Central Line Nursing Guide

CVC Types & Clinical Indications

ⓘ Central venous catheters (CVCs) provide direct access to the central venous circulation. Site and type selection must balance clinical need, patient anatomy, infection risk, and expected duration of therapy.

📋 CVC Type Comparison

Type	Sites	Duration	Primary Indications	Key Points
Non-tunnelled CVC	IJV, SCV, Femoral	Short-term (<14 days)	ICU hemodynamic monitoring, rapid drug/fluid delivery, vasopressors, emergency access	Highest infection risk per day; IJV/SCV preferred over femoral
Tunnelled CVC (Hickman, Broviac)	SCV via tunnel	Long-term (months–years)	Chemotherapy, TPN, long-term antibiotics, haematology, bone marrow transplant	Dacron cuff promotes tissue ingrowth; lower infection risk than non-tunnelled
PICC (Peripherally Inserted Central Catheter)	Basilic, cephalic, brachial vein → SVC	>6 days IV therapy	Prolonged IV antibiotics, irritant drugs (vancomycin, amiodarone), TPN, vesicants	Inserted at bedside/IR; CXR confirmation mandatory; avoid if ESRD (preserve veins)
Implanted Port	SCV / IJV	Years (intermittent use)	Oncology — chemotherapy, blood products; long-term intermittent therapy	Access only with non-coring (Huber) needle; lowest infection rate; highest cost
Introducer Sheath (Cordis)	IJV, Femoral	Short-term	Rapid volume replacement (large bore), pulmonary artery catheter insertion, cardiac procedures	Large calibre (8–9Fr); significant haemorrhage risk if dislodged
Dialysis Catheter Acute / Permcath	IJV, Femoral (acute); SCV (Permcath)	Acute: Days–weeks Permcath: Long-term	Acute kidney injury, CRRT in ICU; chronic HD when AVF not available	Dual-lumen; high flow required (200–400 ml/min); NEVER use for other medications without dialysis team approval

📍 Site Selection: Pros & Cons

Internal Jugular Vein (IJV)

Preferred for non-tunnelled CVC in ICU
US guidance reduces complication rate
Avoid in coagulopathy (compressible site)

Subclavian Vein (SCV)

Lowest CLABSI risk of all sites
Not compressible — avoid in coagulopathy
Risk: pneumothorax, subclavian artery puncture

Femoral Vein

Easiest access in emergency/arrest

Highest CLABSI and DVT risk
Avoid in ambulatory patients
Avoid if suspected abdominal/IVC pathology

📈 CVP Monitoring

⚠ CVP is a trend indicator, not an isolated value. Always interpret in clinical context (respiratory status, ventilation, cardiac function).

Normal CVP range2–8 mmHg

Low CVP (<2 mmHg)Hypovolaemia, vasodilation

Elevated CVP (>12 mmHg)RHF, cardiac tamponade, PEEP effect, fluid overload

CVP waveforma, c, x, v, y waves

Zeroing referencePhlebostatic axis (4th ICS, MAL)

Transducer positionLevel with phlebostatic axis

💡 A fluid challenge response (CVP rise <2 mmHg) is more clinically useful than absolute CVP in guiding fluid therapy.

🔧 Lumen Assignment (Triple-Lumen CVC)

Each lumen of a multi-lumen CVC should have a dedicated purpose. Consistent assignment reduces contamination risk and drug interactions.

Distal Lumen

📈

CVP monitoring
Vasoactive drugs
(noradrenaline, vasopressin)
Blood sampling

Medial Lumen

💧

IV fluid administration
Blood / blood products
Rapid infusions

Proximal Lumen

💊

Routine medications
TPN / lipid infusions
Antibiotics

⚠ TPN should have a dedicated lumen (proximal preferred). Never administer blood products and TPN through the same lumen simultaneously. Document lumen assignment on the CVC dressing label.

Insertion Assistance — Nursing Role

ⓘ The nurse is a critical safety partner during CVC insertion. Your role includes patient preparation, maintaining sterile field, monitoring patient status, and ensuring procedural documentation.

📸 Post-Insertion Verification

CXR mandatory before use (except femoral)
Tip position: cavoatrial junction (lower 1/3 SVC)
Confirm absence of pneumothorax
Check line position: no loops, kinks, malposition
Aspirate blood return from all lumens
Flush all lumens with 10ml 0.9% NaCl
Apply sterile dressing with CHG disc
Label dressing with: date, site, clinician, lumen assignment

CXR Tip Position Assessment

✓ Optimal: Tip at cavoatrial junction — lower 1/3 of SVC, 2–3 cm above RA. The tip should parallel the vessel wall (not transverse).

✗ Do NOT use line if tip in RA/RV (arrhythmia risk), in IJV, in wrong vessel, or pneumothorax present.

⚡ Insertion Complications — Recognition

Pneumothorax

Sudden dyspnoea, decreased breath sounds, hypoxia, tracheal deviation (tension). Confirm CXR. Needle/chest drain decompression.

Arterial Puncture

Bright red pulsatile blood, haematoma. Remove immediately. Apply firm pressure 10 min. Surgical review if expanding.

Air Embolism

Sudden dyspnoea, hypoxia, hypotension, mill-wheel murmur. Head-down left lateral decubitus, high-flow O2, aspirate from distal port.

Arrhythmias

Guidewire/catheter tip in RA/RV. Pull back 2–3 cm. Usually self-limiting. Have defibrillator ready.

Haematoma / Haemothorax

More common with coagulopathy. Monitor vitals, CXR, consider drain.

📄 Insertion Documentation Requirements (JCI)

Line Details

Date & time of insertion
Site (IJV, SCV, femoral — R/L)
Type and brand of catheter
Number of lumens
Gauge and length (cm at skin)

Procedure

Inserting clinician name & grade
US guidance used (Y/N)
Number of attempts
MSB precautions confirmed
CHG skin prep confirmed

Verification

CXR result and tip position
Blood aspirated from all lumens
Dressing type applied
Lumen assignment documented
Patient tolerance

CLABSI Prevention Bundle

⚠ CLABSI (Central Line-Associated Bloodstream Infection) is a leading cause of preventable ICU mortality. Implementing the complete bundle reduces CLABSI rates by up to 66%. Every element matters — partial compliance is insufficient.

📋 IHI Central Line Bundle — 5 Core Elements

Tick each element to track bundle compliance. State saved locally.

1. Hand Hygiene — WHO 5 Moments compliance before ALL line access. Alcohol gel (20-second rub) or soap and water (40 seconds). Gloves do not replace hand hygiene.
2. Maximum Sterile Barrier Precautions — at time of insertion (cap, mask, sterile gown, sterile gloves, full-body drape). See Tab 2 for full checklist.
3. Chlorhexidine Skin Antisepsis — CHG 2% in 70% isopropyl alcohol. Back-and-forth scrub for 30 seconds. Allow to fully dry before puncture.
4. Optimal Site Selection — Subclavian vein preferred (lowest CLABSI risk). Avoid femoral when possible. Document justification if femoral selected.
5. Daily Line Necessity Review — Is this line still needed TODAY? Remove immediately when no longer clinically indicated. Document review in nursing notes.

Bundle compliance: 0/5 elements confirmed today.

🩹 Dressing Management

Transparent Semipermeable Dressing (TSM)

Change every 7 days (routine)
Change immediately if soiled, wet, or lifting
Do NOT change within 24h of insertion unless contaminated
Use sterile technique for all dressing changes

Gauze Dressing

Change every 2 days
Use if patient is diaphoretic or site oozing
Switch to TSM once site stabilised

CHG-Impregnated Disc (BioPatch / Biopatch)

Place at insertion site under dressing
Change with each dressing change
CHG side facing skin (printed side up)
Reduces CLABSI rate by additional 60%

⚠ Write insertion date, dressing change date, and nurse initials on dressing label.

💉 Needleless Connector Care

🚫 The hub/connector is the most common entry point for CLABSI organisms. Decontaminate EVERY TIME.

Disinfection Protocol ("Scrub the Hub")

15-second vigorous scrub with 70% isopropyl alcohol wipe
Allow 15 seconds to dry completely before access
Applies to EVERY access, without exception
Use single-use alcohol swab pad — discard after one use

Connector Change Schedule

Change every 72–96 hours (per facility policy)
Change immediately after blood transfusion
Change immediately after TPN administration
Change if contamination suspected
Change when tubing changed

Blood Sampling via CVC

Discard 5–10 ml blood before sampling
Flush with 10 ml 0.9% NaCl immediately after
Disinfect hub before and after
Avoid sampling from TPN lumen if possible

📅 Line Days Counter — Necessity Review Tool

Enter the CVC insertion date to calculate line days and trigger necessity review.

CVC Insertion Date:

💉 Infusion Management

Infusion Type	Tubing Change Frequency	Special Notes
Standard IV fluids	Every 96 hours (4 days)	Change earlier if product changed or contamination suspected
Blood / blood products	After every unit (within 4h)	Do NOT transfuse blood >4h after spiking
TPN (with lipid)	Every 24 hours	Dedicated lumen; never add medications to TPN bag
Lipid emulsions alone	Every 12 hours	Supports rapid microbial growth
Propofol infusions	Every 6–12 hours	Change with each vial change; lipid vehicle
Vasopressors / inotropes	Every 24 hours	Concurrent change to minimise hypotension risk

Troubleshooting & Complications

🚫 Catheter Occlusion Management

Assessment

Unable to aspirate blood (withdraw occlusion)
Resistance to flushing (push occlusion)
Sluggish flow / infusion pump alarming
Check: kinked tubing, patient position, clamp status first

Types of Occlusion

Thrombotic Occlusion

Most common. Blood clot at tip or within lumen. Resistance/inability to aspirate. Confirmed when mechanical causes excluded.

Drug Precipitate

Incompatible drugs mixed in lumen (e.g., phenytoin + dextrose, ceftriaxone + calcium). Crystal deposition.

Lipid Residue

Lipid buildup from TPN/propofol. White waxy occlusion.

Treatment Protocols

Thrombotic: Alteplase (tPA)

Alteplase 2 mg in 2 ml
Instil into occluded lumen
Dwell time: 30–60 minutes
Aspirate 5 ml blood before flushing
Repeat dose if no response at 120 min
Requires physician order

Acid Precipitate (low pH drug)

Sodium bicarbonate 1 mEq/ml
Dwell 20–60 minutes
Caused by: ceftriaxone, ciprofloxacin, hydrocortisone

Alkaline Precipitate (high pH drug)

0.1 N Hydrochloric acid (HCl) 1 ml
Dwell 20–60 min
Caused by: phenytoin, vancomycin, calcium-phosphate

🦯 Air Embolism — Emergency Protocol

⚠ Potentially fatal. Act immediately.

Recognition

Sudden dyspnoea and hypoxia
Hypotension, tachycardia, cyanosis
Mill-wheel murmur (churning cardiac sound)
Altered consciousness, cardiovascular collapse

Immediate Management

Step 1: Clamp all open lumens immediately
Step 2: Left lateral decubitus (Durant's manoeuvre) + Trendelenburg (head-down) — traps air in right atrium apex
Step 3: High-flow O2 (100% — promotes air reabsorption)
Step 4: Aspirate air via distal CVC port (aspirate 20ml)
Step 5: Call resuscitation team; prepare for CPR
Step 6: Document, incident report, monitor

Prevention

Trendelenburg during insertion/removal
Cap all ports when not in use
Valsalva manoeuvre during guidewire exchange
Occlusive dressing immediately after removal

🧸 CLABSI — Recognition & Response

Suspect CLABSI When:

Temperature >38.3°C or <36°C in patient with CVC
New chills or rigors during/after line access
Erythema, warmth, purulence at insertion site
Positive blood culture with no other source
Clinical deterioration without other explanation

CLABSI Workup

2 sets blood cultures: 1 peripheral + 1 via CVC
Simultaneous draw (within 15 min) for DTP (differential time to positivity)
CXR, full sepsis workup
Swab insertion site if purulent
Notify physician — treat as sepsis

Line Removal Decision

S. aureus, Candida, Gram-negative rods: REMOVE immediately
CoNS (Staph. epi): may attempt salvage in tunnelled/port
Send catheter tip culture if removed (5 cm tip in dry container)

📋 Line Removal Technique

Procedure

Verify physician order for removal
Position patient supine (Trendelenburg for IJV/SCV)
Clamp all infusions running through line
Remove dressing carefully; inspect insertion site
Put on sterile gloves
Withdraw catheter smoothly and slowly
Apply firm pressure with sterile gauze for minimum 5 minutes (longer if coagulopathic)
Apply occlusive petroleum gauze dressing (prevents air embolism via tract)
Leave occlusive dressing in place 24–72 hours
If infection suspected: cut 5 cm distal tip with sterile scissors, send in sterile dry container for semi-quantitative culture

Post-Removal Monitoring

Inspect site at 24h for haematoma/bleeding
Monitor for signs of air embolism (first 30 min)
Document: time of removal, condition of site, reason for removal, catheter tip sent (Y/N)
Count catheter lumens vs. number expected

⚠ NEVER remove a CVC against resistance — risk of catheter fracture/embolisation. Seek senior advice.

Catheter Removal Criteria

No longer clinically indicated
CLABSI / confirmed line infection
Mechanical failure (fracture, kink, complete occlusion)
Line days >14 days non-tunnelled (site rotation)
Accidental displacement/malposition

📈 CVP Waveform Interpretation

The CVP waveform reflects right atrial mechanical events. Abnormalities indicate cardiac pathology.

Atrial Contraction

Right atrial contraction at end of diastole. Follows P wave on ECG. Absent in AF. Giant a-wave: tricuspid stenosis, severe RHF.

Tricuspid Closure

Tricuspid valve closure and early isovolumetric contraction. Small wave. Follows QRS. Often not clearly visible.

Atrial Relaxation

Downstroke — atrial relaxation and tricuspid valve descent during ventricular systole. Blunted/absent in tamponade (x descent).

Venous Filling

Passive atrial filling while tricuspid valve is closed (late systole). Giant v-wave: tricuspid regurgitation.

Ventricular Filling

Tricuspid opens → RA empties into RV. Blunted y descent: tricuspid stenosis, tamponade. Deep y: constrictive pericarditis.

💡 Cannon a-waves (large, irregular): complete heart block or junctional rhythm — RA contracts against closed tricuspid valve. Report to physician immediately.

Documentation, Audit & Quiz

📄 Daily Line Review — Documentation Template

JCI requires daily documented review of all central lines. Use this template in nursing notes.

Date/Time: ________________
CVC Site: [ ] IJV-R [ ] IJV-L [ ] SCV-R [ ] SCV-L [ ] Femoral-R [ ] Femoral-L
Insertion Date: _____________ Line Days: ______
Dressing intact/clean/dry: [ ] Yes [ ] No → Changed today: [ ] Yes [ ] No
Insertion site: [ ] No redness [ ] Erythema [ ] Purulence [ ] Induration
All lumens patent: [ ] Yes [ ] No (document occlusion management)
CHG disc in place: [ ] Yes [ ] No [ ] Changed today
Line still clinically indicated: [ ] Yes [ ] No → Remove today: [ ] Yes
Physician review of necessity: [ ] Confirmed [ ] Pending
Bundle compliance (5 elements): [ ] Complete [ ] Incomplete → Action: ______
Nurse signature: ________________

📊 CLABSI Rate Calculation

ⓘ CLABSI rate is expressed per 1,000 central line days (CLD). This is the international standard metric for ICU infection surveillance.

CLABSI Rate Formula

CLABSI Rate = (CLABSI events ÷ Central Line Days) × 1,000

GCC / National Target<1 per 1,000 line-days

International benchmark (top decile ICU)<0.5 per 1,000 line-days

Central line days countedEach calendar day with any CVC in situ

Insertion day counts asDay 1

Reporting periodMonthly (minimum)

⚠ Example: 2 CLABSIs in a month with 400 central line days = (2/400) × 1000 = 5 per 1,000 line-days — above GCC target.

⚡ Quick Reference Card

Flush Volumes

Pre-access flush10 ml 0.9% NaCl

Post-medication flush10 ml 0.9% NaCl

Post-blood sampling10–20 ml 0.9% NaCl

Heparin lock (if used)3–5 ml (10–100 U/ml)

tPA discard after dwell5 ml before flush

Change Frequencies

TSM dressingEvery 7 days

Gauze dressingEvery 2 days

CHG discWith each dressing change

IV tubing (standard)Every 96h

TPN tubingEvery 24h

Needleless connectorEvery 72–96h

Blood tubingPer unit / within 4h

Lumen Assignment

Distal (brown/marked)CVP / Vasopressors

Medial (white)Fluids / Blood products

Proximal (blue)Medications / TPN

TPN — dedicated lumenProximal preferred

Key Thresholds

CVP normal2–8 mmHg

Review necessity after24h (daily)

CLABSI target (GCC)<1/1000 line-days

Hub scrub time15 sec + 15 sec dry

CHG prep scrub time30 sec + 30 sec dry

Alteplase dwell30–60 min

CVC Types & Clinical Indications

Internal Jugular Vein (IJV)

Subclavian Vein (SCV)

Femoral Vein

Insertion Assistance — Nursing Role

IJV / SCV Insertion

Femoral Vein Insertion

PICC Insertion

CXR Tip Position Assessment

CLABSI Prevention Bundle

Transparent Semipermeable Dressing (TSM)

Gauze Dressing

CHG-Impregnated Disc (BioPatch / Biopatch)

Disinfection Protocol ("Scrub the Hub")

Connector Change Schedule

Blood Sampling via CVC

Troubleshooting & Complications

Assessment

Types of Occlusion

Treatment Protocols

Recognition

Immediate Management

Prevention

Suspect CLABSI When:

CLABSI Workup

Line Removal Decision

Procedure

Post-Removal Monitoring

Catheter Removal Criteria

Documentation, Audit & Quiz

Flush Volumes

Change Frequencies

Lumen Assignment

Key Thresholds