Category B: Observational studies or RCTs without pertinent comparison groups may permit inference of beneficial or harmful relationships among clinical interventions and clinical outcomes. 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. Improvement of internal jugular vein cannulation using an ultrasound-guided technique. Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. 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. Eliminating catheter-related bloodstream infections in the intensive care unit. The epidemiology, antibiograms and predictors of mortality among critically-ill patients with central lineassociated bloodstream infections. Four hundred eighty-one (99.4%) placements were technically successful. Practice guidelines for central venous access: A report by the American Society of Anesthesiologists Task Force on Central Venous Access. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints and are not intended to replace local institutional policies. This line is placed into a large vein in the neck. Misplacement of a guidewire diagnosed by transesophageal echocardiography. Because not all studies of dressings reported event rates, relative risks or hazard ratios (recognizing they approximate relative risks) were pooled. For neonates, infants, and children, confirmation of venous placement may take place after the wire is threaded. Survey Findings. 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. Supplemental Digital Content is available for this article. Fifth, all available information was used to build consensus to finalize the guidelines. 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. The average age of the patients was 78.7 (45-100 years old . . Category A: RCTs report comparative findings between clinical interventions for specified outcomes. ECG, electrocardiography; TEE, transesophageal echocardiography. 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. Venous blood gases must be obtained at the time of central line insertion or upon admission of a patient with an established central line (including femoral venous lines) and as an endpoint to resuscitation or . Allergy to chlorhexidine: Beware of the central venous catheter. This is acceptable so long as you inform the accepting service that the line is not full sterile. 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. Confirmation of endovenous placement of central catheter using the ultrasonographic bubble test., The use of ultrasound during and after central venous catheter insertion. . Editorials, letters, and other articles without data were excluded. See 2017 Food and Drug Administration warning on chlorhexidine allergy. Heterogeneity was quantified with I2 and prediction intervals estimated (see table 1). Subclavian venous catheterization: Greater success rate for less experienced operators using ultrasound guidance. 1)##, When feasible, real-time ultrasound may be used when the subclavian or femoral vein is selected, 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, Static ultrasound may also be used when the subclavian or femoral vein is selected, After insertion of a catheter that went over the needle or a thin-wall needle, confirm venous access***, Do not rely on blood color or absence of pulsatile flow for confirming that the catheter or thin-wall needle resides in the vein, When using the thin-wall needle technique, confirm venous residence of the wire after the wire is threaded, When using the catheter-over-the-needle technique, confirmation that the wire resides in the vein may not be needed (1) when the catheter enters the vein easily and manometry or pressure-waveform measurement provides unambiguous confirmation of venous location of the catheter and (2) when the wire passes through the catheter and enters the vein without difficulty, 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, For central venous catheters placed in the operating room, perform a chest radiograph no later than the early postoperative period to confirm the position of the catheter tip, Verify that the wire has not been retained in the vascular system at the end of the procedure by confirming the presence of the removed wire in the procedural field, If the complete guidewire is not found in the procedural field, order chest radiography to determine whether the guidewire has been retained in the patients vascular system, Literature Findings. Prevention of catheter-related infections by silver coated central venous catheters in oncological patients. Transthoracic echocardiographic guidance for obtaining an optimal insertion length of internal jugular venous catheters in infants. When obtaining central venous access in the femoral vein, the key anatomical landmarks to identify in the inguinal-femoral region are the inguinal ligament and the femoral artery pulsation. Trendelenburg position does not increase cross-sectional area of the internal jugular vein predictably. Effectiveness of stepwise interventions targeted to decrease central catheter-associated bloodstream infections. These large diameter central veins are located universally near a large artery. I have read and accept the terms and conditions. Only studies containing original findings from peer-reviewed journals were acceptable. No search for gray literature was conducted. 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. Refer to appendix 5 for a summary of methods and analysis. New York State Regional Perinatal Care Centers. The consultants and ASA members strongly agree with the recommendation to confirm venous residence of the wire after the wire is threaded if there is any uncertainty that the catheter or wire resides in the vein, and insertion of a dilator or large-bore catheter may then proceed. Confirmation of internal jugular guide wire position utilizing transesophageal echocardiography. This line is placed in a large vein in the groin. Central venous line sepsis in the intensive care unit: A study comparing antibiotic coated catheters with plain catheters. Multimodal interventions for bundle implementation to decrease central lineassociated bloodstream infections in adult intensive care units in a teaching hospital in Taiwan, 20092013. Category A evidence represents results obtained from RCTs, and category B evidence represents observational results obtained from nonrandomized study designs or RCTs without pertinent comparison groups. 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). These guidelines apply to patients undergoing elective central venous access procedures performed by anesthesiologists or healthcare professionals under the direction/supervision of anesthesiologists. Central Line Insertion Care Team Checklist. 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). A central venous catheter, also called a central line or CVC, is a device that helps you receive treatments for various medical conditions. The long-term impact of a program to prevent central lineassociated bloodstream infections in a surgical intensive care unit. Ideally the distal end of a CVC should be orientated vertically within the SVC. Ultrasound guidance improves the success rate of internal jugular vein cannulation: A prospective, randomized trial. Use real-time ultrasound guidance for vessel localization and venipuncture when the internal jugular vein is selected for cannulation (see fig. The guidelines do not address (1) clinical indications for placement of central venous catheters; (2) emergency placement of central venous catheters; (3) patients with peripherally inserted central catheters; (4) placement and residence of a pulmonary artery catheter; (5) insertion of tunneled central lines (e.g., permacaths, portacaths, Hickman, Quinton); (6) methods of detection or treatment of infectious complications associated with central venous catheterization; (7) removal of central venous catheters; (8) diagnosis and management of central venous catheter-associated trauma or injury (e.g., pneumothorax or air embolism), with the exception of carotid arterial injury; (9) management of periinsertion coagulopathy; and (10) competency assessment for central line insertion. 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. The consultants and ASA members agree that static ultrasound may also be used when the subclavian or femoral vein is selected. Anaphylaxis to chlorhexidine-coated central venous catheters: A case series and review of the literature. Comparison of an ultrasound-guided technique. Safety of central venous catheter change over guidewire for suspected catheter-related sepsis: A prospective randomized trial. Your groin area is cleaned and shaved. Methods for confirming that the wire resides in the vein include, but are not limited to, ultrasound (identification of the wire in the vein) or transesophageal echocardiography (identification of the wire in the superior vena cava or right atrium), continuous electrocardiography (identification of narrow-complex ectopy), or fluoroscopy. 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. The rapid atrial swirl sign for assessing central venous catheters: Performance by medical residents after limited training. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Level 2: The literature contains noncomparative observational studies with associative statistics (e.g., correlation, sensitivity, and specificity). The literature is insufficient to evaluate the efficacy of transparent bioocclusive dressings to reduce the risk of infection. Impact of central venous catheter type and methods on catheter-related colonization and bacteraemia. A prospective randomized study to compare ultrasound-guided with nonultrasound-guided double lumen internal jugular catheter insertion as a temporary hemodialysis access. Insufficient Literature. The utility of transthoracic echocardiography to confirm central line placement: An observational study. A collaborative, systems-level approach to eliminating healthcare-associated MRSA, central-lineassociated bloodstream infections, ventilator-associated pneumonia, and respiratory virus infections. Usefulness of ultrasonography for the evaluation of catheter misplacement and complications after central venous catheterization. For neonates, the consultants and ASA members agree with the recommendation to determine the use of chlorhexidine-containing solutions for skin preparation based on clinical judgment and institutional protocol. Algorithm for central venous insertion and verification. 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). Guidance for needle, wire, and catheter placement includes (1) real-time or dynamic ultrasound for vessel localization and guiding the needle to its intended venous location and (2) static ultrasound imaging for the purpose of prepuncture vessel localization. Localize the vein by palpating the femoral artery, or use ultrasonography. 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. Central Line Insertion Care Team Checklist Instructions Operator Requirements: Specify minimum requirements. Ultrasound-guided internal jugular venous cannulation in infants: A prospective comparison with the traditional palpation method. Decreasing central lineassociated bloodstream infections through quality improvement initiative. If you feel any resistance as you advance the guidewire, stop advancing it. Impact of two bundles on central catheter-related bloodstream infection in critically ill patients. Comparison of silver-impregnated with standard multi-lumen central venous catheters in critically ill patients. 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. Ultrasound confirmation of guidewire position may eliminate accidental arterial dilatation during central venous cannulation. 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. 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.