Sometimes (hopefully rarely), the exigencies of time or patient condition will prevent placing a full sterile line. Prevention of catheter-related bloodstream infection in critically ill patients using a disinfectable, needle-free connector: A randomized controlled trial. A controlled study of transesophageal echocardiography to guide central venous catheter placement in congenital heart surgery patients. Advance the wire 20 to 30 cm. Your groin area is cleaned and shaved. 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 recommendation to use a chlorhexidine-containing solution for skin preparation in adults, infants, and children. Risk factors for catheter-related bloodstream infection: A prospective multicenter study in Brazilian intensive care units. 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. Complications of femoral and subclavian venous catheterization in critically ill patients: A randomized controlled trial. Heterogeneity was quantified with I2 and prediction intervals estimated (see table 1). Effect of a second-generation venous catheter impregnated with chlorhexidine and silver sulfadiazine on central catheter-related infections: A randomized, controlled trial. Chlorhexidine and silver-sulfadiazine coated central venous catheters in haematological patients: A double-blind, randomised, prospective, controlled trial. 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. How useful is ultrasound guidance for internal jugular venous access in children? 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. Cerebral infarct following central venous cannulation. These studies do not permit assessing the effect of any single component of a checklist or bundled protocol on infection rates. The consultants and ASA members strongly agree with the recommendation to perform central venous access in the neck or chest with the patient in the Trendelenburg position when clinically appropriate and feasible. Decreasing PICU catheter-associated bloodstream infections: NACHRIs quality transformation efforts. To view a bar chart with the above findings, refer to Supplemental Digital Content 5 (http://links.lww.com/ALN/C10). When an equal number of categorically distinct responses are obtained, the median value is determined by calculating the arithmetic mean of the two middle values. The evidence model below guided the search, providing inclusion and exclusion information regarding patients, procedures, practice settings, providers, clinical interventions, and outcomes. The tube travels through one or more veins until the tip reaches the large vein that empties into your heart ( vena cava ). An RCT comparing maximal barrier precautions (i.e., mask, cap, gloves, gown, large full-body drape) with a control group (i.e., gloves and small drape) reports equivocal findings for reduced colonization and catheter-related septicemia (Category A3-E evidence).72 A majority of observational studies reporting or with calculable levels of statistical significance report that bundles of aseptic protocols (e.g., combinations of hand washing, sterile full-body drapes, sterile gloves, caps, and masks) reduce the frequency of central lineassociated or catheter-related bloodstream infections (Category B2-B evidence).736 These studies do not permit assessing the effect of any single component of a bundled protocol on infection rates. Use full sterile dress. The type of catheter and location of placement will depend on the reason for it's placement. The journey to zero central catheter-associated bloodstream infections: Culture change in an intensive care unit. Ultrasonic examination: An alternative to chest radiography after central venous catheter insertion? Insert the J-curved end of the guidewire into the introducer needle, with the J curve facing up. The literature is insufficient to evaluate whether catheter fixation with sutures, staples, or tape is associated with a higher risk for catheter-related infections. Insert the introducer needle with negative pressure until venous blood is aspirated. 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. Suture the line to allow 4 points of fixation. Literature Findings. The effect of hand hygiene compliance on hospital-acquired infections in an ICU setting in a Kuwaiti teaching hospital. These guidelines apply to patients undergoing elective central venous access procedures performed by anesthesiologists or healthcare professionals under the direction/supervision of anesthesiologists. Simplified point-of-care ultrasound protocol to confirm central venous catheter placement: A prospective study. The policy of the American Society of Anesthesiologists (ASA) Committee on Standards and Practice Parameters is to update practice guidelines every 5 yr. Nonrandomized comparative studies indicate that longer catheterization is associated with higher catheter colonization rates, infection, and sepsis (Category B1-H evidence).21,142145 The literature is insufficient to evaluate whether time intervals between catheter site inspections are associated with the risk for catheter-related infection. The ASA Committee on Standards and Practice Parameters reviews all practice guidelines at the ASA annual meeting and determines update and revision timelines. 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). Nursing care. ( 21460264) Transition to a PICC line for long-term central access. Methods for confirming the position of the catheter tip include chest radiography, fluoroscopy, or point-of-care transthoracic echocardiography or continuous electrocardiography. Survey Findings. Of the 484 attempted placements, 472 (97.5%) were primary placements. Preoperative chlorhexidine anaphylaxis in a patient scheduled for coronary artery bypass graft: A case report. Placing the central line. This line is placed into a large vein in the neck. Nurse-driven quality improvement interventions to reduce hospital-acquired infection in the NICU. 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. The consultants strongly agree and ASA members agree with the recommendation to not routinely administer intravenous antibiotic prophylaxis. Complications and failures of subclavian-vein catheterization. Central venous catheterization: A prospective, randomized, double-blind study. This may be done in your hospital room or an . 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. This update is a revision developed by an ASA-appointed task force of seven members, including five anesthesiologists and two methodologists. Retention of antibacterial activity and bacterial colonization of antiseptic-bonded central venous catheters. The literature is insufficient to evaluate the efficacy of transparent bioocclusive dressings to reduce the risk of infection. 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. Catheter-associated bloodstream infection in the pediatric intensive care unit: A multidisciplinary approach. A retrospective observational study reports that manometry can detect arterial punctures not identified by blood flow and color (Category B3-B evidence).213 The literature is insufficient to address ultrasound, pressure-waveform analysis, blood gas analysis, blood color, or the absence of pulsatile flow as effective methods of confirming catheter or thin-wall needle venous access. Conflict-of-interest documentation regarding current or potential financial and other interests pertinent to the practice guideline were disclosed by all task force members and managed. Bibliographic database searches included PubMed and EMBASE. The consultants and ASA members agree that when feasible, real-time ultrasound may be used when the subclavian or femoral vein is selected. 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. Reduced intravascular catheter infection by antibiotic bonding: A prospective, randomized, controlled trial. The consultants and ASA members agree that static ultrasound may also be used when the subclavian or femoral vein is selected. Literature Findings. Survey Findings. 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 . 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. Iatrogenic injury of vertebral artery resulting in stroke after central venous line insertion. (Co-Chair), Seattle, Washington; Avery Tung, M.D. 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. An unexpected image on a chest radiograph. The needle was exchanged over the wire for an arterial . Femoral vein cannulation performed by residents: A comparison between ultrasound-guided and landmark technique in infants and children undergoing cardiac surgery. Anaphylaxis to chlorhexidine-coated central venous catheters: A case series and review of the literature. Eradicating central lineassociated bloodstream infections statewide: The Hawaii experience. Arterial trauma during central venous catheter insertion: Case series, review and proposed algorithm. Beyond the bundle: Journey of a tertiary care medical intensive care unit to zero central lineassociated bloodstream infections. For studies that report statistical findings, the threshold for significance is P < 0.01. Trendelenburg position, head elevation and a midline position optimize right internal jugular vein diameter. Real-time ultrasound-guided catheterisation of the internal jugular vein: A prospective comparison with the landmark technique in critical care patients. 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. Implementation of central lineassociated bloodstream infection prevention bundles in a surgical intensive care unit using peer tutoring. Reduction of central lineassociated bloodstream infection rates in patients in the adult intensive care unit. The development of evidence-based clinical practice guidelines: Integrating medical science and practice. For neonates, the consultants and ASA members agree with the recommendation to determine the use of transparent or sponge dressings containing chlorhexidine based on clinical judgment and institutional protocol. First, consensus was reached on the criteria for evidence. The consultants and ASA members both strongly agree with the recommendation to minimize the number of needle punctures of the skin. Links to the digital files are provided in the HTML text of this article on the Journals Web site (www.anesthesiology.org). A randomized trial on chlorhexidine dressings for the prevention of catheter-related bloodstream infections in neutropenic patients. American Society of Anesthesiologists Task Force on Central Venous A. Confirmation of endovenous placement of central catheter using the ultrasonographic bubble test., The use of ultrasound during and after central venous catheter insertion. 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. 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. Implementing a multifaceted intervention to decrease central lineassociated bloodstream infections in SEHA (Abu Dhabi Health Services Company) intensive care units: The Abu Dhabi experience. If possible, this site is recommended by United States guidelines. Femoral line. Prospective comparison of two management strategies of central venous catheters in burn patients. Anesthesia was achieved using 1% lidocaine. 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. 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. Small study effects (including potential publication bias) were explored by examining forest and funnel plots, regression tests, trim-and-fill results, and limit meta-analysis. A summary of recommendations can be found in appendix 1. 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. 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.