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Advance the guidewire through the needle and into the vein. Identical surveys were distributed to expert consultants and a random sample of members of the participating organizations. For studies that report statistical findings, the threshold for significance is P < 0.01. Implementation of central venous catheter bundle in an intensive care unit in Kuwait: Effect on central lineassociated bloodstream infections. Chlorhexidine impregnated central venous catheter inducing an anaphylatic shock in the intensive care unit. Evolution and aetiological shift of catheter-related bloodstream infection in a whole institution: The microbiology department may act as a watchtower. The femoral vein lies medial to the femoral artery as it runs distal to the inguinal ligament. ), Tunneled catheters (e.g., Hickman, Quinton, permacaths, portacaths), Arterial cannulation/injury/cerebral embolization/hemorrhage, Wire, knot, inability to remove the catheter, Hospital, intensive care unit length of stay, Number of attempts at central line placement, Time required for placement of central venous catheters, Infections or other complications not associated with central venous catheterization, Mechanical injury or trauma not associated with central venous catheterization, Prospective nonrandomized comparative studies (e.g., quasiexperimental, cohort), Retrospective comparative studies (e.g., case-control), Observational studies (e.g., correlational or descriptive statistics). Literature exclusion criteria (except to obtain new citations): For the systematic review, potentially relevant clinical studies were identified via electronic and manual searches. Use the subclavian site for central lines: Compared to the internal jugular or femoral sites, the subclavian site has a lower risk of thrombosis or line infection. The American Society of Anesthesiologists practice parameter methodology. For these guidelines, central venous access is defined as placement of a catheter such that the catheter is inserted into a venous great vessel. These guidelines have been endorsed by the Society of Cardiovascular Anesthesiologists and the Society for Pediatric Anesthesia. An alternative central venous route for cardiac surgery: Supraclavicular subclavian vein catheterization. Confirmation of venous placement for dialysis catheters should be done by venous blood gas prior to the initial dialysis run. 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. Anaphylactic shock induced by an antiseptic-coated central venous [correction of nervous] catheter. Prospective randomised trial of povidoneiodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters. Central Line Insertion Care Team Checklist Instructions Operator Requirements: Specify minimum requirements. The lack of sufficient scientific evidence in the literature may occur when the evidence is either unavailable (i.e., no pertinent studies found) or inadequate. 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. Real-time ultrasound-guided catheterisation of the internal jugular vein: A prospective comparison with the landmark technique in critical care patients. 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. Effectiveness of stepwise interventions targeted to decrease central catheter-associated bloodstream infections. How useful is ultrasound guidance for internal jugular venous access in children? Femoral line. Literature Findings. Ultrasound-guided cannulation of the internal jugular vein: A prospective, randomized study. Literature Findings. An Updated Report by the American Society of Anesthesiologists Task Force on Central Venous Access, A Tool to Screen Patients for Obstructive Sleep Apnea, ACE (Anesthesiology Continuing Education), Recommendations for Prevention of Infectious Complications, Recommendations for Prevention of Mechanical Trauma or Injury, Recommendations for Management of Arterial Trauma or Injury Arising from Central Venous Access, Appendix 3. Mark, M.D., Durham, North Carolina. Beyond the bundle: Journey of a tertiary care medical intensive care unit to zero central lineassociated bloodstream infections. Guidewire localization by transthoracic echocardiography during central venous catheter insertion: A periprocedural method to evaluate catheter placement. Central venous line sepsis in the intensive care unit: A study comparing antibiotic coated catheters with plain catheters. Validation of the concepts addressed by these guidelines and subsequent recommendations proposed was obtained by consensus from multiple sources, including: (1) survey opinion from consultants who were selected based on their knowledge or expertise in central venous access (2) survey opinions from a randomly selected sample of active members of the ASA; (3) testimony from attendees of publicly held open forums for the original guidelines at a national anesthesia meeting; and (4) internet commentary. Central vascular catheter placement evaluation using saline flush and bedside echocardiography. If you feel any resistance as you advance the guidewire, stop advancing it. Prevention of catheter-related infections by silver coated central venous catheters in oncological patients. Evidence was obtained from two principal sources: scientific evidence and opinion-based evidence. This approach may not be feasible in emergency circumstances or in the presence of other clinical constraints. Meta-analyses of RCTs comparing antibiotic-coated with uncoated catheters indicates that antibiotic-coated catheters are associated with reduced catheter colonization7885 and catheter-related bloodstream infection (Category A1-B evidence).80,81,83,85,86 Meta-analyses of RCTs comparing silver or silver-platinum-carbonimpregnated catheters with uncoated catheters yield equivocal findings for catheter colonization (Category A1-E evidence)8797 but a decreased risk of catheter-related bloodstream infection (Category A1-B evidence).8794,9699 Meta-analyses of RCTs indicate that catheters coated with chlorhexidine and silver sulfadiazine reduce catheter colonization compared with uncoated catheters (Category A1-B evidence)83,95,100118 but are equivocal for catheter-related bloodstream infection (Category A1-E evidence).83,100102,104110,112117,119,120 Cases of anaphylactic shock are reported after placement of a catheter coated with chlorhexidine and silver sulfadiazine (Category B4-H evidence).121129. 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. Literature Findings. Chlorhexidine-impregnated dressing for prevention of colonization of central venous catheters in infants and children: A randomized controlled study. Survey Findings. 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. A multidisciplinary approach to reduce central lineassociated bloodstream infections. Ultrasound-guided central venous cannulation is superior to quick-look ultrasound and landmark methods among inexperienced operators: A prospective randomized study. 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. 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. Eradicating central lineassociated bloodstream infections statewide: The Hawaii experience. 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. Use of electronic medical recordenhanced checklist and electronic dashboard to decrease CLABSIs. Updated by the American Society of Anesthesiologists Task Force on Central Venous Access: Jeffrey L. Apfelbaum, M.D. Ultrasound as a screening tool for central venous catheter positioning and exclusion of pneumothorax. Impact of a prevention strategy targeted at vascular-access care on incidence of infections acquired in intensive care. Intravascular complications of central venous catheterization by insertion site. Meta-analyses of RCTs comparing real-time ultrasound-guided venipuncture of the internal jugular with an anatomical landmark approach report higher first insertion attempt success rates,186197 higher overall success rates,186,187,189192,194204 lower rates of arterial puncture,186188,190201,203,205 and fewer insertion attempts (Category A1-B evidence).188,190,191,194197,199,200,203205 RCTs also indicate reduced access time or times to cannulation with ultrasound compared with a landmark approach (Category A2-B evidence).188,191,194196,199,200,202205, For the subclavian vein, RCTs report fewer insertion attempts with real-time ultrasound-guided venipuncture (Category A2-B evidence),206,207 and higher overall success rates (Category A2-B evidence).206208 When compared with a landmark approach, findings are equivocal for arterial puncture207,208 and hematoma (Category A2-E evidence).207,208 For the femoral vein, an RCT reports a higher first-attempt success rate and fewer needle passes with real-time ultrasound-guided venipuncture compared with the landmark approach in pediatric patients (Category A3-B evidence).209, Meta-analyses of RCTs comparing static ultrasound with a landmark approach yields equivocal evidence for improved overall success for internal jugular insertion (Category A1-E evidence),190,202,210212 overall success irrespective of insertion site (Category A1-E evidence),182,190,202,210212 or impact on arterial puncture rates (Category A1-E evidence).190,202,210212 RCTs comparing static ultrasound with a landmark approach for locating the internal jugular vein report a higher first insertion attempt success rate with static ultrasound (Category A3-B evidence).190,212 The literature is equivocal regarding overall success for subclavian vein access (Category A3-E evidence)182 or femoral vein access when comparing static ultrasound to the landmark approach (Category A3-E evidence).202. Survey Findings. Links to the digital files are provided in the HTML text of this article on the Journals Web site (www.anesthesiology.org). The type of catheter and location of placement will depend on the reason for it's placement. 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. Transthoracic echocardiographic guidance for obtaining an optimal insertion length of internal jugular venous catheters in infants. . Received from the American Society of Anesthesiologists, Schaumburg, Illinois. Fatal brainstem stroke following internal jugular vein catheterization. Confirmation of optimal guidewire length for central venous catheter placement using transesophageal echocardiography. Usefulness of ultrasonography for the evaluation of catheter misplacement and complications after central venous catheterization. Alcoholic povidoneiodine to prevent central venous catheter colonization: A randomized unit-crossover study. The consultants and ASA members strongly agree with the recommendations to wipe catheter access ports with an appropriate antiseptic (e.g., alcohol) before each access when using an existing central venous catheter for injection or aspiration and to cap central venous catheter stopcocks or access ports when not in use. Literature Findings. Literature Findings. A randomized, prospective clinical trial to assess the potential infection risk associated with the PosiFlow needleless connector. Efficacy of antiseptic-impregnated catheters on catheter colonization and catheter-related bloodstream infections in patients in an intensive care unit. An evaluation with ultrasound. Preoperative chlorhexidine anaphylaxis in a patient scheduled for coronary artery bypass graft: A case report. Determine catheter insertion site selection based on clinical need and practitioner judgment, experience, and skill, Select an upper body insertion site when possible to minimize the risk of thrombotic complications relative to the femoral site, Perform central venous access in the neck or chest with the patient in the Trendelenburg position when clinically appropriate and feasible, Select catheter size (i.e., outside diameter) and type based on the clinical situation and skill/experience of the operator, Select the smallest size catheter appropriate for the clinical situation, For the subclavian approach select a thin-wall needle (i.e., Seldinger) technique versus a catheter-over-the-needle (i.e., modified Seldinger) technique, For the jugular or femoral approach, select a thin-wall needle or catheter-over-the-needle technique based on the clinical situation and the skill/experience of the operator, For accessing the vein before threading a dilator or large-bore catheter, 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 (fig. 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. To view a bar chart with the above findings, refer to Supplemental Digital Content 5 (http://links.lww.com/ALN/C10). 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. Assessment of a central lineassociated bloodstream infection prevention program in a burn-trauma intensive care unit. Cardiac tamponade associated with a multilumen central venous catheter. Evidence categories refer specifically to the strength and quality of the research design of the studies. 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. 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 . Anaphylaxis to chlorhexidine-coated central venous catheters: A case series and review of the literature. The consultants and ASA members strongly agree with the recommendations to (1) determine catheter insertion site selection based on clinical need; (2) select an insertion site that is not contaminated or potentially contaminated (e.g., burned or infected skin, inguinal area, adjacent to tracheostomy, or open surgical wound); and (3) select an upper body insertion site when possible to minimize the risk of infection in adults. A summary of recommendations can be found in appendix 1. Example Duties Performed by an Assistant for Central Venous Catheterization. Internal jugular line. The consultants and ASA members both strongly agree with the recommendations to use transparent bioocclusive dressings to protect the site of central venous catheter insertion from infection. Editorials, letters, and other articles without data were excluded. 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. Netcare Antimicrobial Stewardship and Infection Prevention Study Alliance. Fatal respiratory obstruction following insertion of a central venous line. Meta: An R package for meta-analysis (4.9-4). . Comparison of silver-impregnated with standard multi-lumen central venous catheters in critically ill patients. Matching Michigan: A 2-year stepped interventional programme to minimise central venous catheter-blood stream infections in intensive care units in England. This line is placed in a large vein in the groin. Literature Findings. Do not force the wire; it should slide smoothly. Statistically significant (P < 0.01) outcomes are designated as either beneficial (B) or harmful (H) for the patient; statistically nonsignificant findings are designated as equivocal (E). Impact of two bundles on central catheter-related bloodstream infection in critically ill patients. Example of a Central Venous Catheterization Checklist, https://doi.org/10.1097/ALN.0000000000002864, 2023 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting: Carbohydrate-containing Clear Liquids with or without Protein, Chewing Gum, and Pediatric Fasting DurationA Modular Update of the 2017 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting, 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade: A Report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade, 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway, Practice Guidelines for the Prevention, Detection, and Management of Respiratory Depression Associated with Neuraxial Opioid Administration: An Updated Report by the American Society of Anesthesiologists Task Force on Neuraxial Opioids and the American Society of Regional Anesthesia and Pain Medicine*, Practice Guidelines for Obstetric Anesthesia: An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology, Practice Guidelines for Perioperative Blood Management: An Updated Report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management*, Practice Advisory for the Perioperative Management of Patients with Cardiac Implantable Electronic Devices: Pacemakers and Implantable CardioverterDefibrillators 2020: An Updated Report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Cardiac Implantable Electronic Devices, Practice Advisory on Anesthetic Care for Magnetic Resonance Imaging: An Updated Report by the American Society of Anesthesiologists Task Force on Anesthetic Care for Magnetic Resonance Imaging, Copyright 2023 American Society of Anesthesiologists. Catheter-associated bloodstream infection in the pediatric intensive care unit: A multidisciplinary approach. Comparison of central venous catheterization with and without ultrasound guide. 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. Femoral lines are usually used only as provisional access because they have a high risk of infection. All opinion-based evidence relevant to each topic was considered in the development of these guidelines. Chest radiography was used as a reference standard for these studies. Use full sterile dress. Location of the central venous catheter tip with bedside ultrasound in young children: Can we eliminate the need for chest radiography? Prevention of catheter related bloodstream infection by silver iontophoretic central venous catheters: A randomised controlled trial. French Catheter Study Group in Intensive Care. Anaphylaxis to chlorhexidine in a chlorhexidine-coated central venous catheter during general anaesthesia. Survey Findings. This line is placed into a large vein in the neck. Methods From January 2015 to January 2021, 115 patients (48 males and 67 females) with irreducible intertrochanteric femoral fractures were treated. 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). The long-term impact of a program to prevent central lineassociated bloodstream infections in a surgical intensive care unit. Power analysis for random-effects meta-analysis. Antiseptic-impregnated central venous catheters reduce the incidence of bacterial colonization and associated infection in immunocompromised transplant patients. 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. There are a variety of catheter, both size and configuration. 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. Central venous cannulation: Are routine chest radiographs necessary after B-mode and colour Doppler sonography check? Refer to appendix 5 for a summary of methods and analysis. RCTs comparing needleless connectors with standard caps indicate lower rates of microbial contamination of stopcock entry ports with needleless connectors (Category A2-B evidence),151153 but findings for catheter-related bloodstream infection are equivocal (Category A2-E evidence).151,154, Survey Findings. 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. Stepwise introduction of the Best Care Always central-lineassociated bloodstream infection prevention bundle in a network of South African hospitals. Society for Pediatric Anesthesia Winter Meeting, April 17, 2010, San Antonio, Texas; Society of Cardiovascular Anesthesia 32nd Annual Meeting, April 25, 2010, New Orleans, Louisiana; and International Anesthesia Research Society Annual Meeting, May 22, 2011, Vancouver, British Columbia, Canada. Consultants were drawn from the following specialties where central venous access is a concern: anesthesiology (97% of respondents) and critical care (3% of respondents). Findings were then summarized for each evidence linkage and reported in the text of the updated Guideline, with summary evidence tables available as Supplemental Digital Content 4 (http://links.lww.com/ALN/C9). Statistically significant outcomes (P < 0.01) are designated as either beneficial (B) or harmful (H) for the patient; statistically nonsignificant findings are designated as equivocal (E). It's made of a long, thin, flexible tube that enters your body through a vein. Survey Findings. If a physician successfully performs the 5 supervised lines in one site, they are independent for that site only. This description of the venous great vessels is consistent with the venous subset for central lines defined by the National Healthcare Safety Network. Ultrasound localization of central vein catheter and detection of postprocedural pneumothorax: An alternative to chest radiography. Survey findings from task forceappointed expert consultants and a random sample of the ASA membership are fully reported in the text of these guidelines. document the position of the line. Refer to appendix 4 for an example of a list of duties performed by an assistant. The needle was exchanged over the wire for an arterial . This may be done in your hospital room or an . Sometimes (hopefully rarely), the exigencies of time or patient condition will prevent placing a full sterile line. Arterial blood was withdrawn. Five (1.0%) adverse events occurred. The accuracy of electrocardiogram-controlled central line placement. 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. Elimination of central-venous-catheterrelated bloodstream infections from the intensive care unit. Aiming for zero: Decreasing central line associated bacteraemia in the intensive care unit. Does ultrasound imaging before puncture facilitate internal jugular vein cannulation? These large diameter central veins are located universally near a large artery. 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. hemorrhage, hematoma formation, and pneumothorax during central line placement. 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.. Reduction of central line infections in Veterans Administration intensive care units: An observational cohort using a central infrastructure to support learning and improvement. The bubble study: Ultrasound confirmation of central venous catheter placement.