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. Matching Michigan Collaboration & Writing Committee. Central venous catheter colonization and catheter-related bloodstream infections in critically ill patients: A comparison between standard and silver-integrated catheters. Comparison of central venous catheterization with and without ultrasound guide. The consultants and ASA members strongly agree with the recommendation to use real-time ultrasound guidance for vessel localization and venipuncture when the internal jugular vein is selected for cannulation. If you feel any resistance as you advance the guidewire, stop advancing it. NICE guidelines for central venous catheterization in children: Is the evidence base sufficient? 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. Internal jugular line. A central venous catheter, also called a central line or CVC, is a device that helps you receive treatments for various medical conditions. Refer to appendix 5 for a summary of methods and analysis. (Co-Chair), Seattle, Washington; Avery Tung, M.D. The literature is insufficient to evaluate whether catheter fixation with sutures, staples, or tape is associated with a higher risk for catheter-related infections. Alcoholic povidoneiodine to prevent central venous catheter colonization: A randomized unit-crossover study. A total of 3 supervised re-wires is required prior to performing a rewire . National Association of Childrens Hospitals and Related Institutions Pediatric Intensive Care Unit Central LineAssociated Bloodstream Infection Quality Transformation Teams. Case reports of adult patients with arterial puncture by a large-bore catheter/vessel dilator during attempted central venous catheterization indicate severe complications (e.g., cerebral infarction, arteriovenous fistula, hemothorax) after immediate catheter removal (Category B4-H evidence)172,176,253; complications are uncommonly reported for adult patients whose catheters were left in place before surgical consultation and repair (Category B4-E evidence).172,176,254. **, Comparative studies are insufficient to evaluate the efficacy of chlorhexidine and alcohol compared with chlorhexidine without alcohol for skin preparation during central venous catheterization. Survey Findings. Iatrogenic arteriovenous fistula: A complication of percutaneous subclavian vein puncture. Aspirate and flush all lumens and re clamp and apply lumen caps. This approach may not be feasible in emergency circumstances or in the presence of other clinical constraints. No search for gray literature was conducted. Internal jugular vein cannulation: An ultrasound-guided technique. Links to the digital files are provided in the HTML text of this article on the Journals Web site (www.anesthesiology.org). They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert and practitioner opinion, open forum commentary, and clinical feasibility data. Multidisciplinary trauma intensive care unit checklist: Impact on infection rates. A minimum of five independent RCTs (i.e., sufficient for fitting a random-effects model255) is required for meta-analysis. 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. A subclavian artery injury, secondary to internal jugular vein cannulation, is a predictable right-sided phenomenon. Central line placement is a common . Insert the J-curved end of the guidewire into the introducer needle, with the J curve facing up. 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 rate of return was 17.4% (n = 19 of 109). American Society of Anesthesiologists Task Force on Central Venous A. Effectiveness of a programme to reduce the burden of catheter-related bloodstream infections in a tertiary hospital. 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. Reduction of central lineassociated bloodstream infection rates in patients in the adult intensive care unit. Bibliographic database searches included PubMed and EMBASE. Assessment of a central lineassociated bloodstream infection prevention program in a burn-trauma intensive care unit. Prevention of central venous catheter-related bloodstream infection by use of an antiseptic-impregnated catheter: A randomized, controlled trial. Reduction of central line infections in Veterans Administration intensive care units: An observational cohort using a central infrastructure to support learning and improvement. Hospital-wide multidisciplinary, multimodal intervention programme to reduce central venous catheter-associated bloodstream infection. Comparison of bacterial colonization rates of antiseptic impregnated and pure polymer central venous catheters in the critically ill. A comparison between two types of central venous catheters in the prevention of catheter-related infections: The importance of performing all the relevant cultures. If you feel any resistance as you advance the guidewire, stop advancing it. Survey Findings. After review, 729 were excluded, with 284 new studies meeting inclusion criteria. Anaphylaxis to chlorhexidine in a chlorhexidine-coated central venous catheter during general anaesthesia. The policy of the American Society of Anesthesiologists (ASA) Committee on Standards and Practice Parameters is to update practice guidelines every 5 yr. Managing inadvertent arterial catheterization during central venous access procedures. 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. Pacing catheters. 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. Effect of central line bundle on central lineassociated bloodstream infections in intensive care units. Advance the wire 20 to 30 cm. Misplacement of a guidewire diagnosed by transesophageal echocardiography. Use of ultrasound to evaluate internal jugular vein anatomy and to facilitate central venous cannulation in paediatric patients. Target CLAB Zero: A national improvement collaborative to reduce central lineassociated bacteraemia in New Zealand intensive care units. 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. Prevention of catheter-related bloodstream infection in critically ill patients using a disinfectable, needle-free connector: A randomized controlled trial. RCTs report equivocal findings for successful venipuncture when the internal jugular site is compared with the subclavian site (Category A2-E evidence).131,155,156 Equivocal finding are also reported for the femoral versus subclavian site (Category A2-E evidence),130,131 and the femoral versus internal jugular site (Category A3-E evidence).131 RCTs examining mechanical complications (primarily arterial injury, hematoma, and pneumothorax) report equivocal findings for the femoral versus subclavian site (Category A2-E evidence)130,131 as well as the internal jugular versus subclavian or femoral sites (Category A3-E evidence).131. 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. Nursing care. Five (1.0%) adverse events occurred. Detailed descriptions of the ASA process and methodology used in these guidelines may be found in other related publications.25 Appendix 1 contains a footnote indicating where information may be found on the evidence model, literature search process, literature findings, and survey results for these guidelines. Randomized, controlled clinical trial of point-of-care limited ultrasonography assistance of central venous cannulation: The Third Sonography Outcomes Assessment Program (SOAP-3) Trial. Impact of ultrasonography on central venous catheter insertion in intensive care. Confirmation of internal jugular guide wire position utilizing transesophageal echocardiography. subclavian vein (left or right) assessing position. Prepare the centralcatheter kit, and Survey responses for each recommendation are reported using a 5-point scale based on median values from strongly agree to strongly disagree. potential malposition. Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: A randomized controlled trial. Improvement of internal jugular vein cannulation using an ultrasound-guided technique. 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.