Reference — Critical Care · IV Therapy
Central Line Care Reference
Quick-reference for central venous catheter maintenance — CLABSI bundle, dressing frequency, hub disinfection (“scrub the hub”), flushing protocols, blood draw technique, catheter occlusion management, and complication recognition.
Critical Care · IV Therapy
Educational use only. Always follow your institution's central line care policy. Protocols vary by catheter type, institutional guidelines, and patient population. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
CLABSI Prevention Bundle — 5 Elements
| Element | Nursing Action |
|---|---|
| 1. Hand hygiene | Perform before AND after every catheter contact. Alcohol-based rub for routine manipulation; surgical scrub for insertion. Most impactful single intervention. |
| 2. Maximal barrier precautions | At insertion: sterile gloves + sterile gown + mask + cap (inserter). Full-body sterile drape (patient). Observe sterile field — stop if breach. Nurse role: supply setup, observe for breach. |
| 3. Chlorhexidine skin prep | > 0.5% chlorhexidine in alcohol. Back-and-forth friction × 30 seconds. Allow COMPLETE air dry (30–60 sec) before needle insertion. Chlorhexidine-impregnated dressing (Biopatch) at insertion site adds ongoing protection. |
| 4. Optimal site selection | CLABSI risk order: Femoral (highest) > IJ > Subclavian (lowest). Advocate to avoid femoral unless clinically required. Question femoral line placement — is there an alternative? |
| 5. Daily necessity review | Every day: Does this patient still need this central line? Advocate for removal at rounds. CLABSI risk accumulates linearly with dwell time — removing the line = removing the risk. |
Dressing Care
| Transparent dressing (TSM) | Change every 7 days OR if soiled, loosened, or moisture-collecting (wet edges). Allows site visualization without removing dressing. Preferred type in most institutions. |
| Gauze dressing | Change every 48 hours (or per protocol). Use when patient has excessive diaphoresis, drainage, or bleeding at insertion site that prevents TSM adherence. |
| Chlorhexidine disk (Biopatch) | Place gel side DOWN against skin, centered at catheter insertion site. Replace with every dressing change. Do not cut or fold. Reduces biofilm formation at catheter-skin interface. |
| Technique | Sterile technique. Mask on for dressing changes on IJ and subclavian lines (face close to insertion site). Chlorhexidine/alcohol to skin — back-and-forth friction, air dry. Secure catheter to prevent tension on insertion site. |
| Site assessment | Document: insertion site appearance (erythema, tenderness, swelling, drainage), external catheter length, dressing integrity, date of dressing change. Inspect with each shift assessment. |
Hub Disinfection (“Scrub the Hub”)
| Manual scrub | Friction scrub of needleless connector with 70% isopropyl alcohol wipe for a minimum of 15 seconds. Allow to fully dry before access. Scrub before EVERY access — no exceptions. |
| Passive disinfection caps | Alcohol-impregnated caps (e.g., ClearGuard, SwabCap) twist onto unused ports. Maintain passive disinfection between uses. Must still scrub the hub of the cap-removed connector before access. Replace cap after every access. |
| Needleless connectors | Change every 96 hours (or per protocol), with dressing change, and after each blood draw, blood administration, or lipid infusion. Do not change more frequently than every 96 hours without clinical indication (increases contamination risk from manipulation). |
Flushing Protocols by Catheter Type
| Catheter Type | Flush Protocol |
|---|---|
| Open-ended (Hickman, TLC) | 10 mL NS before AND after each infusion (pulsed-flush: push-stop, push-stop × 5). Heparin-lock unused lumens (10 units/mL or 100 units/mL per institutional policy). Positive-pressure technique when removing syringe. |
| Valved (Groshong) | NS flush ONLY — no heparin (Groshong valve prevents backflow of blood). 10 mL NS after infusions, 20 mL NS after blood draws. Same pulsed-flush technique. |
| PICC | 10 mL NS before and after use. Heparin lock if specified by institutional policy. Change dressing weekly at insertion site. Verify tip location in SVC on initial CXR before use. |
| Implanted port (between uses) | Flush with 10 mL NS + heparin lock (100 units/mL, 5 mL) every 4–6 weeks (or per protocol) to maintain patency when not actively in use. Access ONLY with non-coring Huber needle. |
| Pulsed-flush technique | Push 1–2 mL → pause briefly → push 1–2 mL → pause → continue. Creates turbulence within lumen that more effectively removes fibrin and drug residue than continuous flush. Do NOT flush in one continuous uninterrupted stream. |
Blood Draw Technique
| Step 1 — Stop infusions | Pause infusions running through the lumen to be sampled for 1–2 minutes (or per protocol) to clear IV medications that could contaminate specimen. Exception: vasopressors are never stopped — draw from a different lumen. |
| Step 2 — Scrub the hub | Friction scrub needleless connector × 15 seconds with alcohol. Allow to dry. |
| Step 3 — Discard volume | Withdraw and discard 3–5 mL (or 2× catheter dead space volume — per protocol). This discards the flush solution diluting the specimen. Discard into discard syringe or vacutainer. Do NOT return to patient. |
| Step 4 — Draw specimen | Attach appropriately labeled tubes in correct order (per tube order protocol). Draw specimens slowly to prevent hemolysis (especially in small-lumen catheters). |
| Step 5 — Flush | 20 mL NS (pulsed-flush) after blood draw to clear residual blood from lumen (blood left in lumen promotes clot and CLABSI). Re-establish infusions. |
| Lumen selection | Never draw from the lumen running TPN (lipids affect many lab results), heparin infusion (affects coagulation studies), or vasoactive medications. Use dedicated blood draw lumen or designated sampling port. |
Catheter Occlusion Troubleshooting
| Presentation | Unable to flush or aspirate. Sluggish flow. Unable to infuse at ordered rate. Resistance on flushing (NOTE: NEVER force a flush against resistance). |
| Step 1 — Rule out mechanical causes | Clamp check (are clamps open?). Kinked tubing inspection. Patient position (PICC: arm position may affect flow). IV line occlusion vs catheter occlusion distinction. |
| Step 2 — Alteplase (Cathflo) | Alteplase (tissue plasminogen activator): 2 mg/2 mL instilled into occluded lumen. Dwell for 30 minutes (or 120 minutes for persistent occlusion). Withdraw and discard. Assess patency. Repeat × 1 if needed. Requires provider order. |
| Lipid occlusion (TPN lines) | 70% ethanol lock (EtOH lock) — dissolves lipid deposits in catheter. Per institutional protocol. More common in home TPN patients with long-term PICCs. |
| Drug precipitate occlusion | Hydrochloric acid 0.1 N or sodium bicarbonate instillation depending on precipitate type (acid vs alkaline). Pharmacy consultation required. Alteplase will NOT clear drug precipitates — it only dissolves fibrin/thrombus. |
Complication Recognition
| Complication | Signs | Nursing Action |
|---|---|---|
| CLABSI | Fever/chills, rigors, site erythema/warmth/tenderness, positive blood cultures from line (no other source) | Blood cultures × 2 (line + peripheral). Notify provider. Line removal likely. Document as reportable event per policy. |
| Pneumothorax | Decreased breath sounds unilateral, dyspnea, chest pain, hypoxia (post IJ or subclavian insertion) | Obtain CXR immediately. Tension: needle decompression (2nd ICS, MCL). Do NOT use new line until pneumothorax excluded on CXR. |
| Air embolism | Sudden hemodynamic collapse, mill-wheel murmur, chest pain, confusion, hypoxia | Left lateral decubitus (Durant's maneuver) + Trendelenburg position. 100% O₂. Rapid response. |
| DVT/Thrombosis | Arm/neck swelling (PICC-associated), inability to aspirate blood, sluggish infusion, + vein palpable | Ultrasound of extremity. Anticoagulation per provider. Line may be kept in for treatment or removed (provider decision). |
NCLEX Pearls
ALL 5 CLABSI bundle elements required — partial compliance loses synergistic effect. Bundle adherence > 95% is the target.
Site CLABSI risk: femoral (highest) > IJ > subclavian (lowest). Avoid femoral unless clinically required.
Post-insertion CXR required before first use — confirms tip location in SVC/RA junction AND rules out pneumothorax.
Air embolism position: left lateral decubitus (Durant's) + Trendelenburg — air moves to RV apex away from pulmonary outflow tract.
Implanted port: ONLY non-coring Huber needle — regular needles core the septum and destroy the port.
NEVER force flush an occluded catheter — use alteplase (Cathflo). Forced flushing risks clot embolism.
“Scrub the hub” × 15 seconds before EVERY access — even with passive disinfection caps in place.
Related Resources
Standards & sources
Fact-checked Jun 20, 2026This page is written to align with Society of Critical Care Medicine (SCCM) · Surviving Sepsis Campaign · American Association of Critical-Care Nurses (AACN). It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →