Central Venous Catheter Insertion and Maintenance

Insertion Site

A catheter’s insertion site directly influences the subsequent risk for catheter-related infection.  The density of skin flora at the insertion site is a major risk factor for CVC-related BSI.  Certain insertion sites are easier to maintain in a clean and dry manner. Catheters inserted into an internal jugular vein are associated with higher risk for infection than those inserted into a subclavian vein.  Recent studies suggest the femoral site is associated with a higher risk for deep venous thrombosis than the other two sites.  In general, the subclavian site is recommended for infection control purposes.  However, this recommendation must be balanced against issues such as patient comfort, anatomic deformity, and risk of mechanical complications (e.g., bleeding and pneumothorax).

Studies have shown that the risk of infection or mechanical complications increases with each needle stick.  If multiple attempts do not result in successful canalization, providers are encouraged to ask for assistance from a more experienced colleague.  In these challenging line placement situations, providers must remain particularly attuned to their patient's level of comfort and anxiety.

Patient Positioning

Skin Antisepsis

Although povidone-iodine (Betadine) has been the most widely used antiseptic, 2% aqueous chlorhexidine gluconate is actually superior for reducing CVC-related BSIs.  Unless contraindicated, use 2% chlorhexidine for skin antisepsis.  If the patient is allergic to chlorhexidine, use povidone-iodine.  Allow the antiseptic to air dry on the site before insertion.   

If hair must be removed prior to line insertion, clipping is recommended.  Shaving is not appropriate because razors cause local skin abrasions that subsequently increase the risk for infection.

Maximal Barrier Precautions

Compared with peripheral venous catheters, CVCs carry a substantially greater risk for infection.  Therefore, central lines should always be placed using maximal sterile barrier precautions (persons placing the CVC should wear a cap, mask, sterile gown, and sterile gloves, and a large sterile drape should cover the patient's head and extend below the waist).  Studies have consistently shown that the use of maximal barrier precautions reduces the incidence of CVC-related BSIs when compared against standard precautions (sterile gloves and sterile towels).  Of note, maximal barrier precautions are also recommended for any guidewire exchanges.

Prophylactic Antibiotics During Insertion

Prophylaxis with intravenous vancomycin or teicoplanin during catheter insertion has not been demonstrated to reduce the incidence of CVC-related infections.  Since indiscriminate use of antimicrobials independently selects for the acquisition of resistant organisms, this strategy is not recommended.

Topical Antimicrobial Ointment

Several topical ointments have been studied at the catheter insertion site.  One randomized study showed that prophylactic povidone-iodine ointment reduces hemodialysis catheter infections.  Studies with prophylactic mupirocin have shown that it prevents infections, but the ointment ultimately induces mupirocin resistance and damages the integrity of polyurethane catheters.  Rates of catheter colonization with Candida also increase after application of an antimicrobial ointment that has no fungicidal activity.  Overall, many studies show conflicting results and no strong recommendations exist regarding the use of antimicrobial ointments.  If applying one of these ointments to a CVC insertion site, always check for compatibility with the catheter material.

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Abbreviations

BSI = bloodstream infection

CVC = central venous catheter