Chapter 4 Manage Central Lines

Open Resources for Nursing (Open RN); Kimberly Ernstmeyer; Elizabeth Christman

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Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Advanced Skills [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2023.

Nursing Advanced Skills [Internet].

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Chapter 4 Manage Central Lines

4.1. INTRODUCTION

Learning Objectives

Outline indications for insertion of a central venous access device (CVAD)
Compare and contrast the various types of CVADs and where they are inserted
Describe the processes of verifying placement and securing a CVAD
Describe infection control techniques to prevent infections associated with CVADs
Identify potential complications associated with CVADs, prevention, and related nursing interventions
Discuss how to safely change CVAD dressings and needleless connectors
Outline the processes of safely accessing, flushing, and locking CVADs
Describe blood sampling techniques from CVADs
Discuss the components of routine documentation related to CVADs

As the complexity of client conditions continues to evolve within health care settings, the safe use and management of central lines are imperative. A central line is a thin, flexible, large-bore tube inserted into a client’s large vein, also referred to as a central venous access device (CVAD). There are various insertion sites for CVADs (see Figure 4.1[1]). CVADs are commonly guided into the superior vena cava so the distal tip is located in the superior vena cava near the junction with the right atrium. Other CVADs are introduced through the femoral vein so the distal tip sits in the inferior vena cava. CVADs differ from short peripheral IV catheters used for intravenous access because they are placed in central circulation due to the distal tip location.

Figure 4.1

CVAD Insertion Sites

CVADs are used for delivery of medication, fluids, and nutrition and can remain in place long-term. They can also be used for blood draws, hemodynamic monitoring, and transvenous pacing. These lines help ensure consistent vascular access can be easily obtained and utilized by the health care team. This chapter will describe indications for CVADs, explore different types of CVADs, outline related nursing procedures, and discuss nursing management of clients with CVADs.

References

1.: “Central-venous-access-sites.png” by unknown author is licensed under CC B-NC-ND. Access for free at https://www.researchgate.net/figure/Central-venous-access-sites_fig1_334584348 ↵.

4.2. BASIC CONCEPTS

Indications for CVAD

Common indications for CVAD placement include delivery of medication, fluids, and nutrition, especially for clients requiring long-term therapy. CVADs are required for infusion of high osmolarity solutions and vesicant medications. They may also be placed for emergency venous access for clients requiring fluid resuscitation and hemodynamic monitoring.[1] Many clients who require CVADs are older adults, very young children, or those with chronic health conditions.[2]

High osmolarity solutions refer to a highly concentrated solution expressed as the total number of solute particles per liter. High osmolarity solutions, such as total parenteral nutrition and hypertonic IV fluids, are irritating to peripheral vessels and increase the client’s risk for phlebitis, thrombosis, and occlusion. Additionally, vesicant medications (such as certain antineoplastic drugs, antibiotics, electrolytes, and vasopressors) can cause severe tissue injury or destruction if they extravasate. Extravasation refers to leakage of fluid into the tissues around the IV site, causing tissue injury when the catheter has dislodged from the blood vessel but is still in the nearby tissue. For this reason, infusions of high osmolarity solutions and vesicant medications are administered through a CVAD into a large vein such as the superior vena cava. When these solutions enter this larger vessel, the solution is hemodiluted, thus minimizing the risk of these complications from occurring.

Fluid resuscitation refers to infusing a large volume of fluid through the intravenous venous access to restore hemodynamics and optimize tissue perfusion and, ultimately, tissue oxygen delivery. Hemodynamic monitoring is often in place when a client requires fluid resuscitation. Hemodynamic monitoring is the assessment of a critically ill client’s circulatory status and includes measurements of central venous pressure, cardiac output, and blood volume.[3] Central venous pressure (CVP) reflects the pressure in the central veins as they enter the right atrium and is often monitored during fluid resuscitation as measure of preload (i.e., volume status).

Types of Central Venous Access Devices and Locations

There are several types of CVADs, and the selection of which type is used depends upon the specific client’s clinical situation, indication, and duration of treatment. The type of CVAD selected is based on the specific client’s clinical situation. The decision process for selecting an appropriate CVAD involves collaboration among the provider, the client, and the health care team while considering the treatment requirements. Special considerations include examining the expected length of treatment; the specific prescribed treatment; and the client’s vascular characteristics, age, cognitive level, medical history, infusion therapy history, and, if appropriate, their preference for the CVAD site location. Generally, other venous access or alternative delivery methods should be considered prior to inserting a CVAD due to its invasiveness and associated risks. Indications for CVAD insertion and its associated risks should be explained to the client by the provider and documented in their medical record.[4]

CVADs may be inserted centrally or peripherally. A centrally inserted central venous catheter is typically placed into the client’s internal jugular, subclavian, or femoral vein. Peripherally inserted central venous catheters (referred to as PICC lines) are primarily placed through the basilic, cephalic, or brachial veins. Insertion is more successful with fewer complications when guided ultrasound is used for placement.[5]

Only specially trained health care clinicians can select and insert CVADs. The determination of which area (peripheral, midline, or central vein) used to insert a CVAD is based on a suitable venous pathway, optimal vein characteristics, risk of nerve injury, and anatomical variations.[6]

Table 4.2a outlines various types of CVADs, their uses, expected durations, site considerations, and client safety considerations.

Table 4.2a

Central Venous Access Devices

Device	Type of Therapy	Expected Duration	Site Considerations	Rationale and Safety Considerations
Peripherally Inserted Central Catheter (PICC) (See Figure 4.2[7])	Long-term use. May be used to infuse high osmolarity solutions or antibiotic therapy. Power ports may be used for high pressure rapid infusions.	Up to six months.	Utilize median cubital, cephalic, basilic, or brachial veins with sufficient diameter size.	Avoid in clients with end-stage renal disease requiring vein preservation for fistulas and grafts or those with a history of thrombosis, hypercoagulability states, or decreased peripheral vascular flow.
Non-Tunneled CVAD (See Figure 4.3[8])	May be used to infuse high osmolarity solutions.	Days to several weeks.	Insertion sites may be subclavian, external/internal jugular, or femoral veins.	The subclavian vein is favored in adult clients due to decreased risk of catheter-related thrombosis and/or infection.
External Tunneled CVAD (Hickman, Broviac, Groshong) (See Figure 4.4[9])	Long-term intravenous therapy, such as chemotherapy or hemodialysis.	May be long-term or permanent.	Inserted in the chest area via a subclavian or jugular vein. Tunneled subcutaneously from the proximal end of the insertion site to an exit site.	Surgery is required to tunnel the catheter so that part of the catheter lies in the subcutaneous tunnel. This helps prevent organisms from entering the bloodstream by separating where the catheter exists the skin from where it enters the vein. Passing the catheter under the skin also helps keep it better secured.
Implanted Venous Access Device (IVAD), also referred to as an Implanted Port (See Figure 4.5[10])	Long-term medication or IV therapy such as chemotherapy.	May be long-term or permanent.	Placed in a subclavian or jugular vein and attached to a reservoir pocket. The reservoir pocket is a small plastic or metal cylinder, usually placed just below the collar bone, that releases medication into the bloodstream. An IVAD is less obvious than a tunneled catheter and requires little daily care, with less impact on a person’s activities than a PICC line or a tunneled catheter.	Surgery is required to place the port. The port is accessed with a noncoring needle and can be used immediately after placement.

Lumens

CVADs may have a single lumen (opening), double lumen, or multiple lumens that exit at various places along the central catheter. See Figure 4.6^[¹¹^] for an image of a CVAD with two lumens.

Figure 4.6

CVAD Catheters. Used under Fair Use.

Table 4.2b describes different types of lumens based on their exit points, their size, and their uses.

Table 4.2b

Types of Lumens

Lumens	Proximal Lumen	Middle Lumen	Distal Lumen
Size	18 gauge	18 gauge	16 gauge
Uses	Fluids TPN/Lipids Medications	Medications	Blood draw Blood administration Central venous pressure (CVP) monitoring

Insertion of a CVAD

The insertion of a CVAD is an invasive medical procedure requiring informed consent from the client. The insertion should be performed only by a trained, credentialed health professional. Accurate placement of the CVAD tip is confirmed according to agency policy by fluoroscopy during insertion, post-procedure chest X-ray, or a magnet tip locator. Fluoroscopy is an imaging technique that uses X-rays to obtain real-time moving images of the interior of an object within the body. If real-time fluoroscopy is used during the procedure to confirm tip placement, a post-procedure chest X-ray is not required. If fluoroscopy is not used, a post-procedure X-ray is used to confirm tip placement, as well as to check for a possible pneumothorax that can inadvertently occur during insertion. After the tip location is verified, it is essential to document the location in the client’s medical record.[12]

Securement of CVADs

After the placement of the CVAD tip is confirmed, the CVAD must be stabilized and secured to the client. Dislodgement and premature removal of the CVAD increase complications such as infections, vessel injury, and treatment delays. Depending on the location and type of CVAD, it may be stabilized with sutures or a sutureless engineered stabilization device. See Figure 4.7[13] for illustrations of stabilization devices.

Figure 4.7

CVAD Stabilization Devices (A) Simple polyurethane and suture; (B) Sutureless securement device with simple polyurethane; (C) Integrated securement dressing product; (D) Tissue adhesive

The goal of the securement device is to maintain a secure hold on the central line and to prevent it from moving in and out of the insertion site. Sutureless devices, if appropriate, have less risk of infection because they maintain intact skin. Adhesive devices have the risk of causing a skin-related injury such as skin tear or a local reaction to the adhesive. Applying a prophylactic skin barrier prior to applying an adhesive device decreases this risk to the client.

After the catheter is secured, a sterile, transparent semipermeable dressing is applied to cover the insertion site. Some transparent dressings have an impregnated chlorhexidine gel or a biopatch that is directly placed over the insertion site to reduce the growth of microorganisms. In some cases, if there is blood or exudate leaking from the insertion site after initial placement, a sterile gauze dressing may be used to absorb the fluid until the leaking resolves.

Prevention of Central Line-Associated Bloodstream Infections (CLABSI)

When a client has a CVAD, it is crucial to follow evidence-based guidelines regarding its insertion, care, and maintenance to prevent the development of a life-threatening infection. Clients with CVADs are at risk for developing central line-associated bloodstream infections (CLABSI). CLABSI is diagnosed when pathogens are found in the client’s blood in the absence of another source of infection and the client has had a central line in place for more than two calendar days before the infection occurs. CLABSI continues to be one of the most deadly and costly hospital-acquired infections in the United States.[14]

A group of evidence-based practice standards has been formulated by the Institute of Healthcare Improvement (IHI) to reduce the risk of infection related to the insertion and management of CVADs and improve quality of care. CLABSI prevention strategies encompass three areas: clinical indications, insertion, and care and maintenance. These strategies include the following elements[15],[16]:

Hand hygiene as directed by CDC guidelines
Maximal barrier precautions during insertion
Skin antiseptic using chlorhexidine
Optimal site selection, such as avoiding femoral vein access, when possible, for central venous access in adults
Daily assessment of the necessity of the central line and prompt removal if deemed unnecessary
Routine disinfection of catheter hubs, connectors, and injection ports
Changing dressings over the site every two days for gauze dressings, every seven days for semipermeable dressings, or as needed if it becomes damp, loose, or visibly soiled

There have been improvements in CLABSI rates with these IHI practice standards, but, unfortunately, CLABSI continues to be an issue in hospitals despite these prevention measures. Read more information regarding the CDC recommendations to prevent CLABSIs in the following box.

Read the Infection Control Guidelines for Central Lines from the CDC’s web page.

Potential Complications and Unexpected Outcomes of CVADs

Nursing management of clients with CVADs requires strict asepsis, knowledge of the purpose and functions of these devices, and routine interventions to prevent complications. Ongoing assessment and monitoring of the client and the CVAD system are essential for safety, quality care, and positive client outcomes. The following table summarizes possible complications associated with CVADs, their assessments, related prevention actions, and associated nursing interventions.

Table 4.2c

Complications/Unexpected Outcomes of CVADs

Potential Complication	Assessment	Prevention	Nursing Intervention
Occlusion due to clot formation or malpositioning	Perform recommended site and CVAD system care, including equipment function and checking for blood return and the ability to infuse fluid. Assess for pain and edema at the insertion site (i.e., shoulder, ear, neck, or arm). If an implantable port is in place, assess the noncoring needle for correct placement.	Flush the catheter routinely as recommended and according to agency policy. Do not flush against resistance. Keep the catheter free from kinks. Do not mix incompatible medications during infusion that can cause precipitation within the catheter.	Initially, reposition the client. Raise the client’s arm overhead, ask the client to cough and deep breathe, or assist them to stand up and sit down. If appropriate, administer thrombolytics as ordered by the provider. A clogged CVAD may require removal by trained health care personnel per provider order.
Catheter damage or breakage	Assess the site every shift and with flushing. Observe for leaks, tears, pinholes, or drainage after flushing.	Using a 10-mL syringe is preferred for CVADs to avoid increased pressure that can cause a potential rupture. Never flush against resistance. Use needleless system devices and avoid sharp objects such as scissors near the catheter. Follow agency policy regarding the proper clamping procedure if the access device has a closed catheter system.	Clamp the catheter near the insertion site and place sterile gauze over the break or hole until it is repaired. If repair of the catheter is safe and appropriate, use only a repair kit that is recommended by the manufacturer. The CVAD may require removal by trained health care personnel per provider order.
Infection (CLABSI)	Assess the catheter insertion site and surrounding area for redness, edema, drainage, and tenderness. Monitor pertinent laboratory results (e.g., WBC).	Maintain and utilize aseptic technique. Comply with guidelines and agency policies regarding CVAD and follow the recommended CLABSI prevention bundle.	Notify the health care provider and anticipate a blood culture order for suspected CLABSI. Follow agency sepsis prevention and implementation protocol. The CVAD may require removal by trained health care personnel per provider order. Anticipate obtaining a culture of the CVAD tip using sterile scissors and a sterile specimen cup. Diagnosed CLABSIs should be treated as life-threatening. Antibiotics specific to the organism should be initiated. Infection preventionists, vascular access specialists, providers involved with device insertion, and primary nursing staff should review each case in detail, looking for potential contributing factors.[17]
Dislodgment	Measure and document the catheter length per agency policy. Assess for dislodgement by identifying any edema at or around the catheter insertion site. Palpate for coiling of the catheter under the skin.	Ensure the catheter is secured at all times and the dressing is intact. Avoid pulling and manipulating the catheter.	If the catheter is completely dislodged, cover the insertion site and apply direct manual pressure while asking a colleague to call the rapid response team. The client will require monitoring for possible air embolus and reinsertion of a CVAD for critical medications.
Catheter migration (i.e., the catheter moved from its original position)	Assess the patency of the catheter, noting local irritation, swelling, or the inability to aspirate blood. Assess for edema of the arm and hand and distended neck veins. May be able to hear “gurgling” sounds from the catheter. If the catheter tip has advanced into the heart, cardiac dysrhythmias may occur.	Avoid site insertion of a CVAD in areas near the site of a local infection, disrupted skin integrity, or scar tissue.	Notify the provider. A catheter that has migrated externally from its original placement should not be readvanced. A catheter that has migrated internally should be retracted to the original insertion length by a trained health professional.
Skin erosion	Assess the skin at and around the CVAD insertion site. Note any skin separation from the catheter exit site, drainage, contusions, or any indication of skin involvement.	Maintain optimal client nutritional status. For implanted ports, avoid using the same insertion “hole” when accessing it multiple times because this increases the risk of tissue and port breakdown.	Plan for removal of the CVAD per order. Provide effective skin care. Improve nutrition as appropriate to the client’s condition.
Air embolism[18]	An air embolism is the result of a pressure gradient that allows air to enter the bloodstream when flushing or removing the catheter. An air embolism can subsequently occlude blood flow. Signs and symptoms include sudden dyspnea, continuous coughing, and chest pain. Neurological symptoms include seizures, loss of consciousness, altered mental status, and hemiparesis.	Catheter hubs should not be open to air. Ensure all clamps are engaged appropriately for the device.	Call the rapid response team if an air embolism is suspected. Prevent further air embolism if a clamp is not engaged or a hub is open to air. Administer high-flow oxygen and place the client on their left side with their head down. Begin CPR if indicated.
Pneumothorax[19]	Pneumothorax may inadvertently occur during insertion of a CVAD if the needle in the CVAD placed in the neck or chest goes through the vein or misses the vein and pierces the lung, causing it to collapse. Symptoms of a pneumothorax include sharp, stabbing chest pain that worsens when trying to breathe in; shortness of breath; cyanosis; tachypnea; and a dry, hacking cough.	Not applicable.	Call for assistance and ask a colleague to call the rapid response team and notify the provider. Stay with the patient and administer high-flow oxygen. Anticipate placement of a chest tube if the client is hypoxic.
Infiltration or extravasation	Palpate over the catheter insertion site dressing and around the surrounding area for sponginess and observe for redness or swelling. Note any labored breathing exhibited by the client or complaints of pain with infusions. Observe IV flow rate for free-flowing fluid. Aspirate for blood return.	Stop the infusion and/or administration of the vesicant solution. If extravasation occurs, aspirate any remaining medication from the catheter after disconnection to prevent further damage to vessels. To maintain skin integrity, administer antidote or therapeutic medication as appropriate per protocol.^[²⁰^]	Discontinue IV solutions. Apply warm/cold compresses as recommended by agency policy. Notify the provider and anticipate an order for a chest X-ray to evaluate catheter integrity and placement.
Incorrect placement	Assess for inadequate blood withdrawal, blood flowing back into the tubing, hypotension, cardiac dysrhythmias, and neck vein distension.	Verification of catheter placement by chest X-ray after insertion or during real-time guided fluoroscopy.	Stop all fluid and medication administration. Anticipate orders for an X-ray and electrocardiogram. The CVAD may require removal or withdrawal to the correct position by trained health care personnel per provider order.

PICC Line Care[ 21 ]

Avoid venipuncture, peripheral intravenous cannula insertion, and taking blood pressure on the same arm where the PICC is located. Place reminder signs for the health care team members according to agency policy.
Ensure the PICC line dressing stays dry during showering.
Avoid bandages or tight coverings over the PICC line insertion point. Tight elastic coverings can increase the risk of compressing the vein, leading to vein wall irritation, phlebitis, or thrombosis.

References

1.: This work is a derivative of StatPearls by Tse and Schick and is licensed under CC BY 4.0 ↵.
2.: Broadhurst, D., Moureau, N., & Ullman, A. J. The World Congress of Vascular Access (WoCoVA) Skin Impairment Management Advisory Panel. (2017). Management of central venous access device-associated skin impairment: An evidence-based algorithm. Journal of Wound, Ostomy, and Continence Nursing, 44(3), 211-220. https://journals.lww.com/jwocnonline/fulltext/2017/05000/management_of_central_venous_access.2.aspx ↵. [PMC free article: PMC5417573] [PubMed: 28353488]
3.: McCarthy, C. J., Behravesh, S., Naidu, S. G., & Oklu, R. (2016). Air embolism: Practical tips for prevention and treatment. Journal of Clinical Medicine, 5(11), 93. ↵ 10.3390/jcm5110093. [PMC free article: PMC5126790] [PubMed: 27809224] [CrossRef]
4.: NSW Agency for Clinical Innovation. (2021). Central venous access devices (CVAD): Clinical practice guide. Agency for Clinical Innovation. https://aci.health.nsw.gov.au/__data/assets/pdf_file/0010/239626/ACI-CVAD-clinical-practice-guide.pdf ↵.
5.: Chopra, V. (2022). Central venous access devices and approach to device and site selection in humans. UpToDate. Retrieved November 28, 2022, from https://www.uptodate.com/ ↵.
6.: NSW Agency for Clinical Innovation. (2021). Central venous access devices (CVAD): Clinical practice guide. Agency for Clinical Innovation. https://aci.health.nsw.gov.au/__data/assets/pdf_file/0010/239626/ACI-CVAD-clinical-practice-guide.pdf ↵.
7.: "Blausen_0193_Catheter_PICC.png" by Blausen Medical Communications, Inc. is licensed under CC BY 3.0 ↵.
8.: "Blausen_0181_Catheter_CentralVenousAccessDevice_NonTunneled.png" by Blausen.com staff (2014) for "Medical gallery of Blausen Medical 2014" is licensed under CC BY 3.0 ↵.
9.: "Tunneled_venous_access_device.png" by Glynda Rees Doyle and Jodie Anita McCutcheon is licensed under CC BY 4.0 ↵.
10.: "Venous_Access_Port_Catheter.png" by BruceBlaus is licensed under CC BY-SA 4.0 ↵.
11.: "xvthfl4exkgi9wdyt2twbf18gfpi3hdf.jpg" by unknown author used on the basis of Fair Use. Access original image at https://www.bd.com/en-us/products-and-solutions/products/product-families/powerline-central-venous-catheter#eifuresources. ↵.
12.: NSW Agency for Clinical Innovation. (2021). Central venous access devices (CVAD): Clinical practice guide. Agency for Clinical Innovation. https://aci.health.nsw.gov.au/__data/assets/pdf_file/0010/239626/ACI-CVAD-clinical-practice-guide.pdf ↵.
13.: "F1.medium.png" by Amanda Ullman et al., courtesy of BMJ Open is licensed under CC BY-NC 4.0. Access for free at https://bmjopen.bmj.com/content/6/6/e011197 ↵.
14.: Institute for Healthcare Improvement. (n.d.). Central line infection. https://www.ihi.org/Topics/CentralLineInfection/Pages/default.aspx ↵.
15.: Institute for Healthcare Improvement. (n.d.). Central line infection. https://www.ihi.org/Topics/CentralLineInfection/Pages/default.aspx ↵.
16.: The Joint Commission. (n.d.) CLABSI toolkit - Chapter 3. https://www.jointcommission.org/resources/patient-safety-topics/infection-prevention-and-control/central-line-associated-bloodstream-infections-toolkit-and-monograph/clabsi-toolkit---chapter-3/ ↵.
17.: DeVries, M. (2019). Revisiting CLABSI prevention strategies: Part 2 Learn about central line care and maintenance. American Nurse Today, 14(6), 44-47. https://www.myamericannurse.com/wp-content/uploads/2019/06/ant6-INFECTION-CLABSI-2-521a.pdf ↵.
18.: McCarthy, C. J., Behravesh, S., Naidu, S. G., & Oklu, R. (2016). Air embolism: Practical tips for prevention and treatment. Journal of Clinical Medicine, 5(11), 93. ↵ 10.3390/jcm5110093. [PMC free article: PMC5126790] [PubMed: 27809224] [CrossRef]
19.: Tsotsolis, N., Tsirgogianni, K., Kioumis, I., Pitsiou, G., Baka, S., Papaiwannou, A., Karavergou, A., Rapti, A., Trakada, G., Katsikogiannis, N., Tsakiridis, K., Karapantzos, I., Karapantzou, C., Barbetakis, N., Zissimopoulos, A., Kuhajda, I., Andjelkovic, D., Zarogoulidis, K., & Zarogoulidis, P. (2015). Pneumothorax as a complication of central venous catheter insertion. Annals of Translational Medicine, 3(3), 40. ↵ 10.3978/j.issn.2305-5839.2015.02.11. [PMC free article: PMC4356862] [PubMed: 25815301] [CrossRef]
20.: Kim, J. T., Park. J. Y., Lee, H. J., & Cheon, Y. J. (2020). Guidelines for the management of extravasation. Journal of Educational Evaluation for Health Professions, 17:21.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7431942/ ↵. [PMC free article: PMC7431942] [PubMed: 32668826]
21.: Cancer Institute NSW. (2021, July 19). Central venous access devices. https://www.eviq.org.au/clinical-resources/central-venous-access-devices-cvads/112-central-venous-access-devices#key-practice-points-for-clinical-procedures ↵.

4.3. APPLYING THE NURSING PROCESS

Ongoing nursing assessments and interventions are essential to provide safe, quality care when a client has a CVAD. These actions are guided by evidence-based practice standards. In acute care and outpatient settings, the overall goals of CVAD infusion therapy are safe administration of medications and the absence of complications.

Nurses provide routine care and maintenance of CVADs after their insertion, including the following responsibilities:

Providing for ongoing assessment of the insertion site and the infusion system to ensure it is functioning as expected
Performing CVAD dressing changes while ensuring catheter stabilization
Accessing CVADs
Performing intravenous line care and management
Flushing and locking CVADs
De-accessing inserted and implanted CVADs
Performing blood sampling from a CVAD

The nurse may also be involved in other activities related to safe use of CVADs such as culturing for suspected infections and advocating for catheter removal as soon as it is no longer indicated for treatment. In home care and outpatient settings, the nurse also provides education to the client and their family members on how to safely manage the CVAD and when to call the provider with concerns.

Assessment

The nurse must be knowledgeable about the different types and placement locations of CVADs as described in Table 4.2a in the “Basic Concepts” section. Regardless of which type of CVAD device is used, the nurse must routinely assess the site and dressing for integrity, signs of infection, catheter migration, and other signs of complications. Areas beyond the site of insertion must also be assessed, such as the adjacent skin, neck, chest area, and the extremity on the side where the central line is placed. If the catheter is tunneled under the skin, assessment also includes monitoring for pain, swelling, drainage, or erythema. External length is measured at the time of insertion and used for future measurement comparison. If a PICC line is in place, arm circumference is also measured each shift and results compared to previous readings. If arm circumference consistently increases, a deep vein thrombosis may be suspected.

The frequency of site assessment is dependent on the client’s condition and agency policies. Typically, in the acute care setting, site assessment is performed every shift. If the client is in the home care setting, they are educated on how to inspect their site and how frequently this assessment should occur. Home health nurses will assess the site and arm circumference during each visit.

Accurate documentation of site assessment and related monitoring are essential. Documentation of the assessment in the client’s medical record should include CVAD location, type of dressing, site assessment specifics, presence of any complications, and any actions or interventions performed. Table 4.3a summarizes the assessments related to CVADs.

Table 4.3a

Summary of CVAD Assessments

Assessment* *Assessment of the CVAD should occur at least once every shift and as needed in acute care settings.	Description
Assess the entire infusion system.	A complete assessment includes the insertion site and surrounding area, securement device, functioning of the CVAD, and tip location.
Assess for proper functioning of the device.	Observe for constant flow of fluids, high pressure, or occlusion alarms. Assess for blood flow.
Inspect the CVAD dressing.	Determine if the dressing is clean, intact, and dated.
Inspect and palpate the insertion site and surrounding area through the intact dressing.	Check for redness, bluish discoloration on darker skin, swelling, drainage, or a palpable cord. Ask the client if they are experiencing any pain, paresthesia, numbness, or tingling around the area.
Measure the external catheter length.	Compare the measurement results to the initial placement verification results to detect any catheter migration or dislodgement.
Measure the upper arm circumference for PICC lines.	Monitor circumference measurements each shift and compare results. Increasing measurements may indicate possible edema and deep vein thrombosis (DVT). Measurement of the arm circumference should occur 10 cm above the antecubital fossa and compared to the baseline measurement. A 3 cm increase in the circumference may indicate edema associated with a DVT.
Ensure correct labeling of all infusing fluids.	Follow agency policy and procedures for labeling infusing IV fluid and medications.
Ensure all Luer-lock connections are secure.	Secure connections provide safety in guarding against microorganism and air entrance into the closed system, as well as leakage of medications out of the system.
Document the complete assessment in the client EMR.	Complete assessment documentation helps support QSEN or other quality and safety standard informatics.

CVAD Dressing Changes and Site Care

CVAD dressing changes should occur routinely at established intervals according to evidence-based guidelines and agency policies. Many agencies have designated CVAD dressing kits. The dressing protects the insertion site and surrounding tissue from microorganism growth that can accumulate within CVAD hubs and the skin and cause a CLABSI.[1] Ensuring a clean, dry, and intact dressing helps prevent microorganisms from entering the bloodstream.

If the integrity of the CVAD dressing is compromised by moisture or drainage, becomes loose, or if signs of infection are apparent, the dressing should be replaced immediately. The dressing should be labeled with the date, time, and initials of the person completing the task. All CVAD dressing changes should be documented in the client’s medical record per agency policy.

CVAD site care is routinely performed, typically at the same time as the dressing change. Aseptic technique is required when providing site care and dressing changes with meticulous hand hygiene, sterile gloves, and a mask. The preferred skin disinfectant is 2% chlorhexidine for a client older than two months of age.[2] Chlorhexidine skin disinfectant provides antibacterial activity that persists for several hours after it is applied.

Implanted ports require dressings until the area is healed after the port has been implanted under the skin, as well as when accessing the port for intermittent and/or continuous infusions. A specialized noncoring needle is used when accessing implanted ports. (Refer to specific information on “Accessing and De-accessing an Implanted Venous Access Device” later in this section.)

The dressing regimen for tunneled catheters within the acute care setting is typically the same as for nontunneled catheters. However, if the tunneled area is well-healed, a dressing may not be required in the outpatient setting.

There are different types of dressings that may be selected for a CVAD dressing change based on client status, agency policy, and evidence-based guidelines. Transparent semipermeable membrane (TSM) or simple gauze dressings are commonly used. Because TSM dressings are transparent, they allow visualization and inspection of the site area without removing or disturbing the dressing. They are also cost-effective and promote a closed system. Gauze dressings are commonly used for clients who perspire excessively, which interferes with a TSM dressing staying in place. A gauze dressing is also appropriate if the site is draining or if the person has a sensitivity to the transparent dressing.

Per CDC guidelines and infusion nursing’s standards of practice, TSM dressings should be changed at a minimum of every seven days, whereas gauze dressings must be changed at least every 48 hours. Dressings must also be changed as needed, such as for loss of dressing integrity, the presence of drainage or moisture, or signs of infection.[3]

TSM dressings with an impregnated chlorhexidine gel or disc are a newer technology that are becoming more commonly used. An antiseptic foam disc is placed around the catheter insertion site and covered with a TSM dressing. Other TSM dressings have an impregnated chlorhexidine gel within the dressing that is placed over the catheter insertion site. The CDC has not yet made a recommendation regarding use of impregnated dressings.[4] See Figure 4.8[5] for an image of a quad lumen CVAD with an impregnated chlorhexidine disc, subcutaneous and adhesive external securement device (ESD), and bordered semipermeable dressing. In practice, all access ports would have sterile caps attached according to evidence-based practices for infection control.

Figure 4.8

Quad lumen CVAD with a Chlorhexidine (CHG) Disc, Subcutaneous and Adhesive External Securement Device (ESD), and Bordered Semipermeable Dressing

Before performing a CVAD dressing change, review the client’s medical record for previous history, allergies (including allergies to tape or adhesives), previous or baseline length and circumference measurements, and the type of dressing used. Most acute care settings utilize a central line dressing kit that includes standardized accessories necessary for the procedure.

When performing CVAD dressing changes, using aseptic nontouch technique (ANTT) is considered a global standard. The "ANTT approach" identifies key parts and key sites throughout the preparation and implementation of the procedure. A key part is any sterile part of equipment used during an aseptic procedure, such as needle hubs and dressings. A key site is the insertion site, nonintact skin, or an access site for medical devices connected to clients. CVAD insertion sites are considered key sites. ANTT includes four underlying principles to keep in mind while performing invasive procedures:

Always perform meticulous hand hygiene.
Never contaminate key parts.
Touch nonkey parts with confidence.
Take appropriate infection control precautions.

Review Table 4.3b for a summary of CVAD dressing change steps and their rationale.

Table 4.3b

CVAD Dressing Change Steps

Step
Follow standard aseptic nontouch technique (ANTT). Standard ANTT requires the use of a general aseptic field, such as a single use or disinfected surface for placement of all needed supplies to provide a controlled workspace and to promote asepsis. Apply PPE according to the client’s health conditions. The client and the RN both wear a mask during a dressing change to prevent contamination of the site area. Ask the client to turn their head in the opposite direction of the dressing change site to avoid potential contamination of the site. Standard ANTT and PPE reduce the risk of microorganism contamination and exposure to body fluids.
Nonsterile gloves are acceptable when removing a CVAD dressing. When removing the dressing, carefully roll up the edges and remove toward the insertion of the catheter to prevent dislodgement. After removing the dressing, remove the nonsterile gloves, perform hand hygiene, and don sterile gloves.
Most securement devices are integrated within the CVAD dressing kit and are changed with the dressing. If the catheter is secured with sutures, gently and carefully lift the suture plate to cleanse with agency-approved antiseptic, maintaining aseptic technique.
Cleanse the insertion site and surrounding skin with each dressing change using aseptic technique. Using chlorhexidine solution is considered standard practice, but if the client has an allergy or hypersensitivity to its use, povidone-iodine may be used as an alternative. A single-use antiseptic applicator is commonly used. When cleansing, do so in a back-and-forth motion for 30 seconds and allow it to dry. If dry blood or drainage is present on the skin and around the insertion site, it should be cleansed and removed using sterile technique prior to applying a new dressing.
Label the dressing with the date, time, and your initials, as well as the date the dressing should be changed again. Labeling is a quality measure to promote ongoing adherence to agency policies and recommendations.
Document the related assessments, cleansing, and dressing change in the client’s medical record. Documentation in the legal record is required and is also used for reimbursement and quality improvement initiatives.

Accessing CVADs

Each time a CVAD is accessed, there is a chance for exposure to microorganisms from the clinician, the environment, or the client. To reduce this exposure, accessing and manipulations of a CVAD should be kept at a minimum. Adhering to strict hand hygiene and ANTT standards are important strategies to reduce the risk of infection.

When accessing a CVAD, the CVAD access hub or needleless port must be decontaminated with a vigorous scrub technique with a single-use aseptic swab or a scrub hub. A scrub hub is a specific scrubbing device for CVAD hubs and embedded with chlorhexidine and alcohol or 70% alcohol to disinfect catheter hubs or needleless connectors. The suggested scrub time is up to 60 seconds with a minimum of 15 seconds. When decontaminating the hub, generate friction by scrubbing in a twisting motion like juicing an orange. Ensure the top of the hub is scrubbed, as well as the sides.[6]

An alternative to aseptic swabs or scrub hubs is aseptic-impregnated catheter hub protective caps. These caps contain a sponge that is saturated with alcohol or chlorhexidine. They are attached to the access ports and eliminate the need to perform the vigorous scrub. After the caps are removed, they are discarded, and a new sterile cap is applied.

Flushing and Locking CVADs

Flushing is a manual injection of 0.9% sodium chloride to clean the lumen of the catheter. Locking is the injection of a limited volume of a liquid following the catheter flush, for the period of time when the catheter is not used, to prevent intraluminal clot formation and/or catheter colonization.[7]

CVADs require flushing to maintain patency of the line(s) and to prevent the mixing of incompatible solutions and/or medications. The recommended flush is sterile 0.9% sodium chloride unless manufacturer or agency policy requires flushing with an alternate solution.

Central line catheters are flushed according to agency policy. They must be flushed immediately after placement of the initial insertion has been verified, before and after each fluid or medication infusion, and before and after drawing blood from the central line. Additionally, flushing of all lumens of a multi-lumen catheter should be considered after obtaining blood samples to reduce the possibility of blood influx into other lumens due to changing intraluminal pressure. If a CVAD is not being routinely accessed, it is typically flushed and locked every seven days. Implantable ports that are not being accessed should be flushed and locked every 4-6 weeks.[8]

A 10-mL or larger syringe is used to access a CVAD to prevent excess pressure that can damage the lumen. Before flushing the lumen with 0.9% sodium chloride, aspiration of blood should be attempted to ensure patency. The volume of fluid used for flushing should be twice the volume of the lumen.

Instilling the flush fluid into the catheter lumen allows a column of fluid to maintain its patency. A pulsatile flushing technique is recommended with ten small boluses of 1 mL of fluid interrupted by brief pauses. This technique has been found to be more effective at removing solid deposits (such as fibrin, drug participate, or intraluminal bacteria) compared to continuous low flow techniques.[9] Flushing should never occur if force is required against resistance because this can cause rupture of the catheter or mobilization of an occlusive clot.

If resistance is met while flushing or there is inadequate blood return on aspiration, troubleshoot for potential causes and solutions such as repositioning or removing kinks in lines. If these initial steps are not successful, follow agency policy in using a thrombolytic medication (i.e., alteplase) or requesting an order for a port study or central line study with fluoroscopy.

There are different types of needleless connectors through which the CVAD is flushed. If using a negative needleless connector, clamp the lumen while injecting the last 0.5 mL and before the syringe is disconnected to prevent blood reflux back into the catheter tip when the syringe is disconnected. If using a positive needleless connector, clamp after the syringe is disconnected to allow the internal mechanism to activate. For neutral (anti-reflux) needleless connectors, there is no specific clamping procedure required.

Instilling a “locking” fluid into a CVAD catheter causes a column of fluid within the catheter to maintain patency. Recommendations regarding the type of locking solution to use vary. Some studies suggest 0.9% normal saline is as effective as heparin. Follow agency policy and recommendations from the manufacturer.[10]

Standard ANTT (Aseptic Nontouch Technique) is used when flushing and locking central lines, as well as when infusing other fluids and medications. ANTT requires use of meticulous hand hygiene and a single use or disinfected surface for placement of all supplies to provide a controlled workspace and promote asepsis.[11]

Accessing and De-Accessing an Implanted Venous Access Device

The management and care of an implanted venous access device (IVAD), as recommended by the CDC, includes utilizing proper aseptic technique before palpating, accessing, or performing dressing changes. See Figure 4.9[12] for an image of an IVAD that has been placed.

Figure 4.9

Implanted Venous Access Device (IVAD)

When accessing an IVAD, the skin at the site of access must be disinfected with chlorhexidine solution and allowed to dry before accessing the device. Many clients require a lidocaine medication (i.e., EMLA cream or intradermal lidocaine injection) prior to port access to prevent pain. This is especially true for vulnerable populations requiring IVADs such as pediatric, elderly, and oncology clients.

A noncoring needle must be used for accessing IVADs to prevent damage to the device. See Figure 4.10[13] for images related to accessing an IVAD.

Figure 4.10

Implanted Venous Access Device

Some IVADs are “power-injectable” while others are not. This means that some ports can tolerate the pressure required for CT injectable dye while others cannot. The type of needle used to access the port depends on what type of port the client has implanted. Clients with a power-injectable port should have an ID card, bracelet, and some type of identifier. This information should also be recorded in the medical record. If no information is available, the port should be treated as a nonpower injectable port and accessed with a normal port needle and not used for CT dye.

As with all long-term vascular access devices, IVADs are at risk for occlusion or loss of patency because protein buildup can occur on the surface of the device. Flushing and locking implanted ports help to prevent occlusion, but there are no clear recommendations for standardized flushing techniques or volumes. Recommendations from the manufacturers vary with the type of device regarding the use of heparin or saline. Flushing guidelines are typically established by the manufacturer and agency policy.[14] Currently, the consensus of recommendations for flushing implanted ports that are used a minimum of every 8 hours in adult clients is to flush after each infusion of medication or blood administration with 10 mL of 0.9% normal saline or every 24 hours according to the manufacturer’s recommendations.

The majority of techniques that are used for locking IVADs consist of withdrawing the syringe while still applying positive pressure during the injection of the last 0.5 mL of fluid volume. The volume used for locking depends on the reservoir volume and catheter diameters. Formal recommendations for maintenance locking in implanted ports are to flush with 10 mL 0.9% normal saline every four weeks in closed ports. For open-implanted ports, the recommendation is to flush with 10 mL normal saline followed by 5 mL heparin every four weeks.[15] The dose of heparin required to maintain patency can vary from 10 to 1,000 iU/mL, with the concentration of 100 IU/mL in a volume of 3 mL the most commonly used.[16]

Current recommendations for the maintenance of implanted ports indicate the needle should be changed and the port re-accessed every seven days.[17]

View a supplementary YouTube video^[¹⁸^] on CVAD access and care: Ports: Access and Care.

Blood Sampling From a CVAD

Obtaining a blood sample from a CVAD is a responsibility of the registered nurse. Multiple venipunctures frequently occur in acute care settings due to the severity of the medical condition in a client who requires a CVAD. The main advantage of using a CVAD for frequent blood sampling is decreased pain and anxiety compared to the experience of multiple peripheral venipunctures. However, accessing CVADs also has potential risks associated with infection, occlusion, and improper sample taking, resulting in inaccurate test results. Following evidence-based infection prevention practices, limiting the frequency of blood sampling, and following ANTT guidelines help reduce the risk of infection. A summary of key points related to blood sampling from CVADs is outlined in Table 4.3d. See the “Checklist: Obtain a Blood Sample From a CVAD” for the complete steps for this procedure. Note that current guidelines recommend to not use CVADs infusing parental nutrition for blood sampling because manipulation may increase the risk for CLABSI.[19]

During the blood sampling procedure, if any signs or symptoms occur indicating an air embolism, place the client on the left side in Trendelenburg or left lateral decubitus position, call the rapid response team, and notify the provider.

Table 4.3d

Summary of Key Points Related to Blood Sampling From a CVAD

Steps	Rationale
Stop the infusion of fluids and medications into the catheter’s lumens.	Stopping the infusion of fluids or medications prevents these substances from interfering with the blood sample. Current guidelines do not specify a standard length of time for stopping the infusion, but it is associated with the internal volume of the specific CVAD.[20]
Choose the appropriate CVAD lumen for obtaining samples based on the largest lumen or the configuration of the lumen exit sites.	Blood draw requires a large lumen. For catheters with a staggered lumen exit at the tip, the sample should be drawn from the lumen exiting at the point farthest away from the heart and above other lumen exits used for infusion.[21] Follow CVAD manufacturer’s instructions for these decisions.
Vigorously scrub the needless connector for at least 15 seconds with antiseptic scrub and let it dry completely.[22]	Scrubbing prevents microorganism contamination, and drying prevents contamination by substances.
Attach a prefilled 10-mL syringe of preservative-free normal saline to the needleless connector using ANTT. Unclamp the catheter and thoroughly flush the lumen with 10-20 mL of preservative-free 0.9% normal saline.[23] Aspirate slowly for blood, noting the characteristics of the whole blood.	A 10-mL syringe generates lower pressure within the catheter and prevents lumen rupture and/or occlusion.
Clear the dead space by using the push-pull method or discarding the aspirated blood according to agency policy. The discard method requires initial aspiration of 2 to 25 mL of blood (per internal volume of the CVAD, saline flushing prior to drawing the discard volume, and specific laboratory tests needed) and then discarding the syringe before performing the blood sampling.^[²⁴^] The push-pull method utilizes the same syringe used when aspirating to test patency of the catheter. With the syringe still attached, 4 mL to 6 mL of blood is aspirated and then pushed back into the catheter. This aspiration and reinfusion sequence is repeated for four cycles. The blood and syringe are then discarded.[25]	Either method clears the CVAD catheter’s dead space volume and removes any of the blood that becomes diluted with the flush solution. Performing the push-pull method for four cycles allows for an accurate blood sample and also reduces phlebotomy-associated blood loss, particularly when obtaining multiple blood samples. For the discard method, coagulation studies require the largest discard volume to produce accurate results, but this volume of discarded blood can lead to hospital-acquired anemia.
After obtaining the blood sample, thoroughly flush the CVAD lumen with 10-20 mL of preservative-free 0.9% normal saline.[26]	Flushing thoroughly prevents occlusion.

Evaluation

Daily evaluation for the necessity of continuing the CVAD is important and supported by the CLABSI prevention guidelines. Evaluating the client’s cardio-respiratory status every shift and as needed per client condition prompts early recognition of potential complications.

Clients who are receiving infusion therapy and/or medication treatment require ongoing monitoring of laboratory values, intake/output, daily weights, and vital signs to evaluate their current fluid and electrolyte balances.

Nurses also evaluate the client’s understanding of the CVAD. If the client will be discharged home with an IVAD, it is imperative they understand how to manage their device safely and when to notify the provider. They will also need referrals to a home health agency, as well as supplies to manage the device on an outpatient basis, such as extra dressings, flushes, and tubing.

References

1.: NSW Agency for Clinical Innovation. (2021). Central venous access devices (CVAD): Clinical practice guide. Agency for Clinical Innovation. https://aci.health.nsw.gov.au/__data/assets/pdf_file/0010/239626/ACI-CVAD-clinical-practice-guide.pdf ↵.
2.: Centers for Disease Control and Prevention. (2015, November 5). Summary of recommendations: Guidelines for the prevention of intravascular catheter-related infections (2011). https://www.cdc.gov/infectioncontrol/guidelines/bsi/recommendations.html ↵.
3.: Gorski, L. (2021). A look at 2021 infusion therapy standards of practice. Home Healthcare Now , 39(2), 62-71. https://www.nursingcenter.com/wkhlrp/Handlers/articleContent.pdf?key=pdf_01845097-202103000-00002 ↵. [PubMed: 33662964]
4.: Centers for Disease Control and Prevention. (2015, November 5). Summary of recommendations: Guidelines for the prevention of intravascular catheter-related infections (2011). https://www.cdc.gov/infectioncontrol/guidelines/bsi/recommendations.html ↵.
5.: “ID-112-CVAD-IJ-CICC-Oct-2020-2.jpeg” by E. Alexandrou used with permission. Access the original image at https://www.eviq.org.au/clinical-resources/central-venous-access-devices-cvads/112-central-venous-access-devices#short-term-cvads ↵.
6.: The Joint Commission. (2023). Central line-associated bloodstream infection toolkit and monograph. https://www.jointcommission.org/resources/patient-safety-topics/infection-prevention-and-control/central-line-associated-bloodstream-infections-toolkit-and-monograph/ ↵.
7.: Godelieve, A. G. (2015). Flushing and locking of venous catheters: Available evidence and evidence deficit. Nursing Research and Practice , 2015. ↵ 10.1155/2015/985686. [PMC free article: PMC4446496] [PubMed: 26075094] [CrossRef]
8.: Gorski, L. A., Hadaway, L., Hagle, M. E., Broadhurst, D., Clare, S., Kleidon, T., Meyer, B. M., Nickel, B., Rowley, S., Sharpe, E., & Alexander, M. (2021). Infusion therapy standards of practice (8th ed.). Journal of Infusion Nursing: The Official Publication of the Infusion Nurses Society, 44(1S Suppl 1), S1–S224. 10.1097/NAN.0000000000000396 ↵ 10.1097/NAN.0000000000000396. [PubMed: 33394637] [CrossRef] [CrossRef]
9.: Gorski, L. A., Hadaway, L., Hagle, M. E., Broadhurst, D., Clare, S., Kleidon, T., Meyer, B. M., Nickel, B., Rowley, S., Sharpe, E., & Alexander, M. (2021). Infusion therapy standards of practice (8th ed.). Journal of Infusion Nursing: The Official Publication of the Infusion Nurses Society, 44(1S Suppl 1), S1–S224. 10.1097/NAN.0000000000000396 ↵ 10.1097/NAN.0000000000000396. [PubMed: 33394637] [CrossRef] [CrossRef]
10.: Gorski, L. (2021). A look at 2021 infusion therapy standards of practice. Home Healthcare Now , 39(2), 62-71. https://www.nursingcenter.com/wkhlrp/Handlers/articleContent.pdf?key=pdf_01845097-202103000-00002 ↵. [PubMed: 33662964]
11.: Gorski, L. (2021). A look at 2021 infusion therapy standards of practice. Home Healthcare Now , 39(2), 62-71. https://www.nursingcenter.com/wkhlrp/Handlers/articleContent.pdf?key=pdf_01845097-202103000-00002 ↵. [PubMed: 33662964]
12.: “Port-catheter.jpg” by Una Smith (talk) is licensed under CC0 ↵.
13.: “Diagram_showing_an_implantable_port_under_the_skin_CRUK_100.svg” by Cancer Research UK and “Venous_Access_Port_Catheter.png” by BruceBlaus are both licensed under CC BY-SA 4.0 ↵.
14.: Blanco-Guzman, M. O. (2018). Implanted vascular access device options: A focused review on safety and outcomes [Review]. Transfusion , 58, 558-568. https://onlinelibrary.wiley.com/doi/pdfdirect/10.1111/trf.14503 ↵. [PubMed: 29443407]
15.: Blanco-Guzman, M. O. (2018). Implanted vascular access device options: A focused review on safety and outcomes [Review]. Transfusion , 58, 558-568. https://onlinelibrary.wiley.com/doi/pdfdirect/10.1111/trf.14503 ↵. [PubMed: 29443407]
16.: Oliveira, F. J. G., Rodrigues, A. B., Ramos, I. C., & Caetano, J. Á. (2020). Dosage of heparin for patency of the totally implanted central venous catheter in cancer patients. Revista Latino-Americana de Enfermagem , 28, e3304. ↵ 10.1590/1518-8345.3326.3304. [PMC free article: PMC7304977] [PubMed: 32578754] [CrossRef]
17.: Oncology Nursing Society. (2017). Access device standards of practice for oncology nursing. https://www.ons.org/books/access-device-standards-practice-oncology-nursing ↵.
18.: Moffott Cancer Center. (2018, October 31). Ports: Access and care [Video]. YouTube. All rights reserved. https://youtu.be/KtCwEdQbPRQ ↵.
19.: Gorski, L. (2021). A look at 2021 infusion therapy standards of practice. Home Healthcare Now , 39(2), 62-71. https://www.nursingcenter.com/wkhlrp/Handlers/articleContent.pdf?key=pdf_01845097-202103000-00002 ↵. [PubMed: 33662964]
20.: Gorski, L. (2021). A look at 2021 infusion therapy standards of practice. Home Healthcare Now , 39(2), 62-71. https://www.nursingcenter.com/wkhlrp/Handlers/articleContent.pdf?key=pdf_01845097-202103000-00002 ↵. [PubMed: 33662964]
21.: Gorski, L. (2021). A look at 2021 infusion therapy standards of practice. Home Healthcare Now , 39(2), 62-71. https://www.nursingcenter.com/wkhlrp/Handlers/articleContent.pdf?key=pdf_01845097-202103000-00002 ↵. [PubMed: 33662964]
22.: The Joint Commission. (2023). Central line-associated bloodstream infection toolkit and monograph. https://www.jointcommission.org/resources/patient-safety-topics/infection-prevention-and-control/central-line-associated-bloodstream-infections-toolkit-and-monograph/ ↵.
23.: Gorski, L. (2021). A look at 2021 infusion therapy standards of practice. Home Healthcare Now , 39(2), 62-71. https://www.nursingcenter.com/wkhlrp/Handlers/articleContent.pdf?key=pdf_01845097-202103000-00002 ↵. [PubMed: 33662964]
24.: Gorski, L. (2021). A look at 2021 infusion therapy standards of practice. Home Healthcare Now , 39(2), 62-71. https://www.nursingcenter.com/wkhlrp/Handlers/articleContent.pdf?key=pdf_01845097-202103000-00002 ↵. [PubMed: 33662964]
25.: McBride, C., Miller-Hoover, S., & Proudfoot, J. A. (2018). A standard push-pull protocol for waste-free sampling in the pediatric intensive care unit. Journal of Infusion Nursing: The Official Publication of the Infusion Nurses Society , 41(3), 189–197. ↵ 10.1097/NAN.0000000000000279. [PMC free article: PMC6214664] [PubMed: 29659467] [CrossRef]
26.: Gorski, L. (2021). A look at 2021 infusion therapy standards of practice. Home Healthcare Now , 39(2), 62-71. https://www.nursingcenter.com/wkhlrp/Handlers/articleContent.pdf?key=pdf_01845097-202103000-00002 ↵. [PubMed: 33662964]

4.4. CHECKLIST: CHANGE A CVAD DRESSING AND NEEDLELESS CONNECTOR

*Disclaimer: Always follow agency policy and manufacturer recommendations

Checklist: Change a CVAD Dressing and Needleless Connector[ 1 ],[ 2 ]

Review the client’s medical record for information related to the central venous access device and indications.
Determine the date of the last dressing change.
Gather the necessary equipment:
- Antiseptic (chlorhexidine preferred)
- Sterile transparent semipermeable dressing (may be chlorhexidine-impregnated) or sterile 4” × 4” (10-cm × 10-cm) gauze pad
- Sterile tape
- Sterile drape
- Alcohol-free skin barrier solution
- Sterile gloves
- Gloves
- Masks x 2 (one for nurse and one for the client)
- Label
- Sterile needless connectors
- Sterile disinfectant caps
- Sterile, preservative-free, prefilled syringes with 10 mL 0.9% normal saline (Number of syringes required based on number of lumens of the CVAD)
- Stabilization device, if indicated, such as a Stat Lock or Stay Fix
- Antimicrobial patch or biopatch for placement over the insertion site
- *Many facilities have sterile pre-packaged CVAD dressing kits that contain the necessary supplies for a CVAD dressing change. Use of pre-packaged kits is recommended when available.
Perform hand hygiene.
Confirm the client’s identity using at least two patient identifiers and check allergies.
Provide privacy.
Explain the procedure to the client and family (if appropriate) and answer any questions. Family members should also wear a mask if present in the room during the dressing change.
Raise the bed to the appropriate working height.
Measure the external catheter length through the intact dressing.
Put on a mask. Instruct the client to put on a mask and turn their head opposite from the CVAD site.
Perform hand hygiene and put on gloves.
Assemble the supplies on a sterile field.
Remove the existing dressing by lifting the edge of the dressing at the catheter hub and gently pulling it perpendicular to the skin toward the insertion site. Discard the dressing in an appropriate receptacle. Remove the engineered stabilization device and discard it.
Assess the catheter-skin junction and surrounding skin. Inspect the catheter integrity.
Remove gloves and perform hand hygiene.
Don sterile gloves.
Follow manufacturer’s recommendations for appropriate cleansing products, application, and dry times. Always allow the product to dry naturally without wiping, fanning, or blowing on the skin.[3] Cleansing products are typically applied using a back-and-forth motion while moving vertically and horizontally for at least 30 seconds. Apply a skin barrier solution, engineered stabilization device, and/or chlorhexidine-impregnated sponge according to the manufacturer’s instructions.
Apply a transparent semipermeable dressing over the catheter insertion site. Label the dressing with the date according to agency policy.
Open the needleless connector package using sterile technique and inspect the integrity of the device. Attach the prefilled 10-mL normal saline syringe and prime the connector.
Ensure the clamp between the connector and the catheter is closed.
Remove the existing needleless connector. Perform a vigorous scrub of the catheter hub per facility policy. Allow it to dry completely.
Attach the new primed needleless connector to the catheter hub and rotate to tighten.
Unclamp the catheter and aspirate for a blood return. If blood is aspirated, slowly inject the normal saline flush into the catheter using a pulsatile flushing technique.[4]
Clamp the catheter and remove the syringe.
Place a new antiseptic-impregnated sterile port cap on the needleless connector, if available.
Dispose of used equipment in appropriate receptacles.
Remove and discard gloves and other personal protective equipment, if worn.
Perform hand hygiene.
In an inpatient setting, help the client into a comfortable position and place personal items, the tray table, and the call light within easy reach. Make sure the client knows how to use the call light to summon assistance. To ensure the client’s safety, raise the appropriate number of side rails and lower the bed to the lowest position. Ensure the bed is locked.
Perform hand hygiene.
Document the procedure and assessments.

Documentation Cues:

Date/Time of procedure
Condition and appearance of site, condition, and type of securement device, if used
Measurement of catheter (if appropriate and performed)
Number of lumens to the catheter
Type of dressing applied with date/time
ANTT technique and masking for the procedure were used
Injection cap change and to which lumens and date/time of cap change
Type of stabilization device used
Client’s tolerance of the procedure
Teaching provided to the patient and family (if applicable), understanding, and follow-up teaching needed
Any unexpected outcomes, if the health care provider was notified due to any complications, what interventions were provided to the client, and the client’s response to treatment

View the following YouTube video[5] showing an instructor demonstration of changing a CVAD dressing and needless connectors.

References

1.: Clinical skills: Essentials collection (1st ed.). (2021). Elsevier. ↵.
2.: Lippincott procedures. http://procedures.lww.com ↵.
3.: Gorski, L. A., Hadaway, L., Hagle, M. E., Broadhurst, D., Clare, S., Kleidon, T., Meyer, B. M., Nickel, B., Rowley, S., Sharpe, E., & Alexander, M. (2021). Infusion therapy standards of practice (8th ed.). Journal of Infusion Nursing: The Official Publication of the Infusion Nurses Society, 44(1S Suppl 1), S1–S224. 10.1097/NAN.0000000000000396 ↵ 10.1097/NAN.0000000000000396. [PubMed: 33394637] [CrossRef] [CrossRef]
4.: Gorski, L. A., Hadaway, L., Hagle, M. E., Broadhurst, D., Clare, S., Kleidon, T., Meyer, B. M., Nickel, B., Rowley, S., Sharpe, E., & Alexander, M. (2021). Infusion therapy standards of practice (8th ed.). Journal of Infusion Nursing: The Official Publication of the Infusion Nurses Society, 44(1S Suppl 1), S1–S224. 10.1097/NAN.0000000000000396 ↵ 10.1097/NAN.0000000000000396. [PubMed: 33394637] [CrossRef] [CrossRef]
5.: Chippewa Valley Technical College. (2023, January 5). Changing a CVAD dressing and needleless connectors [Video]. YouTube. Video licensed under CC BY 4.0. https://youtu.be/AGhezALw_Aw ↵.

4.5. CHECKLIST: OBTAIN A BLOOD SAMPLE FROM A CVAD

*Disclaimer: Always follow agency policy and manufacturer recommendations

Checklist: Obtain a Blood Sample From a CVAD[ 1 ],[ 2 ]

Verify the provider’s order.
Gather the necessary equipment:
- Gloves
- 10-mL prefilled syringes containing preservative-free normal saline flush solution (or syringes specifically designed to generate lower injection pressure)
- Antiseptic pads or scrubs (chlorhexidine-based, povidone-iodine, or alcohol)
- Appropriately sized syringes or needleless blood collection tube holder
- Blood collection tubes
- Labels
- Laboratory biohazard transport bag
- Puncture-resistant sharps disposal container
Perform hand hygiene.
Confirm the client’s identity using at least two patient identifiers and check allergies.
Provide privacy.
Explain the procedure to the client and family (if appropriate) and answer any questions.
Put on gloves and, if splashing is likely, put on a mask with a face shield or a mask and goggles.
Raise the bed to waist level when providing care.
Trace the tubing from the client to its point of origin.
Stop any infusing IV fluids, including those running through another lumen of the catheter. Follow agency policy for how long the IV fluids must be stopped before the blood draw. Clamp the lumen, if appropriate. Detach the administration set from the needleless connector and place a sterile cap over the end of the administration set, if necessary.
If no IV fluids are infusing and an antiseptic-impregnated sterile cap is covering the end of the needleless connector, replace it according to agency policy. For example, if drawing blood for blood cultures, agencies may require changing the cap before the blood draw to prevent contamination of blood culture results.
Perform a vigorous mechanical scrub of the needleless connector for at least 15 seconds using an antiseptic pad. Allow it to air dry; do not fan or wave over it.
While maintaining sterility of the syringe tip, attach a prefilled syringe containing preservative-free normal saline solution to the needleless connector. Unclamp the catheter and slowly aspirate for blood return. Troubleshoot if no blood return occurs; notify the practitioner if troubleshooting is ineffective.
If blood return occurs, slowly inject the preservative-free normal saline solution into the catheter.
Using the attached syringe used for flushing, aspirate the same volume of blood as amount of saline used to flush the catheter.
Clamp the catheter and remove and discard the blood collection tube or syringe.
Perform a vigorous mechanical scrub of the needleless connector for at least 15 seconds using an antiseptic pad, allow it to dry, connect an empty syringe to the catheter, release the clamp, and withdraw the blood sample.
Clamp the catheter and remove the syringe.
Change the needleless connector according to the manufacturer’s instructions.
Perform a vigorous mechanical scrub of the needleless connector for at least five seconds using an antiseptic pad; allow it to dry.
While maintaining sterility of the syringe tip, attach the syringe containing preservative-free normal saline solution.
Unclamp the catheter, slowly inject the preservative-free normal saline solution into the catheter, and then reclamp the catheter.
Remove and discard the syringe.
Continue the client’s prescribed continuous IV infusion; if the client doesn’t have a continuous infusion prescribed, proceed with locking the device if required by the facility. Discard the syringe.
Place a new antiseptic-impregnated sterile cap, if available at the facility, on the needleless connector after locking it with saline.
If blood was obtained using a syringe, use the blood transfer unit to transfer the blood into appropriate blood collection tubes.
Label the samples in the presence of the client.
Place all blood collection tubes in a laboratory biohazard transport bag and send them to the laboratory with a completed laboratory request form.
Dispose of used equipment in appropriate receptacles.
Remove and discard gloves and other personal protective equipment.
Perform hand hygiene.
In an inpatient setting, help the client into a comfortable position and place personal items, the tray table, and the call light within easy reach. Make sure the client knows how to use the call light to summon assistance. To ensure the client’s safety, raise the appropriate number of side rails and lower the bed to the lowest position. Ensure the bed is locked.
Perform hand hygiene.
Document the procedure and assessments.

Documentation Cues:

Date and time the blood sample was drawn
Volume of blood withdrawn
Lumen used if the client has a multi-lumen central venous access catheter
Laboratory tests for which the sample was drawn
Time the sample was sent to the laboratory
Assessment of the catheter exit site and the patency of the catheter
Absence of signs and symptoms of complications
Presence of blood return on aspiration
Lack of resistance when flushing
Amount and types of flushes used
Teaching provided to the client and family (if applicable), understanding, and follow-up teaching needed

View a YouTube video[3] showing an instructor demonstration of this skill:

References

1.: Clinical skills: Essentials collection (1st ed.). (2021). Elsevier. ↵.
2.: Lippincott procedures. http://procedures.lww.com ↵.
3.: Chippewa Valley Technical College. (2023, January 5). Obtaining a blood sample from a central venous access device (CVAD) [Video]. YouTube. Video licensed under CC BY 4.0. ↵.

4.6. CHECKLIST: ACCESS AN IMPLANTED VENOUS ACCESS DEVICE

Checklist: Access an Implanted Venous Access Device[ 1 ],[ 2 ]

Review the client’s medical record for information about the implanted venous access device. Determine if the device is “power injectable.”
Ensure confirmation of catheter tip placement.
Verify the provider’s order if required by the facility.
Determine whether the client has a history of allergies or contraindications to the antiseptic, anesthetic, or prescribed solution.
Gather the necessary equipment:
- Gloves
- Masks
- Sterile gloves
- Sterile drape
- Safety-engineered noncoring needle (smallest gauge necessary to accommodate the prescribed therapy and length that allows external components to sit level with the skin and securely within the implanted venous access device) with attached extension set tubing
- Antiseptic pad or applicator (chlorhexidine-based, povidone iodine, or alcohol)
- Sterile 10-mL syringes (or syringes specifically designed to generate lower injection pressure) prefilled with preservative-free normal saline solution
- Sterile transparent semipermeable dressing (may be chlorhexidine-impregnated)
- Sterile needleless connector
- Securement device (follow agency policy)
Perform hand hygiene.
Confirm the client’s identity using at least two patient identifiers and check allergies.
Provide privacy.
Explain the procedure to the client and family (if appropriate) and answer any questions.
Assess the client’s pain tolerance and discuss preferences for using local anesthetic. If warranted, prepare and administer EMLA cream or intradermal lidocaine prior to accessing the implanted venous access device, as prescribed.
Raise the client’s bed to working level.
Perform hand hygiene.
Put on gloves.
Ask the client to put on a mask and then position them for comfort with their head turned toward the opposite side of the implanted venous access device.
Assess the skin overlying and surrounding the implanted venous access device. Report abnormal findings to the provider.
Palpate and locate the septum; assess for device rotation.
Remove and discard gloves.
Perform hand hygiene.
Put on a mask.
Perform hand hygiene.
Open the supplies and prepare a sterile field using a sterile drape. Using sterile technique, place the supplies on the sterile field.
Perform hand hygiene.
Put on sterile gloves.
Clean the site of the implanted venous access device with an antiseptic solution following the manufacturer’s instructions.
Attach a needleless connector to the extension set attached to the noncoring needle.
Maintaining sterility of the syringe tip, attach a syringe containing preservative-free normal saline solution to the needleless connector and prime the extension set and noncoring needle with preservative-free normal saline solution. Clamp the extension set tubing.
Palpate and stabilize the implanted venous access device with the nondominant hand.
Grasp the noncoring needle with the dominant hand and insert the noncoring needle perpendicular to the skin through the septum of the implanted venous access device until the needle tip comes in contact with the back of the implanted venous access device.
Unclamp the extension tubing and aspirate for blood return and then flush the implanted venous access device with preservative-free normal saline solution.
Secure the noncoring needle with an engineered-stabilization device. Support the wings of the noncoring needle with sterile gauze; make sure that the gauze doesn’t prevent visualization of the needle insertion site.
If applicable, place a chlorhexidine-impregnated sponge dressing beneath the needle, following the manufacturer’s directions.
Apply a sterile semipermeable transparent dressing over the insertion site, noncoring needle, and upper portion of the extension tubing.
Label the dressing with the current date or the date the dressing change is due as directed by the facility.
Discard the used supplies. Dispose of used equipment and waste in an appropriate receptacle.
Remove and discard gloves and mask.
Perform hand hygiene.
In an inpatient setting, help the client into a comfortable position and place personal items, the tray table, and the call light within easy reach. Make sure the client knows how to use the call light to summon assistance. To ensure the client’s safety, raise the appropriate number of side rails and lower the bed to the lowest position. Ensure the bed is locked.
Perform hand hygiene.
Document procedure and assessments.

Documentation Cues:

Date and time
Location appearance of the site
Needle gauge and length
Number of attempts to access implanted venous access device
Any unexpected outcomes and interventions
Amount and type of flush solution used
Patency of the catheter
Presence of blood return
Lack of resistance when flushing
Client’s tolerance of the procedure
Teaching provided to the client and family (if applicable), understanding of that teaching, and any need for follow-up teaching

View a YouTube video[3] showing an instructor demonstration of this skill:

References

1.: Clinical skills: Essentials collection (1st ed.). (2021). Elsevier. ↵.
2.: Lippincott procedures. http://procedures.lww.com ↵.
3.: Chippewa Valley Technical College. (2023, January 5). Accessing an implantable port [Video]. YouTube. Video licensed under CC BY 4.0. https://youtu.be/BGOTSPZdFdE ↵.

4.7. DOCUMENTATION

Sample Documentation for a CVAD Dressing Change:

11/19/20XX 0900

Double lumen PICC line dressing was changed to the right upper arm using a prepackaged CVAD dressing kit. Old dressing was removed and discarded. Site is without redness, swelling, exudate, or indication of complications. Client denies discomfort at the insertion site or along the vein track. Pre-procedure, catheter measured 4 cm external from insertion site to hub, which corresponds to the initial insertion external measurement. Upper arm circumference 10 cm above insertion site is 23 cm, which corresponds to the previous shift’s measurement of 23 cm. No visible swelling or subcutaneous emphysema is observed. Nurse and client donned sterile masks. Per sterile technique, site area was cleansed with chlorhexidine scrub for 30 seconds and allowed to air dry. Device secured with Statlock followed by chlorhexidine gel impregnated sterile transparent dressing. Line flushed freely with 10mL of sterile, preservative-free 0.9% normal saline after obtaining brisk blood return. Needleless injection ports x2 were replaced and passive caps x2 were changed. Post-procedure, catheter measured 4 cm external from insertion site to hub, which corresponds to the initial insertion external measurement. Dressing dated and labeled. Client tolerated the procedure well without complications.

Jane Smith, RN

4.8. LEARNING ACTIVITIES

Exercises

(Answers to the exercises are located in the Answer Key at the back of the book).

Case Study #1

Autumn, age 32, has a history of Diabetes Mellitus Type II and has been admitted to the hospital with a left lower leg wound that developed cellulitis. She has been receiving antibiotic therapy in the hospital for the past two days through a right upper arm PICC line and is now ready for discharge. When at home, she will continue to receive cefazolin 500 mg IV every 8 hours for the next 14 days.

1.: What will you provide for patient education for Autumn regarding her PICC line?
2.: What are the maintenance care priorities for care of the PICC line?
3.: Are there any specific concerns related to Autumn’s need for a PICC line that should be monitored or addressed?
4.: What is the purpose of the PICC line?
5.: How often should a PICC line be assessed?
6.: How does the dressing get changed for a PICC line?
7.: What makes a PICC line different from a peripheral IV and from an implanted port?

Test your knowledge using a NCLEX Next Generation-style question. You may reset and resubmit your answers to this question an unlimited number of times.

IV. GLOSSARY

Air embolism

The result of a pressure gradient that allows air to enter the bloodstream when flushing the catheter.

Aseptic-impregnated catheter hub

A specific device or product that has an aseptic particulate embedded within it to prevent biological contaminants from entering a susceptible host. An example of an aseptic-impregnated device is a chlorhexidine impregnated CVAD dressing.

Aseptic nontouch technique (ANTT)

A global standard used to prevent healthcare-acquired infections. ANTT identifies key parts and key sites throughout the preparation and implementation of the procedure. A key part is any sterile part of equipment used during an aseptic procedure, such as needle hubs and dressings. A key site is the insertion site, nonintact skin, or an access site for medical devices connected to clients. ANTT includes four underlying principles to keep in mind while performing invasive procedures:

Always perform meticulous hand hygiene.

Never contaminate key parts.

Touch nonkey parts with confidence.

Take appropriate infection control precautions.

Central line-associated bloodstream infection (CLABSI)

A laboratory-confirmed bloodstream infection not related to an infection at another site that develops within 48 hours of a central line placement. Most CLABSI cases are preventable with proper aseptic techniques, surveillance, and management strategies.

Central venous access device (CVAD)

A central line is a thin, flexible, large-bore tube inserted into a client’s large vein.

Central venous pressure (CVP)

Pressure observed within the central veins as the veins enter the right atrium. Central venous pressure is a good indicator of right heart function and is often monitored during fluid resuscitation.

Extravasation

Leakage of fluid into the tissues around the IV site causing tissue injury when the catheter has dislodged from the blood vessel but is still in the nearby tissue.

Fluid resuscitation

Infusing a large volume of fluid through the intravenous venous access to restore hemodynamics and optimize tissue perfusion and, ultimately, tissue oxygen delivery.

Fluoroscopy

A medical procedure that makes a real-time video of the movements inside a part of the body by passing X-rays through the body over a period of time.

Flushing

A manual injection of 0.9% sodium chloride to clean the catheter.

Hemodynamic monitoring

The assessment of a critically ill client’s circulatory status and includes measurements of central venous pressure, cardiac output, and blood volume.

Locking

The injection of a limited volume of a liquid following the catheter flush, for the period of time when the catheter is not used, to prevent intraluminal clot formation and/or catheter colonization.

Reservoir pocket

A small pocket, either a plastic or metal cylinder, usually placed just below the collar bone and connected to a catheter that enters a large vein such as the subclavian.

Scrub hub

A scrubbing device with an embedded alcohol product such as chlorhexidine with alcohol or 70% alcohol to disinfect catheter hubs or needleless connectors.

Vesicant medications

Certain medications such as antineoplastic drugs, antibiotics, electrolytes, and vasopressors that can cause severe tissue injury or destruction.

Bookshelf ID: NBK594495

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Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Advanced Skills [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2023. Chapter 4 Manage Central Lines.
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Nursing Advanced Skills [Internet].

Chapter 4 Manage Central Lines

4.1. INTRODUCTION

Learning Objectives

References

4.2. BASIC CONCEPTS

Indications for CVAD

Types of Central Venous Access Devices and Locations

Table 4.2a

Lumens

Table 4.2b

Insertion of a CVAD

Securement of CVADs

Prevention of Central Line-Associated Bloodstream Infections (CLABSI)

Read the Infection Control Guidelines for Central Lines from the CDC’s web page.

Potential Complications and Unexpected Outcomes of CVADs

Table 4.2c

References

4.3. APPLYING THE NURSING PROCESS

Assessment

Table 4.3a

CVAD Dressing Changes and Site Care

Table 4.3b

Accessing CVADs

Flushing and Locking CVADs

Accessing and De-Accessing an Implanted Venous Access Device

View a supplementary YouTube video[18] on CVAD access and care: Ports: Access and Care.

Blood Sampling From a CVAD

Table 4.3d

Evaluation

References

4.4. CHECKLIST: CHANGE A CVAD DRESSING AND NEEDLELESS CONNECTOR

View the following YouTube video[5] showing an instructor demonstration of changing a CVAD dressing and needless connectors.

References

4.5. CHECKLIST: OBTAIN A BLOOD SAMPLE FROM A CVAD

View a YouTube video[3] showing an instructor demonstration of this skill:

References

4.6. CHECKLIST: ACCESS AN IMPLANTED VENOUS ACCESS DEVICE

View a YouTube video[3] showing an instructor demonstration of this skill:

References

4.7. DOCUMENTATION

4.8. LEARNING ACTIVITIES

Exercises

IV. GLOSSARY

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View a supplementary YouTube video^[¹⁸^] on CVAD access and care: Ports: Access and Care.