Overview

Central venous access devices (CVADs) — PICCs, tunneled catheters, implanted ports, and non-tunneled central lines — terminate in or near the superior vena cava. Because the tip sits in a large central vessel near the heart, these lines carry risks distinct from peripheral IVs: air embolism, central line-associated bloodstream infection (CLABSI), and pneumothorax (at insertion). A PICC is a central line even though it is placed in the arm — it gets central-line care, not peripheral-IV protocols. Post-insertion chest X-ray confirms tip placement before first use. Maintenance is built on the CLABSI bundle: hand hygiene, scrub-the-hub for ≥15 seconds before every access, sterile dressing changes with chlorhexidine, and daily review of whether the line is still needed.

Indications

long-term IV antibiotics

total parenteral nutrition

hypertonic — requires central access

chemotherapy

vesicants need central delivery

vasopressors

frequent blood sampling

poor peripheral venous access

hemodynamic monitoring

central venous pressure

Before the Procedure

perform hand hygiene

core CLABSI-bundle element before any line contact

verify chest X-ray tip confirmation

before first use of a new central line

gather sterile dressing-change supplies

chlorhexidine, sterile gloves, mask, CHG disc

don a mask

and have client turn head away from the site

assess dressing integrity

change immediately if damp, loosened, or soiled

scrub the hub 15 seconds

alcohol friction before every access

During — Monitoring

use strict sterile technique

sterile gloves for dressing changes, not clean gloves

scrub the hub before each access≥15 seconds

mechanical friction disrupts biofilm

flush with normal saline before and after use

heparin lock per facility protocol for certain catheters

place client in Trendelenburg before disconnection

before any cap change or tubing change

have client perform Valsalva on disconnection

bear down to raise intrathoracic pressure and keep air out

inspect insertion site every shift

redness, swelling, drainage, tenderness

review daily line necessity

remove as soon as no longer needed

Technique

Sterile central-line dressing change (in order)

Hand hygiene, mask, head turned awaycut airborne contamination first
Remove old dressing + inspect sitelook for redness, drainage, tenderness
Hand hygiene + sterile glovesfresh sterile field after the soiled dressing
Chlorhexidine back-and-forth scrub, dry fullyfriction scrub — NOT a circular wipe
CHG disc + labeled transparent dressingcontinuous antimicrobial + visible site

After — Complications

air embolism Hallmark

sudden chest pain, dyspnea, hypotension, 'mill-wheel' murmur; clamp line + left lateral Trendelenburg

central line-associated bloodstream infection

fever, rigors, purulent site drainage; obtain paired cultures

pneumothorax

insertion complication — dyspnea, decreased breath sounds

catheter occlusion

prevent with pulsatile push-pause flushing

catheter dislodgement

exit-site or tunnel infection

erythema, drainage at the site

venous thrombosis

Patient Teaching

keep the dressing clean and dry

report a loose or wet dressing

loosened, damp, or soiled

do not submerge the site in water

no swimming or bath immersion

report fever

early sign of bloodstream infection

report chills

report redness at the site

report drainage at the site

always scrub the hub before line access

report sudden shortness of breath

possible air embolism

report sudden chest pain

possible air embolism

Report Nowescalate immediately

sudden chest pain after line opened to air Hallmark

air embolism — clamp the line, place LEFT lateral Trendelenburg, call for help

acute dyspnea with hypotension

air embolism — clamp + left lateral Trendelenburg

mill-wheel murmur

churning murmur of venous air embolism

fever with rigors

CLABSI — draw paired cultures (central + peripheral), notify provider

purulent drainage at insertion site

with erythema — line infection; anticipate line removal

catheter accidentally pulled out

apply pressure; risk of air entry and bleeding

dressing damp, loosened, or soiled

change immediately — breached barrier raises infection risk

unable to flush or aspirate the line

occlusion — do not force the flush

Clinical Pearl

A PICC is a central line — central-line rules, not peripheral. Scrub the hub 15 seconds every single time, and anytime the line opens to air: position DOWN (Trendelenburg) and have the client bear DOWN (Valsalva). If air gets in: clamp the line and roll them LEFT and LOW.

Central Line Care