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The effect of process control on the incidence of central venous catheter-associated bloodstream infections and mortality in intensive care units in Mexico. Prepare the skin with chlorhexidine, and cover the area with a sterile drape. Managing inadvertent arterial catheterization during central venous access procedures. Iatrogenic arteriovenous fistula: A complication of percutaneous subclavian vein puncture. Survey responses were recorded using a 5-point scale and summarized based on median values., Strongly agree: Median score of 5 (at least 50% of the responses are 5), Agree: Median score of 4 (at least 50% of the responses are 4 or 4 and 5), Equivocal: Median score of 3 (at least 50% of the responses are 3, or no other response category or combination of similar categories contain at least 50% of the responses), Disagree: Median score of 2 (at least 50% of responses are 2 or 1 and 2), Strongly disagree: Median score of 1 (at least 50% of responses are 1), The rate of return for the survey addressing guideline recommendations was 37% (n = 40 of 109) for consultants. Literature Findings. 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. After review, 729 were excluded, with 284 new studies meeting inclusion criteria. Category B: Observational studies or RCTs without pertinent comparison groups may permit inference of beneficial or harmful relationships among clinical interventions and clinical outcomes. Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit using the Institute for Healthcare Improvement Central Line Bundle. Catheter-related infection and thrombosis of the internal jugular vein in hematologic-oncologic patients undergoing chemotherapy: A prospective comparison of silver-coated and uncoated catheters. 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. For meta-analyses of antimicrobial, silver, or silver-sulfadiazine catheters studies reported actual event rates and odds ratios were pooled. 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. 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. Please read and accept the terms and conditions and check the box to generate a sharing link. Resource preparation topics include (1) assessing the physical environment where central venous catheterization is planned to determine the feasibility of using aseptic techniques; (2) availability of a standardized equipment set; (3) use of a checklist or protocol for central venous catheter placement and maintenance; and (4) use of an assistant for central venous catheterization. 1)****, Use real-time ultrasound guidance for vessel localization and venipuncture when the internal jugular vein is selected for cannulation (see fig. 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. Monitoring central line pressure waveforms and pressures. Preparation of these updated guidelines followed a rigorous methodological process. French Catheter Study Group in Intensive Care. A randomized trial comparing povidoneiodine to a chlorhexidine gluconate-impregnated dressing for prevention of central venous catheter infections in neonates. Additional caution should be exercised in patients requiring femoral vein catheterization who have had prior arterial surgery. Once the central line is in place, remove the wire. In most instances, central venous access with ultrasound guidance is considered the standard of care. 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). Literature Findings. 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 ). Effectiveness of stepwise interventions targeted to decrease central catheter-associated bloodstream infections. These studies do not permit assessing the effect of any single component of a checklist or bundled protocol on infection rates. 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. Links to the digital files are provided in the HTML text of this article on the Journals Web site (www.anesthesiology.org). Power analysis for random-effects meta-analysis. Fixed-effects models were fitted using MantelHaenszel or inverse variance weighting as appropriate. 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. Reduced intravascular catheter infection by antibiotic bonding: A prospective, randomized, controlled trial. Algorithm for central venous insertion and verification. Advance the wire 20 to 30 cm. Use of ultrasound to evaluate internal jugular vein anatomy and to facilitate central venous cannulation in paediatric patients. A prospective randomized study. Comparison of the efficacy of three topical antiseptic solutions for the prevention of catheter colonization: A multicenter randomized controlled study. If a physician successfully performs the 5 supervised lines in one site, they are independent for that site only. Comparison of the effect of the Trendelenburg and passive leg raising positions on internal jugular vein size in critically ill patients. Choice of route for central venous cannulation: Subclavian or internal jugular vein? Literature Findings. Microbiological evaluation of central venous catheter administration hubs. Methods for confirming the position of the catheter tip include chest radiography, fluoroscopy, or point-of-care transthoracic echocardiography or continuous electrocardiography. Confirmation of correct central venous catheter position in the preoperative setting by echocardiographic bubble-test.. Reduction of central lineassociated bloodstream infection rates in patients in the adult intensive care unit. 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. Insert the J-curved end of the guidewire into the introducer needle, with the J curve facing up. Literature Findings. . 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. Effect of a second-generation venous catheter impregnated with chlorhexidine and silver sulfadiazine on central catheter-related infections: A randomized, controlled trial. Trendelenburg position does not increase cross-sectional area of the internal jugular vein predictably. Nursing care. ECG, electrocardiography; TEE, transesophageal echocardiography. There were three (0.6%) technical failures due to previously undiagnosed iliofemoral venous occlusive disease. 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. Assessment of a central lineassociated bloodstream infection prevention program in a burn-trauma intensive care unit. Catheter-associated bloodstream infection in the pediatric intensive care unit: A multidisciplinary approach. Survey Findings. Practice Guidelines for Central Venous Access 2020: An Updated Report by the American Society of Anesthesiologists Task Force on Central Venous Access. Both the systematic literature review and the opinion data are based on evidence linkages or statements regarding potential relationships between interventions and outcomes associated with central venous access. In total, 4,491 unique new citations were identified, with 1,013 full articles assessed for eligibility. A prospective randomized trial of an antibiotic- and antiseptic-coated central venous catheter in the prevention of catheter-related infections. Literature exclusion criteria (except to obtain new citations): For the systematic review, potentially relevant clinical studies were identified via electronic and manual searches. The literature is insufficient to evaluate the efficacy of transparent bioocclusive dressings to reduce the risk of infection. 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. 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. 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 small . If a physician successfully performs the 5 supervised lines in one site, they are independent for that site only. Literature Findings. The consultants strongly agree and ASA members agree with the recommendation to not routinely administer intravenous antibiotic prophylaxis. Because not all studies of dressings reported event rates, relative risks or hazard ratios (recognizing they approximate relative risks) were pooled. Usefulness of ultrasonography for the evaluation of catheter misplacement and complications after central venous catheterization. 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. A central venous catheter, also called a central line or CVC, is a device that helps you receive treatments for various medical conditions. . 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. It's made of a long, thin, flexible tube that enters your body through a vein. A prospective clinical trial to evaluate the microbial barrier of a needleless connector. The ASA Committee on Standards and Practice Parameters reviews all practice guidelines at the ASA annual meeting and determines update and revision timelines. For example: o A minimum of 5 supervised successful procedures in both the chest and femoral sites is required (10 total). Prospective randomised trial of povidoneiodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters. The femoral vein is the major deep vein of the lower extremity. Location of the central venous catheter tip with bedside ultrasound in young children: Can we eliminate the need for chest radiography? 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 . Anesthesiology 2020; 132:843 doi: https://doi.org/10.1097/ALN.0000000000002864. Real-time ultrasound-guided catheterisation of the internal jugular vein: A prospective comparison with the landmark technique in critical care patients. Consultants were drawn from the following specialties where central venous access is a concern: anesthesiology (97% of respondents) and critical care (3% of respondents). Comparison of alcoholic chlorhexidine and povidoneiodine cutaneous antiseptics for the prevention of central venous catheter-related infection: A cohort and quasi-experimental multicenter study. These guidelines have been endorsed by the Society of Cardiovascular Anesthesiologists and the Society for Pediatric Anesthesia. Target CLAB Zero: A national improvement collaborative to reduce central lineassociated bacteraemia in New Zealand intensive care units. Iatrogenic injury of vertebral artery resulting in stroke after central venous line insertion. Central venous cannulation: Are routine chest radiographs necessary after B-mode and colour Doppler sonography check? 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. The tube travels through one or more veins until the tip reaches the large vein that empties into your heart ( vena cava ). Standardizing central line safety: Lessons learned for physician leaders. 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. Retention of antibacterial activity and bacterial colonization of antiseptic-bonded central venous catheters. Reducing PICU central lineassociated bloodstream infections: 3-year results. Significant reduction of central-line associated bloodstream infections in a network of diverse neonatal nurseries. 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. If a chlorhexidine-containing dressing is used, the consultants and ASA members both strongly agree with the recommendation to observe the site daily for signs of irritation, allergy or, necrosis. If you feel any resistance as you advance the guidewire, stop advancing it. Ultrasound for localization of central venous catheter: A good alternative to chest x-ray? Biopatch: A new concept in antimicrobial dressings for invasive devices. Advance the wire 20 to 30 cm. (Chair). Decreasing central-lineassociated bloodstream infections in Connecticut intensive care units. Prospective comparison of two management strategies of central venous catheters in burn patients. Copyright 2019, the American Society of Anesthesiologists, Inc. All Rights Reserved. The consultants strongly agree and ASA members agree with the recommendation that after the injury has been evaluated and a treatment plan has been executed, confer with the surgeon regarding relative risks and benefits of proceeding with the elective surgery versus deferring surgery to allow for a period of patient observation. Saline flush test: Can bedside sonography replace conventional radiography for confirmation of above-the-diaphragm central venous catheter placement? Of the 484 attempted placements, 472 (97.5%) were primary placements. Random-effects models were fitted with inverse variance weighting using the DerSimonian and Laird estimate of between-study variance. These large diameter central veins are located universally near a large artery. Anaphylaxis to chlorhexidine-coated central venous catheters: A case series and review of the literature. Suture the line to allow 4 points of fixation. The rapid atrial swirl sign for assessing central venous catheters: Performance by medical residents after limited training. 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.