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). A multitiered strategy of simulation training, kit consolidation, and electronic documentation is associated with a reduction in central lineassociated bloodstream infections. Chlorhexidine-impregnated dressings and prevention of catheter-associated bloodstream infections in a pediatric intensive care unit. Dressing Use of ultrasound to evaluate internal jugular vein anatomy and to facilitate central venous cannulation in paediatric patients. RCTs comparing needleless connectors with standard caps indicate lower rates of microbial contamination of stopcock entry ports with needleless connectors (Category A2-B evidence),151153 but findings for catheter-related bloodstream infection are equivocal (Category A2-E evidence).151,154, Survey Findings. Ultrasound confirmation of guidewire position may eliminate accidental arterial dilatation during central venous cannulation. The consultants and ASA members both strongly agree with the recommendation to minimize the number of needle punctures of the skin. Reduction and surveillance of device-associated infections in adult intensive care units at a Saudi Arabian hospital, 20042011. Analyses were conducted in R version 3.5.3256 using the Meta257 and Metasens258 packages. 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. Decreasing catheter colonization through the use of an antiseptic-impregnated catheter: A continuous quality improvement project. Does ultrasound imaging before puncture facilitate internal jugular vein cannulation? 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. The tube travels through one or more veins until the tip reaches the large vein that empties into your heart ( vena cava ). These studies do not permit assessing the effect of any single component of a checklist or bundled protocol on infection rates. 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. Studies also report high specificities of transthoracic ultrasound for excluding the presence of a pneumothorax.216,218,219,227229,232,233,236,238,240. 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. Survey responses for each recommendation are reported using a 5-point scale based on median values from strongly agree to strongly disagree. All opinion-based evidence relevant to each topic was considered in the development of these guidelines. 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. 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. tip too high: proximal SVC. Maintaining and sustaining the On the CUSP: Stop BSI model in Hawaii. 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). Palpating the femoral pulse throughout the procedure, the introducer needle was inserted into the femoral artery. Prevention of central venous catheter-related bloodstream infection by use of an antiseptic-impregnated catheter: A randomized, controlled trial. 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). Decreasing central lineassociated bloodstream infections through quality improvement initiative. 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. Catheter infection: A comparison of two catheter maintenance techniques. Beyond the intensive care unit bundle: Implementation of a successful hospital-wide initiative to reduce central lineassociated bloodstream infections. To view a bar chart with the above findings, refer to Supplemental Digital Content 5 (http://links.lww.com/ALN/C10). Central venous line sepsis in the intensive care unit: A study comparing antibiotic coated catheters with plain catheters. Evaluation of antiseptic-impregnated central venous catheters for prevention of catheter-related infection in intensive care unit patients. The Texas Medical Center Catheter Study Group. 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. Literature Findings. Identical surveys were distributed to expert consultants and a random sample of members of the participating organizations. Proper maintenance of CVCs includes disinfection of catheter hubs, connectors, and injection ports and changing dressings over the site every two days for gauze . Central Line Insertion Care Team Checklist Instructions Operator Requirements: Specify minimum requirements. Survey Findings. Femoral line. Subclavian venous catheterization: Greater success rate for less experienced operators using ultrasound guidance. The policy of the American Society of Anesthesiologists (ASA) Committee on Standards and Practice Parameters is to update practice guidelines every 5 yr. 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. Citation searching (backward and forward) of relevant meta-analyses and other systematic reviews was also performed; pre-2011 studies relevant to meta-analyses or use of ultrasound were eligible for inclusion. A prospective randomized study. In most instances, central venous access with ultrasound guidance is considered the standard of care. Although interobserver agreement among task force members and two methodologists was not assessed for this update, the original guidelines reported agreement levels using a statistic for two-rater agreement pairs as follows: (1) research design, = 0.70 to 1.00; (2) type of analysis, = 0.60 to 0.84; (3) evidence linkage assignment, = 0.91 to 1.00; and (4) literature inclusion for database, = 0.28 to 1.00. 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. 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. Internal jugular vein cannulation: An ultrasound-guided technique. All meta-analyses are conducted by the ASA methodology group. Literature Findings. Prevention of mechanical trauma or injury: Patient preparation for needle insertion and catheter placement, Awake versus anesthetized patient during insertion, Positive pressure (i.e., mechanical) versus spontaneous ventilation during insertion, Patient position: Trendelenburg versus supine, Surface landmark inspection to identify target vein, Selection of catheter composition (e.g., polyvinyl chloride, polyethylene, Teflon), Selection of catheter type (all types will be compared with each other), Use of a finder (seeker) needle versus no seeker needle (e.g., a wider-gauge access needle), Use of a thin-wall needle versus a cannula over a needle before insertion of a wire for the Seldinger technique, Monitoring for needle, wire, and catheter placement, Ultrasound (including audio-guided Doppler ultrasound), Prepuncture identification of insertion site versus no ultrasound, Guidance during needle puncture and placement versus no ultrasound, Confirmation of venous insertion of needle, Identification of free aspiration of dark (Po2) nonpulsatile blood, Confirmation of venous placement of catheter, Manometry versus direct pressure measurement (via pressure transducer), Timing of x-ray immediately after placement versus postop. The authors declare no competing interests. Address correspondence to the American Society of Anesthesiologists: 1061 American Lane, Schaumburg, Illinois 60173. Skin antisepsis with chlorhexidinealcohol, for Japanese Society of Education for Physicians and Trainees in Intensive Care (JSEPTIC) Clinical Trial Group. Multidisciplinary trauma intensive care unit checklist: Impact on infection rates. 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. Of the respondents, 82% indicated that the guidelines would have no effect on the amount of time spent on a typical case, and 17.6% indicated that there would be an increase of the amount of time spent on a typical case with the implementation of these guidelines. 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. A controlled study of transesophageal echocardiography to guide central venous catheter placement in congenital heart surgery patients. Confirmation of optimal guidewire length for central venous catheter placement using transesophageal echocardiography. The effect of position and different manoeuvres on internal jugular vein diameter size. New York State Regional Perinatal Care Centers. Evaluation of chlorhexidine and silver-sulfadiazine impregnated central venous catheters for the prevention of bloodstream infection in leukaemic patients: A randomized controlled trial. Biopatch: A new concept in antimicrobial dressings for invasive devices. tient's leg away from midline. Avoiding complications and decreasing costs of central venous catheter placement utilizing electrocardiographic guidance. Survey Findings. 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). 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. The incidence of complications after the double-catheter technique for cannulation of the right internal jugular vein in a university teaching hospital. Only studies containing original findings from peer-reviewed journals were acceptable. 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. Evaluation and classification of evidence for the ASA clinical practice guidelines, Millers Anesthesia. Eliminating central lineassociated bloodstream infections: A national patient safety imperative. Fourth, additional opinions were solicited from random samples of active ASA members. Elimination of central-venous-catheterrelated bloodstream infections from the intensive care unit. A subclavian artery injury, secondary to internal jugular vein cannulation, is a predictable right-sided phenomenon. Time-series analysis to observe the impact of a centrally organized educational intervention on the prevention of central-lineassociated bloodstream infections in 32 German intensive care units. Effect of central line bundle on central lineassociated bloodstream infections in intensive care units. For membership respondents, the survey rate of return was 8% (n = 393 of 5,000) members. Received from the American Society of Anesthesiologists, Schaumburg, Illinois. There are many uses of these catheters. For these guidelines, central venous access is defined as placement of a catheter such that the catheter is inserted into a venous great vessel. Reduction of catheter-related infections in neutropenic patients: A prospective controlled randomized trial using a chlorhexidine and silver sulfadiazine-impregnated central venous catheter. 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. It can be used to confirm that the catheter or the guidewire has travelled towards the SVC. Transthoracic echocardiographic guidance for obtaining an optimal insertion length of internal jugular venous catheters in infants. 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. 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. The consultants and ASA members agree with the recommendation to use an assistant during placement of a central venous catheter. 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. Five (1.0%) adverse events occurred. 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). Survey Findings. Reduction of central line infections in Veterans Administration intensive care units: An observational cohort using a central infrastructure to support learning and improvement. Fatal respiratory obstruction following insertion of a central venous line. Refer to appendix 4 for an example of a list of duties performed by an assistant. Complications of femoral and subclavian venous catheterization in critically ill patients: A randomized controlled trial. Evidence was obtained from two principal sources: scientific evidence and opinion-based evidence. Intravascular complications of central venous catheterization by insertion site. This line is placed in a large vein in the groin. Target CLAB Zero: A national improvement collaborative to reduce central lineassociated bacteraemia in New Zealand intensive care units. Prevention of intravascular catheter-related infection with newer chlorhexidine-silver sulfadiazinecoated catheters: A randomized controlled trial. Two episodes of life-threatening anaphylaxis in the same patient to a chlorhexidine-sulphadiazine-coated central venous catheter. 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. Usefulness of ultrasonography for the evaluation of catheter misplacement and complications after central venous catheterization. Evidence categories refer specifically to the strength and quality of the research design of the studies. Influence of triple-lumen central venous catheters coated with chlorhexidine and silver sulfadiazine on the incidence of catheter-related bacteremia. Ultrasound for localization of central venous catheter: A good alternative to chest x-ray? The authors thank David G. Nickinovich, Ph.D., Nickinovich Research and Consulting, Inc. (Bellevue, Washington) for his service as methodology consultant for this task force and his invaluable contributions to the original version of these Guidelines. Ultrasound-guided central venous cannulation is superior to quick-look ultrasound and landmark methods among inexperienced operators: A prospective randomized study. If possible, this site is recommended by United States guidelines. The needle was exchanged over the wire for an arterial . Standardizing central line safety: Lessons learned for physician leaders. Nosocomial sepsis: Evaluation of the efficacy of preventive measures in a level-III neonatal intensive care unit. If you feel any resistance as you advance the guidewire, stop advancing it. 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. Metasens: Advanced Statistical Methods to Model and Adjust for Bias in Meta-Analysis. Four hundred eighty-one (99.4%) placements were technically successful. Verification of needle, wire, and catheter placement includes (1) confirming that the catheter or thin-wall needle resides in the vein, (2) confirming venous residence of the wire, and (3) confirming residence of the catheter in the venous system and final catheter tip position.. Monitoring central line pressure waveforms and pressures. A prospective, randomized study in critically ill patients using the Oligon Vantex catheter. 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. Once the central line is in place, remove the wire. 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. Evolution and aetiological shift of catheter-related bloodstream infection in a whole institution: The microbiology department may act as a watchtower. These large diameter central veins are located universally near a large artery. The variation between the two techniques reflects mitigation steps for the risk that the thin-wall needle in the Seldinger technique could move out of the vein and into the wall of an artery between the manometry step and the threading of the wire step. Confirmation of endovenous placement of central catheter using the ultrasonographic bubble test., The use of ultrasound during and after central venous catheter insertion. The insertion process includes catheter site selection, insertion under ultrasound guidance, catheter site dressing regimens, securement devices, and use of a CVC insertion bundle. Microbiological evaluation of central venous catheter administration hubs. 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. Prospective comparison of ultrasound and CXR for confirmation of central vascular catheter placement. Femoral vein cannulation performed by residents: A comparison between ultrasound-guided and landmark technique in infants and children undergoing cardiac surgery. Real-time ultrasound-guided catheterisation of the internal jugular vein: A prospective comparison with the landmark technique in critical care patients. Heterogeneity was quantified with I2 and prediction intervals estimated (see table 1). Bibliographic database searches included PubMed and EMBASE. 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. 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. Comparison of the effect of the Trendelenburg and passive leg raising positions on internal jugular vein size in critically ill patients. subclavian vein (left or right) assessing position. Ultrasound-assisted cannulation of the internal jugular vein: A prospective comparison to the external landmark-guided technique. Submitted for publication March 15, 2019. 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. Complications and failures of subclavian-vein catheterization. The effects of the Trendelenburg position and the Valsalva manoeuvre on internal jugular vein diameter and placement in children.

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