A central vascular access device (CVAD) is a catheter whose tip lies in a large central vein — ideally the lower third of the superior vena cava near the cavoatrial junction (SVC–right atrium junction). High blood flow there rapidly dilutes irritating solutions.

Indications

• Vesicants and irritants given continuously (chemotherapy, vasopressors)
• Parenteral nutrition and other hyperosmolar solutions
• Long-term therapy (antibiotics, chemotherapy), frequent blood sampling
• Hemodynamic monitoring (central venous pressure), hemodialysis or apheresis (special catheters)
• No usable peripheral access

Types

Central lines carry greater risks than peripheral catheters: central line–associated bloodstream infection (CLABSI), pneumothorax, air embolism, thrombosis, and catheter malposition.

• Insertion site: redness, tenderness, drainage, swelling, bleeding; dressing intact, dry, dated
• External catheter length (compare with the length documented at insertion) — migration suggests malposition
• Arm circumference above a PICC site (baseline and when swelling is suspected) — increase suggests thrombosis
• Signs of venous thrombosis: arm, neck, or face swelling, distended neck or chest veins, pain
• Respiratory status after insertion (pneumothorax)
• Lumen function: flushes easily, blood return present
• Systemic infection signs: fever, chills, hypotension, especially without another source — CLABSI must be suspected even if the site looks clean
• Daily: is the line still necessary?

• Tip position confirmation before first use — chest X-ray after internal jugular or subclavian insertion confirms the tip location and excludes pneumothorax; many PICCs are confirmed by ECG-based tip location technology instead
• Tip in the right atrium or ventricle risks dysrhythmias and, rarely, perforation with tamponade; tip too short (upper SVC, innominate or subclavian vein) increases thrombosis
• Blood cultures from the catheter and a peripheral vein when CLABSI is suspected (time-to-positivity comparison)
• Venous Doppler ultrasound for suspected catheter-related thrombosis
• Central venous pressure (CVP): zero and level the transducer at the phlebostatic axis — fourth intercostal space at the midaxillary line (level of the right atrium), with the client supine (head of bed up to about 30–45 degrees is acceptable if consistent). Normal about 2–8 mmHg. A transducer system uses a pressure bag inflated to 300 mmHg to keep a continuous slow flush that maintains patency and an accurate waveform

CLABSI prevention bundle

Insertion

• Hand hygiene
• Maximal sterile barrier precautions: cap, mask, sterile gown, sterile gloves, full-body sterile drape for the operator (and mask/cap for assistants)
• Chlorhexidine (more than 0.5%) with alcohol skin antisepsis, allowed to dry
• Site selection: for nontunneled catheters in adults, subclavian preferred for infection risk; avoid the femoral vein in adults; ultrasound guidance
• Checklist with authority for any team member to stop the procedure for a sterility break

Maintenance

• Daily review of necessity; remove promptly when not essential
• Scrub the hub before every access; disinfecting caps
• Sterile dressing: transparent dressing at least every 7 days, gauze every 2 days, immediately if damp, loose, or soiled; chlorhexidine-impregnated dressings for many short-term catheters
• Daily chlorhexidine bathing in ICU clients (per policy)
• Administration set changes on schedule (continuous sets every 96 hours to 7 days; PN and lipid sets every 24 hours)
• Dedicated lumen for parenteral nutrition when possible
• No routine catheter replacement to prevent infection

Occlusion management

• Thrombotic occlusion: alteplase instilled per protocol (commonly 2 mg/2 mL, dwell 30–120 minutes). Contraindicated in active internal bleeding; assess for bleeding
• Precipitate occlusion: drug- or mineral-specific clearing agents per protocol
• Mechanical: check clamps, kinks, sutures, pinch-off syndrome (subclavian catheter compressed between clavicle and first rib — occlusion that changes with arm position)

Locking: saline or low-concentration heparin (e.g., 10 units/mL) per policy and device instructions. Heparin locks carry a small risk of heparin-induced thrombocytopenia and dosing errors — verify concentration. Implanted ports not in use are flushed and locked about monthly (or per manufacturer, up to every 3 months).

Listed in priority order.

1. Air embolism prevention and response
   • Keep all connections Luer-locked and clamps closed when lumens are open to air
   • Tubing change or cap change: clamp the catheter; have the client perform the Valsalva maneuver (or change during exhalation if ventilated)
   • Suspected air embolism (sudden dyspnea, chest pain, hypotension, tachycardia, churning "mill wheel" murmur, altered consciousness): clamp the catheter or cover the site, place the client on the left side with the head down (left lateral Trendelenburg) if not contraindicated, give 100% oxygen, call for help
2. After insertion: monitor for pneumothorax (dyspnea, decreased breath sounds, chest pain, falling SpO₂) and bleeding; do not use the line until tip position is confirmed
3. Aseptic care: hand hygiene, sterile technique (sterile gloves and mask per policy) for dressing changes; clean with chlorhexidine-alcohol; label dressings
4. Flushing
   • Preservative-free 0.9% sodium chloride, commonly 10 mL before and after each medication and 20 mL after blood draws, blood, or parenteral nutrition in adults
   • Use 10 mL-diameter syringes (or larger) — smaller syringes generate high pressure that can rupture the catheter, especially PICCs
   • Push-pause technique; never force against resistance
   • Check for blood return before giving vesicants or medications
5. Implanted port access: sterile technique, non-coring (Huber) needle of appropriate length, stabilize the port between fingers, confirm blood return; change the needle and dressing at least every 7 days during continuous access
6. PICC precautions: no blood pressure cuffs or tourniquets on the PICC arm; avoid heavy lifting with that arm; measure external length and arm circumference per policy
7. Blood sampling: stop infusions per policy, discard the initial volume (or use a push-pull method), then flush well; avoid drawing from the lumen used for PN when possible
8. Removal of nontunneled catheters and PICCs: position flat or slightly head-down (for neck or chest sites); ask the client to perform the Valsalva maneuver (or remove at the end of exhalation); apply pressure until hemostasis, then an air-occlusive dressing for at least 24 hours; inspect the tip for intactness and compare length; the client stays flat about 30 minutes. Tunneled catheters and ports are removed by a provider
9. Documentation: device type, lumens, insertion length and external length, tip confirmation, dressing changes, flushes, blood return, site condition

• Keep the dressing clean, dry, and intact; cover it for showering; no swimming or soaking
• Report fever, chills, redness or drainage at the site, arm or neck swelling, shortness of breath, chest pain, or a leaking or damaged catheter
• If the catheter breaks or is damaged, clamp it between the break and the insertion site (closer to the body) and seek care immediately
• PICC arm: no blood pressure readings, avoid heavy lifting or vigorous repetitive activity
• Home infusion: hand hygiene, hub scrubbing, flushing technique, and emergency contacts
• Carry a device identification card (ports)

• Tip belongs in the lower SVC near the cavoatrial junction; confirm by chest X-ray (or ECG method) before use — X-ray also rules out pneumothorax
• CLABSI bundle: hand hygiene, maximal sterile barriers, chlorhexidine-alcohol skin prep, avoid femoral site (subclavian preferred for nontunneled), daily review and prompt removal
• Suspect CLABSI with unexplained fever and chills even when the site looks normal
• Dressings: transparent every 7 days, gauze every 2 days
• Flush with 10 mL syringes or larger (lower pressure); 10 mL saline, 20 mL after blood or PN
• Valsalva during tubing change and removal to prevent air embolism
• Air embolism → clamp, left side, head down, 100% oxygen
• Implanted port → non-coring (Huber) needle
• No BP cuff on the PICC arm
• CVP zero at the phlebostatic axis (4th ICS, midaxillary line); normal about 2–8 mmHg
• Occlusive dressing for 24 hours after removal; check the tip is intact