Guide — Critical Care · IV Therapy
Central Line Nursing Guide
Central venous catheter types (non-tunneled CVC, PICC, tunneled CVC, implanted port), insertion site selection, CLABSI prevention bundle (5 key interventions), dressing care, lumen flushing protocols, blood sampling technique, and complication recognition and management.
12 min read · Critical Care · IV Therapy
Educational use only. Central line care protocols are institution-specific. Always follow your facility's central line policy. Central line insertion is a provider/advanced practice procedure — nursing role is assistance, maintenance, and complication monitoring. 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.
Central Venous Access Types
Non-Tunneled Central Venous Catheter (CVC)
Examples: Triple-lumen catheter (TLC), Introducer sheath, Dialysis catheter
| Insertion sites | Internal jugular (IJ), Subclavian, Femoral |
| Lumens / Dwell | 1–3 lumens (proximal, medial, distal ports) · Days to weeks — short-term acute care |
| Indications | Vasopressors (must have central access), TPN, CVP monitoring, large volume resuscitation, hemodynamic monitoring, multiple simultaneous infusions, hemodialysis (specialized catheter needed) |
| CLABSI risk | HIGH — highest CLABSI risk among CVC types, especially femoral |
| Nursing Notes | Preferred sites: subclavian (lowest CLABSI) > IJ > femoral (highest CLABSI risk). Daily line necessity assessment. Chlorhexidine impregnated dressing recommended. |
Peripherally Inserted Central Catheter (PICC)
Examples: Single-lumen PICC, Double-lumen PICC, Power PICC (for contrast injection)
| Insertion sites | Basilic vein (preferred), Brachial vein, Cephalic vein — advanced to superior vena cava |
| Lumens / Dwell | 1–3 lumens · Weeks to months — intermediate-term therapy |
| Indications | IV antibiotics > 5–7 days, long-term IV medications, TPN, chemotherapy, frequent blood draws, patients with poor peripheral access |
| CLABSI risk | LOWER than non-tunneled CVCs; upper arm insertion reduces infection risk vs femoral |
| Nursing Notes | Arm circumference before and during use (DVT monitoring). Verify tip position in SVC by CXR before use. Weekly dressing changes. No BP cuff, venipuncture, or heavy lifting on PICC arm. Power PICC required for contrast injections (flow rate tolerance). |
Tunneled Central Catheter
Examples: Hickman catheter, Broviac catheter, Groshong catheter, Mahurkar (HD)
| Insertion sites | Tunneled subcutaneously from chest wall insertion → SVC tip. Entry site separate from skin tunnel exit site (Dacron cuff anchors in tissue). |
| Lumens / Dwell | 1–3 lumens; valved (Groshong) or open-ended (Hickman) · Months to years — long-term therapy |
| Indications | Long-term TPN, chemotherapy, home IV therapy, frequent blood transfusions, bone marrow transplant |
| CLABSI risk | LOWER than non-tunneled — Dacron cuff creates infection barrier |
| Nursing Notes | Dacron cuff prevents microbial migration — do NOT remove or damage during dressing changes. Blood draws require 5–10 mL discard for each lumen. Open-ended (Hickman): flush with heparin. Groshong (valved): flush with NS only. |
Implanted Port (Port-a-Cath)
Examples: Single-lumen port, Double-lumen port, Power Port
| Insertion sites | Port reservoir surgically placed subcutaneously in chest wall; catheter tunneled to SVC |
| Lumens / Dwell | 1–2 lumens (accessed via non-coring Huber needle through skin into port chamber) · Years — most durable central access |
| Indications | Intermittent long-term chemotherapy, periodic IV medications in outpatient oncology, home care |
| CLABSI risk | LOWEST — completely subcutaneous when not accessed; minimal infection risk between use |
| Nursing Notes | MUST use non-coring Huber needle (regular needles will damage the port septum). Palpate port outline before accessing. Flush with 10 mL NS after each use + heparin lock when not in use. If not accessed regularly (> 4–6 weeks): monthly or per protocol heparin flush to maintain patency. |
CLABSI Prevention Bundle
The 5-element CLABSI prevention bundle reduced CLABSI rates by >60% when implemented with 100% compliance. All five elements must be performed — partial compliance loses the synergistic effect.
1. Hand Hygiene
| Evidence | Perform hand hygiene before and after catheter insertion or any catheter manipulation. Surgical scrub preferred for insertion; alcohol-based rub for manipulation. This is the single most important CLABSI prevention intervention. |
| Nursing Role | Before touching the line — hands. Every time. This applies to accessing hubs, changing dressings, drawing blood, and adjusting infusions. Teach patients and visitors not to touch catheter site. |
2. Maximal Barrier Precautions (at Insertion)
| Evidence | Inserter: sterile gloves, sterile gown, mask, cap. Patient: full-body sterile drape (head to toe). This was the intervention that most dramatically reduced CLABSI rates in landmark studies (Pronovost, Michigan Health and Hospitals Association). |
| Nursing Role | Nurse role at insertion: ensure inserter has full barrier, prep supplies, observe for breach. If sterile field is broken — stop procedure and restart. Do NOT rush this step. |
3. Chlorhexidine Skin Antisepsis
| Evidence | Use > 0.5% chlorhexidine in alcohol for skin prep (chlorhexidine/isopropanol solution preferred). Apply using back-and-forth friction for 30 seconds. Allow to DRY COMPLETELY before needle insertion (30–60 seconds). Dry chlorhexidine kills bacteria; wet or premature insertion is less effective. |
| Nursing Role | Never blot or wave dry — allow air dry. Chlorhexidine-impregnated dressings (Biopatch) at catheter insertion site add additional biofilm protection. If patient has chlorhexidine allergy: povidone-iodine or 70% isopropyl alcohol. |
4. Optimal Site Selection (Avoid Femoral)
| Evidence | Site preference: Subclavian ≥ Internal Jugular > Femoral. Femoral: HIGHEST infection risk (proximity to groin flora, difficult dressing maintenance, patient movement). Subclavian: lowest infection risk but higher mechanical complication risk (pneumothorax). IJ: intermediate risk, easier for ultrasound guidance. |
| Nursing Role | Advocate for avoidance of femoral access when possible. In patients with coagulopathy or thrombocytopenia: IJ may be preferred (compressible if bleeding occurs). Always question femoral line placement — is there a clinical reason? |
5. Daily Review of Line Necessity — Remove ASAP
| Evidence | Every day: Does this patient still need this central line? Can oral medications replace IV? Can a peripheral IV substitute? Is the line being used? CLABSI risk accumulates linearly with time — removing unnecessary catheters is the most sustainable prevention strategy. |
| Nursing Role | Advocate for line removal in rounds. Document line necessity discussion. A catheter that 'might be needed later' has CLABSI risk NOW. Nursing best practice: discuss catheter necessity at daily safety huddle and during provider rounds. |
Dressing Care & Lumen Management
| Dressing frequency | Transparent semipermeable membrane (TSM) dressing: every 7 days OR whenever soiled, loosened, or damp. Gauze dressing: every 48 hours (less visualization). Chlorhexidine gel disk (Biopatch): replace with dressing change. |
| Dressing technique | Sterile technique. Chlorhexidine/alcohol to skin — back and forth friction, allow to dry completely. Secure catheter to prevent tension. Document site assessment (erythema, tenderness, drainage, catheter external length). |
| Needleless access hubs | Scrub the hub for 15 seconds with alcohol wipe ("scrub the hub") before every access. Passive disinfection caps (alcohol-impregnated) reduce CLABSI when left on between uses. |
| Flushing (open-ended) | 10 mL NS flush before AND after each infusion (pulse-flash technique: push-stop, push-stop). Heparin-lock for unused lumens per protocol (10 units/mL or 100 units/mL per institutional policy). Use positive-pressure technique when disconnecting syringe. |
| Flushing (valved — Groshong) | NS flush only (no heparin needed — valve prevents backflow of blood). 10 mL NS after infusions, 20 mL after blood draws. |
| Blood draw technique | (1) Scrub the hub. (2) Withdraw and discard 3–5 mL (or 2× dead space volume — per policy). (3) Draw sample into labeled tubes. (4) Flush with 20 mL NS. (5) Resume infusions. Never draw from lumen running TPN, heparin, or medications that could interfere with results. |
Complications
Central Line-Associated Bloodstream Infection (CLABSI)
Timing: Typically > 48h after insertion (at-risk anytime during dwell)
| Signs | Fever or chills, rigors, erythema/warmth/tenderness at insertion site, purulent discharge, positive blood cultures (from line and peripheral) |
| Prevention | 5-component CLABSI prevention bundle (see above) |
| Nursing Action | Obtain blood cultures: one from each lumen AND peripheral site before antibiotics. Notify provider. Prepare for possible line removal — infected CVCs are typically removed and replaced at new site after antimicrobial treatment begins. Document suspected CLABSI per institutional policy (reportable event). |
Pneumothorax (Subclavian / IJ Insertion)
Timing: Immediately after insertion or within hours
| Signs | Unilateral decreased breath sounds, dyspnea, pleuritic chest pain, tracheal deviation (tension), hypotension (tension pneumothorax) |
| Prevention | Ultrasound guidance during insertion; post-procedure CXR before using new line |
| Nursing Action | Post-insertion CXR is MANDATORY before first use — confirms tip position AND rules out pneumothorax. Report new respiratory symptoms immediately. For tension pneumothorax: emergency needle decompression at 2nd ICS MCL (do NOT wait for CXR). |
Air Embolism
Timing: During insertion, dressing changes, or hub manipulation
| Signs | Mill-wheel murmur, sudden hemodynamic collapse, chest pain, confusion, hypoxia |
| Prevention | Keep patient flat or Trendelenburg during insertion; have patient perform Valsalva maneuver when line is open to air; use Luer-lock connections |
| Nursing Action | Place patient in left lateral decubitus Trendelenburg position (air moves to RV apex, away from pulmonary outflow). Call rapid response. High-flow oxygen. Trendelenburg: air rises to RV, preventing pulmonary outflow obstruction. Aspiration may be attempted. |
Catheter Occlusion / Thrombosis
Timing: Days to weeks after insertion
| Signs | Inability to flush or aspirate blood; sluggish infusion flow; arm swelling (PICC-related DVT) |
| Prevention | Regular flushing protocol; use positive pressure technique when removing syringe; avoid IV fat emulsions through small-gauge lumens |
| Nursing Action | Do NOT force flush an occluded catheter — may dislodge clot. Try alteplase (tPA) catheter-directed thrombolysis per protocol (Cathflo 2 mg, dwell 30 min–2h). PICC arm swelling: assess for DVT with ultrasound. Positional occlusion (tip moves with arm): adjust position and reassess. |
Arterial Puncture / Malposition
Timing: At time of insertion
| Signs | Pulsatile bright red blood during insertion, blood pressure in line matching arterial BP, CXR showing line in incorrect position |
| Prevention | Ultrasound guidance; CXR after insertion; never infuse vasopressors without confirmed central placement |
| Nursing Action | Suspected arterial puncture: remove needle/guidewire immediately, apply firm prolonged pressure (30+ minutes for IJ/subclavian — not compressible). NEVER infuse medications into an improperly positioned CVC until tip confirmed on CXR. Document tip location: should be at SVC/RA junction on CXR. |
NCLEX Pearls
CLABSI prevention: all 5 bundle elements must be completed — partial compliance does not achieve the full risk reduction.
Site preference for CLABSI risk: subclavian > IJ > femoral. Femoral = highest infection risk.
Post-insertion CXR is mandatory before first use — confirms SVC tip position AND rules out pneumothorax.
Air embolism treatment: left lateral decubitus (Durant's maneuver) + Trendelenburg + high-flow O₂.
"Scrub the hub" × 15 seconds with alcohol before every access — even with passive disinfection caps.
Implanted port: MUST use non-coring Huber needle — regular needles damage the septum and destroy the port.
Never force a flush into an occluded catheter. Use alteplase (Cathflo) per protocol. Forced flushing risks clot embolism.
Daily line necessity assessment — removing an unnecessary central line is the single most impactful long-term CLABSI prevention strategy.
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 →