Central lines are any line that is placed into the larger vessels of the heart. Any catheter that is inserted and sitting in the superior or inferior vena cava is considered a central line.
Central line insertions
It is an invasive and sterile procedure that requires consent. The pt will be draped and the nurses and physicians will gown up their sterile gowns. When catheters are placed the patient is lying flat and given a numbing medication called lidocaine and pain medication. Make sure to have some sterile flushes handy in case you need to flush the line. Your job as a nurse will be to assist the person placing the line which can be an NP, MD, PA, and also monitoring vitals. Then the line is being advanced you may see some ectopy on the monitor, this usually happens when the tip of the catheter hits the right atrium (atrial tickle). If there is some ectopy let the physician know so they can pull back on the catheter. Once placed it is then sutured and anchored in place.
Some common central lines are PowerPICC, Hickman, Broviac, Groshong.
A PICC is a peripherally inserted central catheter.
PICCs are narrow flexible catheters usually inserted through a vein in the peripheral region. It is slid through until the tip reaches a large vessel in the heart called the superior vena cava. Usually placed in the upper arm.
Central lines can be inserted through:
- internal jugular vein
- common femoral vein
- subclavian veins
- basilic vein
- brachial vein
- cephalic vein
The major benefit to PICCs is that they allow for the administration of drugs that would not be able to be given through a peripheral line. They also give the patients the ability to have a long-term catheter for continuous use, for chemo, hemodialysis, etc…
Central line uses
Central lines can have multiple lumens or be single. The most common ones are a single lumen, double, and triple lumen.
- Prolonged IV antibiotic use
- Long Term medication infusions
- Multiple access was obtained with one line.
- TPN, Chemo
- Long-term inotropic therapy, vasopressors
- Home and sub-acute discharge
- Blood draws
Thicker than a PICC and temporarily used for hemodialysis or CRRT. a fistula is preferred over this method. It can be tunneled or temporary and should only be used for dialysis but can be used in emergent situations for medications.
Tunneled vs non-tunneled catheters
Tunneled catheters are placed for longer-term use and many times patients can be sent home with them. Tunneled catheters are passed under the skin and then fed into a large vein. Tunneled catheters also have something called a cuff which facilitates tissue growth to anchor it in place.
Also used for long-term treatment. It is implanted so that it sits underneath the skin usually in the upper chest. They need an occasional flush but otherwise don’t require much care. They can also be multiple.
Risks and Complications
Central lines are great; they provide critical access during critical times however there is some risk associated with central lines.
Rare but can occur during insertion and when giving medications.
Air bubbles enter the bloodstream and can travel to the brain, heart or lungs causing a MI, stroke, or respiratory failure.
Signs and Symptoms
- difficulty breathing or respiratory failure
- chest pain or heart failure
- muscle or joint pains
- mental status changes, such as confusion or loss of consciousness
- low blood pressure
- blue skin hue
Infections leading to sepsis can happen during the insertion period and after if proper maintenance isn’t done.
Signs and Symptoms
- Redness or swelling on site
- Purulent drainage
- Elevated WBCs
Inflammation of the vein where the catheter is inserted.
Signs and Symptoms
- Redness, pain, or drainage at the site
- Streak formation along the vein
Any catheter that is inserted will be at risk for thrombus formation and then embolism.
- After insertion, you will need to get an x-ray to confirm placement. Daily x-rays are not needed unless you are having problems with the catheter. One thing that can happen is catheter malposition, which will be revealed on the x-ray.
- A central line can be pulled back if it migrates but should not be pushed further in.
- Dressing changes are sterile procedures. Dressings need to be kept dry and changed if wet.
- The dressing should be changed per hospital policy, some places change them weekly and some every 72 hours. Keep in mind that every time you do a dressing change you expose the line to infection so they should not be done whenever.
- Some catheters need to be flushed with heparin.
- Keep lumens patent by flushing at least once a shift or keep a KVO going.
- Clean lumens with alcohol before using or keep caps on them.
- Using a 10 ml syringe generates the proper intra lumen pressure.
- Catheters that have clamps require heparin flushes, if clamps are not present it is a saline-only catheter.
- Avoid blood pressures on the side of the line.
- Always protect the catheter from tugging.
According to healthypeople.gov the most common HAIs include:
- Catheter-associated urinary tract infections
- Surgical site infections
- Bloodstream infections
- C. diff
CLABSI or Central Line-Associated Bloodstream Infections account for thousands of deaths a year and million dollars in added costs to the healthcare system.