Contamination of central venous catheters in immunocompromised patients: A comparison between two different types of central venous catheters. 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. Assessment of a central lineassociated bloodstream infection prevention program in a burn-trauma intensive care unit. The consultants and ASA members agree that static ultrasound may also be used when the subclavian or femoral vein is selected. Insert the J-curved end of the guidewire into the introducer needle, with the J curve facing up. Survey Findings. 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. The effects of the Trendelenburg position and the Valsalva manoeuvre on internal jugular vein diameter and placement in children. Ultrasound-guided central venous cannulation is superior to quick-look ultrasound and landmark methods among inexperienced operators: A prospective randomized study. Comparison of silver-impregnated with standard multi-lumen central venous catheters in critically ill patients. Effect of a second-generation venous catheter impregnated with chlorhexidine and silver sulfadiazine on central catheter-related infections: A randomized, controlled trial. 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. Chlorhexidine-impregnated dressing for prevention of colonization of central venous catheters in infants and children: A randomized controlled study. Cerebral infarct following central venous cannulation. These guidelines are intended for use by anesthesiologists and individuals under the supervision of an anesthesiologist. Comparison of needle insertion and guidewire placement techniques during internal jugular vein catheterization: The thin-wall introducer needle technique. Category A: RCTs report comparative findings between clinical interventions for specified outcomes. . Beyond the bundle: Journey of a tertiary care medical intensive care unit to zero central lineassociated bloodstream infections. Ultrasound guidance outcomes were pooled using risk or mean differences (continuous outcomes) for clinical relevance. Aiming for zero: Decreasing central line associated bacteraemia in the intensive care unit. Central venous cannulation: Are routine chest radiographs necessary after B-mode and colour Doppler sonography check? 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. Advance the guidewire through the needle and into the vein. Impact of a national multimodal intervention to prevent catheter-related bloodstream infection in the ICU: The Spanish experience. The epidemiology, antibiograms and predictors of mortality among critically-ill patients with central lineassociated bloodstream infections. 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. Prospective randomised trial of povidoneiodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters. The impact of a quality improvement intervention to reduce nosocomial infections in a PICU. Central venous catheters coated with minocycline and rifampin for the prevention of catheter-related colonization and bloodstream infections: A randomized, double-blind trial. Internal jugular vein diameter in pediatric patients: Are the J-shaped guidewire diameters bigger than internal jugular vein? Ultrasonic examination: An alternative to chest radiography after central venous catheter insertion? 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. Use of electronic medical recordenhanced checklist and electronic dashboard to decrease CLABSIs. Eliminating central lineassociated bloodstream infections: A national patient safety imperative. This may be done in your hospital room or an . 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. Only studies containing original findings from peer-reviewed journals were acceptable. A central venous catheter, also called a central line or CVC, is a device that helps you receive treatments for various medical conditions. Survey Findings. Subclavian venous catheterization: Greater success rate for less experienced operators using ultrasound guidance. Insufficient Literature. Level 3: The literature contains a single RCT, and findings from this study are reported as evidence. 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. 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. Double-lumen central venous catheters impregnated with chlorhexidine and silver sulfadiazine to prevent catheter colonisation in the intensive care unit setting: A prospective randomised study. 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. Fluoroscopy-guided subclavian vein catheterization in 203 children with hematologic disease. 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. Prepare the centralcatheter kit, and - 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. The syringe was removed and a guidewire was advanced through the needle into the femoral artery. 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 . 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. 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. Retention of antibacterial activity and bacterial colonization of antiseptic-bonded central venous catheters. Survey Findings. A multicentre analysis of catheter-related infection based on a hierarchical model. Avoiding complications and decreasing costs of central venous catheter placement utilizing electrocardiographic guidance. Always confirm placement with ultrasound, looking for reverberation artifact of the needle and tenting of the vessel wall. 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. 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. Using a combined nursing and medical approach to reduce the incidence of central line associated bacteraemia in a New Zealand critical care unit: A clinical audit. Aspirate and flush all lumens and re clamp and apply lumen caps. A complete bibliography used to develop this updated Advisory, arranged alphabetically by author, is available as Supplemental Digital Content 1, http://links.lww.com/ALN/C6. 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). For neonates, infants, and children, confirmation of venous placement may take place after the wire is threaded. Nursing care. Beyond the intensive care unit bundle: Implementation of a successful hospital-wide initiative to reduce central lineassociated bloodstream infections. The literature is insufficient to evaluate outcomes associated with the routine use of intravenous prophylactic antibiotics. Prevention of catheter-related infections by silver coated central venous catheters in oncological patients. A multidisciplinary approach to reduce central lineassociated bloodstream infections. 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. Confirmation of correct central venous catheter position in the preoperative setting by echocardiographic bubble-test.. Literature Findings. Evidence levels refer specifically to the strength and quality of the summarized study findings (i.e., statistical findings, type of data, and the number of studies reporting/replicating the findings). A minimum of 5 supervised successful procedures in both the chest and femoral sites is required (10 total). I have read and accept the terms and conditions. Literature Findings. The Texas Medical Center Catheter Study Group. A prospective clinical trial to evaluate the microbial barrier of a needleless connector. Level 4: The literature contains case reports. This line is placed into the vein that runs behind the collarbone. Survey Findings. However, only findings obtained from formal surveys are reported in the document. 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 . Sensitivity to effect measure was also examined. 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. An alternative central venous route for cardiac surgery: Supraclavicular subclavian vein catheterization. The accuracy of electrocardiogram-controlled central line placement. The consultants and ASA members both strongly agree with the recommendation to minimize the number of needle punctures of the skin. Case reports describe severe injury (e.g., hemorrhage, hematoma, pseudoaneurysm, arteriovenous fistula, arterial dissection, neurologic injury including stroke, and severe or lethal airway obstruction) when unintentional arterial cannulation occurs with large-bore catheters (Category B4-H evidence).169178, An RCT comparing a thin-wall needle technique versus a catheter-over-the-needle for right internal jugular vein insertion in adults reports equivocal findings for first-attempt success rates and frequency of complications (Category A3-E evidence)179; for right-sided subclavian insertion in adults an RCT reports first-attempt success more likely and fewer complications with a thin-wall needle technique (Category A3-B evidence).180 One RCT reports equivocal findings for first-attempt success rates and frequency of complications when comparing a thin-wall needle with catheter-over-the-needle technique for internal jugular vein insertion (preferentially right) in neonates (Category A3-E evidence).181 Observational studies report a greater frequency of complications occurring with increasing number of insertion attempts (Category B3-H evidence).182184 One nonrandomized comparative study reports a higher frequency of dysrhythmia when two central venous catheters are placed in the same vein (right internal jugular) compared with placement of one catheter in the vein (Category B1-H evidence); differences in carotid artery punctures or hematomas were not noted (Category B1-E evidence).185. No search for gray literature was conducted. Because not all studies of dressings reported event rates, relative risks or hazard ratios (recognizing they approximate relative risks) were pooled. Ultrasound guidance improves the success rate of internal jugular vein cannulation: A prospective, randomized trial. Decreasing catheter colonization through the use of an antiseptic-impregnated catheter: A continuous quality improvement project. 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. These guidelines apply to patients undergoing elective central venous access procedures performed by anesthesiologists or healthcare professionals under the direction/supervision of anesthesiologists. 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. Methods for confirming the position of the catheter tip include chest radiography, fluoroscopy, or point-of-care transthoracic echocardiography or continuous electrocardiography. Survey responses for each recommendation are reported using a 5-point scale based on median values from strongly agree to strongly disagree. Please read and accept the terms and conditions and check the box to generate a sharing link. Posterior cerebral infarction following loss of guide wire. Prevention of central venous catheter sepsis: A prospective randomized trial. Insert the introducer needle with negative pressure until venous blood is aspirated. Chlorhexidine-related refractory anaphylactic shock: A case successfully resuscitated with extracorporeal membrane oxygenation. Central venous line sepsis in the intensive care unit: A study comparing antibiotic coated catheters with plain catheters. The incidence of complications after the double-catheter technique for cannulation of the right internal jugular vein in a university teaching hospital. Misplacement of a guidewire diagnosed by transesophageal echocardiography. For these updated guidelines, a systematic search and review of peer-reviewed published literature was conducted, with scientific findings summarized and reported below and in the document. The consultants strongly agree and ASA members agree with the recommendation to use static ultrasound imaging before prepping and draping for prepuncture identification of anatomy to determine vessel localization and patency when the internal jugular vein is selected for cannulation. 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. This line is placed into a large vein in the neck. Address correspondence to the American Society of Anesthesiologists: 1061 American Lane, Schaumburg, Illinois 60173. 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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