Localize the vein by palpating the femoral artery, or use ultrasonography. Pacing catheters. Internal jugular line. This is acceptable so long as you inform the accepting service that the line is not full sterile. They should be exchanged for lines above the diaphragm as soon as possible. The small . Catheter-Related Infections in ICU (CRI-ICU) Group. Antiseptic-bonded central venous catheters and bacterial colonisation. 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. The impact of central line insertion bundle on central lineassociated bloodstream infection. 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. Refer to appendix 5 for a summary of methods and analysis. These values represented moderate to high levels of agreement. I have read and accept the terms and conditions. . Comparison of three techniques for internal jugular vein cannulation in infants. Survey Findings. Ultrasound-guided cannulation of the internal jugular vein: A prospective, randomized study. 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. 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. A multicenter intervention to prevent catheter-associated bloodstream infections. 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.) The rapid atrial swirl sign for assessing central venous catheters: Performance by medical residents after limited training. (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. Category B: Observational studies or RCTs without pertinent comparison groups may permit inference of beneficial or harmful relationships among clinical interventions and clinical outcomes. Opinion surveys were developed by the task force to address each clinical intervention identified in the document. Evaluation of chlorhexidine and silver-sulfadiazine impregnated central venous catheters for the prevention of bloodstream infection in leukaemic patients: A randomized controlled trial. The long-term effect of bundle care for catheter-related blood stream infection: 5-year follow-up. Catheter infection risk related to the distance between insertion site and burned area. 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. Fixed-effects models were fitted using MantelHaenszel or inverse variance weighting as appropriate. Is traditional reading of the bedside chest radiograph appropriate to detect intraatrial central venous catheter position? tient's leg away from midline. A multidisciplinary approach to reduce central lineassociated bloodstream infections. Survey responses for each recommendation are reported using a 5-point scale based on median values from strongly agree to strongly disagree. Refer to appendix 4 for an example of a list of duties performed by an assistant. The consultants and ASA members strongly agree with the recommendation to use real-time ultrasound guidance for vessel localization and venipuncture when the internal jugular vein is selected for cannulation. Preoperative chlorhexidine anaphylaxis in a patient scheduled for coronary artery bypass graft: A case report. Complications and failures of subclavian-vein catheterization. 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. Comparison of Oligon catheters and chlorhexidine-impregnated sponges with standard multilumen central venous catheters for prevention of associated colonization and infections in intensive care unit patients: A multicenter, randomized, controlled study. 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. Do not force the wire; it should slide smoothly. Literature Findings. A prospective randomized study to compare ultrasound-guided with nonultrasound-guided double lumen internal jugular catheter insertion as a temporary hemodialysis access. Prospective comparison of two management strategies of central venous catheters in burn patients. 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.. Significant reduction of central-line associated bloodstream infections in a network of diverse neonatal nurseries. Catheter-related infection and thrombosis of the internal jugular vein in hematologic-oncologic patients undergoing chemotherapy: A prospective comparison of silver-coated and uncoated catheters. 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 . document the position of the line. Confirmation of correct central venous catheter position in the preoperative setting by echocardiographic bubble-test.. Suture the line to allow 4 points of fixation. The policy of the American Society of Anesthesiologists (ASA) Committee on Standards and Practice Parameters is to update practice guidelines every 5 yr. 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. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Prepare the skin with chlorhexidine, and cover the area with a sterile drape. Updated by the American Society of Anesthesiologists Task Force on Central Venous Access: Jeffrey L. Apfelbaum, M.D. 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. Alcoholic povidoneiodine to prevent central venous catheter colonization: A randomized unit-crossover study. Level 4: The literature contains case reports. Antimicrobial durability and rare ultrastructural colonization of indwelling central catheters coated with minocycline and rifampin. Literature Findings. In addition, practice guidelines developed by the American Society of Anesthesiologists (ASA) are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. Comparison of an ultrasound-guided technique. Refer to appendix 3 for an example of a checklist or protocol. Ultrasound guidance improves the success rate of internal jugular vein cannulation: A prospective, randomized trial. 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. Bibliographic database searches included PubMed and EMBASE. 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 . Ultrasound guidance outcomes were pooled using risk or mean differences (continuous outcomes) for clinical relevance. Confirmation of internal jugular guide wire position utilizing transesophageal echocardiography. For neonates, infants, and children, confirmation of venous placement may take place after the wire is threaded. 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. Survey Findings. Five (1.0%) adverse events occurred. Do not advance the line until you have hold of the end of the wire. A prospective, randomized study in critically ill patients using the Oligon Vantex catheter. Retention of the antibiotic teicoplanin on a hydromer-coated central venous catheter to prevent bacterial colonization in postoperative surgical patients. One RCT comparing chlorhexidine (2% aqueous solution without alcohol) with povidoneiodine (10% without alcohol) for skin preparation reports equivocal findings for catheter colonization and catheter-related bacteremia (Category A3-E evidence).73 An RCT comparing chlorhexidine (2% with 70% isopropyl alcohol) with povidoneiodine (5% with 69% ethanol) with or without scrubbing finds lower rates of catheter colonization for chlorhexidine (Category A3-B evidence) and equivocal evidence for dec reased catheter-related bloodstream infection (Category A3-E evidence).74 A third RCT compared two chlorhexidine concentrations (0.5% or 1.0% in 79% ethanol) with povidoneiodine (10% without alcohol), reporting equivocal evidence for colonization (Category A3-E evidence) and catheter-related bloodstream infection (Category A3-E evidence).75 A quasiexperimental study (secondary analysis of an RCT) reports a lower rate of catheter-related bloodstream infection with chlorhexidine (2% with 70% alcohol) than povidoneiodine (5% with 69% alcohol) (Category B1-B evidence).76 The literature is insufficient to evaluate the safety of antiseptic solutions containing chlorhexidine in neonates, infants and children. Implementing a multifaceted intervention to decrease central lineassociated bloodstream infections in SEHA (Abu Dhabi Health Services Company) intensive care units: The Abu Dhabi experience. Power analysis for random-effects meta-analysis. 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. Comparison of alcoholic chlorhexidine and povidoneiodine cutaneous antiseptics for the prevention of central venous catheter-related infection: A cohort and quasi-experimental multicenter study. 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. Evolution and aetiological shift of catheter-related bloodstream infection in a whole institution: The microbiology department may act as a watchtower. Central venous cannulation: Are routine chest radiographs necessary after B-mode and colour Doppler sonography check? 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. Survey Findings. Chest radiography was used as a reference standard for these studies. Ideally the distal end of a CVC should be orientated vertically within the SVC. Prevention of central venous catheter related infections with chlorhexidine gluconate impregnated wound dressings: A randomized controlled trial. The consultants and ASA members strongly agree with the following recommendations: (1) after final catheterization and before use, confirm residence of the catheter in the venous system as soon as clinically appropriate; (2) confirm the final position of the catheter tip as soon as clinically appropriate; (3) for central venous catheters placed in the operating room, perform a chest radiograph no later than the early postoperative period to confirm the position of the catheter tip; (4) verify that the wire has not been retained in the vascular system at the end of the procedure by confirming the presence of the removed wire in the procedural field; and (5) if the complete guidewire is not found in the procedural field, order chest radiography to determine whether the guidewire has been retained in the patients vascular system. Ultrasound-guided internal jugular venous cannulation in infants: A prospective comparison with the traditional palpation method. Meta-analyses from other sources are reviewed but not included as evidence in this document. Evidence was obtained from two principal sources: scientific evidence and opinion-based evidence. These evidence categories are further divided into evidence levels. Random-effects models were fitted with inverse variance weighting using the DerSimonian and Laird estimate of between-study variance. Prospective comparison of ultrasound and CXR for confirmation of central vascular catheter placement. 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. Chlorhexidine-impregnated dressing for prevention of colonization of central venous catheters in infants and children: A randomized controlled study. A chest x-ray will be performed immediately following thoracic central line placement to assure line placement and rule out pneumothorax. Ultrasound-assisted cannulation of the internal jugular vein: A prospective comparison to the external landmark-guided technique. A 20-year retained guidewire: Should it be removed? Complications of femoral and subclavian venous catheterization in critically ill patients: A randomized controlled trial. The femoral vein is the major deep vein of the lower extremity. ECG, electrocardiography; TEE, transesophageal echocardiography. However, only findings obtained from formal surveys are reported in the document. How useful is ultrasound guidance for internal jugular venous access in children? The consultants and ASA members agree with the recommendation to use skin preparation solutions containing alcohol unless contraindicated. ( 21460264) Transition to a PICC line for long-term central access. Survey Findings. Ultrasonography: A novel approach to central venous cannulation. For neonates, infants, and children, confirmation of venous placement may take place after the wire is threaded. The needle insertion path: Insert procedural needles (local anesthetic, finder, and introducer needles) 2 to 4 cm inferior to the inguinal ligament, 1 cm medial to the femoral artery, at a 45 to 60 angle into the skin, and aim toward the umbilicus. Insert the introducer needle with negative pressure until venous blood is aspirated. Advance the guidewire through the needle and into the vein. Improvement of internal jugular vein cannulation using an ultrasound-guided technique. A prospective randomized trial of an antibiotic- and antiseptic-coated central venous catheter in the prevention of catheter-related infections. Survey findings from task forceappointed expert consultants and a random sample of the ASA membership are fully reported in the text of these guidelines. Level 1: The literature contains nonrandomized comparisons (e.g., quasiexperimental, cohort [prospective or retrospective], or case-control research designs) with comparative statistics between clinical interventions for a specified clinical outcome. 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. Transthoracic echocardiographic guidance for obtaining an optimal insertion length of internal jugular venous catheters in infants. Accepted studies from the previous guidelines were also rereviewed, covering the period of January 1, 1971, through June 31, 2011. Confirmation of endovenous placement of central catheter using the ultrasonographic bubble test., The use of ultrasound during and after central venous catheter insertion. Decreasing central lineassociated bloodstream infections through quality improvement initiative. Literature Findings. Nursing care. Consultants were drawn from the following specialties where central venous access is a concern: anesthesiology (97% of respondents) and critical care (3% of respondents). The original guidelines were developed by an ASA appointed task force of 12 members, consisting of anesthesiologists in private and academic practices from various geographic areas of the United States and two methodologists from the ASA Committee on Standards and Practice Parameters. Aseptic insertion of central venous lines to reduce bacteraemia: The central line associated bacteraemia in NSW intensive care units (CLAB ICU) collaborative. If you feel any resistance as you advance the guidewire, stop advancing it. A literature search strategy and PRISMA* flow diagram are available as Supplemental Digital Content 2 (http://links.lww.com/ALN/C7). Refer to appendix 2 for an example of a list of standardized equipment for adult patients. A prospective randomized study. NICE guidelines for central venous catheterization in children: Is the evidence base sufficient? Intravascular complications of central venous catheterization by insertion site. Target CLAB Zero: A national improvement collaborative to reduce central lineassociated bacteraemia in New Zealand intensive care units. The consultants and ASA members agree that static ultrasound may also be used when the subclavian or femoral vein is selected. A randomized trial on chlorhexidine dressings for the prevention of catheter-related bloodstream infections in neutropenic patients. Is a routine chest x-ray necessary for children after fluoroscopically assisted central venous access? 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. 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.