For studies that report statistical findings, the threshold for significance is P < 0.01. The Central Venous Catheter-Related Infections Study Group. The guidelines do not address (1) clinical indications for placement of central venous catheters; (2) emergency placement of central venous catheters; (3) patients with peripherally inserted central catheters; (4) placement and residence of a pulmonary artery catheter; (5) insertion of tunneled central lines (e.g., permacaths, portacaths, Hickman, Quinton); (6) methods of detection or treatment of infectious complications associated with central venous catheterization; (7) removal of central venous catheters; (8) diagnosis and management of central venous catheter-associated trauma or injury (e.g., pneumothorax or air embolism), with the exception of carotid arterial injury; (9) management of periinsertion coagulopathy; and (10) competency assessment for central line insertion. Use real-time ultrasound guidance for vessel localization and venipuncture when the internal jugular vein is selected for cannulation (see fig. This description of the venous great vessels is consistent with the venous subset for central lines defined by the National Healthcare Safety Network. 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). Ultrasound guidance improves the success rate of internal jugular vein cannulation: A prospective, randomized trial. The consultants and ASA members agree that when feasible, real-time ultrasound may be used when the subclavian or femoral vein is selected. 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. ), Tunneled catheters (e.g., Hickman, Quinton, permacaths, portacaths), Arterial cannulation/injury/cerebral embolization/hemorrhage, Wire, knot, inability to remove the catheter, Hospital, intensive care unit length of stay, Number of attempts at central line placement, Time required for placement of central venous catheters, Infections or other complications not associated with central venous catheterization, Mechanical injury or trauma not associated with central venous catheterization, Prospective nonrandomized comparative studies (e.g., quasiexperimental, cohort), Retrospective comparative studies (e.g., case-control), Observational studies (e.g., correlational or descriptive statistics). The consultants and ASA members strongly agree with the recommendation to confirm venous residence of the wire after the wire is threaded if there is any uncertainty that the catheter or wire resides in the vein, and insertion of a dilator or large-bore catheter may then proceed. Proper maintenance of CVCs includes disinfection of catheter hubs, connectors, and injection ports and changing dressings over the site every two days for gauze . Always confirm placement with ultrasound, looking for reverberation artifact of the needle and tenting of the vessel wall. Netcare Antimicrobial Stewardship and Infection Prevention Study Alliance. 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 central lineassociated bloodstream infections through quality improvement initiative. Mark, M.D., Durham, North Carolina. 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. RCTs comparing subclavian and femoral insertion sites report higher rates of catheter colonization at the femoral site (Category A2-H evidence); findings for catheter-related sepsis or catheter-related bloodstream infection are equivocal (Category A2-E evidence).130,131 An RCT finds a higher rate of catheter colonization for internal jugular compared with subclavian insertion (Category A3-H evidence) and for femoral compared with internal jugular insertion (Category A3-H evidence); evidence is equivocal for catheter-related bloodstream infection for either comparison (Category A3-E evidence).131 A nonrandomized comparative study of burn patients reports that catheter colonization and catheter-related bloodstream infection occur more frequently with an insertion site closer to the burn location (Category B1-H evidence).132. 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. 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. After review of all evidentiary information, the task force placed each recommendation into one of three categories: (1) provide the intervention or treatment, (2) the intervention or treatment may be provided to the patient based on circumstances of the case and the practitioners clinical judgment, or (3) do not provide the intervention or treatment. Prospective comparison of two management strategies of central venous catheters in burn patients. 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. Fatal brainstem stroke following internal jugular vein catheterization. Allergy to chlorhexidine: Beware of the central venous catheter. Links to the digital files are provided in the HTML text of this article on the Journals Web site (www.anesthesiology.org). The SiteRite ultrasound machine: An aid to internal jugular vein cannulation. Efficacy of antiseptic-impregnated catheters on catheter colonization and catheter-related bloodstream infections in patients in an intensive care unit. Literature Findings. In 2017, the ASA Committee on Standards and Practice Parameters requested that these guidelines be updated. Methods From January 2015 to January 2021, 115 patients (48 males and 67 females) with irreducible intertrochanteric femoral fractures were treated. Practice guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. A prospective randomized study. The long-term impact of a program to prevent central lineassociated bloodstream infections in a surgical intensive care unit. A summary of recommendations can be found in appendix 1. In total, 4,491 unique new citations were identified, with 1,013 full articles assessed for eligibility. Peripherally inserted percutaneous intravenous central catheter (PICC line) placement for long-term use (e.g., chemotherapy regimens, antibiotic therapy, total parenteral nutrition, chronic vasoactive agent administration . Palpating the femoral pulse throughout the procedure, the introducer needle was inserted into the femoral artery. Strict hand hygiene and other practices shortened stays and cut costs and mortality in a pediatric intensive care unit. Because not all studies of dressings reported event rates, relative risks or hazard ratios (recognizing they approximate relative risks) were pooled. complications such as central venous stenosis, access thrombosis, or exhaustion of suitable access sites in the upper extremity, ultimately result in pursuing vascular access creation in the lower . Central venous catheter colonization in critically ill patients: A prospective, randomized, controlled study comparing standard with two antiseptic-impregnated catheters. Comparison of the effect of the Trendelenburg and passive leg raising positions on internal jugular vein size in critically ill patients. Hospital-wide multidisciplinary, multimodal intervention programme to reduce central venous catheter-associated bloodstream infection. 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. Refer to appendix 3 for an example of a checklist or protocol. The average age of the patients was 78.7 (45-100 years old . Sustained reduction of central lineassociated bloodstream infections outside the intensive care unit with a multimodal intervention focusing on central line maintenance. These studies were combined with 258 pre-2011 articles from the previous guidelines, resulting in a total of 542 articles accepted as evidence for these guidelines. Images in cardiovascular medicine: Percutaneous retrieval of a lost guidewire that caused cardiac tamponade. Fluoroscopy-guided subclavian vein catheterization in 203 children with hematologic disease. Severe anaphylactic reaction due to a chlorhexidine-impregnated central venous catheter. The consultants and ASA members strongly agree with the recommendation to use a chlorhexidine-containing solution for skin preparation in adults, infants, and children. ( 21460264) Transition to a PICC line for long-term central access. Although observational studies report that Trendelenburg positioning (i.e., head down from supine) increases the right internal jugular vein diameter or cross-sectional area in adult volunteers (Category B2-B evidence),157161 findings are equivocal for studies enrolling adult patients (Category B2-E evidence).158,162164 Observational studies comparing the Trendelenburg position and supine position in pediatric patients report increased right internal jugular vein diameter or cross-sectional area (Category B2-B evidence),165167 and one observational study of newborns reported similar findings (Category B2-B evidence).168 The literature is insufficient to evaluate whether Trendelenburg positioning improves insertion success rates or decreases the risk of mechanical complications. The femoral vein is the major deep vein of the lower extremity. The consultants strongly agree and ASA members agree with the recommendation to determine the use of sutures, staples, or tape for catheter fixation on a local or institutional basis. Guidewire catheter change in central venous catheter biofilm formation in a burn population. Society for Pediatric Anesthesia Winter Meeting, April 17, 2010, San Antonio, Texas; Society of Cardiovascular Anesthesia 32nd Annual Meeting, April 25, 2010, New Orleans, Louisiana; and International Anesthesia Research Society Annual Meeting, May 22, 2011, Vancouver, British Columbia, Canada. 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. 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. 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. For membership respondents, the survey rate of return was 8% (n = 393 of 5,000) members. For neonates, the consultants and ASA members agree with the recommendation to determine the use of chlorhexidine-containing solutions for skin preparation based on clinical judgment and institutional protocol. o Avoid the femoral vein for inserting CVCs (except in children); catheter is inserted into the subclavian or internal jugular unless a PICC line is used. Impact of central venous catheter type and methods on catheter-related colonization and bacteraemia. How To Do Femoral Vein Cannulation - Critical Care Medicine - MSD Ultrasound confirmation of guidewire position may eliminate accidental arterial dilatation during central venous cannulation. Eradicating central lineassociated bloodstream infections statewide: The Hawaii experience. Random-effects models were fitted with inverse variance weighting using the DerSimonian and Laird estimate of between-study variance. These guidelines apply to patients undergoing elective central venous access procedures performed by anesthesiologists or healthcare professionals under the direction/supervision of anesthesiologists. 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. 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. Reduction of central line infections in Veterans Administration intensive care units: An observational cohort using a central infrastructure to support learning and improvement. Accurate placement of central venous catheters: A prospective, randomized, multicenter trial. 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. 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).

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