Ultrasound-assisted cannulation of the internal jugular vein: A prospective comparison to the external landmark-guided technique. Ultrasound-guided supraclavicular central venous catheter tip positioning via the right subclavian vein using a microconvex probe. Impact of ultrasonography on central venous catheter insertion in intensive care. Heterogeneity was quantified with I2 and prediction intervals estimated (see table 1). Eliminating arterial injury during central venous catheterization using manometry. Elimination of central-venous-catheterrelated bloodstream infections from the intensive care unit. Is a routine chest x-ray necessary for children after fluoroscopically assisted central venous access? Your groin area is cleaned and shaved. 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 consultants and ASA members agree that needleless catheter access ports may be used on a case-by-case basis, Do not routinely administer intravenous antibiotic prophylaxis, In preparation for the placement of central venous catheters, use aseptic techniques (e.g., hand washing) and maximal barrier precautions (e.g., sterile gowns, sterile gloves, caps, masks covering both mouth and nose, full-body patient drapes, and eye protection), Use a chlorhexidine-containing solution for skin preparation in adults, infants, and children, For neonates, determine the use of chlorhexidine-containing solutions for skin preparation based on clinical judgment and institutional protocol, If there is a contraindication to chlorhexidine, povidoneiodine or alcohol may be used, Unless contraindicated, use skin preparation solutions containing alcohol, For selected patients, use catheters coated with antibiotics, a combination of chlorhexidine and silver sulfadiazine, or silver-platinum-carbonimpregnated catheters based on risk of infection and anticipated duration of catheter use, Do not use catheters containing antimicrobial agents as a substitute for additional infection precautions, Determine catheter insertion site selection based on clinical need, 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), In adults, select an upper body insertion site when possible to minimize the risk of infection, Determine the use of sutures, staples, or tape for catheter fixation on a local or institutional basis, Minimize the number of needle punctures of the skin, Use transparent bioocclusive dressings to protect the site of central venous catheter insertion from infection, Unless contraindicated, dressings containing chlorhexidine may be used in adults, infants, and children, For neonates, determine the use of transparent or sponge dressings containing chlorhexidine based on clinical judgment and institutional protocol, If a chlorhexidine-containing dressing is used, observe the site daily for signs of irritation, allergy, or necrosis, Determine the duration of catheterization based on clinical need, Assess the clinical need for keeping the catheter in place on a daily basis, Remove catheters promptly when no longer deemed clinically necessary, Inspect the catheter insertion site daily for signs of infection, Change or remove the catheter when catheter insertion site infection is suspected, When a catheter-related infection is suspected, a new insertion site may be used for catheter replacement rather than changing the catheter over a guidewire, Clean catheter access ports with an appropriate antiseptic (e.g., alcohol) before each access when using an existing central venous catheter for injection or aspiration, Cap central venous catheter stopcocks or access ports when not in use, Needleless catheter access ports may be used on a case-by-case basis. The consultants and ASA members strongly agree with the recommendation to determine catheter insertion site selection based on clinical need and practitioner judgment, experience, and skill. 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). 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. Femoral vein cannulation performed by residents: A comparison between ultrasound-guided and landmark technique in infants and children undergoing cardiac surgery. Assessment of conceptual issues, practicality, and feasibility of the guideline recommendations was also evaluated, with opinion data collected from surveys and other sources. A randomized trial comparing povidoneiodine to a chlorhexidine gluconate-impregnated dressing for prevention of central venous catheter infections in neonates. Ultrasound confirmation of guidewire position may eliminate accidental arterial dilatation during central venous cannulation. Prevention of catheter-related bloodstream infection in critically ill patients using a disinfectable, needle-free connector: A randomized controlled trial. 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. Positioning the tip of a central venous catheter (CVC) within the superior vena cava (SVC) at or just above the level of the carina is generally considered acceptable for most short-term uses, such as fluid administration or monitoring of central venous pressure. Central vascular catheter placement evaluation using saline flush and bedside echocardiography. Confirmation of optimal guidewire length for central venous catheter placement using transesophageal echocardiography. Influence of triple-lumen central venous catheters coated with chlorhexidine and silver sulfadiazine on the incidence of catheter-related bacteremia. Chlorhexidine-impregnated dressings and prevention of catheter-associated bloodstream infections in a pediatric intensive care unit. Remove the dilator and pass the central line over the Seldinger wire. Prevention of central venous catheter related infections with chlorhexidine gluconate impregnated wound dressings: A randomized controlled trial. Internal jugular line. The consultants strongly agree and ASA members agree with the recommendation to not routinely administer intravenous antibiotic prophylaxis. For meta-analyses of antimicrobial, silver, or silver-sulfadiazine catheters studies reported actual event rates and odds ratios were pooled. Retention of antibacterial activity and bacterial colonization of antiseptic-bonded central venous catheters. ), 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). These guidelines apply to patients undergoing elective central venous access procedures performed by anesthesiologists or healthcare professionals under the direction/supervision of anesthesiologists. Category A: RCTs report comparative findings between clinical interventions for specified outcomes. 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. The consultants and ASA members strongly agree with the recommendation to confirm venous access after insertion of a catheter that went over the needle or a thin-wall needle and with the recommendation to not rely on blood color or absence of pulsatile flow for confirming that the catheter or thin-wall needle resides in the vein. Saline flush test: Can bedside sonography replace conventional radiography for confirmation of above-the-diaphragm central venous catheter placement? Prospective comparison of two management strategies of central venous catheters in burn patients. Preparation of these updated guidelines followed a rigorous methodological process. 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. The rate of return was 17.4% (n = 19 of 109). Comparison of the efficacy of three topical antiseptic solutions for the prevention of catheter colonization: A multicenter randomized controlled study. 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. Managing inadvertent arterial catheterization during central venous access procedures. In this document, only the highest level of evidence is included in the summary report for each interventionoutcome pair, including a directional designation of benefit, harm, or equivocality. Prospective comparison of ultrasound and CXR for confirmation of central vascular catheter placement. 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. The consultants strongly agree and ASA members agree with the recommendation to use a checklist or protocol for placement and maintenance of central venous catheters. Five (1.0%) adverse events occurred. Updated by the American Society of Anesthesiologists Task Force on Central Venous Access: Jeffrey L. Apfelbaum, M.D. Reduced intravascular catheter infection by antibiotic bonding: A prospective, randomized, controlled trial. Ideally the distal end of a CVC should be orientated vertically within the SVC. Contamination of central venous catheters in immunocompromised patients: A comparison between two different types of central venous catheters. Central venous catheter colonization and catheter-related bloodstream infections in critically ill patients: A comparison between standard and silver-integrated catheters. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. 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. An RCT of 5% povidoneiodine with 70% alcohol compared with 10% povidoneiodine alone indicates that catheter tip colonization is reduced with alcohol containing solutions (Category A3-B evidence); equivocal findings are reported for catheter-related bloodstream infection and clinical signs of infection (Category A3-E evidence).77. Stepwise introduction of the Best Care Always central-lineassociated bloodstream infection prevention bundle in a network of South African hospitals. A multicentre analysis of catheter-related infection based on a hierarchical model. Central lineassociated bloodstream infection in a trauma intensive care unit: Impact of implementation of Society for Healthcare Epidemiology of America/Infectious Diseases Society of America practice guidelines. Arterial misplacement of large-caliber cannulas during jugular vein catheterization: Case for surgical management. . 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. Ultrasound-guided central venous cannulation is superior to quick-look ultrasound and landmark methods among inexperienced operators: A prospective randomized study. The type of catheter and location of placement will depend on the reason for it's placement. This description of the venous great vessels is consistent with the venous subset for central lines defined by the National Healthcare Safety Network. Procedural and educational interventions to reduce ventilator-associated pneumonia rate and central lineassociated blood stream infection rate. Effects of varying entry points and trendelenburg positioning degrees in internal jugular vein area measurements of newborns. Evaluation of antiseptic-impregnated central venous catheters for prevention of catheter-related infection in intensive care unit patients. Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. Palpating the femoral pulse throughout the procedure, the introducer needle was inserted into the femoral artery. **, Comparative studies are insufficient to evaluate the efficacy of chlorhexidine and alcohol compared with chlorhexidine without alcohol for skin preparation during central venous catheterization. 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. Submitted for publication March 15, 2019. COPD, chronic obstructive pulmonary disease; CPR, cardiopulmonary resuscitation; ECG, electrocardiography; IJ, internal jugular; PA, pulmonary artery; TEE, transesophageal echocardiography. 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 . Guidewire localization by transthoracic echocardiography during central venous catheter insertion: A periprocedural method to evaluate catheter placement. Use full sterile dress. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Comparison of triple-lumen central venous catheters impregnated with silver nanoparticles (AgTive). Localize the vein by palpating the femoral artery, or use ultrasonography. Efficacy of antiseptic-impregnated catheters on catheter colonization and catheter-related bloodstream infections in patients in an intensive care unit. Insert the J-curved end of the guidewire into the introducer needle, with the J curve facing up. Fifth, all available information was used to build consensus to finalize the guidelines. In 2017, the ASA Committee on Standards and Practice Parameters requested that these guidelines be updated. No difference in catheter sepsis between standard and antiseptic central venous catheters: A prospective randomized trial. 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. Impact of two bundles on central catheter-related bloodstream infection in critically ill patients. 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. 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. A prospective randomized study to compare ultrasound-guided with nonultrasound-guided double lumen internal jugular catheter insertion as a temporary hemodialysis access. The ASA Committee on Standards and Practice Parameters reviews all practice guidelines at the ASA annual meeting and determines update and revision timelines. Evaluation of chlorhexidine and silver-sulfadiazine impregnated central venous catheters for the prevention of bloodstream infection in leukaemic patients: A randomized controlled trial. Incidence of mechanical complications of central venous catheterization using landmark technique: Do not try more than 3 times. Citation searching (backward and forward) of relevant meta-analyses and other systematic reviews was also performed; pre-2011 studies relevant to meta-analyses or use of ultrasound were eligible for inclusion. 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. 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. Anaphylaxis to chlorhexidine in a chlorhexidine-coated central venous catheter during general anaesthesia. 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. Received from the American Society of Anesthesiologists, Schaumburg, Illinois. 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. Subclavian venous catheterization: Greater success rate for less experienced operators using ultrasound guidance. Consultants were drawn from the following specialties where central venous access is a concern: anesthesiology (97% of respondents) and critical care (3% of respondents). Advance the wire 20 to 30 cm. Severe anaphylactic reaction due to a chlorhexidine-impregnated central venous catheter. Benefits of minocycline and rifampin-impregnated central venous catheters: A prospective, randomized, double-blind, controlled, multicenter trial. Insert the introducer needle with negative pressure until venous blood is aspirated. The consultants and ASA members strongly agree with the recommendation to use a chlorhexidine-containing solution for skin preparation in adults, infants, and children. Algorithm for central venous insertion and verification. A randomized, prospective clinical trial to assess the potential infection risk associated with the PosiFlow needleless connector. The long-term effect of bundle care for catheter-related blood stream infection: 5-year follow-up. Refer to appendix 3 for an example of a checklist or protocol. The percentage of responding consultants expecting no change associated with each linkage were as follows: (1) resource preparation (environment with aseptic techniques, standardized equipment set) = 89.5%; (2) use of a trained assistant = 100%; (3) use of a checklist or protocol for placement and maintenance = 89.5%; (4) aseptic preparation (hand washing, sterile full-body drapes, etc.) An unexpected image on a chest radiograph. Address correspondence to the American Society of Anesthesiologists: 1061 American Lane, Schaumburg, Illinois 60173. Literature Findings. The consultants and ASA members strongly agree that when unintended cannulation of an arterial vessel with a dilator or large-bore catheter occurs, leave the dilator or catheter in place and immediately consult a general surgeon, a vascular surgeon, or an interventional radiologist regarding surgical or nonsurgical catheter removal for adults. Chlorhexidine and silver-sulfadiazine coated central venous catheters in haematological patients: A double-blind, randomised, prospective, controlled trial. 1)****, Use real-time ultrasound guidance for vessel localization and venipuncture when the internal jugular vein is selected for cannulation (see fig. 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. Arterial blood was withdrawn. These suggestions include, but are not limited to, positioning the patient in the Trendelenburg position, using the Valsalva maneuver, applying direct pressure to the puncture site, using air-occlusive dressings, and monitoring the patient for a reasonable period of time after catheter removal. Intravascular complications of central venous catheterization by insertion site.
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