Loading
When a central line is put in, the team follows a checklist: clean hands, a cap, mask, sterile gown and gloves for the person inserting it, a sterile drape over the whole body, and chlorhexidine in alcohol on the skin, left to dry. Someone watches and can stop the procedure if a step is missed. For long treatments such as chemotherapy, a tunnelled line or a port is usually the right kind of line.
The insertion bundle in SHEA/IDSA/APIC 2022 is a set of essential practices: an evidence-based list of indications (low quality), education and competency of inserters (moderate), a process such as a checklist with an empowered observer (moderate), hand hygiene (moderate), an all-inclusive cart or kit (moderate), ultrasound guidance (high), maximum sterile barrier precautions with cap, mask, sterile gown, sterile gloves and a full-body drape (moderate; CDC IB; epic3 Class C), and alcoholic chlorhexidine skin preparation of at least 2% allowed to dry (high; epic3 Class A; CDC IA at more than 0.5%). Site choice: subclavian preferred for non-tunnelled lines in the ICU (high) and avoid the femoral vein in adults (CDC IA); in children the femoral site may be considered when upper sites are contraindicated. Use the fewest lumens needed (CDC IB, epic3 Class A); for long-term access use a tunnelled line or implanted port (epic3 Class A); PICCs are not a strategy to lower infection risk (SHEA). No systemic antibiotic prophylaxis at insertion (SHEA high, CDC IB, epic3 Class A). Replace a line placed in an emergency without assured asepsis within 48 hours (CDC IB). Antiseptic- or antimicrobial-impregnated catheters are an additional approach where rates stay high.
Why: The surest way to prevent a line infection is not to place a line that is not needed.
“Provide easy access to an evidence-based list of indications for CVC use to minimize unnecessary CVC placement (Quality of Evidence: LOW)”
SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 · Quality of Evidence: LOW
Why: Cancer treatment often lasts months; devices built for long use, with fewer openings, carry less infection risk over that time.
“Use a tunnelled or implanted central venous access device with a subcutaneous port for patients in whom long-term vascular access is required.”
Journal of Hospital Infection (Loveday et al., commissioned by the Department of Health) 2014 · Class A
Why: Infection and mechanical complications fall with experience and a consistent technique.
“Designate only trained personnel who demonstrate competence for the insertion and maintenance of peripheral and central intravascular catheters.”
CDC/HICPAC 2011 · Category IA
Why: A second person catches missed steps that the busy inserter will not.
“HCP should be empowered to stop the procedure if breaches in aseptic technique are observed.”
SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 · Quality of Evidence: MODERATE
Why: Leaving the sterile field to fetch an item is a common way asepsis is broken.
“A catheter cart or kit that contains all necessary components for aseptic catheter insertion should be available and easily accessible in all units where CVCs are inserted.”
SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 · Quality of Evidence: MODERATE
Why: Hands carry the skin germs that cause most early line infections.
“Perform hand hygiene prior to catheter insertion or manipulation (Quality of Evidence: MODERATE)”
SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 · Quality of Evidence: MODERATE
Why: Groin lines carry more infection in adults; the subclavian has the lowest infection risk but more risk of lung puncture and is avoided in people who may need dialysis.
“Avoid using the femoral vein for central venous access in adult patients”
CDC/HICPAC 2011 · Category IA
Why: Ultrasound cuts the number of attempts and mechanical complications.
“Use ultrasound guidance for catheter insertion (Quality of Evidence: HIGH)”
SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 · Quality of Evidence: HIGH
Why: A large sterile field stops the guidewire and catheter touching anything unclean.
“A mask, cap, sterile gown, and sterile gloves are to be worn by all HCP involved in the catheter insertion procedure.”
SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 · Quality of Evidence: MODERATE
Why: A PICC is a central line and carries a similar infection risk in hospital patients.
“Use maximal sterile barrier precautions, including the use of a cap, mask, sterile gown, sterile gloves, and a sterile full body drape, for the insertion of CVCs, PICCs, or guidewire exchange”
CDC/HICPAC 2011 · Category IB
Why: Chlorhexidine in alcohol is the most effective skin antiseptic for line insertion, and it works only once it has dried.
“Before catheter insertion, apply an alcoholic chlorhexidine solution containing at least 2% chlorhexidine gluconate to the insertion site.”
SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 · Quality of Evidence: HIGH
Why: Preventive antibiotics at insertion do not lower line infections and they breed resistance.
“Do not routinely administer intranasal or systemic antimicrobials before insertion or during the use of an intravascular device to prevent catheter colonisation or bloodstream infection.”
Journal of Hospital Infection (Loveday et al., commissioned by the Department of Health) 2014 · Class A
Why: A line placed in a rush is more likely to have been contaminated.
“When adherence to aseptic technique cannot be ensured (i.e., catheters inserted during a medical emergency), replace the catheter as soon as possible, i.e., within 48 hours”
CDC/HICPAC 2011 · Category IB
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
The SHEA/IDSA/APIC 2022 essential practices at insertion, which CDC/HICPAC 2011 and epic3 broadly share: indication check, competent inserters, a checklist with an empowered observer, hand hygiene, an all-inclusive kit, ultrasound guidance, maximum sterile barrier precautions with a full-body drape, alcoholic chlorhexidine skin preparation allowed to dry, and no antibiotic prophylaxis. The sources differ in the strength and detail: chlorhexidine concentration is at least 2% in SHEA (high) and epic3 (Class A, 2% in 70% isopropyl alcohol) but more than 0.5% with alcohol in CDC (IA); maximum sterile barriers are moderate quality in SHEA, Category IB in CDC and Class C in epic3, and SHEA notes one randomised trial in surgical patients found no added benefit; SHEA prefers the subclavian site only for ICU placement and calls the site risk outside the ICU unclear. For people having long cancer treatment, epic3 recommends a tunnelled line or an implanted port (Class A), and SHEA warns that a PICC is not a way to lower infection risk.
SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 · CDC/HICPAC 2011 · Journal of Hospital Infection (Loveday et al., commissioned by the Department of Health) 2014
Where it differs: Uses chlorhexidine with silver sulfadiazine or minocycline with rifampin catheters for lines expected to stay more than 5 days, in units whose CLABSI rate is above target despite the essential practices, or for patients with limited access and recurrent infection.
Evidence: SHEA additional approach, quality of evidence high in adults and moderate in children; CDC Category IA under the same conditions; epic3 Class A for adults. SHEA notes many of the trials predate routine bundles and the benefit on top of them is unknown.
SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 · CDC/HICPAC 2011 · Journal of Hospital Infection (Loveday et al., commissioned by the Department of Health) 2014
Where it differs: In children and infants the femoral vein may be considered if upper body sites are contraindicated; a tunnelled femoral line with an exit site in the mid-thigh, outside the nappy area, may be safer.
Evidence: Stated by SHEA without a separate grade; CDC's femoral avoidance (Category IA) is for adults.
SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 · CDC/HICPAC 2011
Where it differs: Uses povidone-iodine in alcohol instead of chlorhexidine where the patient is sensitive to chlorhexidine; CDC also allows tincture of iodine, an iodophor or 70% alcohol.
Evidence: epic3 Class A within the skin preparation recommendation; CDC Category IA within its recommendation; CDC lists the comparison of chlorhexidine and povidone-iodine, both in alcohol, as unresolved.
Journal of Hospital Infection (Loveday et al., commissioned by the Department of Health) 2014 · CDC/HICPAC 2011
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Alcoholic chlorhexidine skin preparation “Use an alcoholic chlorhexidine antiseptic for skin preparation (Quality of Evidence: HIGH)” | Quality of Evidence: HIGH | SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 |
| 2% chlorhexidine in 70% isopropyl alcohol, single use, allowed to dry, before CVC insertion “Decontaminate the skin at the insertion site with a single-use application of 2% chlorhexidine gluconate in 70% isopropyl alcohol (or povidone iodine in alcohol for patients with sensitivity to chlorhexidine) and allow to dry prior to the insertion of a central venous access device.” | Class A | Journal of Hospital Infection (Loveday et al., commissioned by the Department of Health) 2014 |
| More than 0.5% chlorhexidine with alcohol before CVC insertion | Category IA | CDC/HICPAC 2011 |
| Maximum sterile barrier precautions “Use maximum sterile barrier precautions during CVC insertion (Quality of Evidence: MODERATE)” | Quality of Evidence: MODERATE | SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 |
| Maximal sterile barrier precautions | Category IB | CDC/HICPAC 2011 |
| Maximal sterile barrier precautions “Use maximal sterile barrier precautions for the insertion of central venous access devices.” | Class C | Journal of Hospital Infection (Loveday et al., commissioned by the Department of Health) 2014 |
| A checklist or similar process at insertion “In ICU and non-ICU settings, a facility should have a process in place, such as a checklist, to ensure adherence to infection prevention practices at the time of CVC insertion (Quality of Evidence: MODERATE)” | Quality of Evidence: MODERATE | SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 |
| Subclavian site preferred for ICU placement “The subclavian site is preferred to reduce infectious complications when the catheter is placed in the ICU setting (Quality of Evidence: HIGH)” | Quality of Evidence: HIGH | SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 |
| Minimum number of lumens “Use a catheter with the minimum number of ports or lumens essential for management of the patient.” | Class A | Journal of Hospital Infection (Loveday et al., commissioned by the Department of Health) 2014 |
Shares Peripherally inserted central catheters (PICC lines), Implanted ports for chemotherapy (port-a-cath, power-injectable, apheresis and intraperitoneal ports), Central venous access (port, PICC line).
Shares Implanted port access, flushing and care in adults having cancer treatment, Peripherally inserted central catheters (PICC lines), Implanted ports for chemotherapy (port-a-cath, power-injectable, apheresis and intraperitoneal ports), Central venous access (port, PICC line).
Shares Implanted port access, flushing and care in adults having cancer treatment, Peripherally inserted central catheters (PICC lines), Implanted ports for chemotherapy (port-a-cath, power-injectable, apheresis and intraperitoneal ports), Central venous access (port, PICC line).
Shares Peripherally inserted central catheters (PICC lines), Implanted ports for chemotherapy (port-a-cath, power-injectable, apheresis and intraperitoneal ports), Central venous access (port, PICC line).
Shares Peripherally inserted central catheters (PICC lines), Central venous access (port, PICC line).
Shares Peripherally inserted central catheters (PICC lines), Implanted ports for chemotherapy (port-a-cath, power-injectable, apheresis and intraperitoneal ports), Central venous access (port, PICC line).
Shares Implanted port access, flushing and care in adults having cancer treatment, Peripherally inserted central catheters (PICC lines), Implanted ports for chemotherapy (port-a-cath, power-injectable, apheresis and intraperitoneal ports), Central venous access (port, PICC line).
Shares Peripherally inserted central catheters (PICC lines), Implanted ports for chemotherapy (port-a-cath, power-injectable, apheresis and intraperitoneal ports), Central venous access (port, PICC line).