Overview
Definition:
The central line bundle is a set of evidence-based practices implemented by healthcare professionals to prevent central venous catheter-associated bloodstream infections (CLABSIs)
Adherence to these bundles significantly reduces infection rates
Audits are systematic evaluations to assess compliance with the bundle components and identify areas for improvement.
Epidemiology:
CLABSIs are a significant cause of morbidity and mortality in critically ill pediatric patients
In pediatric intensive care units, CLABSI rates can range from 1 to 10 per 1000 catheter-days, depending on patient population and hospital practices
Despite advancements, CLABSIs remain a preventable healthcare-associated infection.
Clinical Significance:
Preventing CLABSIs is crucial in pediatrics due to the vulnerability of young patients to infections
CLABSIs lead to prolonged hospital stays, increased healthcare costs, antibiotic resistance, and higher mortality rates
Strict adherence to central line bundles and regular audits are fundamental to improving patient outcomes and ensuring safe care.
Central Line Bundle Components
Hand Hygiene:
Perform hand hygiene before and after palpating the catheter site, and before and after inserting, dressing, scrubbing, or manipulating the catheter
Use alcohol-based hand rubs or soap and water.
Maximal Sterile Barrier Precautions:
Use a maximal sterile barrier during insertion, including a cap, mask, sterile gown, sterile gloves, and a large sterile drape.
Chlorhexidine Gluconate Skin Antisepsis:
Use 2% chlorhexidine gluconate (CHG) in alcohol for skin preparation before insertion
Allow adequate drying time.
Optimal Catheter Site Selection:
Select the best possible insertion site to minimize infection risk
Avoid the femoral vein in adults if possible
in pediatrics, preferred sites often include subclavian or internal jugular veins, depending on patient age and catheter type.
Daily Review Of Line Necessity:
Daily review of the continued need for the central venous catheter
Remove catheters as soon as they are no longer medically necessary.
Adherence Strategies
Education And Training:
Provide regular, comprehensive training on bundle components to all healthcare providers involved in central line insertion and care
Use simulation-based training for insertion techniques.
Competency Assessment:
Ensure healthcare providers demonstrate competency in aseptic technique and bundle adherence before performing central line insertions
Regular competency checks are essential.
Visible Reminders And Checklists:
Utilize bedside checklists for insertion and maintenance
Display visual reminders of bundle components in critical care areas.
Team Based Approach:
Foster a culture of safety where all team members feel empowered to speak up if they observe non-adherence
Multidisciplinary rounds can reinforce bundle compliance.
Audit And Feedback Process
Data Collection:
Systematically collect data on adherence to each component of the central line bundle during insertion and maintenance
This can be done through direct observation, chart reviews, or a combination of both.
Performance Monitoring:
Track adherence rates over time and identify trends
Benchmark against internal goals and external standards if available.
Feedback Mechanisms:
Provide timely, specific, and constructive feedback to individuals and teams regarding their adherence rates
Highlight successes and areas needing improvement.
Quality Improvement Cycles:
Use audit data to drive quality improvement initiatives
Implement changes, re-audit, and evaluate the impact of interventions to continuously improve CLABSI prevention.
Pediatric Specific Considerations
Neonatal And Infant Challenges:
Specific challenges in neonates and infants include smaller vein diameters, increased risk of accidental dislodgement, and potential for vascular damage
Aseptic technique is paramount.
Site Selection In Children:
Site selection in pediatric patients depends on age, weight, catheter size, and intended duration
Ultrasound guidance is highly recommended for all central line insertions in pediatrics to improve success rates and reduce complications.
Dressing And Maintenance:
Use transparent semipermeable dressings that are changed regularly (e.g., every 48-72 hours for gauze, or per policy for transparent dressings)
Ensure proper securement to prevent dislodgement.
Antimicrobial Lock Therapy:
Consider antimicrobial lock therapy in specific high-risk pediatric patients as per institutional guidelines, though evidence for routine use in all patients is still evolving.
Complications Of Central Lines
Infection Related:
Central line-associated bloodstream infections (CLABSIs)
Local site infections
Pneumonia (if associated with mechanical ventilation).
Mechanical Complications:
Pneumothorax or hemothorax (during insertion)
Arterial puncture
Nerve injury
Arrhythmias
Catheter malposition
Catheter occlusion or fracture
Thrombosis.
Prevention Of Mechanical Complications:
Use of ultrasound guidance for insertion
Proper training and competency
Correct catheter selection for the vessel size
Adequate catheter securement.
Key Points
Exam Focus:
Understand the 5 components of the central line bundle
Know the principles of aseptic technique
Be aware of common pediatric sites and challenges
Recall audit and feedback as critical for QI.
Clinical Pearls:
Always use ultrasound for central line insertion in pediatrics
Remove the line as soon as it is no longer needed
Hand hygiene is the single most important step
Empower the entire team to be vigilant about adherence.
Common Mistakes:
Inadequate hand hygiene
Compromising sterile field during insertion
Not using chlorhexidine
Failure to daily review line necessity
Lack of systematic audits and feedback loops.