CENTRAL VENOUS CATHETER GUIDELINES
Dr. Pradeep Govil, Consultant, Department of Anaesthesia and Intensive Care
Max Hospital, Saket, N.Delhi Central Venous Catheters (CVCs) and peripherally inserted central catheters (PICCs) are used for medium to long term venous access. These devices enable the administration of drugs, blood products, parenteral nutrition, sampling of blood and central venous pressure monitoring.
There are different types of CVC and it is extremely important to establish which is being dealt with at any given time.
Central Venous Catheter (CVC) - A catheter inserted into a centrally located vein with the tip residing in the vena cava; it permits intermittent or continuous infusion and / access into the venous system.

Peripherally inserted central catheter (PICC) - A soft, flexible, central venous catheter inserted into an extremity and advanced until the tip is positioned in the lower third of the superior vena cava.

Indications:
a) Standard IV access in ICU patients:
i) Fluid administration (including elective transfusion)
ii) TPN, hypertonic solutions (amiodarone, nimodipine, etc.)
iii) Vasoactive infusions
b) Monitoring of right atrial pressure (CVP)
c) Venous access for:
i) Pulmonary artery catheterisation (PAC)
ii) Continuous renal replacement therapy (CVVHDF), plasmapheresis.
iii) Jugular bulb oximetry.
iv) Transvenous pacing.
d) Resuscitation
i) Standard 3-lumen CVCs are not appropriate for acute volume
resuscitation (consider a PAC sheath)


Management protocol: (applies to all types of CVC):
a) Types:
i) 20cm triple lumen antimicrobial impregnated (rifampicin/minocycline) catheter, the standard CVC for all ICU patients
ii) Non-impregnated catheters inserted outside the ICU should be changed to a impregnated catheter according to clinical indication.
iii) Vascath catheters are used for CVVHDF and plasmapheresis
iv) Pulmonary artery catheter sheath (part of the PAC kit)
b) Sites:
i) Subclavian is the preferred site for routine stable patients, followed by internal jugular.
ii) Femoral access is preferable where:
• Limited IV access (burns, multiple previous CVC’s),
• Thoracic approach is considered hazardous:
(1) Severe respiratory failure from any cause (PaO2/FiO2 < 150)
(2) Hyper expanded lung fields (severe asthma,bullous lung disease)
(3) Coagulopathy (see below)
• Inexperienced staff requiring urgent access, where supervision is not immediately available.
c) Coagulopathic patients:
i) INR > 2.0 or APTT > 50s → correct with FFP
ii) Platelets < 50,000 → transfuse 1 pack (5u) platelets
iii) Failure to increment platelet count after transfusion → avoid subclavian
iv) Uncontrolled coagulopathy → use femoral approach or PICC
d) Technique policy
• Local anaesthesia in awake patients.
• Strict aseptic technique at insertion:
a) Hand disinfection: surgical scrub with chlorhexidine for >1 minute
b) Sterile barrier: gown, glove, cap and mask and sterile drapes.
c) Skin prep: chlorhexidine 1% / 75% alcohol
• Seldinger technique should preferably be used.
• Suture all lines
• Dressing: non occlusive dressing
• Flush all lumens with heparinised saline
• Check Chest X Ray prior to use.
e) Maintenance
i) Routine IV administration set change at 5 days.
ii) ii) Daily inspection of the insertion site and clinical examination for infection irrespective of duration of insertion.
iii) Catheters are left in place as long as clinically indicated and changed when:
• Evidence of systemic infection
- New, unexplained fever
- Unexplained rise in WCC
- Deterioration in organ function
- Positive blood culture by venipuncture with likely organisms (S. epidermidis, candida spp.), and/or
• Evidence of local infection - inflammation or pus at the insertion site
iv) Guidewire exchanges are actively discouraged. They may be indicated in the following situations, after discussion with a Consultant:
a) Mechanical problems in a new catheter (leaks or kinks)
b) Difficult or limited central access (eg burns).
v) Maintenance of lumen patency
a) Central venous catheters
- Flush unused lumens with 1ml heparinized saline (1u/ml) 8 hourly
b) Vascath: into each lumen 8 hourly,
• Withdraw 2ml and discard.
• Flush with 2ml normal saline
• Flush 1.5ml solution (5000U heparin/2ml).

Complications:
a) At insertion
i) Arterial puncture
a) Haematoma with mass effect
b) Arterial thrombosis/embolism
ii) Pneumothorax, haemothorax, chylothorax
iii) Neural injury (phrenic, brachial plexus, femoral.)
b) Passage of wire/catheter
i) Arrhythmias
ii) Perforation of SVC, RA; tamponade
c) Presence of catheter
i) Catheter infection: rates increase under the following conditions:
• Size of catheter - thicker catheters (pulmonary artery catheters,
• Vascaths)
• Site of catheter - femoral > internal jugular > subclavian sites
• Number of lumens
• Nature of fluid through catheters - TPN or dextrose solutions
ii) Thrombosis
iii) Catheter/Air embolism
iv) Knotting of catheters (esp PAC)
v) Pulmonary infarct / arterial rupture (PAC)
vi) HITS secondary to heparin.
NB: Where insertion of a CVC presents “significant risk” in a non-urgent situation, consider insertion of a PICC line as an alternative.






HEPARIN LOCK FOR CENTRAL VENOUS CATHETER LINES

• Management of care of central venous catheters (CVC) may only be undertaken by trained personnel.
• Central Venous Catheters lumen extension (pigtail) must be heparin locked when not in use, or after each intermittent medication, to ensure patency.
• Procedure should be carried out every forty-eight hours unless line is already assessed.
• Procedure must be carried out under strict asepsis.
• The patient should experience no infection through contamination of the CVC line during his/her stay at the Hospital.

EQUIPMENT:
• Sterile dressing pack 2 10-x10cm sterile gauze packs
• IV solution, as ordered
• Antimicrobial solution
• 1 pair sterile gloves Rubbish bin
• Yellow luer lock cap one per pigtail Heparin flush (sodium heparin 50u/50mls) per pigtail
• 2 x 5ml syringes per pigtail
• 1 x 1ml syringe per pigtail
• Sodium Heparin 5000u/ml needles to draw up solutions

PROCEDURES:
• Explain the procedure to the patient prior to procedure.
• Aseptic preparation prior to commencing procedure.
• Prepare dressing pack at bedside prior to positioning patient.
• Clamp off line of CVC pigtail being heparin locked with blue slide clamp.
• Position patient in bed on back.
• Clamp off line of CVC pigtail being changed, with blue slide clamp.
• Remove Heparin label from luer lock cap on pigtail if present.
• Thoroughly swab CVC pigtail and IV line being heparin locked, 5 cm down from luer lock cap on pigtail and including yellow cap connection with Hibitane solution from dressing pack.
• Place cleaned CVC pigtail on sterile towel from dressing pack and allow solution to dry before proceeding to next step.
• Place on sterile gloves.
• Disconnect luer lock cap from CVC pigtail which has been cleaned and place on sterile towel
• Draw out 5 mLs of blood from CVC pigtail with 5 mL syringe from dressing pack set up and discard.
• Flush CVC pigtail with 5 mls of Heparin flush, drawn up with the use of sterile gauze to maintain sterility.
• Next flush CVC pigtail with appropriate amount of Sodium Heparin 5000 u/ mL with 1 mL syringe also drawn up with the use of sterile gauze to maintain sterility.
• Do not allow entry of air into CVC pigtail through injection by syringes.
• Place new luer lock cap on CVC pigtail.
• Mark luer lock cap on CVC pigtail with green Heparin label.
• Observe for leakage or blood back up from CVC pigtail connection site.
• Label IV administration set with time and date of change.
• Record date and time of next line change on flow chart.
• Note in patients' chart that the lines have been changed and any problems noted during procedure.




CENTRAL VENOUS CATHETER SITE DRESSING

Management and care of Central Venous Catheters (CVC) may only be undertaken by trained personnel.
 Central Venous Catheter dressings must be changed at least every 72 hours or when dressing becomes soiled.
 Area around catheter insertion site will remain free from any signs or symptoms of possible infections.
 Area around catheter insertion site will remain aseptic to decrease chances of possible infection.
 Any sign of infection or possible infection will be reported for assessment at the earliest possible moment.
OUTCOMES ANTICIPATED:
 The area around the catheter insertion site is to remain infection free during the hospital stay of the patient.
 If infection does occur, arrangement must be made for earliest possible site change to be carried out.
 SPECIAL CONSIDERATIONS: Patients with long term Central Catheters in place may carry out the procedures they are familiar with under supervision of a qualified Nurse from hospital
 While in hospital, management of the Central Line by the patient must meet the standards set down by hospital
EQUIPMENT:
• Dressing pack x 1
• Antimicrobial solution
• Rubbish bin
PROCEDURE:
• Explain procedure to patient prior to commencement.
• Aseptic preparation prior to commencing procedure.
• Prepare dressing pack at bedside prior to positioning patient.
• Place patient in supine position.
• Remove old dressing and check site for discomfort, redness, inflammation and/ or leakage of fluids from around insertion site.
• Clean area around insertion site with antimicrobial solution, allow area to dry before applying Water proof dressing.
• Label dressing with time and date of change.
• Record date and time of dressing change on flow chart.
Procedure: CENTRAL VENOUS CATHETER LINE CHANGE

• Central Venous Catheter external tubing changes must be preformed every seventy-two (72) hours, or
- if there is damage to the line
- if line contamination occurs.
• Procedure must be carried out under strict asepsis
• All infusion tubes to be labelled with the time and date of last change.
• Catheters must not be compressed with clamps containing serrated teeth.
• The patient should experience no infection through contamination of the CVC line during his or her stay.
Equipment:
• Sterile dressing pack two 10 cm x 10 cm sterile gauze packs
• new IV administration set IV solution, as ordered,
• Antimicrobial solution one pair sterile gloves
• Infusion Pump
• Rubbish bin

Procedure:
• Explain the procedure to the patient prior to procedure
• Aseptic preparation prior to commencing procedure.
• Prepare dressing pack at bedside prior to positioning patient.
• Hang new IV solution, spike new solution bag with new administration set (protecting distal end from contamination by placing distal end on open dressing pack).
• Prime IV line with appropriate solution (remove all air from IV line) and clamp administration set with roller clamp.
• On CVC lumen extension (pigtail) being changed, stop infusion pump and clamp IV line, with roller clamp.
• Clamp off line of CVC pigtail being changed with blue slide clamp.
• Place new IV administration set and IV solution into Infusion Pump.
• Position patient in bed on back.
• Thoroughly swab CVC pigtail and IV line being changed 5 cm on both sides of port connection with antimicrobial solution from dressing pack.
• Place cleaned CVC pigtail and IV line on sterile towel from dressing pack and allow solution to dry before proceeding to next step.
• Start Infusion Pump and allow fluid to run into sterile field of dressing pack.
• Disconnect cleaned IV line from CVC pigtail which has been cleaned and place on sterile towel.
• Connect new IV line too CVC pigtail and remove blue slide clamp from CVC pigtail
• Observe for leakage or blood back up from CVC pigtail connection site.
• Label IV administration set with time and date of change.
• Record date and time of next line change on flow chart.
• Note in patients' chart that the lines have been changed and any problems noted during procedure.

REMOVAL OF CENTRAL VENOUS LINE STANDARDS:

• Upon removal of the CVC, Universal precautions must be maintained to avoid contamination of the health care worker through exposure to blood borne pathogens.
• Aseptic technique is used at the insertion site to decrease chances of infection to the patient.
• Dressing is to remain in place 24-72 hours according to length of time that catheter was in place.
• Observe patient post removal for the following i.e signs and symptoms of bleeding, air embolism or infection of at the site.

EQUIPMENT:
• Sterile dressing pack Air occlusive dressing with antimicrobial ointment
• Antimicrobial solution one pair sterile gloves
• Rubbish bin Sterile jar to collect catheter tip is infection is suspected
• Stitch cutter for removing sutures Sterile scissors
PROCEDURE:
• Explain the procedure to the patient prior to procedure.
• Aseptic preparation prior to commencing procedure.
• Prepare dressing pack at bedside prior to positioning patient.
• Turn off all infusions
• Place patient in Trendelburg or supine position.
• Instruct patient to preform Valsalva maneuver or to hold breath on command.
• If tip of catheter to be sent for cultures have sterile equipement ready.
• If tip to be cultured prep skin around site with aseptic solution and remove catheter at 90 degree angle
• Remove suture holding in CVC while insuring CVC does not accidently migrate out. Ensure all suture material has been removed.
• As catheter is removed ask patient to preform Valsalva maneuver or to hold breath.
• Immediately cover area with sterile guaze to apply pressure to area.
• Cover the site with occlusive dressing while patient is still reforming Valsalva maneuver.
• Reposition patient.


References:
1. Merrer J et al. Complications of femoral and subclavian venous catheterisation in critically ill patients. JAMA 2001. Aug 286(6):700-707

2. LSC, (2002). Standards of care of external central venous catheters in adults. London Standing Conference.


3. NICE, (2003). Infection control: prevention of healthcare- associated infections in primary and community care (clinical guidelines 2) London: NICE.

4. Pellowe CM et al (2004) The epic project. Updating the evidence base for national evidence- based guidelines for preventing healthcare associated infections in NHS hospitals in England : a report with recommendations; British Journal of Infection control, 5 (6) 10-16.

Corresponding Author E mail: govilpradeep@hotmail.com