Once the central line is in place, remove the wire. Zero risk for central lineassociated bloodstream infection: Are we there yet? 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. The development of evidence-based clinical practice guidelines: Integrating medical science and practice. These updated guidelines were developed by means of a five-step process. Comparison of the efficacy of three topical antiseptic solutions for the prevention of catheter colonization: A multicenter randomized controlled study. Iatrogenic injury of vertebral artery resulting in stroke after central venous line insertion. The literature is insufficient to evaluate whether catheter fixation with sutures, staples, or tape is associated with a higher risk for catheter-related infections. Survey Findings. Sterility In the ED, there are only two ways to place central lines: Full Sterile or Non-Sterile There is no in-between. Anesthesia was achieved using 1% lidocaine. Five (1.0%) adverse events occurred. 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. Heterogeneity was quantified with I2 and prediction intervals estimated (see table 1). Eliminating arterial injury during central venous catheterization using manometry. Reduction and surveillance of device-associated infections in adult intensive care units at a Saudi Arabian hospital, 20042011. Incidence of mechanical complications of central venous catheterization using landmark technique: Do not try more than 3 times. 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 . If you feel any resistance as you advance the guidewire, stop advancing it. Confirmation of correct central venous catheter position in the preoperative setting by echocardiographic bubble-test.. RCTs report equivocal findings for catheter tip colonization when catheters are changed at 3-day versus 7-day intervals (Category A2-E evidence).146,147 RCTs report equivocal findings for catheter tip colonization when guidewires are used to change catheters compared with new insertion sites (Category A2-E evidence).148150. Methods for confirming that the catheter or thin-wall needle resides in the vein include, but are not limited to, ultrasound, manometry, or pressure-waveform analysis measurement. The femoral vein is the major deep vein of the lower extremity. Reduced colonization and infection with miconazole-rifampicin modified central venous catheters: A randomized controlled clinical trial. 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. Opinion surveys were developed by the task force to address each clinical intervention identified in the document. The authors declare no competing interests. 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. Standardizing central line safety: Lessons learned for physician leaders. The literature is insufficient to evaluate the efficacy of transparent bioocclusive dressings to reduce the risk of infection. 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 . . 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. 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. Missed carotid artery cannulation: A line crossed and lessons learnt. Choice of route for central venous cannulation: Subclavian or internal jugular vein? Reducing central lineassociated bloodstream infections in three ICUs at a tertiary care hospital in the United Arab Emirates. Fatal respiratory obstruction following insertion of a central venous line. 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. The American Society of Anesthesiologists practice parameter methodology. Nurse-driven quality improvement interventions to reduce hospital-acquired infection in the NICU. Peripheral IV insertion and care. A controlled study of transesophageal echocardiography to guide central venous catheter placement in congenital heart surgery patients. The needle was exchanged over the wire for an arterial . The procedure to place a femoral central line is as follows: You will have to lie down on your back for this procedure. The literature is insufficient to evaluate the effect of the physical environment for aseptic catheter insertion, availability of a standardized equipment set, or the use of an assistant on outcomes associated with central venous catheterization. For these guidelines, central venous access is defined as placement of a catheter such that the catheter is inserted into a venous great vessel. For neonates, infants, and children, confirmation of venous placement may take place after the wire is threaded. Level 4: The literature contains case reports. Effectiveness of stepwise interventions targeted to decrease central catheter-associated bloodstream infections. (Co-Chair), Seattle, Washington; Avery Tung, M.D. Two episodes of life-threatening anaphylaxis in the same patient to a chlorhexidine-sulphadiazine-coated central venous catheter. . The average age of the patients was 78.7 (45-100 years old . Inferred findings are given a directional designation of beneficial (B), harmful (H), or equivocal (E). The consultants and ASA members both agree with the recommendation that dressings containing chlorhexidine may be used in adults, infants, and children unless contraindicated. 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. Simplified point-of-care ultrasound protocol to confirm central venous catheter placement: A prospective study. (Chair). For meta-analyses of antimicrobial, silver, or silver-sulfadiazine catheters studies reported actual event rates and odds ratios were pooled. A randomized trial comparing povidoneiodine to a chlorhexidine gluconate-impregnated dressing for prevention of central venous catheter infections in neonates. Inadvertent prolonged cannulation of the carotid artery. 1), After insertion of a catheter that went over the needle or a thin-wall needle, confirm venous access, If there is any uncertainty that the catheter or wire resides in the vein, confirm venous residence of the wire after the wire is threaded; insertion of a dilator or large-bore catheter may then proceed, After final catheterization and before use, confirm residence of the catheter in the venous system as soon as clinically appropriate####, Confirm the final position of the catheter tip as soon as clinically appropriate*****, Example of a Standardized Equipment Cart for Central Venous Catheterization for Adult Patients. 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. Randomized, controlled clinical trial of point-of-care limited ultrasonography assistance of central venous cannulation: The Third Sonography Outcomes Assessment Program (SOAP-3) Trial. 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. In most instances, central venous access with ultrasound guidance is considered the standard of care. For example: o A minimum of 5 supervised successful procedures in both the chest and femoral sites is required (10 total). Aspirate and flush all lumens and re clamp and apply lumen caps. Second, original published articles from peer-reviewed journals relevant to the perioperative management of central venous catheters were evaluated and added to literature included in the original guidelines. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Survey Findings. As the vein is punctured, a flash of dark venous blood into the syringe indicates that the needle tip is within the femoral vein lumen. Ultrasonic examination: An alternative to chest radiography after central venous catheter insertion? Only studies containing original findings from peer-reviewed journals were acceptable. Advance the guidewire through the needle and into the vein. Ultrasound as a screening tool for central venous catheter positioning and exclusion of pneumothorax. The consultants and ASA members strongly agree with the following recommendations: (1) determine the duration of catheterization based on clinical need; (2) assess the clinical need for keeping the catheter in place on a daily basis; (3) remove catheters promptly when no longer deemed clinically necessary; (4) inspect the catheter insertion site daily for signs of infection; (5) change or remove the catheter when catheter insertion site infection is suspected; and (6) when a catheter-related infection is suspected, replace the catheter using a new insertion site rather than changing the catheter over a guidewire. Category A: RCTs report comparative findings between clinical interventions for specified outcomes. 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. 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). Your groin area is cleaned and shaved. Four hundred eighty-one (99.4%) placements were technically successful. Images in cardiovascular medicine: Percutaneous retrieval of a lost guidewire that caused cardiac tamponade. Survey Findings. R: A Language and Environment for Statistical Computing. Survey Findings. In 2017, the ASA Committee on Standards and Practice Parameters requested that these guidelines be updated. Please read and accept the terms and conditions and check the box to generate a sharing link. Survey Findings. The purposes of these guidelines are to (1) provide guidance regarding placement and management of central venous catheters; (2) reduce infectious, mechanical, thrombotic, and other adverse outcomes associated with central venous catheterization; and (3) improve management of arterial trauma or injury arising from central venous catheterization. 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. 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. Ultrasound-guided internal jugular venous cannulation in infants: A prospective comparison with the traditional palpation method. If possible, this site is recommended by United States guidelines. 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. The consultants and ASA members strongly agree with the recommendation to use aseptic techniques (e.g., hand washing) and maximal barrier precautions (e.g., sterile gowns, sterile gloves, caps, masks covering both mouth and nose, and full-body patient drapes) in preparation for the placement of central venous catheters. Fixed-effects models were fitted using MantelHaenszel or inverse variance weighting as appropriate. Intravascular complications of central venous catheterization by insertion site. Central venous catheters are placed typically in one of 3 large central veins: the internal jugular vein (IJ), subclavian vein (SCL), or femoral vein. Placing the central line. Literature Findings. Meta-analyses from other sources are reviewed but not included as evidence in this document. For femoral line CVL, the needle insertion site should be located approximately 1 to 3 cm below the inguinal ligament and 0.5 to 1 cm medial where the femoral artery pulsates. 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. hemorrhage, hematoma formation, and pneumothorax during central line placement. 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. Maintaining and sustaining the On the CUSP: Stop BSI model in Hawaii. Preparation of these updated guidelines followed a rigorous methodological process. NICE guidelines for central venous catheterization in children: Is the evidence base sufficient? Catheter maintenance consists of (1) determining the optimal duration of catheterization, (2) conducting catheter site inspections, (3) periodically changing catheters, and (4) changing catheters using a guidewire instead of selecting a new insertion site. Assessment of conceptual issues, practicality, and feasibility of the guideline recommendations was also evaluated, with opinion data collected from surveys and other sources. Identical surveys were distributed to expert consultants and a random sample of members of the participating organizations. A total of 3 supervised re-wires is required prior to performing a rewire . tip too high: proximal SVC. Chlorhexidine-related refractory anaphylactic shock: A case successfully resuscitated with extracorporeal membrane oxygenation. 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. Ties are calculated by a predetermined formula. 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. Reducing PICU central lineassociated bloodstream infections: 3-year results. Impregnated central venous catheters for prevention of bloodstream infection in children (the CATCH trial): A randomised controlled trial. . However, only findings obtained from formal surveys are reported in the document. Ultrasound-assisted cannulation of the internal jugular vein: A prospective comparison to the external landmark-guided technique. Aseptic insertion of central venous lines to reduce bacteraemia: The central line associated bacteraemia in NSW intensive care units (CLAB ICU) collaborative. Prospective comparison of two management strategies of central venous catheters in burn patients. Effects of varying entry points and trendelenburg positioning degrees in internal jugular vein area measurements of newborns. 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. Complications of femoral and subclavian venous catheterization in critically ill patients: A randomized controlled trial. Reduction of catheter-related bloodstream infections through the use of a central venous line bundle: Epidemiologic and economic consequences. window the image to best visualize the line. Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. Multidisciplinary trauma intensive care unit checklist: Impact on infection rates. Reduced rates of catheter-associated infection by use of a new silver-impregnated central venous catheter. potential malposition. Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit using the Institute for Healthcare Improvement Central Line Bundle. . Impact of a national multimodal intervention to prevent catheter-related bloodstream infection in the ICU: The Spanish experience. The consultants are equivocal and ASA members agree that when using the catheter-over-the-needle technique, confirmation that the wire resides in the vein may not be needed (1) if the catheter enters the vein easily and manometry or pressure-waveform measurement provides unambiguous confirmation of venous location of the catheter and (2) if the wire passes through the catheter and enters the vein without difficulty. Chlorhexidine-impregnated dressings and prevention of catheter-associated bloodstream infections in a pediatric intensive care unit. The Texas Medical Center Catheter Study Group. Random-effects models were fitted with inverse variance weighting using the DerSimonian and Laird estimate of between-study variance. Two observational studies indicate that ultrasound can confirm venous placement of the wire before dilation or final catheterization (Category B3-B evidence).214,215 Observational studies also demonstrate that transthoracic ultrasound can confirm residence of the guidewire in the venous system (Category B3-B evidence).216219 One observational study indicates that transesophageal echocardiography can be used to identify guidewire position (Category B3-B evidence),220 and case reports document similar findings (Category B4-B evidence).221,222, Observational studies indicate that transthoracic ultrasound can confirm correct catheter tip position (Category B2-B evidence).216,217,223240 Observational studies also indicate that fluoroscopy241,242 and chest radiography243,244 can identify the position of the catheter (Category B2-B evidence). Do not force the wire; it should slide smoothly. No difference in catheter sepsis between standard and antiseptic central venous catheters: A prospective randomized trial. Of the 484 attempted placements, 472 (97.5%) were primary placements. Impact of ultrasonography on central venous catheter insertion in intensive care. The central line is placed in your body during a brief procedure. The insertion process includes catheter site selection, insertion under ultrasound guidance, catheter site dressing regimens, securement devices, and use of a CVC insertion bundle. An evaluation with ultrasound. There are many uses of these catheters. A prospective randomized study to compare ultrasound-guided with nonultrasound-guided double lumen internal jugular catheter insertion as a temporary hemodialysis access. Order a chest x-ray to check for line position and pneumothorax if a jugular or subclavian line has . An observational study reports that implementation of a trauma intensive care unit multidisciplinary checklist is associated with reduced catheter-related infection rates (Category B2-B evidence).6 Observational studies report that central lineassociated or catheter-related bloodstream infection rates are reduced when intensive care unit-wide bundled protocols are implemented736(Category B2-B evidence); evidence from fewer observational studies is equivocal3755(Category B2-E evidence); other observational studies5671 do not report levels of statistical significance or lacked sufficient data to calculate them. 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. The consultants and ASA members agree with the recommendation to use an assistant during placement of a central venous catheter. Cerebral infarct following central venous cannulation. Local anesthetic is used to numb the insertion site. See 2017 Food and Drug Administration warning on chlorhexidine allergy. Suture the line to allow 4 points of fixation. Decreasing PICU catheter-associated bloodstream infections: NACHRIs quality transformation efforts. Implementing a multifaceted intervention to decrease central lineassociated bloodstream infections in SEHA (Abu Dhabi Health Services Company) intensive care units: The Abu Dhabi experience. Verification methods for needle, wire, or catheter placement may include any one or more of the following: ultrasound, manometry, pressure-waveform analysis, venous blood gas, fluoroscopy, continuous electrocardiography, transesophageal echocardiography, and chest radiography. Comparison of alcoholic chlorhexidine and povidoneiodine cutaneous antiseptics for the prevention of central venous catheter-related infection: A cohort and quasi-experimental multicenter study. Your physician will locate the femoral pulse with their nondominant hand. The consultants strongly agree and ASA members agree with the recommendation to not routinely administer intravenous antibiotic prophylaxis. The searches covered an 8.3-yr period from January 1, 2011, through April 30, 2019. First, consensus was reached on the criteria for evidence. Prevention of catheter-related infections by silver coated central venous catheters in oncological patients. 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. Literature Findings. Guidewire catheter change in central venous catheter biofilm formation in a burn population. Prevention of central venous catheter-related bloodstream infection by use of an antiseptic-impregnated catheter: A randomized, controlled trial. Ultrasound-guided cannulation of the internal jugular vein: A prospective, randomized study. Literature Findings. The consultants and ASA members both strongly agree with the recommendation to minimize the number of needle punctures of the skin. Beyond the intensive care unit bundle: Implementation of a successful hospital-wide initiative to reduce central lineassociated bloodstream infections. The long-term impact of a program to prevent central lineassociated bloodstream infections in a surgical intensive care unit. Level 2: The literature contains noncomparative observational studies with associative statistics (e.g., correlation, sensitivity, and specificity). Anaphylaxis to chlorhexidine-coated central venous catheters: A case series and review of the literature. 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. A randomized, prospective clinical trial to assess the potential infection risk associated with the PosiFlow needleless connector. A chest x-ray will be performed immediately following thoracic central line placement to assure line placement and rule out pneumothorax. These guidelines are intended for use by anesthesiologists and individuals under the supervision of an anesthesiologist. Prevention of catheter-related bloodstream infection in critically ill patients using a disinfectable, needle-free connector: A randomized controlled trial. Target CLAB Zero: A national improvement collaborative to reduce central lineassociated bacteraemia in New Zealand intensive care units. Efficacy of antiseptic-impregnated catheters on catheter colonization and catheter-related bloodstream infections in patients in an intensive care unit. A 20-year retained guidewire: Should it be removed? Ultrasound guidance outcomes were pooled using risk or mean differences (continuous outcomes) for clinical relevance. Catheter-associated bloodstream infection in the pediatric intensive care unit: A multidisciplinary approach. Always confirm placement with ultrasound, looking for reverberation artifact of the needle and tenting of the vessel wall. 1)##, When feasible, real-time ultrasound may be used when the subclavian or femoral vein is selected, 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, Static ultrasound may also be used when the subclavian or femoral vein is selected, After insertion of a catheter that went over the needle or a thin-wall needle, confirm venous access***, Do not rely on blood color or absence of pulsatile flow for confirming that the catheter or thin-wall needle resides in the vein, When using the thin-wall needle technique, confirm venous residence of the wire after the wire is threaded, When using the catheter-over-the-needle technique, confirmation that the wire resides in the vein may not be needed (1) when the catheter enters the vein easily and manometry or pressure-waveform measurement provides unambiguous confirmation of venous location of the catheter and (2) when the wire passes through the catheter and enters the vein without difficulty, If there is any uncertainty that the catheter or wire resides in the vein, confirm venous residence of the wire after the wire is threaded; insertion of a dilator or large-bore catheter may then proceed, After final catheterization and before use, confirm residence of the catheter in the venous system as soon as clinically appropriate, Confirm the final position of the catheter tip as soon as clinically appropriate, 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, 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, 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, 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.