Retention of antibacterial activity and bacterial colonization of antiseptic-bonded central venous catheters. The consultants and ASA members agree that needleless catheter access ports may be used on a case-by-case basis, Do not routinely administer intravenous antibiotic prophylaxis, In preparation for the placement of central venous catheters, use aseptic techniques (e.g., hand washing) and maximal barrier precautions (e.g., sterile gowns, sterile gloves, caps, masks covering both mouth and nose, full-body patient drapes, and eye protection), Use a chlorhexidine-containing solution for skin preparation in adults, infants, and children, For neonates, determine the use of chlorhexidine-containing solutions for skin preparation based on clinical judgment and institutional protocol, If there is a contraindication to chlorhexidine, povidoneiodine or alcohol may be used, Unless contraindicated, use skin preparation solutions containing alcohol, For selected patients, use catheters coated with antibiotics, a combination of chlorhexidine and silver sulfadiazine, or silver-platinum-carbonimpregnated catheters based on risk of infection and anticipated duration of catheter use, Do not use catheters containing antimicrobial agents as a substitute for additional infection precautions, Determine catheter insertion site selection based on clinical need, Select an insertion site that is not contaminated or potentially contaminated (e.g., burned or infected skin, inguinal area, adjacent to tracheostomy or open surgical wound), In adults, select an upper body insertion site when possible to minimize the risk of infection, Determine the use of sutures, staples, or tape for catheter fixation on a local or institutional basis, Minimize the number of needle punctures of the skin, Use transparent bioocclusive dressings to protect the site of central venous catheter insertion from infection, Unless contraindicated, dressings containing chlorhexidine may be used in adults, infants, and children, For neonates, determine the use of transparent or sponge dressings containing chlorhexidine based on clinical judgment and institutional protocol, If a chlorhexidine-containing dressing is used, observe the site daily for signs of irritation, allergy, or necrosis, Determine the duration of catheterization based on clinical need, Assess the clinical need for keeping the catheter in place on a daily basis, Remove catheters promptly when no longer deemed clinically necessary, Inspect the catheter insertion site daily for signs of infection, Change or remove the catheter when catheter insertion site infection is suspected, When a catheter-related infection is suspected, a new insertion site may be used for catheter replacement rather than changing the catheter over a guidewire, Clean catheter access ports with an appropriate antiseptic (e.g., alcohol) before each access when using an existing central venous catheter for injection or aspiration, Cap central venous catheter stopcocks or access ports when not in use, Needleless catheter access ports may be used on a case-by-case basis. The consultants and ASA members strongly agree with the recommendations to (1) determine catheter insertion site selection based on clinical need; (2) select an insertion site that is not contaminated or potentially contaminated (e.g., burned or infected skin, inguinal area, adjacent to tracheostomy, or open surgical wound); and (3) select an upper body insertion site when possible to minimize the risk of infection in adults. A randomized trial on chlorhexidine dressings for the prevention of catheter-related bloodstream infections in neutropenic patients. Ultrasound guidance improves the success rate of internal jugular vein cannulation: A prospective, randomized trial. Central venous access above the diaphragm, unless contraindicated, is generally preferred to femoral venous access in patients who require central venous access. The long-term impact of a program to prevent central lineassociated bloodstream infections in a surgical intensive care unit. Intravascular complications of central venous catheterization by insertion site. The consultants and ASA members agree that when feasible, real-time ultrasound may be used when the subclavian or femoral vein is selected. Prevention of catheter-related infections by silver coated central venous catheters in oncological patients. Survey Findings. These studies do not permit assessing the effect of any single component of a checklist or bundled protocol on infection rates. Ideally the distal end of a CVC should be orientated vertically within the SVC. Choice of route for central venous cannulation: Subclavian or internal jugular vein? Saline flush test: Can bedside sonography replace conventional radiography for confirmation of above-the-diaphragm central venous catheter placement? First, consensus was reached on the criteria for evidence. Benefits of minocycline and rifampin-impregnated central venous catheters: A prospective, randomized, double-blind, controlled, multicenter trial. American Society of Anesthesiologists Task Force on Central Venous A. These updated guidelines were developed by means of a five-step process. Peripherally inserted percutaneous intravenous central catheter (PICC line) placement for long-term use (e.g., chemotherapy regimens, antibiotic therapy, total parenteral nutrition, chronic vasoactive agent administration . Using the comprehensive unit-based safety program model for sustained reduction in hospital infections. Needle insertion, wire placement, and catheter placement includes (1) selection of catheter size and type; (2) use of a wire-through-thin-wall needle technique (i.e., Seldinger technique) versus a catheter-over-the-needle-then-wire-through-the-catheter technique (i.e., modified Seldinger technique); (3) limiting the number of insertion attempts; and (4) introducing two catheters in the same central vein. Literature Findings. Studies also report high specificities of transthoracic ultrasound for excluding the presence of a pneumothorax.216,218,219,227229,232,233,236,238,240. Statistically significant outcomes (P < 0.01) are designated as either beneficial (B) or harmful (H) for the patient; statistically nonsignificant findings are designated as equivocal (E). Chlorhexidine and silver-sulfadiazine coated central venous catheters in haematological patients: A double-blind, randomised, prospective, controlled trial. The consultants and ASA members agree with the recommendation to use catheters coated with antibiotics or a combination of chlorhexidine and silver sulfadiazine based on infectious risk and anticipated duration of catheter use for selected patients. RCTs comparing continuous electrocardiographic guidance for catheter placement with no electrocardiography indicate that continuous electrocardiography is more effective in identifying proper catheter tip placement (Category A2-B evidence).245247 Case reports document unrecognized retained guidewires resulting in complications including embolization and fragmentation,248 infection,249 arrhythmia,250 cardiac perforation,248 stroke,251 and migration through soft-tissue (Category B-4H evidence).252. Sterility In the ED, there are only two ways to place central lines: Full Sterile or Non-Sterile There is no in-between. Elective central venous access procedures, Emergency central venous access procedures, Any setting where elective central venous access procedures are performed, Providers working under the direction of anesthesiologists, Individuals who do not perform central venous catheterization, Selection of a sterile environment (e.g., operating room) for elective central venous catheterization, Availability of a standardized equipment set (e.g., kit/cart/set of tools) for central venous catheterization, Use of a trained assistant for central venous catheterization, Use of a checklist for central venous catheter placement and maintenance, Washing hands immediately before placement, Sterile gown, gloves, mask, cap for the operators, Shaving hair versus clipping hair versus no hair removal, Skin preparation with versus without alcohol, Antibiotic-coated catheters versus no coating, Silver-impregnated catheters versus no coating, Heparin-coated catheters versus no coating, Antibiotic-coated or silver-impregnated catheter cuffs, Selecting an insertion site that is not contaminated or potentially contaminated (e.g., burned or infected skin, a site adjacent to a tracheostomy site), Long-term versus short-term catheterization, Frequency of assessing the necessity of retaining access, Frequency of insertion site inspection for signs of infection, At specified time intervals versus no specified time intervals, One specified time interval versus another time interval, Changing over a wire versus a new catheter at a new site, Injecting or aspirating using an existing central venous catheter, Aseptic techniques (e.g., wiping port with alcohol). Pediatric Patients: o Optimal catheter type and site selection in children is more co mplex, with the internal jugular vein or femoral vein most commonly used. Proper maintenance of CVCs includes disinfection of catheter hubs, connectors, and injection ports and changing dressings over the site every two days for gauze . Severe anaphylactic reaction due to a chlorhexidine-impregnated central venous catheter. Next, place the larger (20- to 22-gauge) needle immediately. A multicenter intervention to prevent catheter-associated bloodstream infections. Survey responses for each recommendation are reported using a 5-point scale based on median values from strongly agree to strongly disagree. : Prospective randomized comparison with landmark-guided puncture in ventilated patients. The guidelines do not address (1) clinical indications for placement of central venous catheters; (2) emergency placement of central venous catheters; (3) patients with peripherally inserted central catheters; (4) placement and residence of a pulmonary artery catheter; (5) insertion of tunneled central lines (e.g., permacaths, portacaths, Hickman, Quinton); (6) methods of detection or treatment of infectious complications associated with central venous catheterization; (7) removal of central venous catheters; (8) diagnosis and management of central venous catheter-associated trauma or injury (e.g., pneumothorax or air embolism), with the exception of carotid arterial injury; (9) management of periinsertion coagulopathy; and (10) competency assessment for central line insertion. **, Comparative studies are insufficient to evaluate the efficacy of chlorhexidine and alcohol compared with chlorhexidine without alcohol for skin preparation during central venous catheterization. The small . No respondents indicated that new equipment, supplies, or training would not be needed to implement the guidelines, and 88.9% indicated that implementation of the guidelines would not require changes in practice that would affect costs. The literature is insufficient to evaluate outcomes associated with the routine use of intravenous prophylactic antibiotics. Ultrasound-guided internal jugular venous cannulation in infants: A prospective comparison with the traditional palpation method. Literature Findings. Literature Findings. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints and are not intended to replace local institutional policies. Use full sterile dress. Ultrasound as a screening tool for central venous catheter positioning and exclusion of pneumothorax. Category A evidence represents results obtained from RCTs, and category B evidence represents observational results obtained from nonrandomized study designs or RCTs without pertinent comparison groups. Images in cardiovascular medicine: Percutaneous retrieval of a lost guidewire that caused cardiac tamponade. For femoral line CVL, the needle insertion site should be located approximately 1 to 3 cm below the inguinal ligament and 0.5 to 1 cm medial where the femoral artery pulsates. Second, original published articles from peer-reviewed journals relevant to the perioperative management of central venous catheters were evaluated and added to literature included in the original guidelines. Iatrogenic arteriovenous fistula: A complication of percutaneous subclavian vein puncture. Decreasing catheter colonization through the use of an antiseptic-impregnated catheter: A continuous quality improvement project. Failure of antiseptic bonding to prevent central venous catheter-related infection and sepsis. The consultants and ASA members strongly agree with the recommendation to perform central venous catheterization in an environment that permits use of aseptic techniques and to ensure that a standardized equipment set is available for central venous access. A prospective randomized trial of an antibiotic- and antiseptic-coated central venous catheter in the prevention of catheter-related infections. Eliminating central lineassociated bloodstream infections: A national patient safety imperative. Microbiological evaluation of central venous catheter administration hubs. Survey Findings. Interventions intended to prevent infectious complications associated with central venous access include, but are not limited to, (1) intravenous antibiotic prophylaxis; (2) aseptic preparation of practitioner, staff, and patients; (3) selection of antiseptic solution; (4) selection of catheters containing antimicrobial agents; (5) selection of catheter insertion site; (6) catheter fixation method; (7) insertion site dressings; (8) catheter maintenance procedures; and (9) aseptic techniques using an existing central venous catheter for injection or aspiration. To view a bar chart with the above findings, refer to Supplemental Digital Content 5 (http://links.lww.com/ALN/C10). tip should be at the cavoatrial junction. ), Tunneled catheters (e.g., Hickman, Quinton, permacaths, portacaths), Arterial cannulation/injury/cerebral embolization/hemorrhage, Wire, knot, inability to remove the catheter, Hospital, intensive care unit length of stay, Number of attempts at central line placement, Time required for placement of central venous catheters, Infections or other complications not associated with central venous catheterization, Mechanical injury or trauma not associated with central venous catheterization, Prospective nonrandomized comparative studies (e.g., quasiexperimental, cohort), Retrospective comparative studies (e.g., case-control), Observational studies (e.g., correlational or descriptive statistics). The consultants and ASA members strongly agree with the recommendation to confirm venous residence of the wire after the wire is threaded if there is any uncertainty that the catheter or wire resides in the vein, and insertion of a dilator or large-bore catheter may then proceed. potential malposition. A multidisciplinary approach to reduce central lineassociated bloodstream infections. Eradicating central lineassociated bloodstream infections statewide: The Hawaii experience. Additional caution should be exercised in patients requiring femoral vein catheterization who have had prior arterial surgery. Statistically significant (P < 0.01) outcomes are designated as either beneficial (B) or harmful (H) for the patient; statistically nonsignificant findings are designated as equivocal (E). Effectiveness of a programme to reduce the burden of catheter-related bloodstream infections in a tertiary hospital. For neonates, the consultants and ASA members agree with the recommendation to determine the use of transparent or sponge dressings containing chlorhexidine based on clinical judgment and institutional protocol. The long-term effect of bundle care for catheter-related blood stream infection: 5-year follow-up. However, only findings obtained from formal surveys are reported in the document. Pacing catheters. Prevention of central venous catheter sepsis: A prospective randomized trial. It can be used to confirm that the catheter or the guidewire has travelled towards the SVC. The subclavian veins are an often favored site for central venous access, including emergency and acute care access, and tunneled catheters and subcutaneous ports for chemotherapy, prolonged antimicrobial therapy, and parenteral . The tube travels through one or more veins until the tip reaches the large vein that empties into your heart ( vena cava ). Literature Findings. RCTs comparing subclavian and femoral insertion sites report higher rates of catheter colonization at the femoral site (Category A2-H evidence); findings for catheter-related sepsis or catheter-related bloodstream infection are equivocal (Category A2-E evidence).130,131 An RCT finds a higher rate of catheter colonization for internal jugular compared with subclavian insertion (Category A3-H evidence) and for femoral compared with internal jugular insertion (Category A3-H evidence); evidence is equivocal for catheter-related bloodstream infection for either comparison (Category A3-E evidence).131 A nonrandomized comparative study of burn patients reports that catheter colonization and catheter-related bloodstream infection occur more frequently with an insertion site closer to the burn location (Category B1-H evidence).132. The consultants and ASA members strongly agree that when unintended cannulation of an arterial vessel with a dilator or large-bore catheter occurs, leave the dilator or catheter in place and immediately consult a general surgeon, a vascular surgeon, or an interventional radiologist regarding surgical or nonsurgical catheter removal for adults. Insert the J-curved end of the guidewire into the introducer needle, with the J curve facing up. tient's leg away from midline. They also may serve as a resource for other physicians (e.g., surgeons, radiologists), nurses, or healthcare providers who manage patients with central venous catheters. Femoral lines are usually used only as provisional access because they have a high risk of infection. An alternative central venous route for cardiac surgery: Supraclavicular subclavian vein catheterization. For meta-analyses of antimicrobial, silver, or silver-sulfadiazine catheters studies reported actual event rates and odds ratios were pooled. See 2017 Food and Drug Administration warning on chlorhexidine allergy. ECG, electrocardiography; TEE, transesophageal echocardiography. Refer to appendix 3 for an example of a checklist or protocol. Antimicrobial durability and rare ultrastructural colonization of indwelling central catheters coated with minocycline and rifampin. Survey Findings. There are a variety of catheter, both size and configuration. Comparison of silver-impregnated with standard multi-lumen central venous catheters in critically ill patients. Category A: RCTs report comparative findings between clinical interventions for specified outcomes. The consultants strongly agree and ASA members agree with the recommendation to determine the use of sutures, staples, or tape for catheter fixation on a local or institutional basis. Level 1: The literature contains a sufficient number of RCTs to conduct meta-analysis, and meta-analytic findings from these aggregated studies are reported as evidence. Survey Findings. Editorials, letters, and other articles without data were excluded. For studies that report statistical findings, the threshold for significance is P < 0.01. Ultrasound for localization of central venous catheter: A good alternative to chest x-ray? Confirmation of endovenous placement of central catheter using the ultrasonographic bubble test., The use of ultrasound during and after central venous catheter insertion. Two observational studies indicate that ultrasound can confirm venous placement of the wire before dilation or final catheterization (Category B3-B evidence).214,215 Observational studies also demonstrate that transthoracic ultrasound can confirm residence of the guidewire in the venous system (Category B3-B evidence).216219 One observational study indicates that transesophageal echocardiography can be used to identify guidewire position (Category B3-B evidence),220 and case reports document similar findings (Category B4-B evidence).221,222, Observational studies indicate that transthoracic ultrasound can confirm correct catheter tip position (Category B2-B evidence).216,217,223240 Observational studies also indicate that fluoroscopy241,242 and chest radiography243,244 can identify the position of the catheter (Category B2-B evidence). If possible, this site is recommended by United States guidelines. Methods for confirming the position of the catheter tip include chest radiography, fluoroscopy, or point-of-care transthoracic echocardiography or continuous electrocardiography. Comparison of bacterial colonization rates of antiseptic impregnated and pure polymer central venous catheters in the critically ill. A comparison between two types of central venous catheters in the prevention of catheter-related infections: The importance of performing all the relevant cultures. The literature is insufficient to evaluate the effect of the physical environment for aseptic catheter insertion, availability of a standardized equipment set, or the use of an assistant on outcomes associated with central venous catheterization. Statewide NICU central-lineassociated bloodstream infection rates decline after bundles and checklists. Refer to appendix 5 for a summary of methods and analysis. These guidelines have been endorsed by the Society of Cardiovascular Anesthesiologists and the Society for Pediatric Anesthesia. This algorithm compares the thin-wall needle (i.e., Seldinger) technique versus the catheter-over-the needle (i.e., modified Seldinger) technique in critical safety steps to prevent unintentional arterial placement of a dilator or large-bore catheter. The consultants and ASA members strongly agree with the recommendation to select catheter size (i.e., outside diameter) and type based on the clinical situation and skill/experience of the operator. The consultants and ASA members both strongly agree with the recommendation to minimize the number of needle punctures of the skin. Perform central venous catheterization in an environment that permits use of aseptic techniques, Ensure that a standardized equipment set is available for central venous access, Use a checklist or protocol for placement and maintenance of central venous catheters, Use an assistant during placement of a central venous catheter#. Fatal brainstem stroke following internal jugular vein catheterization. New York State Regional Perinatal Care Centers. Methods for confirming that the catheter is still in the venous system after catheterization and before use include manometry or pressure-waveform measurement. = 100%; (5) selection of antiseptic solution for skin preparation = 100%; (6) catheters with antibiotic or antiseptic coatings/impregnation = 68.5%; (7) catheter insertion site selection (for prevention of infectious complications) = 100%; (8) catheter fixation methods (sutures, staples, tape) = 100%; (9) insertion site dressings = 100%; (10) catheter maintenance (insertion site inspection, changing catheters) = 100%; (11) aseptic techniques using an existing central line for injection or aspiration = 100%; (12) selection of catheter insertion site (for prevention of mechanical trauma) = 100%; (13) positioning the patient for needle insertion and catheter placement = 100%; (14) needle insertion, wire placement, and catheter placement (catheter size, type) = 100%; (15) guiding needle, wire, and catheter placement (ultrasound) = 100%; (16) verifying needle, wire, and catheter placement = 100%; (17) confirmation of final catheter tip location = 89.5%; and (18) management of trauma or injury arising from central venous catheterization = 100%. Iatrogenic injury of vertebral artery resulting in stroke after central venous line insertion. Impact of ultrasonography on central venous catheter insertion in intensive care. Central venous catheters coated with minocycline and rifampin for the prevention of catheter-related colonization and bloodstream infections: A randomized, double-blind trial. The needle was exchanged over the wire for an arterial . 1), After insertion of a catheter that went over the needle or a thin-wall needle, confirm venous access, If there is any uncertainty that the catheter or wire resides in the vein, confirm venous residence of the wire after the wire is threaded; insertion of a dilator or large-bore catheter may then proceed, After final catheterization and before use, confirm residence of the catheter in the venous system as soon as clinically appropriate####, Confirm the final position of the catheter tip as soon as clinically appropriate*****, Example of a Standardized Equipment Cart for Central Venous Catheterization for Adult Patients. Catheter-Related Infections in ICU (CRI-ICU) Group. Supplemental Digital Content is available for this article. Conflict-of-interest documentation regarding current or potential financial and other interests pertinent to the practice guideline were disclosed by all task force members and managed. The literature is insufficient to evaluate whether catheter fixation with sutures, staples, or tape is associated with a higher risk for catheter-related infections. RCTs comparing subclavian and femoral insertion sites report that the femoral site has a higher risk of thrombotic complications in adult patients (Category A2-H evidence)130,131; one RCT131 concludes that thrombosis risk is higher with internal jugular than subclavian catheters (Category A3-H evidence), whereas for femoral versus internal jugular catheters, findings are equivocal (Category A3-E evidence). These studies were combined with 258 pre-2011 articles from the previous guidelines, resulting in a total of 542 articles accepted as evidence for these guidelines. Ultrasonography: A novel approach to central venous cannulation. The vessel traverses the thigh and takes a superficial course at the femoral triangle before passing beneath the inguinal ligament into the pelvis as the external iliac vein ( figure 1A-B ). Ultrasound-guided supraclavicular central venous catheter tip positioning via the right subclavian vein using a microconvex probe. The authors declare no competing interests. Literature Findings. Effect of a second-generation venous catheter impregnated with chlorhexidine and silver sulfadiazine on central catheter-related infections: A randomized, controlled trial. Random-effects models were fitted with inverse variance weighting using the DerSimonian and Laird estimate of between-study variance. Advance the wire 20 to 30 cm. The consultants and ASA members agree with the recommendation to use an assistant during placement of a central venous catheter. The consultants and ASA members strongly agree with the following recommendations: (1) determine the duration of catheterization based on clinical need; (2) assess the clinical need for keeping the catheter in place on a daily basis; (3) remove catheters promptly when no longer deemed clinically necessary; (4) inspect the catheter insertion site daily for signs of infection; (5) change or remove the catheter when catheter insertion site infection is suspected; and (6) when a catheter-related infection is suspected, replace the catheter using a new insertion site rather than changing the catheter over a guidewire. Opinion surveys were developed by the task force to address each clinical intervention identified in the document. Decreasing central-lineassociated bloodstream infections in Connecticut intensive care units. From ICU to hospital-wide: Extending central line associated bacteraemia (CLAB) prevention. If you feel any resistance as you advance the guidewire, stop advancing it. complications such as central venous stenosis, access thrombosis, or exhaustion of suitable access sites in the upper extremity, ultimately result in pursuing vascular access creation in the lower . Reduced rates of catheter-associated infection by use of a new silver-impregnated central venous catheter. Arterial trauma during central venous catheter insertion: Case series, review and proposed algorithm. Eliminating catheter-related bloodstream infections in the intensive care unit. Catheter infection: A comparison of two catheter maintenance techniques. The incidence of complications after the double-catheter technique for cannulation of the right internal jugular vein in a university teaching hospital. The ASA Committee on Standards and Practice Parameters reviews all practice guidelines at the ASA annual meeting and determines update and revision timelines. The consultants and ASA members agree that static ultrasound may also be used when the subclavian or femoral vein is selected. Survey Findings. For example: o A minimum of 5 supervised successful procedures in both the chest and femoral sites is required (10 total). A significance level of P < 0.01 was applied for analyses. This line is placed into the vein that runs behind the collarbone. No difference in catheter sepsis between standard and antiseptic central venous catheters: A prospective randomized trial. This is a particular concern during peripheral insertion or insertion of catheters via the axillary vein or subclavian vein, when ultrasound scanning of the internal jugular vein may rule out a 'wrong' upward direction of the catheter or wire. RCTs report equivocal findings for successful venipuncture when the internal jugular site is compared with the subclavian site (Category A2-E evidence).131,155,156 Equivocal finding are also reported for the femoral versus subclavian site (Category A2-E evidence),130,131 and the femoral versus internal jugular site (Category A3-E evidence).131 RCTs examining mechanical complications (primarily arterial injury, hematoma, and pneumothorax) report equivocal findings for the femoral versus subclavian site (Category A2-E evidence)130,131 as well as the internal jugular versus subclavian or femoral sites (Category A3-E evidence).131. If a physician successfully performs the 5 supervised lines in one site, they are independent for that site only.