Central Lines in ICU:

Navigating the double

edged sword
Dr Sankalpa Vithanage
Critical care Physician
National Hospital Colombo
Outline

✓What – Central Venous Catheter

✓How – Insertion of a Central Venous Catheter
✓How – Care of CV line in ICU
✓What went wrong – Case scenarios
What - Central Venous Catheter

Intravascular device that terminates at or close to the heart or one of

the great vessels

Used to provide short-, medium- and long-term venous access.

Types of CV Catheters
✓1. Non Tunnelled Central Catheters

✓2. Tunnelled Central catheters

✓3. Peripherally inserted central catheters

✓4. Implantable ports

Outline

✓What – Central Venous Catheter

✓How – Insertion of a Central Venous Catheter
✓How – Care of CV line in ICU
✓What went wrong – Case scenarios
How – Insertion of a CV Catheter
Before the procedure – reading out the safety check list
How – Insertion of a CV Catheter
Steps
1. Hand hygiene
2. Site selection
3. Selection of appropriate catheter and technique
4. Full barrier precautions during insertion
5. Skin preparation
6. US guidance
7. Documentation
How – Insertion of a CV Catheter
Hand hygiene
Hand hygiene remains the 1st & most important step during the insertion
& maintenance of the CV line, in CLABSI prevention. Mitchell et al. (2020)

✓Use liquid soap

✓6 stage hand washing technique
✓Dry hands with a sterile cloth

Alegranzi and Pittet J Hosp Infect 2009 73:305-315;

Backman C et al Am J Infect Control 2008 36 (5):333-48;
Clin Infect Dis 1999;29:1287-94;
Pittet et al. Lancet 2000;356:1307-1312
How – Insertion of a CV Catheter
Site selection
✓The femoral site should be avoided.
Femoral vs subclavian lines:
➢Higher rate of infectious complications (colonization and BSI
combined) in femoral grp: 19.8% vs 4.5% (p < .001)
➢Higher rate of thrombotic complications in femoral grp: 21.5% vs.
1.9% (p < .001); complete thrombosis 6% vs 0%
✓Order of preference:
1) Subclavian → 2) Internal Jugular → 3) Femoral
How – Insertion of a CV Catheter
Selection of appropriate catheter and technique
✓Catheter with minimum number of lumens needed
✓16 cm catheter for RIJ and 20 cm catheter for LIJ
✓Avoid subclavian route for dialysis catheter insertion.
✓Use Seldinger technique and make sure to remove
guidwire
How – Insertion of a CV Catheter
Full barrier precautions during insertion
✓Non-sterile cap and mask
✓All hair should be under cap
✓Mask should cover nose & mouth tightly
✓Sterile gown and gloves
✓Fully cover the patient with sterile drape
How – Insertion of a CV Catheter
Skin preparation
✓1st line - 2% chlorhexidine + 70% Isopropyl alcohol*
(2nd line; Povidone iodine E.g. – in allergy)
✓30 second scrub
(2 minutes if groin)
✓1 minute to dry

This meta-analysis found that use of CHG

reduced the risk of CLABSI by 49%
How – Insertion of a CV Catheter
US guidance
✓ US guided vascular localization is compulsory
✓ Clean the probe before procedure
✓ Always scan & confirm the suitability of the site prior to procedure
✓ Sterile probe cover with gel inside Meta-analysis of 18 RCTs
Failed placement: RR  86%
✓ Do not apply unsterile gel on site Complications:
First attempt failure:
RR  57%
RR  41%
✓ Clean the probe again after the procedure Attempts:
Time:
 1.5
 69.3( sec)
How – Insertion of a CV Catheter
Documentation

✓CVC insertion record should be filled by the operator

✓Insertion date should be clearly documented
✓Imaging should be ordered to confirm
location and exclude complications
Outline

✓What – Central Venous Catheter

✓How – Insertion of a Central Venous Catheter
✓How – Care of CV line in ICU
✓What went wrong – Case scenarios
How – Care of CV line in ICU
Hand Hygiene – Again…!!!
✓Hand Washing or Hand sanitization (Alcohol based) every time
accessing CV line.
✓Using gloves does not preclude the need for
hand hygiene
✓Should practice 5 moments of hand hygiene
How – Care of CV line in ICU
Site care
✓Line should be well secured (silk/vicryl/nylon)
✓Transparent dressing should be applied
✓Timing of dressing change
✓Any dressing that is damp, loose, or soiled Immediately
✓Transparent dressing Every 7 days
✓Gauze dressing Every 48 hours
How – Care of CV line in ICU
Hub care
✓Clean needleless connector/hub before every access with 70%
alcohol
✓Perform “Scrub the Hub” at least for 15 sec.
✓Changing needless connectors
✓ With tubing change
✓As needed if occluded or if visible blood or debris
is seen in or on connector
✓ Every 96 hrs if not being accessed
✓Prior to drawing blood cultures
How – Care of CV line in ICU
Tubing care
✓Replace tubing used to administer
✓Propofol infusions every 12 - 24 hours
✓Blood, blood products, or fat emulsions within 24 hours
✓Replace administration sets that are continuously used,
no more frequently than at 96-hour intervals
✓Dedicated line for TPN when indicated
How – Care of CV line in ICU
Screening for infections
✓Daily check site of CV line for erythema/induration
✓Catheter tip for sampling should be sent when indicated
✓Blood for cultures from central lines should always accompanied by
sample from a peripheral stab at the same time
✓Blood taken for cultures during the insertion of
central line is considered as a peripheral sample
How – Care of CV line in ICU
Removal of CVC
✓Assess the need for the catheter each day and remove ASAP
✓Remove or change the catheters inserted in wards at earliest
✓Always try to remove central lines before sending patients to wards.
Outline

✓What – Central Venous Catheter

✓How – Insertion of a Central Venous Catheter
✓How – Care of CV line in ICU
✓What went wrong – Case scenarios
What went wrong – Case 1
Mr. S, 55 year, No past medical Hx
✓Mr. S, underwent elective surgery for colon resection due to a
malignancy. The surgery went well, and he was transferred to the SICU
for postoperative care.
✓A non-tunnelled CV line was inserted in the right IJ vein by anaesthetist
before surgery
✓Postoperative Care: pain management, fluid resuscitation, and
prophylactic antibiotics given. Surgical site was healthy
✓5th post op day, Mr. Smith develop fever, chills, tachycardia with
tachypnoea. paired Blood cultures were collected.
What went wrong – Case 1
Both CV line & Peripheral blood cultures were positive for coagulase
negative Staphylococci and DTTP of 3 hours. CRBSI was diagnosed
Management:
1. CV line was promptly removed.
2. IV Teicoplanin was empirically started, which later changed to
Flucloxacillin with the sensitivity report
3. Mr. S was closely monitored in the SICU, and appropriate supportive
care given
• Mr. S’ fever subsided, and he showed signs of improvement. He was
discharged from the SICU after a few days
What went wrong – Case 2
Mr H, 23 year old, had severe TBI following RTA.
✓He underwent Decompressive craniectomy & admitted to
neurotrauma ICU
✓His neurological recovery was slow & GCS was 6/15, weaned from
ventilator following tracheostomy on day 5
✓On day 8 he develop high fever spikes and found to have cerebral
abscess on CECT, which was evacuated and started on IV Meropenem
and Vancomycin 6 week course.
✓Radiology guided PiCC line was inserted to facilitate long cause of
antibiotics.
What went wrong – Case 2
✓On day 21 of therapy, He develop high spiking Fever with drop in
blood pressure requiring Vasopressor support.
✓Paired blood cultures & Tracheostomy secretions were send for
cultures while C-xray and CECT was performed which were normal
✓Both cultures were positive for MDR Acinetobacter with DTTP of 150
mins. CRBSI was diagnosed.
What went wrong – Case 2
Management:
1. IV Colistin was started
2. PiCC line was removed promptly and IJ CV line was inserted for
vasopressor support
3. Vasopressor support was weaned off after 2 days and Fever
subsided.

Mr H was stepdown to HDU on day 30 while continuing his CNS

antibiotics.
Thank You