The consultants strongly agree and ASA members agree with the recommendation to not routinely administer intravenous antibiotic prophylaxis. . Proper maintenance of CVCs includes disinfection of catheter hubs, connectors, and injection ports and changing dressings over the site every two days for gauze . Supplemental Digital Content is available for this article. Standardizing central line safety: Lessons learned for physician leaders. To view a bar chart with the above findings, refer to Supplemental Digital Content 5 (http://links.lww.com/ALN/C10). Literature Findings. window the image to best visualize the line. Advance the guidewire through the needle and into the vein. Prospective randomised trial of povidoneiodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters. 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#. (Co-Chair), Wilmette, Illinois; Richard T. Connis, Ph.D. (Chief Methodologist), Woodinville, Washington; Karen B. Domino, M.D., M.P.H., Seattle, Washington; Mark D. Grant, M.D., Ph.D. (Senior Methodologist), Schaumburg, Illinois; and Jonathan B. Level 4: The literature contains case reports. Methods for confirming that the catheter is still in the venous system after catheterization and before use include manometry, pressure-waveform measurement, or contrast-enhanced ultrasound. The consultants and ASA members agree that static ultrasound may also be used when the subclavian or femoral vein is selected. Determine catheter insertion site selection based on clinical need and practitioner judgment, experience, and skill, Select an upper body insertion site when possible to minimize the risk of thrombotic complications relative to the femoral site, Perform central venous access in the neck or chest with the patient in the Trendelenburg position when clinically appropriate and feasible, Select catheter size (i.e., outside diameter) and type based on the clinical situation and skill/experience of the operator, Select the smallest size catheter appropriate for the clinical situation, For the subclavian approach select a thin-wall needle (i.e., Seldinger) technique versus a catheter-over-the-needle (i.e., modified Seldinger) technique, For the jugular or femoral approach, select a thin-wall needle or catheter-over-the-needle technique based on the clinical situation and the skill/experience of the operator, For accessing the vein before threading a dilator or large-bore catheter, base the decision to use a thin-wall needle technique or a catheter-over-the-needle technique at least in part on the method used to confirm that the wire resides in the vein (fig. The accuracy of electrocardiogram-controlled central line placement. Example Duties Performed by an Assistant for Central Venous Catheterization. A chest x-ray will be performed immediately following thoracic central line placement to assure line placement and rule out pneumothorax. The consultants and ASA members strongly agree with the recommendation to confirm venous access after insertion of a catheter that went over the needle or a thin-wall needle and with the recommendation to not rely on blood color or absence of pulsatile flow for confirming that the catheter or thin-wall needle resides in the vein. Literature Findings. These guidelines have been endorsed by the Society of Cardiovascular Anesthesiologists and the Society for Pediatric Anesthesia. Ultrasonic examination: An alternative to chest radiography after central venous catheter insertion? Literature Findings. Survey Findings. The literature is insufficient to evaluate outcomes associated with the routine use of intravenous prophylactic antibiotics. Skin antisepsis with chlorhexidinealcohol, for Japanese Society of Education for Physicians and Trainees in Intensive Care (JSEPTIC) Clinical Trial Group. Central venous catheters are placed typically in one of 3 large central veins: the internal jugular vein (IJ), subclavian vein (SCL), or femoral vein. Incidence of mechanical complications of central venous catheterization using landmark technique: Do not try more than 3 times. The femoral vein is the major deep vein of the lower extremity. Ties are calculated by a predetermined formula. 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. Chlorhexidine impregnated central venous catheter inducing an anaphylatic shock in the intensive care unit. Comparison of three techniques for internal jugular vein cannulation in infants. This description of the venous great vessels is consistent with the venous subset for central lines defined by the National Healthcare Safety Network. The consultants and ASA members strongly agree with the recommendations to wipe catheter access ports with an appropriate antiseptic (e.g., alcohol) before each access when using an existing central venous catheter for injection or aspiration and to cap central venous catheter stopcocks or access ports when not in use. A randomized, prospective clinical trial to assess the potential infection risk associated with the PosiFlow needleless connector. Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit using the Institute for Healthcare Improvement Central Line Bundle. Central venous catheters revisited: Infection rates and an assessment of the new fibrin analysing system brush. Central Line Insertion Care Team Checklist Instructions Operator Requirements: Specify minimum requirements. Survey Findings. 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. Third, consultants who had expertise or interest in central venous catheterization and who practiced or worked in various settings (e.g., private and academic practice) were asked to participate in opinion surveys addressing the appropriateness, completeness, and feasibility of implementation of the draft recommendations and to review and comment on a draft of the guidelines. This may be done in your hospital room or an . An unexpected image on a chest radiograph. Fourth, additional opinions were solicited from random samples of active ASA members. Ultrasound for localization of central venous catheter: A good alternative to chest x-ray? For studies that report statistical findings, the threshold for significance is P < 0.01. Aspirate and flush all lumens and re clamp and apply lumen caps. Remove the dilator and pass the central line over the Seldinger wire. Sterility In the ED, there are only two ways to place central lines: Full Sterile or Non-Sterile There is no in-between. The consultants strongly agree and ASA members agree with the recommendation to confirm venous residence of the wire after the wire is threaded when using the thin-wall needle technique. Do not force the wire; it should slide smoothly. Pacing catheters. One RCT comparing chlorhexidine (2% aqueous solution without alcohol) with povidoneiodine (10% without alcohol) for skin preparation reports equivocal findings for catheter colonization and catheter-related bacteremia (Category A3-E evidence).73 An RCT comparing chlorhexidine (2% with 70% isopropyl alcohol) with povidoneiodine (5% with 69% ethanol) with or without scrubbing finds lower rates of catheter colonization for chlorhexidine (Category A3-B evidence) and equivocal evidence for dec reased catheter-related bloodstream infection (Category A3-E evidence).74 A third RCT compared two chlorhexidine concentrations (0.5% or 1.0% in 79% ethanol) with povidoneiodine (10% without alcohol), reporting equivocal evidence for colonization (Category A3-E evidence) and catheter-related bloodstream infection (Category A3-E evidence).75 A quasiexperimental study (secondary analysis of an RCT) reports a lower rate of catheter-related bloodstream infection with chlorhexidine (2% with 70% alcohol) than povidoneiodine (5% with 69% alcohol) (Category B1-B evidence).76 The literature is insufficient to evaluate the safety of antiseptic solutions containing chlorhexidine in neonates, infants and children. The syringe was removed and a guidewire was advanced through the needle into the femoral artery. Femoral vein cannulation performed by residents: A comparison between ultrasound-guided and landmark technique in infants and children undergoing cardiac surgery. Advance the guidewire through the needle and into the vein. R: A Language and Environment for Statistical Computing. The literature is insufficient to evaluate whether catheter fixation with sutures, staples, or tape is associated with a higher risk for catheter-related infections. Level 2: The literature contains noncomparative observational studies with associative statistics (e.g., correlation, sensitivity, and specificity). Comparison of an ultrasound-guided technique. Mark, M.D., Durham, North Carolina. Reduced intravascular catheter infection by antibiotic bonding: A prospective, randomized, controlled trial. Central venous access: The effects of approach, position, and head rotation on internal jugular vein cross-sectional area. Comparison of central venous catheterization with and without ultrasound guide. 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. Consultants were drawn from the following specialties where central venous access is a concern: anesthesiology (97% of respondents) and critical care (3% of respondents). Reduced rates of catheter-associated infection by use of a new silver-impregnated central venous catheter. Inadequate literature cannot be used to assess relationships among clinical interventions and outcomes because a clear interpretation of findings is not obtained due to methodological concerns (e.g., confounding of study design or implementation) or the study does not meet the criteria for content as defined in the Focus of the guidelines. Accurate placement of central venous catheters: A prospective, randomized, multicenter trial. Central venous catheterization: A prospective, randomized, double-blind study. An additional survey was sent to the consultants accompanied by a draft of the guidelines asking them to indicate which, if any, of the recommendations would change their clinical practices if the guidelines were instituted. How useful is ultrasound guidance for internal jugular venous access in children? Methods for confirming that the catheter is still in the venous system after catheterization and before use include manometry or pressure-waveform measurement. Randomized controlled trial of chlorhexidine dressing and highly adhesive dressing for preventing catheter-related infections in critically ill adults. Evolution and aetiological shift of catheter-related bloodstream infection in a whole institution: The microbiology department may act as a watchtower. A central venous catheter, also called a central line or CVC, is a device that helps you receive treatments for various medical conditions. These guidelines are intended for use by anesthesiologists and individuals under the supervision of an anesthesiologist. Preoperative chlorhexidine anaphylaxis in a patient scheduled for coronary artery bypass graft: A case report. Refer to appendix 3 for an example of a checklist or protocol. Do not force the wire; it should slide smoothly. The consultants and ASA members agree with the recommendations to (1) select the smallest size catheter appropriate for the clinical situation; (2) select a thin-wall needle (i.e., Seldinger) technique versus a catheter-over-the-needle (i.e., modified Seldinger) technique for the subclavian approach; (3) select a thin-wall needle or catheter-over-the-needle technique for the jugular or femoral approach based on the clinical situation and the skill/experience of the operator; and (4) base the decision to use a thin-wall needle technique or a catheter-over-the-needle technique at least in part on the method used to confirm that the wire resides in the vein before a dilator or large-bore catheter is threaded. Procedural and educational interventions to reduce ventilator-associated pneumonia rate and central lineassociated blood stream infection rate. Decreasing catheter-related bloodstream infections in the intensive care unit: Interventions in a medical center in central Taiwan. . Retention of the antibiotic teicoplanin on a hydromer-coated central venous catheter to prevent bacterial colonization in postoperative surgical patients. 1)##, When feasible, real-time ultrasound may be used when the subclavian or femoral vein is selected, Use static ultrasound imaging before prepping and draping for prepuncture identification of anatomy to determine vessel localization and patency when the internal jugular vein is selected for cannulation, Static ultrasound may also be used when the subclavian or femoral vein is selected, After insertion of a catheter that went over the needle or a thin-wall needle, confirm venous access***, Do not rely on blood color or absence of pulsatile flow for confirming that the catheter or thin-wall needle resides in the vein, When using the thin-wall needle technique, confirm venous residence of the wire after the wire is threaded, When using the catheter-over-the-needle technique, confirmation that the wire resides in the vein may not be needed (1) when the catheter enters the vein easily and manometry or pressure-waveform measurement provides unambiguous confirmation of venous location of the catheter and (2) when the wire passes through the catheter and enters the vein without difficulty, 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, For central venous catheters placed in the operating room, perform a chest radiograph no later than the early postoperative period to confirm the position of the catheter tip, Verify that the wire has not been retained in the vascular system at the end of the procedure by confirming the presence of the removed wire in the procedural field, If the complete guidewire is not found in the procedural field, order chest radiography to determine whether the guidewire has been retained in the patients vascular system, Literature Findings. Central catheters provide dependable intravenous access and enable hemodynamic monitoring and blood sampling [ 1-3 ]. This line is placed into the vein that runs behind the collarbone. The policy of the American Society of Anesthesiologists (ASA) Committee on Standards and Practice Parameters is to update practice guidelines every 5 yr. Survey Findings. Evidence was obtained from two principal sources: scientific evidence and opinion-based evidence. Significant reduction of central-line associated bloodstream infections in a network of diverse neonatal nurseries. These studies do not permit assessing the effect of any single component of a checklist or bundled protocol on infection rates. Risk factors for central venous catheter-related infections in surgical and intensive care units. Reduction of catheter-related bloodstream infections through the use of a central venous line bundle: Epidemiologic and economic consequences. Single-operator ultrasound-guided central venous catheter insertion verifies proper tip placement. I have read and accept the terms and conditions. An observational study reports that implementation of a trauma intensive care unit multidisciplinary checklist is associated with reduced catheter-related infection rates (Category B2-B evidence).6 Observational studies report that central lineassociated or catheter-related bloodstream infection rates are reduced when intensive care unit-wide bundled protocols are implemented736(Category B2-B evidence); evidence from fewer observational studies is equivocal3755(Category B2-E evidence); other observational studies5671 do not report levels of statistical significance or lacked sufficient data to calculate them. Publications identified by task force members were also considered. Support was provided solely by the American Society ofAnesthesiologists (Schaumburg, Illinois). Multimodal interventions for bundle implementation to decrease central lineassociated bloodstream infections in adult intensive care units in a teaching hospital in Taiwan, 20092013. Aiming for zero: Decreasing central line associated bacteraemia in the intensive care unit. The average age of the patients was 78.7 (45-100 years old . Prevention of catheter-related infections by silver coated central venous catheters in oncological patients. 1)****, Use real-time ultrasound guidance for vessel localization and venipuncture when the internal jugular vein is selected for cannulation (see fig. Confirmation of endovenous placement of central catheter using the ultrasonographic bubble test., The use of ultrasound during and after central venous catheter insertion. Category A: RCTs report comparative findings between clinical interventions for specified outcomes. Three-rater values between two methodologists and task force reviewers were: (1) research design, = 0.70; (2) type of analysis, = 0.68; (3) linkage assignment, = 0.79; and (4) literature database inclusion, = 0.65. The literature is insufficient to evaluate whether cleaning ports or capping stopcocks when using an existing central venous catheter for injection or aspiration decreases the risk of catheter-related infections. Subclavian venous catheterization: Greater success rate for less experienced operators using ultrasound guidance. Antimicrobial durability and rare ultrastructural colonization of indwelling central catheters coated with minocycline and rifampin. This line is placed into a large vein in the neck. This document updates the Practice Guidelines for Central Venous Access: A Report by the American Society of Anesthesiologists Task Force on Central Venous Access, adopted by the ASA in 2011 and published in 2012.1. The consultants and ASA members strongly agree with the recommendation to use aseptic techniques (e.g., hand washing) and maximal barrier precautions (e.g., sterile gowns, sterile gloves, caps, masks covering both mouth and nose, and full-body patient drapes) in preparation for the placement of central venous catheters. Catheter-Related Infections in ICU (CRI-ICU) Group. When obtaining central venous access in the femoral vein, the key anatomical landmarks to identify in the inguinal-femoral region are the inguinal ligament and the femoral artery pulsation. Survey Findings. Prevention of intravascular catheter-related infection with newer chlorhexidine-silver sulfadiazinecoated catheters: A randomized controlled trial. The rapid atrial swirl sign for assessing central venous catheters: Performance by medical residents after limited training. Positioning the tip of a central venous catheter (CVC) within the superior vena cava (SVC) at or just above the level of the carina is generally considered acceptable for most short-term uses, such as fluid administration or monitoring of central venous pressure. Guidance for needle, wire, and catheter placement includes (1) real-time or dynamic ultrasound for vessel localization and guiding the needle to its intended venous location and (2) static ultrasound imaging for the purpose of prepuncture vessel localization. Fatal brainstem stroke following internal jugular vein catheterization. A literature search strategy and PRISMA* flow diagram are available as Supplemental Digital Content 2 (http://links.lww.com/ALN/C7). 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. 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. Meta-analyses of RCTs comparing antibiotic-coated with uncoated catheters indicates that antibiotic-coated catheters are associated with reduced catheter colonization7885 and catheter-related bloodstream infection (Category A1-B evidence).80,81,83,85,86 Meta-analyses of RCTs comparing silver or silver-platinum-carbonimpregnated catheters with uncoated catheters yield equivocal findings for catheter colonization (Category A1-E evidence)8797 but a decreased risk of catheter-related bloodstream infection (Category A1-B evidence).8794,9699 Meta-analyses of RCTs indicate that catheters coated with chlorhexidine and silver sulfadiazine reduce catheter colonization compared with uncoated catheters (Category A1-B evidence)83,95,100118 but are equivocal for catheter-related bloodstream infection (Category A1-E evidence).83,100102,104110,112117,119,120 Cases of anaphylactic shock are reported after placement of a catheter coated with chlorhexidine and silver sulfadiazine (Category B4-H evidence).121129. Assessment of a central lineassociated bloodstream infection prevention program in a burn-trauma intensive care unit. Monitoring central line pressure waveforms and pressures. potential malposition. A prospective clinical trial to evaluate the microbial barrier of a needleless connector. Inferred findings are given a directional designation of beneficial (B), harmful (H), or equivocal (E). (Committee Chair), Chicago, Illinois; Stephen M. Rupp, M.D. Anesthesiology 2020; 132:843 doi: https://doi.org/10.1097/ALN.0000000000002864. Implementation of central venous catheter bundle in an intensive care unit in Kuwait: Effect on central lineassociated bloodstream infections. These values represented moderate to high levels of agreement. Palpating the femoral pulse throughout the procedure, the introducer needle was inserted into the femoral artery. Central venous catheter colonization in critically ill patients: A prospective, randomized, controlled study comparing standard with two antiseptic-impregnated catheters. Impact of two bundles on central catheter-related bloodstream infection in critically ill patients. A prospective randomized study. Category B: Observational studies or RCTs without pertinent comparison groups may permit inference of beneficial or harmful relationships among clinical interventions and clinical outcomes. In most instances, central venous access with ultrasound guidance is considered the standard of care. Survey Findings. Findings were then summarized for each evidence linkage and reported in the text of the updated Guideline, with summary evidence tables available as Supplemental Digital Content 4 (http://links.lww.com/ALN/C9). Catheter infection risk related to the distance between insertion site and burned area. 1), The number of insertion attempts should be based on clinical judgment, The decision to place two catheters in a single vein should be made on a case-by-case basis. Fluoroscopy-guided subclavian vein catheterization in 203 children with hematologic disease. Impregnated central venous catheters for prevention of bloodstream infection in children (the CATCH trial): A randomised controlled trial. These evidence categories are further divided into evidence levels. Impact of a national multimodal intervention to prevent catheter-related bloodstream infection in the ICU: The Spanish experience. Methods for confirming the position of the catheter tip include chest radiography, fluoroscopy, or point-of-care transthoracic echocardiography or continuous electrocardiography. Next, place the larger (20- to 22-gauge) needle immediately. Ultrasound evaluation of central veinsin the intensive care unit: Effects of dynamic manoeuvres. Resource preparation topics include (1) assessing the physical environment where central venous catheterization is planned to determine the feasibility of using aseptic techniques; (2) availability of a standardized equipment set; (3) use of a checklist or protocol for central venous catheter placement and maintenance; and (4) use of an assistant for central venous catheterization. Chlorhexidine-impregnated dressings and prevention of catheter-associated bloodstream infections in a pediatric intensive care unit. The consultants strongly agree and ASA members agree with the recommendation to not use catheters containing antimicrobial agents as a substitute for additional infection precautions. Central venous catheters coated with minocycline and rifampin for the prevention of catheter-related colonization and bloodstream infections: A randomized, double-blind trial. Choice of route for central venous cannulation: Subclavian or internal jugular vein? Evidence levels refer specifically to the strength and quality of the summarized study findings (i.e., statistical findings, type of data, and the number of studies reporting/replicating the findings). Target CLAB Zero: A national improvement collaborative to reduce central lineassociated bacteraemia in New Zealand intensive care units. Chest radiography was used as a reference standard for these studies. 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, For neonates, infants, and children, determine on a case-by-case basis whether to leave the catheter in place and obtain consultation or to remove the catheter nonsurgically, After the injury has been evaluated and a treatment plan has been executed, confer with the surgeon regarding relative risks and benefits of proceeding with the elective surgery versus deferring surgery to allow for a period of patient observation, 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, If a chlorhexidine-containing dressing is used, observe the site daily for signs of irritation, allergy or necrosis, For accessing the vein before threading a dilator or large-bore catheter, base the decision to use a thin-wall needle technique or a catheter-over-the-needle technique at least in part on the method used to confirm that the wire resides in the vein (fig.

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