Interventions intended to prevent mechanical trauma or injury associated with central venous access include but are not limited to (1) selection of catheter insertion site; (2) positioning the patient for needle insertion and catheter placement; (3) needle insertion, wire placement, and catheter placement; (4) guidance for needle, guidewire, and catheter placement, and (5) verification of needle, wire, and catheter placement. Literature Findings. Influence of triple-lumen central venous catheters coated with chlorhexidine and silver sulfadiazine on the incidence of catheter-related bacteremia. A total of 3 supervised re-wires is required prior to performing a rewire . A central venous catheter, also called a central line or CVC, is a device that helps you receive treatments for various medical conditions. Implementation of central lineassociated bloodstream infection prevention bundles in a surgical intensive care unit using peer tutoring. Subclavian venous catheterization: Greater success rate for less experienced operators using ultrasound guidance. Case reports describe severe injury (e.g., hemorrhage, hematoma, pseudoaneurysm, arteriovenous fistula, arterial dissection, neurologic injury including stroke, and severe or lethal airway obstruction) when unintentional arterial cannulation occurs with large-bore catheters (Category B4-H evidence).169178, An RCT comparing a thin-wall needle technique versus a catheter-over-the-needle for right internal jugular vein insertion in adults reports equivocal findings for first-attempt success rates and frequency of complications (Category A3-E evidence)179; for right-sided subclavian insertion in adults an RCT reports first-attempt success more likely and fewer complications with a thin-wall needle technique (Category A3-B evidence).180 One RCT reports equivocal findings for first-attempt success rates and frequency of complications when comparing a thin-wall needle with catheter-over-the-needle technique for internal jugular vein insertion (preferentially right) in neonates (Category A3-E evidence).181 Observational studies report a greater frequency of complications occurring with increasing number of insertion attempts (Category B3-H evidence).182184 One nonrandomized comparative study reports a higher frequency of dysrhythmia when two central venous catheters are placed in the same vein (right internal jugular) compared with placement of one catheter in the vein (Category B1-H evidence); differences in carotid artery punctures or hematomas were not noted (Category B1-E evidence).185. Literature Findings. Survey Findings. Posterior cerebral infarction following loss of guide wire. A randomized trial comparing povidoneiodine to a chlorhexidine gluconate-impregnated dressing for prevention of central venous catheter infections in neonates. No difference in catheter sepsis between standard and antiseptic central venous catheters: A prospective randomized trial. Reduction of central line infections in Veterans Administration intensive care units: An observational cohort using a central infrastructure to support learning and improvement. Real-time ultrasound-guided subclavian vein cannulation, The influence of the direction of J-tip on the placement of a subclavian catheter: Real time ultrasound-guided cannulation. RCTs report equivocal findings for catheter tip colonization when catheters are changed at 3-day versus 7-day intervals (Category A2-E evidence).146,147 RCTs report equivocal findings for catheter tip colonization when guidewires are used to change catheters compared with new insertion sites (Category A2-E evidence).148150. A retrospective observational study reports that manometry can detect arterial punctures not identified by blood flow and color (Category B3-B evidence).213 The literature is insufficient to address ultrasound, pressure-waveform analysis, blood gas analysis, blood color, or the absence of pulsatile flow as effective methods of confirming catheter or thin-wall needle venous access. Of the 484 attempted placements, 472 (97.5%) were primary placements. Example Duties Performed by an Assistant for Central Venous Catheterization. Identical surveys were distributed to expert consultants and a random sample of members of the participating organizations. Central catheters provide dependable intravenous access and enable hemodynamic monitoring and blood sampling [ 1-3 ]. 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. After review, 729 were excluded, with 284 new studies meeting inclusion criteria. Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: A randomized controlled trial. 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. An unexpected image on a chest radiograph. The policy of the American Society of Anesthesiologists (ASA) Committee on Standards and Practice Parameters is to update practice guidelines every 5 yr. For these guidelines, central venous access is defined as placement of a catheter such that the catheter is inserted into a venous great vessel. Reduced rates of catheter-associated infection by use of a new silver-impregnated central venous catheter. 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. The percentage of responding consultants expecting no change associated with each linkage were as follows: (1) resource preparation (environment with aseptic techniques, standardized equipment set) = 89.5%; (2) use of a trained assistant = 100%; (3) use of a checklist or protocol for placement and maintenance = 89.5%; (4) aseptic preparation (hand washing, sterile full-body drapes, etc.) These recommendations may be adopted, modified, or rejected according to clinical needs and constraints and are not intended to replace local institutional policies. 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). Catheter infection risk related to the distance between insertion site and burned area. window the image to best visualize the line. Prevention of catheter-related infections by silver coated central venous catheters in oncological patients. (Chair). The consultants strongly agree and ASA members agree with the recommendation that 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. The consultants and ASA members strongly agree with the recommendation to use real-time ultrasound guidance for vessel localization and venipuncture when the internal jugular vein is selected for cannulation. From ICU to hospital-wide: Extending central line associated bacteraemia (CLAB) prevention. The consultants and ASA members strongly agree with the recommendation to perform central venous access in the neck or chest with the patient in the Trendelenburg position when clinically appropriate and feasible. Fixed-effects models were fitted using MantelHaenszel or inverse variance weighting as appropriate. Studies also report high specificities of transthoracic ultrasound for excluding the presence of a pneumothorax.216,218,219,227229,232,233,236,238,240. To view a bar chart with the above findings, refer to Supplemental Digital Content 5 (http://links.lww.com/ALN/C10). Within the text of these guidelines, literature classifications are reported for each intervention using the following: Category A level 1, meta-analysis of randomized controlled trials (RCTs); Category A level 2, multiple RCTs; Category A level 3, a single RCT; Category B level 1, nonrandomized studies with group comparisons; Category B level 2, nonrandomized studies with associative findings; Category B level 3, nonrandomized studies with descriptive findings; and Category B level 4, case series or case reports. Remove the dilator and pass the central line over the Seldinger wire. Use real-time ultrasound guidance for vessel localization and venipuncture when the internal jugular vein is selected for cannulation (see fig. Prevention of central venous catheter-related bloodstream infection by use of an antiseptic-impregnated catheter: A randomized, controlled trial. Multimodal interventions for bundle implementation to decrease central lineassociated bloodstream infections in adult intensive care units in a teaching hospital in Taiwan, 20092013. Survey Findings. There were three (0.6%) technical failures due to previously undiagnosed iliofemoral venous occlusive disease. Assessment of conceptual issues, practicality, and feasibility of the guideline recommendations was also evaluated, with opinion data collected from surveys and other sources. In addition, practice guidelines developed by the American Society of Anesthesiologists (ASA) are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. Opinion surveys were developed by the task force to address each clinical intervention identified in the document. 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. An RCT of 5% povidoneiodine with 70% alcohol compared with 10% povidoneiodine alone indicates that catheter tip colonization is reduced with alcohol containing solutions (Category A3-B evidence); equivocal findings are reported for catheter-related bloodstream infection and clinical signs of infection (Category A3-E evidence).77. (Committee Chair), Chicago, Illinois; Stephen M. Rupp, M.D. The type of catheter and location of placement will depend on the reason for it's placement. As the vein is punctured, a flash of dark venous blood into the syringe indicates that the needle tip is within the femoral vein lumen. Impact of a prevention strategy targeted at vascular-access care on incidence of infections acquired in intensive care. A prospective randomised trial comparing insertion success rate and incidence of catheterisation-related complications for subclavian venous catheterisation using a thin-walled introducer needle or a catheter-over-needle technique. Decreasing PICU catheter-associated bloodstream infections: NACHRIs quality transformation efforts. A prospective randomized study to compare ultrasound-guided with nonultrasound-guided double lumen internal jugular catheter insertion as a temporary hemodialysis access. Cerebral infarct following central venous cannulation. Antiseptic-impregnated central venous catheters reduce the incidence of bacterial colonization and associated infection in immunocompromised transplant patients. The effect of position and different manoeuvres on internal jugular vein diameter size. Femoral lines are usually used only as provisional access because they have a high risk of infection. Editorials, letters, and other articles without data were excluded. A controlled study of transesophageal echocardiography to guide central venous catheter placement in congenital heart surgery patients. Objective To investigate the efficacy of the minimally invasive clamp reduction technique via the anterior approach in the treatment of irreducible intertrochanteric femoral fractures. . Central venous access: The effects of approach, position, and head rotation on internal jugular vein cross-sectional area. Incidence of mechanical complications of central venous catheterization using landmark technique: Do not try more than 3 times. A chest x-ray will be performed immediately following thoracic central line placement to assure line placement and rule out pneumothorax. Heterogeneity was quantified with I2 and prediction intervals estimated (see table 1). visualize the tip of the line. Inferred findings are given a directional designation of beneficial (B), harmful (H), or equivocal (E). Guidewire localization by transthoracic echocardiography during central venous catheter insertion: A periprocedural method to evaluate catheter placement. Implementing a multifaceted intervention to decrease central lineassociated bloodstream infections in SEHA (Abu Dhabi Health Services Company) intensive care units: The Abu Dhabi experience. For example: o A minimum of 5 supervised successful procedures in both the chest and femoral sites is required (10 total). Internal jugular line. Aiming for zero: Decreasing central line associated bacteraemia in the intensive care unit. 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. Always confirm placement with ultrasound, looking for reverberation artifact of the needle and tenting of the vessel wall. American Society of Anesthesiologists Task Force on Central Venous A. In most instances, central venous access with ultrasound guidance is considered the standard of care. They should be exchanged for lines above the diaphragm as soon as possible. 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. The journey to zero central catheter-associated bloodstream infections: Culture change in an intensive care unit. Metasens: Advanced Statistical Methods to Model and Adjust for Bias in Meta-Analysis. In 2017, the ASA Committee on Standards and Practice Parameters requested that these guidelines be updated. Is a routine chest x-ray necessary for children after fluoroscopically assisted central venous access? Refer to appendix 2 for an example of a list of standardized equipment for adult patients. Significant reduction of central-line associated bloodstream infections in a network of diverse neonatal nurseries. Methods for confirming the position of the catheter tip include chest radiography, fluoroscopy, or point-of-care transthoracic echocardiography or continuous electrocardiography. Misplacement of a guidewire diagnosed by transesophageal echocardiography. Use the subclavian site for central lines: Compared to the internal jugular or femoral sites, the subclavian site has a lower risk of thrombosis or line infection. Effect of a second-generation venous catheter impregnated with chlorhexidine and silver sulfadiazine on central catheter-related infections: A randomized, controlled trial. Prospective comparison of two management strategies of central venous catheters in burn patients. The Texas Medical Center Catheter Study Group. hemorrhage, hematoma formation, and pneumothorax during central line placement. This line is placed in a large vein in the groin. Femoral line. 2012 Emery A. Rovenstine Memorial Lecture: The genesis, development, and future of the American Society of Anesthesiologists evidence-based practice parameters. Contamination of central venous catheters in immunocompromised patients: A comparison between two different types of central venous catheters. It's made of a long, thin, flexible tube that enters your body through a vein. 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). The consultants and ASA members strongly agree with the recommendation to use a chlorhexidine-containing solution for skin preparation in adults, infants, and children. Impact of central venous catheter type and methods on catheter-related colonization and bacteraemia. They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert and practitioner opinion, open forum commentary, and clinical feasibility data. subclavian vein (left or right) assessing position. Comparison of silver-impregnated with standard multi-lumen central venous catheters in critically ill patients. Pacing catheters. Allergy to chlorhexidine: Beware of the central venous catheter. Central venous catheters coated with minocycline and rifampin for the prevention of catheter-related colonization and bloodstream infections: A randomized, double-blind trial. Supported by the American Society of Anesthesiologists and developed under the direction of the Committee on Standards and Practice Parameters, Jeffrey L. Apfelbaum, M.D. A multidisciplinary approach to reduce central lineassociated bloodstream infections. The consultants and ASA members agree with the recommendation to use skin preparation solutions containing alcohol unless contraindicated. Aspirate and flush all lumens and re clamp and apply lumen caps. Placing the central line. The impact of a quality improvement intervention to reduce nosocomial infections in a PICU. Mark, M.D., Durham, North Carolina. An intervention to decrease catheter-related bloodstream infections in the ICU. Anesthesia was achieved using 1% lidocaine. Safety of central venous catheter change over guidewire for suspected catheter-related sepsis: A prospective randomized trial. Prospective comparison of ultrasound and CXR for confirmation of central vascular catheter placement. Links to the digital files are provided in the HTML text of this article on the Journals Web site (www.anesthesiology.org). Insert the introducer needle with negative pressure until venous blood is aspirated. Ties are calculated by a predetermined formula. Reducing PICU central lineassociated bloodstream infections: 3-year results. 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. Evaluation of antiseptic-impregnated central venous catheters for prevention of catheter-related infection in intensive care unit patients. This may be done in your hospital room or an . Fifth, all available information was used to build consensus to finalize the guidelines. Literature Findings. This line is placed into the vein that runs behind the collarbone. (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. 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). The literature relating to seven evidence linkages contained enough studies with well defined experimental designs and statistical information to conduct formal meta-analyses (table 1). Approved by the American Society of Anesthesiologists House of Delegates on October 23, 2019. Meta: An R package for meta-analysis (4.9-4). Suggestions for minimizing such risk are those directed at raising central venous pressure during and immediately after catheter removal and following a defined nursing protocol. Evidence categories refer specifically to the strength and quality of the research design of the studies. Severe anaphylactic reaction due to a chlorhexidine-impregnated central venous catheter. An alternative central venous route for cardiac surgery: Supraclavicular subclavian vein catheterization. Practice guidelines for central venous access: A report by the American Society of Anesthesiologists Task Force on Central Venous Access. Comparison of three techniques for internal jugular vein cannulation in infants. Methods From January 2015 to January 2021, 115 patients (48 males and 67 females) with irreducible intertrochanteric femoral fractures were treated. Fatal respiratory obstruction following insertion of a central venous line. When an equal number of categorically distinct responses are obtained, the median value is determined by calculating the arithmetic mean of the two middle values. Chlorhexidine and silver-sulfadiazine coated central venous catheters in haematological patients: A double-blind, randomised, prospective, controlled trial. Chlorhexidine-impregnated dressing for prevention of colonization of central venous catheters in infants and children: A randomized controlled study. 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. For these updated guidelines, a systematic search and review of peer-reviewed published literature was conducted, with scientific findings summarized and reported below and in the document. The consultants and ASA members both strongly agree with the recommendation to minimize the number of needle punctures of the skin. For meta-analyses of antimicrobial, silver, or silver-sulfadiazine catheters studies reported actual event rates and odds ratios were pooled. For neonates, infants, and children, confirmation of venous placement may take place after the wire is threaded. Is traditional reading of the bedside chest radiograph appropriate to detect intraatrial central venous catheter position? These guidelines are intended for use by anesthesiologists and individuals under the supervision of an anesthesiologist.