Central Line Care

A central line dressing change done wrong doesn't just risk infection — it risks air embolism. The positioning, timing, and technique details are high-yield NCLEX territory.

Central venous access devices (CVADs) — including PICCs, tunneled catheters, implanted ports, and non-tunneled central lines — terminate in or near the superior vena cava. Because these lines sit in large central vessels, they carry risks distinct from peripheral IVs: air embolism, central line-associated bloodstream infection (CLABSI), and pneumothorax (during insertion). Dressing changes use strict sterile technique with chlorhexidine skin prep and occur every 7 days for transparent semi-permeable dressings or every 48 hours for gauze dressings, or immediately if the dressing becomes damp, loosened, or soiled. Before any line disconnection or cap change, place the patient in Trendelenburg position and instruct them to perform a Valsalva maneuver (bear down) to increase intrathoracic pressure and prevent air from entering the catheter. Needleless connectors are scrubbed with alcohol for at least 15 seconds (scrub the hub) before each access. Flush with normal saline before and after each use; heparin flushes follow facility protocol for certain catheter types. Monitor the insertion site every shift for redness, swelling, drainage, or tenderness — signs of infection or infiltration. Post-insertion chest X-ray confirms tip placement before first use for central lines (including PICCs unless an alternative confirmation method such as intracavitary ECG is used). If air embolism is suspected, immediately clamp the line and position the patient in left lateral Trendelenburg.

Key Distinctions

Don't confuse CLABSI prevention (sterile dressing changes, scrub the hub, daily line necessity review) with peripheral IV phlebitis prevention (site rotation every 72-96 hours) — different timelines, different protocols. Students often think air embolism risk applies equally to all IV lines, but it is clinically significant only with central lines because of their proximity to the heart. A PICC is a central line — it requires central line care, not peripheral IV protocols, despite being inserted in the arm.

Clinical Pearl

Trendelenburg + Valsalva = the air embolism safety combo. Anytime you open a central line to air, position DOWN and have the patient bear DOWN.