Prevention of catheter-related infections by silver coated central venous catheters in oncological patients. Nurse-driven quality improvement interventions to reduce hospital-acquired infection in the NICU. 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. Supplemental Digital Content is available for this article. Ultrasound-assisted cannulation of the internal jugular vein: A prospective comparison to the external landmark-guided technique. 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. Do not force the wire; it should slide smoothly. Category A: RCTs report comparative findings between clinical interventions for specified outcomes. Literature exclusion criteria (except to obtain new citations): For the systematic review, potentially relevant clinical studies were identified via electronic and manual searches. Literature Findings. Ultrasound guidance outcomes were pooled using risk or mean differences (continuous outcomes) for clinical relevance. The literature is insufficient to evaluate whether catheter fixation with sutures, staples, or tape is associated with a higher risk for catheter-related infections. 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). In this document, only the highest level of evidence is included in the summary report for each interventionoutcome pair, including a directional designation of benefit, harm, or equivocality. The effect of position and different manoeuvres on internal jugular vein diameter size. The femoral vein lies medial to the femoral artery as it runs distal to the inguinal ligament. 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. Retention of antibacterial activity and bacterial colonization of antiseptic-bonded central venous catheters. The Texas Medical Center Catheter Study Group. Severe anaphylactic reaction due to a chlorhexidine-impregnated central venous catheter. Central venous line placement is the insertion of a catherter/tube through the neck or body and into a large vein that connects to the heart. 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 central line is placed in your body during a brief procedure. Editorials, letters, and other articles without data were excluded. tip should be at the cavoatrial junction. Insert the J-curved end of the guidewire into the introducer needle, with the J curve facing up. Proper maintenance of CVCs includes disinfection of catheter hubs, connectors, and injection ports and changing dressings over the site every two days for gauze . (Chair). Eradicating central lineassociated bloodstream infections statewide: The Hawaii experience. The consultants and ASA members agree with the recommendation to use skin preparation solutions containing alcohol unless contraindicated. Comparison of silver-impregnated with standard multi-lumen central venous catheters in critically ill patients. Prevention of catheter related bloodstream infection by silver iontophoretic central venous catheters: A randomised controlled trial. No search for gray literature was conducted. document the position of the line. Literature Findings. 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. Aseptic insertion of central venous lines to reduce bacteraemia: The central line associated bacteraemia in NSW intensive care units (CLAB ICU) collaborative. Multimodal interventions for bundle implementation to decrease central lineassociated bloodstream infections in adult intensive care units in a teaching hospital in Taiwan, 20092013. The effect of process control on the incidence of central venous catheter-associated bloodstream infections and mortality in intensive care units in Mexico. The Central Venous Catheter-Related Infections Study Group. The venous great vessels include the superior vena cava, inferior vena cava, brachiocephalic veins, internal jugular veins, subclavian veins, iliac veins, and common femoral veins. Excluded are catheters that terminate in a systemic artery. Literature Findings. Case reports of adult patients with arterial puncture by a large-bore catheter/vessel dilator during attempted central venous catheterization indicate severe complications (e.g., cerebral infarction, arteriovenous fistula, hemothorax) after immediate catheter removal (Category B4-H evidence)172,176,253; complications are uncommonly reported for adult patients whose catheters were left in place before surgical consultation and repair (Category B4-E evidence).172,176,254. These seven evidence linkages are: (1) antimicrobial catheters, (2) silver impregnated catheters, (3) chlorhexidine and silver-sulfadiazine catheters, (4) dressings containing chlorhexidine, and (5) ultrasound guidance for venipuncture. 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. Ideally the distal end of a CVC should be orientated vertically within the SVC. The average age of the patients was 78.7 (45-100 years old . Ultrasound-guided cannulation of the internal jugular vein: A prospective, randomized study. There are many uses of these catheters. Literature Findings. Incidence of mechanical complications of central venous catheterization using landmark technique: Do not try more than 3 times. For example: o A minimum of 5 supervised successful procedures in both the chest and femoral sites is required (10 total). For neonates, infants, and children, confirmation of venous placement may take place after the wire is threaded. Submitted for publication March 15, 2019. These values represented moderate to high levels of agreement. Literature Findings. A minimum of five independent RCTs (i.e., sufficient for fitting a random-effects model255) is required for meta-analysis. Is traditional reading of the bedside chest radiograph appropriate to detect intraatrial central venous catheter position? Decreasing central-lineassociated bloodstream infections in Connecticut intensive care units. 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. Anaphylactic shock induced by an antiseptic-coated central venous [correction of nervous] catheter. A subclavian artery injury, secondary to internal jugular vein cannulation, is a predictable right-sided phenomenon. 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 syringe was removed and a guidewire was advanced through the needle into the femoral artery. 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. 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). The literature is insufficient to evaluate the efficacy of transparent bioocclusive dressings to reduce the risk of infection. . Pooled estimates from RCTs are consistent with lower rates of catheter colonization with chlorhexidine sponge dressings compared with standard polyurethane (Category A1-B evidence)90,133138 but equivocal for catheter-related bloodstream infection (Category A1-E evidence).90,133140 An RCT reports a higher frequency of severe localized contact dermatitis in neonates with chlorhexidine-impregnated dressings compared with povidoneiodineimpregnated dressings (Category A3-H evidence)133; findings concerning dermatitis from RCTs in adults are equivocal (Category A2-E evidence).90,134,136,137,141. Microbiological evaluation of central venous catheter administration hubs. The tube travels through one or more veins until the tip reaches the large vein that empties into your heart ( vena cava ). Venous blood gases must be obtained at the time of central line insertion or upon admission of a patient with an established central line (including femoral venous lines) and as an endpoint to resuscitation or . Impact of a national multimodal intervention to prevent catheter-related bloodstream infection in the ICU: The Spanish experience. 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. For studies that report statistical findings, the threshold for significance is P < 0.01. Evaluation of chlorhexidine and silver-sulfadiazine impregnated central venous catheters for the prevention of bloodstream infection in leukaemic patients: A randomized controlled trial. Strict hand hygiene and other practices shortened stays and cut costs and mortality in a pediatric intensive care unit. The effect of hand hygiene compliance on hospital-acquired infections in an ICU setting in a Kuwaiti teaching hospital. Safety of central venous catheter change over guidewire for suspected catheter-related sepsis: A prospective randomized trial. This line is placed into a large vein in the neck. Comparison of an ultrasound-guided technique. 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). Validation of the concepts addressed by these guidelines and subsequent recommendations proposed was obtained by consensus from multiple sources, including: (1) survey opinion from consultants who were selected based on their knowledge or expertise in central venous access (2) survey opinions from a randomly selected sample of active members of the ASA; (3) testimony from attendees of publicly held open forums for the original guidelines at a national anesthesia meeting; and (4) internet commentary. Next, place the larger (20- to 22-gauge) needle immediately. R: A Language and Environment for Statistical Computing. Antimicrobial durability and rare ultrastructural colonization of indwelling central catheters coated with minocycline and rifampin. The consultants are equivocal and ASA members agree that when using the catheter-over-the-needle technique, confirmation that the wire resides in the vein may not be needed (1) if the catheter enters the vein easily and manometry or pressure-waveform measurement provides unambiguous confirmation of venous location of the catheter and (2) if the wire passes through the catheter and enters the vein without difficulty. Comparison of central venous catheterization with and without ultrasound guide. Choice of route for central venous cannulation: Subclavian or internal jugular vein? Do not force the wire; it should slide smoothly. Chlorhexidine and gauze and tape dressings for central venous catheters: A randomized clinical trial. Level 2: The literature contains multiple RCTs, but the number of RCTs is not sufficient to conduct a viable meta-analysis for the purpose of these Guidelines. Decreasing PICU catheter-associated bloodstream infections: NACHRIs quality transformation efforts. Femoral vein cannulation performed by residents: A comparison between ultrasound-guided and landmark technique in infants and children undergoing cardiac surgery. An evaluation with ultrasound. The consultants strongly agree and ASA members agree with the recommendation to not routinely administer intravenous antibiotic prophylaxis. Although catheter removal is not addressed by these guidelines (and is not typically performed by anesthesiologists), the risk of venous air embolism upon removal is a serious concern. The consultants and ASA members both strongly agree with the recommendations to use transparent bioocclusive dressings to protect the site of central venous catheter insertion from infection. Placement of a femoral line may be indicated in the following situations: to obtain vascular access when peripheral access cannot be accomplished, to administer hemodialysis when access at a. The consultants agree and ASA members strongly agree with the recommendations to select an upper body insertion site to minimize the risk of thrombotic complications relative to the femoral site. Meta-analyses from other sources are reviewed but not included as evidence in this document. This line is placed into the vein that runs behind the collarbone. 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. Confirmation of optimal guidewire length for central venous catheter placement using transesophageal echocardiography. Only studies containing original findings from peer-reviewed journals were acceptable. Nursing care. 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#. Anesthesiology 2020; 132:843 doi: https://doi.org/10.1097/ALN.0000000000002864. The femoral vein is the major deep vein of the lower extremity. potential malposition. Simplified point-of-care ultrasound protocol to confirm central venous catheter placement: A prospective study. An intervention to decrease catheter-related bloodstream infections in the ICU. The lack of sufficient scientific evidence in the literature may occur when the evidence is either unavailable (i.e., no pertinent studies found) or inadequate. Implementation of central venous catheter bundle in an intensive care unit in Kuwait: Effect on central lineassociated bloodstream infections. Please read and accept the terms and conditions and check the box to generate a sharing link. 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. Contamination of central venous catheters in immunocompromised patients: A comparison between two different types of central venous catheters. Both the systematic literature review and the opinion data are based on evidence linkages or statements regarding potential relationships between interventions and outcomes associated with central venous access. window the image to best visualize the line. These suggestions include, but are not limited to, positioning the patient in the Trendelenburg position, using the Valsalva maneuver, applying direct pressure to the puncture site, using air-occlusive dressings, and monitoring the patient for a reasonable period of time after catheter removal. Chlorhexidine and silver-sulfadiazine coated central venous catheters in haematological patients: A double-blind, randomised, prospective, controlled trial. Complications of femoral and subclavian venous catheterization in critically ill patients: A randomized controlled trial. Local anesthetic is used to numb the insertion site. Location of the central venous catheter tip with bedside ultrasound in young children: Can we eliminate the need for chest radiography? Five (1.0%) adverse events occurred. The authors declare no competing interests. Fluoroscopy-guided subclavian vein catheterization in 203 children with hematologic disease. Accepted studies from the previous guidelines were also rereviewed, covering the period of January 1, 1971, through June 31, 2011. A neonatal PICC can be inserted at the patient's bedside with the use of an analgesic agent and radiographic verification, and it can remain in place for several weeks or months. There were three (0.6%) technical failures due to previously undiagnosed iliofemoral venous occlusive disease. Matching Michigan: A 2-year stepped interventional programme to minimise central venous catheter-blood stream infections in intensive care units in England. Saline flush test: Can bedside sonography replace conventional radiography for confirmation of above-the-diaphragm central venous catheter placement? 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. In most instances, central venous access with ultrasound guidance is considered the standard of care. 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.) Literature Findings. 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. The accuracy of electrocardiogram-controlled central line placement. Trendelenburg position, head elevation and a midline position optimize right internal jugular vein diameter. The literature is insufficient to evaluate outcomes associated with the routine use of intravenous prophylactic antibiotics. This update is a revision developed by an ASA-appointed task force of seven members, including five anesthesiologists and two methodologists. 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 consultants agree and ASA members strongly agree that the number of insertion attempts should be based on clinical judgment and that the decision to place two catheters in a single vein should be made on a case-by-case basis. Anaphylaxis to chlorhexidine-coated central venous catheters: A case series and review of the literature. They should be exchanged for lines above the diaphragm as soon as possible. Monitoring central line pressure waveforms and pressures. Prevention of catheter-related bloodstream infection in critically ill patients using a disinfectable, needle-free connector: A randomized controlled trial. Survey Findings. Literature Findings. The American Society of Anesthesiologists practice parameter methodology. 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. 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. Decreasing catheter-related bloodstream infections in the intensive care unit: Interventions in a medical center in central Taiwan. 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. Survey Findings. Internal jugular vein cannulation: An ultrasound-guided technique. Maintaining and sustaining the On the CUSP: Stop BSI model in Hawaii. Heterogeneity was quantified with I2 and prediction intervals estimated (see table 1). Does ultrasound imaging before puncture facilitate internal jugular vein cannulation? Survey Findings. Comparison of needle insertion and guidewire placement techniques during internal jugular vein catheterization: The thin-wall introducer needle technique. Bibliographic database searches included PubMed and EMBASE. An Updated Report by the American Society of Anesthesiologists Task Force on Central Venous Access, A Tool to Screen Patients for Obstructive Sleep Apnea, ACE (Anesthesiology Continuing Education), Recommendations for Prevention of Infectious Complications, Recommendations for Prevention of Mechanical Trauma or Injury, Recommendations for Management of Arterial Trauma or Injury Arising from Central Venous Access, Appendix 3. Comparison of triple-lumen central venous catheters impregnated with silver nanoparticles (AgTive). The femoral vein is the major deep vein of the lower extremity. Methods for confirming that the wire resides in the vein include, but are not limited to, ultrasound (identification of the wire in the vein) or transesophageal echocardiography (identification of the wire in the superior vena cava or right atrium), continuous electrocardiography (identification of narrow-complex ectopy), or fluoroscopy. 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. Mark, M.D., Durham, North Carolina. A central venous catheter, also called a central line or CVC, is a device that helps you receive treatments for various medical conditions. trace the line from its insertion towards the heart. The long-term effect of bundle care for catheter-related blood stream infection: 5-year follow-up. Survey Findings. Practice guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. Ultrasound for localization of central venous catheter: A good alternative to chest x-ray? Survey Findings. NICE guidelines for central venous catheterization in children: Is the evidence base sufficient? If possible, this site is recommended by United States guidelines. Prepare the centralcatheter kit, and Objective To investigate the efficacy of the minimally invasive clamp reduction technique via the anterior approach in the treatment of irreducible intertrochanteric femoral fractures. Zero risk for central lineassociated bloodstream infection: Are we there yet? Detailed descriptions of the ASA process and methodology used in these guidelines may be found in other related publications.25 Appendix 1 contains a footnote indicating where information may be found on the evidence model, literature search process, literature findings, and survey results for these guidelines. Each pertinent outcome reported in a study was classified by evidence category and level and designated as beneficial, harmful, or equivocal. Reducing PICU central lineassociated bloodstream infections: 3-year results. 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. Efficacy of silver-coating central venous catheters in reducing bacterial colonization. Level 3: The literature contains noncomparative observational studies with descriptive statistics (e.g., frequencies, percentages). A multitiered strategy of simulation training, kit consolidation, and electronic documentation is associated with a reduction in central lineassociated bloodstream infections. Prevention of central venous catheter-related bloodstream infection by use of an antiseptic-impregnated catheter: A randomized, controlled trial. - right femoral line: find the arterial pulse and enter the skin 1 cm medial to this, at a 45 angle to the vertical and heading parallel to the artery. Palpating the femoral pulse throughout the procedure, the introducer needle was inserted into the femoral artery. Sometimes (hopefully rarely), the exigencies of time or patient condition will prevent placing a full sterile line. 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. A delayed diagnosis of a retained guidewire during central venous catheterisation: A case report and review of the literature. Effectiveness of stepwise interventions targeted to decrease central catheter-associated bloodstream infections. There are a variety of catheter, both size and configuration. These updated guidelines were developed by means of a five-step process. Cerebral infarct following central venous cannulation. The catheter over-the-needle technique may provide more stable venous access if manometry is used for venous confirmation. 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 .