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. This description of the venous great vessels is consistent with the venous subset for central lines defined by the National Healthcare Safety Network. 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 . Comparison of bacterial colonization rates of antiseptic impregnated and pure polymer central venous catheters in the critically ill. A comparison between two types of central venous catheters in the prevention of catheter-related infections: The importance of performing all the relevant cultures. Pacing catheters. Evolution and aetiological shift of catheter-related bloodstream infection in a whole institution: The microbiology department may act as a watchtower. Choice of route for central venous cannulation: Subclavian or internal jugular vein? Advance the wire 20 to 30 cm. A central venous catheter, also called a central line or CVC, is a device that helps you receive treatments for various medical conditions. The insertion process includes catheter site selection, insertion under ultrasound guidance, catheter site dressing regimens, securement devices, and use of a CVC insertion bundle. New York State Regional Perinatal Care Centers. Cerebral infarct following central venous cannulation. Ultrasound guidance improves the success rate of internal jugular vein cannulation: A prospective, randomized trial. 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. 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. R: A Language and Environment for Statistical Computing. visualize the tip of the line. The consultants and ASA members agree with the recommendation to use an assistant during placement of a central venous catheter. Effects of the Trendelenburg position and positive end-expiratory pressure on the internal jugular vein cross-sectional area in children with simple congenital heart defects. Findings from these RCTs are reported separately as evidence. If a physician successfully performs the 5 supervised lines in one site, they are independent for that site only. Nurse-driven quality improvement interventions to reduce hospital-acquired infection in the NICU. Insufficient Literature. The average age of the patients was 78.7 (45-100 years old . Survey Findings. tip too high: proximal SVC. Incidence of mechanical complications of central venous catheterization using landmark technique: Do not try more than 3 times. Arterial blood was withdrawn. Impact of a national multimodal intervention to prevent catheter-related bloodstream infection in the ICU: The Spanish experience. Assessment of a central lineassociated bloodstream infection prevention program in a burn-trauma intensive care unit. Chlorhexidine impregnated central venous catheter inducing an anaphylatic shock in the intensive care unit. 1)****, Use real-time ultrasound guidance for vessel localization and venipuncture when the internal jugular vein is selected for cannulation (see fig. 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. Survey Findings. The consultants and ASA members agree with the recommendations to (1) select the smallest size catheter appropriate for the clinical situation; (2) select a thin-wall needle (i.e., Seldinger) technique versus a catheter-over-the-needle (i.e., modified Seldinger) technique for the subclavian approach; (3) select a thin-wall needle or catheter-over-the-needle technique for the jugular or femoral approach based on the clinical situation and the skill/experience of the operator; and (4) base the decision to use a thin-wall needle technique or a catheter-over-the-needle technique at least in part on the method used to confirm that the wire resides in the vein before a dilator or large-bore catheter is threaded. If there is a contraindication to chlorhexidine, the consultants strongly agree and ASA members agree with the recommendation that povidoneiodine or alcohol may be used. Central venous cannulation: Are routine chest radiographs necessary after B-mode and colour Doppler sonography check? Management of trauma or injury arising from central venous catheterization: Management of arterial cannulation, arterial injury, or cerebral embolization, Pulling out a catheter from the carotid artery versus the subclavian artery, Immediate removal versus retaining catheter until a vascular surgery consult is obtained, Management of catheter or wire shearing or loss, Management of hemo/pneumothorax; retroperitoneal bleeding after femoral catheterization, Management of wire knot, wire, or catheter that will not come out, Management of thromboembolism during removal, Floatation and residence (i.e., maintenance) issues of a pulmonary artery catheter, Central venous catheters versus other methods of assessing volume status or presence of tamponade/pericarditis (e.g., pulse pressure variability and echo), Clinical indications for placement of central venous catheters, Detection and treatment of infectious complications, Education, training, and certification of providers, Monitoring central line pressure waveforms and pressures, 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, etc. The consultants and ASA members strongly agree that 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. Localize the vein by palpating the femoral artery, or use ultrasonography. Publications identified by task force members were also considered. Literature Findings. Level 2: The literature contains noncomparative observational studies with associative statistics (e.g., correlation, sensitivity, and specificity). : Prospective randomized comparison with landmark-guided puncture in ventilated patients. Managing inadvertent arterial catheterization during central venous access procedures. Remove the dilator and pass the central line over the Seldinger wire. Example Duties Performed by an Assistant for Central Venous Catheterization. Refer to appendix 5 for a summary of methods and analysis. Hospital-wide multidisciplinary, multimodal intervention programme to reduce central venous catheter-associated bloodstream infection. Comparison of triple-lumen central venous catheters impregnated with silver nanoparticles (AgTive). Please read and accept the terms and conditions and check the box to generate a sharing link. 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. (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. 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). Survey Findings. The consultants and ASA members strongly agree with the recommendations to (1) determine catheter insertion site selection based on clinical need; (2) 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); and (3) select an upper body insertion site when possible to minimize the risk of infection in adults. A summary of recommendations can be found in appendix 1. Anaphylaxis to chlorhexidine-coated central venous catheters: A case series and review of the literature. The authors declare no competing interests. Literature Findings. I have read and accept the terms and conditions. Survey Findings. Nursing care. Elimination of central-venous-catheterrelated bloodstream infections from the intensive care unit. The effect of hand hygiene compliance on hospital-acquired infections in an ICU setting in a Kuwaiti teaching hospital. The consultants and ASA members agree that static ultrasound may also be used when the subclavian or femoral vein is selected. Impregnated central venous catheters for prevention of bloodstream infection in children (the CATCH trial): A randomised controlled trial. 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. 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. Efficacy of silver-coating central venous catheters in reducing bacterial colonization. Insert the J-curved end of the guidewire into the introducer needle, with the J curve facing up. The results of the surveys are reported in tables 2 and 3 and are summarized in the text of the guidelines.#####, American Society of Anesthesiologists Member Survey Results. Advance the wire 20 to 30 cm. Zero risk for central lineassociated bloodstream infection: Are we there yet? Prevention of catheter-related infections by silver coated central venous catheters in oncological patients. Eradicating central lineassociated bloodstream infections statewide: The Hawaii experience. Ultrasound evaluation of central veinsin the intensive care unit: Effects of dynamic manoeuvres. Simplified point-of-care ultrasound protocol to confirm central venous catheter placement: A prospective study. Cardiac tamponade associated with a multilumen central venous catheter. Literature Findings. 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. These evidence categories are further divided into evidence levels. 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. If possible, this site is recommended by United States guidelines. An additional survey was sent to the consultants accompanied by a draft of the guidelines asking them to indicate which, if any, of the recommendations would change their clinical practices if the guidelines were instituted. The consultants strongly agree and ASA members agree with the recommendation to not use catheters containing antimicrobial agents as a substitute for additional infection precautions. All opinion-based evidence relevant to each topic was considered in the development of these guidelines. The tube travels through one or more veins until the tip reaches the large vein that empties into your heart ( vena cava ). Reduced intravascular catheter infection by antibiotic bonding: A prospective, randomized, controlled trial. 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). Comparison of needle insertion and guidewire placement techniques during internal jugular vein catheterization: The thin-wall introducer needle technique. Effect of a second-generation venous catheter impregnated with chlorhexidine and silver sulfadiazine on central catheter-related infections: A randomized, controlled trial. Impact of central venous catheter type and methods on catheter-related colonization and bacteraemia. Implementation of central lineassociated bloodstream infection prevention bundles in a surgical intensive care unit using peer tutoring. Catheter-associated bloodstream infection in the pediatric intensive care unit: A multidisciplinary approach. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints and are not intended to replace local institutional policies. Reducing central lineassociated bloodstream infections in three ICUs at a tertiary care hospital in the United Arab Emirates. Confirmation of optimal guidewire length for central venous catheter placement using transesophageal echocardiography. Received from the American Society of Anesthesiologists, Schaumburg, Illinois. Use full sterile dress. 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. Comparison of an ultrasound-guided technique. Additional caution should be exercised in patients requiring femoral vein catheterization who have had prior arterial surgery. Evidence categories refer specifically to the strength and quality of the research design of the studies. Failure of antiseptic bonding to prevent central venous catheter-related infection and sepsis. Eliminating catheter-related bloodstream infections in the intensive care unit. Ultrasound confirmation of guidewire position may eliminate accidental arterial dilatation during central venous cannulation. Mark, M.D., Durham, North Carolina. A minimum of 5 supervised successful procedures in both the chest and femoral sites is required (10 total). Ultrasound-guided supraclavicular central venous catheter tip positioning via the right subclavian vein using a microconvex probe. The literature is insufficient to evaluate whether catheter fixation with sutures, staples, or tape is associated with a higher risk for catheter-related infections. Evaluation of antiseptic-impregnated central venous catheters for prevention of catheter-related infection in intensive care unit patients. Internal jugular line. Iatrogenic arteriovenous fistula: A complication of percutaneous subclavian vein puncture. Survey Findings. Standardizing central line safety: Lessons learned for physician leaders. - 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. Nosocomial sepsis: Evaluation of the efficacy of preventive measures in a level-III neonatal intensive care unit. Impact of two bundles on central catheter-related bloodstream infection in critically ill patients. 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. 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. Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. 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's made of a long, thin, flexible tube that enters your body through a vein. 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. Four hundred eighty-one (99.4%) placements were technically successful. Catheter infection: A comparison of two catheter maintenance techniques. 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 . Subclavian venous catheterization: Greater success rate for less experienced operators using ultrasound guidance. 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. To view a bar chart with the above findings, refer to Supplemental Digital Content 5 (http://links.lww.com/ALN/C10). 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. Accepted studies from the previous guidelines were also rereviewed, covering the period of January 1, 1971, through June 31, 2011. Fluoroscopy-guided subclavian vein catheterization in 203 children with hematologic disease. In 2017, the ASA Committee on Standards and Practice Parameters requested that these guidelines be updated. 2012 Emery A. Rovenstine Memorial Lecture: The genesis, development, and future of the American Society of Anesthesiologists evidence-based practice parameters. 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. Ultrasound guidance outcomes were pooled using risk or mean differences (continuous outcomes) for clinical relevance. 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. Multidisciplinary trauma intensive care unit checklist: Impact on infection rates. The consultants and ASA members both agree with the recommendation that dressings containing chlorhexidine may be used in adults, infants, and children unless contraindicated. 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. The long-term effect of bundle care for catheter-related blood stream infection: 5-year follow-up.