive dressing must be replaced.

 daily discussion about whether or not the central venous catheter is still indicated.
If deemed unnecessary for further management, the central venous catheter should
be removed expeditiously.
SAFETY GUIDELINES WHILE CENTRAL LINE CARE

1. Wash hands before doing any central line care and wear gloves.
2. Always keep a clean and dry dressing over the central line.
3. Follow the instructions for cleaning the cap and using the sterile
equipment.
4. Always keep sharp objects away from the central line.
5. If the central line is hard to flush do not try to flush inform the intensivist.
SAFETY GUIDELINES WHILE CENTRAL LINE CARE

6. Maintain CLABSI bundles, record date of insertion and day of the catheter.
7. As per CDC guidelines use only sterile way to access catheters.
8. Immediately replace dressings that are wet, solid. Or dislodged
9. Perform routine dressing changes using aseptic technique with sterile gloves
10. Change gauze dressing at least every two days or semipermeable dressing at
least every seven days
11. For patients 18 years of age or older, use chlorhexidine impregnated dressing
that specific a clinical indication for reducing CLABSI
SAFETY GUIDELINES WHILE CENTRAL LINE CARE

12. Change administration sets for continuous infusions no more frequently than every 24
hours.
13. If blood products or fat emulsions are administered change tubing every 24 hours
14. Perform a daily audit to assess whether each central line is still needed are not
15. Provide a checklist to the clinician to ensure adherence to aseptic insertion practices.
16. Use hospital-specific or collaborative based performance measures to ensure compliance
with recommended practices.
17. Educate health care workers about indications for a central line, proper procedures for
insertion and maintenance, and appropriate infection prevention measures.
INSERTION BUNDLE
FOR CENTRAL LINE
1. Hand hygiene before and after insertion of central line

2. Use maximum sterile PPE: gloves, gown, drapes, cap and mask

3. Site of insertion—Subclavian preferred, avoid femoral

4. Skin preparation—by antiseptics such as chlorhexidine

5. Skin must be completely dry after use of antiseptics

6. Use semi-permeable dressing

7. Document data and time of insertion

CARE BUNDLE AT AIIMS MANGALAGIRI BY DEPT. OF MICROBIOLOGY

Central lin`e bundle

Hand hygiene

Daily Alcohol hub

aseptic decontamination
central line
care during
handling
CHG 2% for
dressing changes

Any local signs of infection?

Dressing changed?

Assessment of readiness to
remove- documented?
 REFERENCES
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Dec;14(4):184-5. [PubMed]
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3. Konner K. History of vascular access for hemodialysis. Nephrol Dial Transplant. 2005
Dec;20(12):2629-35. [PubMed]
4. http”//booksite.elevevier.com/97803233766 2
5. Ipe TS, Marques MB. Vascular access for therapeutic plasma exchange. Transfusion. 2018
Feb;58 Suppl 1:580-589. [PubMed]
 REFERENCES
6. American Society of Anesthesiologists Task Force on Central Venous Access. Rupp SM,
Apfelbaum JL, Blitt C, Caplan RA, Connis RT, Domino KB, Fleisher LA, Grant S, Mark
JB, Morray JP, Nickinovich DG, Tung A. Practice guidelines for central venous access: a
report by the American Society of Anesthesiologists Task Force on Central Venous
Access. Anesthesiology. 2012 Mar;116(3):539-73. [PubMed]
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Shock: What Is the Current State of the Art? Semin Respir Crit Care Med. 2015
Dec;36(6):890-8. [PubMed]
8. Kolikof J, Peterson K, Baker AM. Central Venous Catheter. [Updated 2022 Dec 19]. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available
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