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Central Lines...WHAT? - Richelle Guinigundo - APP Conference 2026
With Dr. Rochelle Guinigundo
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Central designation of a catheter depends on where the tip ends up (SVC, lower SVC, SVC-RA junction, or right atrium), not where the catheter exits the skin.
A tunneled line means the catheter entered the skin at a different location than where it entered the vessel, tunneling underneath tissue; 99% of tunneled lines have a cuff.
Cincinnati Children's uses a vascular access order based on the Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics (MAGIC), an evidence-based method that improves safety and supports preservation of vascular health.
Catheters can cause damage to the epithelium, clots, and complete vessel obstruction.
A port placed 7 days ago that was not accessed in the operating room is ready to use and can be accessed at any time, though the 7-10 day healing period involves surgical swelling and increased pain.
The needle size chosen to access a port in the first 14-17 days may differ from the size used later due to healing and swelling.
The 7-day wait before accessing a new port is a nursing initiative to decrease pain when starting IVs, not a safety requirement.
A single-view chest X-ray can determine if a catheter tip is central (two vertebrae down from the bifurcation defines the central target area).
HD (hemodialysis) lines have radio-opaque clamps visible on X-ray, allowing identification of line type.
A cuff appears on X-ray as a visible structure underneath the skin, indicating the line is tunneled.
Power-injectable ports display 'CT' labeling visible on X-ray; absence of CT labeling indicates the port is not power-injectable.
X-ray can reveal if a port has flipped in its pocket by showing reversed CT lettering.
The dacron cuff is a piece of plastic with small nubs (softer than Velcro) that the body heals to by forming granulation tissue, functioning like Velcro to hold the line in place.
Cuff maturation typically takes 21 to 36 days; in immunocompromised patients (e.g., neutropenic oncology patients), maturation may take longer.
Exposed cuff increases risk of line infection because the cuff is antimicrobial, and there is concern the line may not remain central without the cuff holding it in place.
At Cincinnati Children's, sutures are no longer needed after day 43 post-placement (day 42 is borderline).
Granulation tissue around central lines is a normal healing response, not a complication; the patient is trying to heal a hole that clinicians don't want to close.
White catheters (Bard brand, silicone) are not power-injectable; purple catheters (polyurethane) are power-injectable.
Power-injectable lines can tolerate up to 325 PSI, allowing use with CT power injectors; silicone lines will break under power contrast or rapid infuser pressure.
Accessing a port through cellulitis or port pocket infection risks introducing infection into the bloodstream.
Port pocket infections may be salvageable by drawing peripheral blood cultures to guide antibiotic therapy, or may require complete system removal if the pocket is too infected.
For a PICC that won't aspirate, the institutional algorithm involves: ruling out mechanical complications at the site (kinking), obtaining X-ray to confirm tip position, and if malpositioned, readjusting or replacing the catheter.
At Cincinnati Children's, the vascular access team (VAT) can come to clinics to troubleshoot line problems and escalates to surgery as needed.
Mineral occlusions (e.g., from TPN concentration issues) are treated with sodium bicarbonate instillation; lipid occlusions are treated with ethanol; precipitate occlusions are treated with L-cysteine.
Community providers without access to Cincinnati Children's vascular access team should direct patients with line complications to the emergency department.
Occlusion-clearing agents are locked in the catheter for a dwell time until they become inert, then aspirated or flushed through to avoid harming the patient.
Thrombotic occlusions are treated with TPA, which is the most common occlusion type encountered.
Patients with central lines who develop fever at home should be sent to the emergency department for workup.
A catheter can fracture within the vessel and migrate to unintended locations such as the ventricle, requiring retrieval via cardiac catheterization lab.
For a bleeding or cracked catheter, emergency management involves wrapping gauze around the line and clamping with a hemostat between the patient and the crack; the line requires replacement.
Patients at home with central lines or PICCs should have an emergency kit containing hemostats and gauze to clamp a cracked line before presenting to the emergency room.
Chlorhexidine gluconate (CHG) is the standard antiseptic for central line site cleaning; betadine is used for patients with CHG allergy.
Friction during site cleaning (30 seconds of scrubbing) is more important than the specific antiseptic product used.
Preventing needle rocking (using CHG pads, biodisc, or tape) and applying an occlusive dressing are key to preventing catheter-associated bloodstream infections; consistency of technique matters more than specific products.