Central venous catheter care may be complicated by complex patient considerations.
Central-line associated bloodstream infection risk factors are multifaceted.
Case report to highlight patient complexity that challenges bundled practices.
Central venous catheters are necessary in treatment and care of pediatric patients with short gut syndrome. Despite necessity, central venous catheters come with the risk of developing central line associated blood stream infections (CLABSI). This manuscript describes a complex, pediatric gastroenterology patient with multiple risk factors who developed a CLABSI. Short gut syndrome patients can develop skin conditions and complications that may challenge nursing practice to mitigate CLABSI. Further research is needed on preventing CLABSIs in complex pediatric patients to provide the best practice implications for nursing.