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. Interventions intended to prevent mechanical trauma or injury associated with central venous access include but are not limited to (1) selection of catheter insertion site; (2) positioning the patient for needle insertion and catheter placement; (3) needle insertion, wire placement, and catheter placement; (4) guidance for needle, guidewire, and catheter placement, and (5) verification of needle, wire, and catheter placement. Saline flush test: Can bedside sonography replace conventional radiography for confirmation of above-the-diaphragm central venous catheter placement? Power analysis for random-effects meta-analysis. A multicentre analysis of catheter-related infection based on a hierarchical model. Nursing care. Literature Findings. Beyond the bundle: Journey of a tertiary care medical intensive care unit to zero central lineassociated bloodstream infections. Ties are calculated by a predetermined formula. PICC Placement in the Neonate | NEJM This line is placed into a large vein in the neck. A 20-year retained guidewire: Should it be removed? Benefits of minocycline and rifampin-impregnated central venous catheters: A prospective, randomized, double-blind, controlled, multicenter trial. Central Line (Central Venous Access Device) - Saint Luke's Health System The utility of transthoracic echocardiography to confirm central line placement: An observational study. Decreasing catheter-related bloodstream infections in the intensive care unit: Interventions in a medical center in central Taiwan. 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. Standardizing central line safety: Lessons learned for physician leaders. Central Line Placement - Medicalopedia 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. 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. Alcoholic povidoneiodine to prevent central venous catheter colonization: A randomized unit-crossover study. CLABSI Toolkit - Chapter 3 | The Joint Commission The consultants and ASA members agree with the recommendation to use skin preparation solutions containing alcohol unless contraindicated. Metasens: Advanced Statistical Methods to Model and Adjust for Bias in Meta-Analysis. Evidence was obtained from two principal sources: scientific evidence and opinion-based evidence. Incidence of mechanical complications of central venous catheterization using landmark technique: Do not try more than 3 times. The literature is insufficient to evaluate outcomes associated with the routine use of intravenous prophylactic antibiotics. An alternative central venous route for cardiac surgery: Supraclavicular subclavian vein catheterization. Ultrasound-assisted cannulation of the internal jugular vein: A prospective comparison to the external landmark-guided technique. 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. Iatrogenic arteriovenous fistula: A complication of percutaneous subclavian vein puncture. An unexpected image on a chest radiograph. Level 2: The literature contains multiple RCTs, but the number of RCTs is not sufficient to conduct a viable meta-analysis for the purpose of these Guidelines. To view a bar chart with the above findings, refer to Supplemental Digital Content 5 (http://links.lww.com/ALN/C10). Preoperative chlorhexidine anaphylaxis in a patient scheduled for coronary artery bypass graft: A case report. Central line placement is a common . How useful is ultrasound guidance for internal jugular venous access in children? Accurate placement of central venous catheters: A prospective, randomized, multicenter trial. o Avoid the femoral vein for inserting CVCs (except in children); catheter is inserted into the subclavian or internal jugular unless a PICC line is used. Central venous catheter colonization in critically ill patients: A prospective, randomized, controlled study comparing standard with two antiseptic-impregnated catheters. It can be used to confirm that the catheter or the guidewire has travelled towards the SVC. Antiseptic-impregnated central venous catheters reduce the incidence of bacterial colonization and associated infection in immunocompromised transplant patients. Survey Findings. Practice Guidelines for Central Venous Access 2020: Bibliographic database searches included PubMed and EMBASE. How To Do Femoral Vein Cannulation - Critical Care Medicine - MSD Fifth, all available information was used to build consensus to finalize the guidelines. Time-series analysis to observe the impact of a centrally organized educational intervention on the prevention of central-lineassociated bloodstream infections in 32 German intensive care units. Methods for confirming that the catheter is still in the venous system after catheterization and before use include manometry, pressure-waveform measurement, or contrast-enhanced ultrasound. 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. Double-lumen central venous catheters impregnated with chlorhexidine and silver sulfadiazine to prevent catheter colonisation in the intensive care unit setting: A prospective randomised study. Aspirate and flush all lumens and re clamp and apply lumen caps. 1), The number of insertion attempts should be based on clinical judgment, The decision to place two catheters in a single vein should be made on a case-by-case basis. Effects of varying entry points and trendelenburg positioning degrees in internal jugular vein area measurements of newborns. Impact of ultrasonography on central venous catheter insertion in intensive care. Missed carotid artery cannulation: A line crossed and lessons learnt. The development of evidence-based clinical practice guidelines: Integrating medical science and practice. CVC position on chest x-ray (summary) - Radiopaedia Practice Guidelines for Central Venous Access 2020: An Updated Report by the American Society of Anesthesiologists Task Force on Central Venous Access. 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. Choice of route for central venous cannulation: Subclavian or internal jugular vein? Ultrasonic examination: An alternative to chest radiography after central venous catheter insertion? Literature Findings. For membership respondents, the survey rate of return was 8% (n = 393 of 5,000) members. A prospective randomized study. 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. Ultrasound localization of central vein catheter and detection of postprocedural pneumothorax: An alternative to chest radiography. The consultants agree and ASA members strongly agree with the recommendations to select an upper body insertion site to minimize the risk of thrombotic complications relative to the femoral site. 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. All opinion-based evidence relevant to each topic was considered in the development of these guidelines. tip too high: proximal SVC. In this document, 249 are referenced, with a complete bibliography of articles used to develop these guidelines, organized by section, available as Supplemental Digital Content 3 (http://links.lww.com/ALN/C8). Survey Findings. . Assessment of conceptual issues, practicality, and feasibility of the guideline recommendations was also evaluated, with opinion data collected from surveys and other sources. Multimodal interventions for bundle implementation to decrease central lineassociated bloodstream infections in adult intensive care units in a teaching hospital in Taiwan, 20092013. The needle was exchanged over the wire for an arterial . Consider confirming venous residence of the wire. Fatal brainstem stroke following internal jugular vein catheterization. Netcare Antimicrobial Stewardship and Infection Prevention Study Alliance. The consultants and ASA members both agree with the recommendation that dressings containing chlorhexidine may be used in adults, infants, and children unless contraindicated. 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. Confirmatory xray after US-guided tunneled femoral CVC placement The literature is insufficient to evaluate whether catheter fixation with sutures, staples, or tape is associated with a higher risk for catheter-related infections. Central vascular catheter placement evaluation using saline flush and bedside echocardiography. Insufficient Literature. Prevention of central venous catheter related infections with chlorhexidine gluconate impregnated wound dressings: A randomized controlled trial. Copyright 2019, the American Society of Anesthesiologists, Inc. All Rights Reserved. Antiseptic-bonded central venous catheters and bacterial colonisation. Catheter infection risk related to the distance between insertion site and burned area. 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. visualize the tip of the line. Meta: An R package for meta-analysis (4.9-4). Prospective randomised trial of povidoneiodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters. Central venous catheters revisited: Infection rates and an assessment of the new fibrin analysing system brush. RCTs comparing subclavian and femoral insertion sites report that the femoral site has a higher risk of thrombotic complications in adult patients (Category A2-H evidence)130,131; one RCT131 concludes that thrombosis risk is higher with internal jugular than subclavian catheters (Category A3-H evidence), whereas for femoral versus internal jugular catheters, findings are equivocal (Category A3-E evidence). The central line is placed in your body during a brief procedure. Comparison of silver-impregnated with standard multi-lumen central venous catheters in critically ill patients. Dressing A neonatal PICC can be inserted at the patient's bedside with the use of an analgesic agent and radiographic verification, and it can remain in place for several weeks or months. There are a variety of catheter, both size and configuration. There were three (0.6%) technical failures due to previously undiagnosed iliofemoral venous occlusive disease. Allergy to chlorhexidine: Beware of the central venous catheter. Category B: Observational studies or RCTs without pertinent comparison groups may permit inference of beneficial or harmful relationships among clinical interventions and clinical outcomes. Ultrasound validation of maneuvers to increase internal jugular vein cross-sectional area and decrease compressibility. The Central Venous Catheter-Related Infections Study Group. Single-operator ultrasound-guided central venous catheter insertion verifies proper tip placement. 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. Confirmation of internal jugular guide wire position utilizing transesophageal echocardiography. Refer to appendix 5 for a summary of methods and analysis. Central Line Placement - StatPearls - NCBI Bookshelf For these updated guidelines, a systematic search and review of peer-reviewed published literature was conducted, with scientific findings summarized and reported below and in the document. Tunneled femoral dialysis catheter: Practical pointers Example Duties Performed by an Assistant for Central Venous Catheterization. Retention of the antibiotic teicoplanin on a hydromer-coated central venous catheter to prevent bacterial colonization in postoperative surgical patients. A sonographically guided technique for central venous access. Placing the central line. Confirmation of venous placement for dialysis catheters should be done by venous blood gas prior to the initial dialysis run. Refer to appendix 2 for an example of a list of standardized equipment for adult patients. Ultrasound-guided internal jugular venous cannulation in infants: A prospective comparison with the traditional palpation method. Central catheters provide dependable intravenous access and enable hemodynamic monitoring and blood sampling [ 1-3 ]. Each pertinent outcome reported in a study was classified by evidence category and level and designated as beneficial, harmful, or equivocal. The impact of central line insertion bundle on central lineassociated bloodstream infection. Sometimes (hopefully rarely), the exigencies of time or patient condition will prevent placing a full sterile line. Survey findings from task forceappointed expert consultants and a random sample of the ASA membership are fully reported in the text of these guidelines. The syringe was removed and a guidewire was advanced through the needle into the femoral artery. Implementation of central venous catheter bundle in an intensive care unit in Kuwait: Effect on central lineassociated bloodstream infections. Chest X-ray - Tubes - CV Catheters - Position - Radiology Masterclass Literature Findings. Comparison of an ultrasound-guided technique. Chlorhexidine and gauze and tape dressings for central venous catheters: A randomized clinical trial. Ultrasound Guided Femoral Central Line Insertion - YouTube A multitiered strategy of simulation training, kit consolidation, and electronic documentation is associated with a reduction in central lineassociated bloodstream infections.